A.

Whipple Procedure

Post-Operative Orders:

1. POD #0:

 Admit to ICU
 NPO
 O2 via nasal canula to keep sat > 92%

 Glucose management: Glucometer check Q 6 hours when NPO.

 Pain management as per Anesthesia team if epidural is in place

 If no Epidural in place - start Morphine PCA after patient is extubated

 Incentive Spirometer 10-15x Q1 hour

 IVF – LR @ 150 ml/hour – adjust in patients with CHF

 JP drains to bulb suction. Strip, empty, and record Q shift and prn

 NGT to gravity. Flush q4hrs with 30cc Sterile water or NS. Resident AND nurse
must check NGT q 4 hrs to ensure it is sumping correctly and working.

 SCDs B/L

 Foley to gravity drainage.

 Input/Output Q1 hour

 Vital signs Q1 hour

 Medications:

 IV Antibiotics per protocol Q6 hours x 4 doses

 Nexium 40 mg IV daily

 Metoclopromide 10 mg IV q 6hr
  Magnesium 2 Grams IV x 1

 Albuterol/Atrovent Nebs Q4 hours after extubation.

 Critical care sliding scale (low)

 Post-op labs: KFT, CBC, LFT, Amylase

 CXR - if s/p central line placement.

2. POD #1:

 AM LABS – KFT , CBC , LFT

 Transfer to floor if meets criteria (based on clinical decision of chief

resident/fellow on AM rounds). No cardiac monitor unless patient has cardiac
history or persistent tachycardia/arrhythmia.
 Vital signs Q4 hour
 I/O qSHIFT
 D/C NGT unless output > 300 ml / shift.
 OOB tid to chair
 Ambulate in hall tid with assistance
 Decrease IVF to 83 ml/hour.
 Clexane 40 mg SC Daily, start if HB stable

3. POD #2:

 Erythromycin 200 mg IV Q6 hours if available, otherwise metoclopramide 10 mg

IV q 6 hrs
 Discontinue Central line after 2 PIV in place.
 Lasix 20 mg IV x 1 (may hold at discretion of chief/fellow).
 Decrease IVF to 42 ml/hour.
 Sips of clear liquids.

4. POD #3:
 AM LABS – Neph panel, CBC with platelet count
 Advance diet to clear liquids ad lib.
 Plan to D/C Epidural (must call APS by 10AM and remove epidural prior to 4pm)
 When Epidural D/Ced – Start
o Panadolo 1 gm PO q 6 hrs
o Celebrex 200 mg PO q 12 hrs
o Tramal 50 mg PO q 6 hrs PRN
o Morphine 4 mg IV q 4 hrs PRN
5. POD #4:

 Advance diet to soft diet.

 Start Pancrelipase or Creon MT 10 2 capsules po with meals and 1 with snacks

6. POD #5:

 Send right JP for amylase and bilirubin.

 Advance to regular diet.
 Continue Erythromycin IV until day of discharge, unless patient is having loose
stools.
 If right JP drain amylase and bilirubin are normal and drainage is serosanguinous,
may d/c this drain with approval of chief/fellow in evening of POD#5.

7. POD #6

 Send left JP for amylase and bilirubin

 If left JP drain amylase and bilirubin are normal and drainage is serosanguinous,
may d/c this drain with approval of chief/fellow prior to discharge.
 Discharge on POD #6 or POD # 7.

8. Discharge Orders

 Diet: 6-8 small meals per day.

 Pancrelipase MT 10 – 2 capsules po with meals and 1 with snacks
 Nexium 40mg po daily - Give refills x 5
 Panadolo 1 gm PO q 6 hrs
 Celebrex 200 mg PO q 12 hrs
 Tramal 50 mg PO q 6 hrs PRN
 Clexane 40 mg SC daily x 28 days total from day of surgery
 May shower, no soaking in tub or swimming pool x 4 weeks
 No heavy lifting >10lbs x 6 weeks
 No driving x3-4 weeks or while on pain medicine
 Call the 24hr service pager 2022 for T>101, nausea, vomiting, increase in
abdominal pain, redness or drainage from wound, change in character of drainage.