DIEP and TRAM Flap surgery guidelines

Day prior to surgery

To ensure an efficient start patients attend ward 18 at 13:00 the day prior to surgery to allow:

• Anaesthetic visit. Please try to see your patient on ward 18 on the day before surgery. If this is not possible try to delegate this task to another anaesthetist. Please give standard fasting instructions for 08:00 start.
• Consent check +FY1/nursing clerk-in and pain team visit.
• DVT Prophylaxis prescribed by FY1. Administered on ward 18 on the evening prior to surgery (before patient goes home for night). Ongoing prescription at 22:00.
• Pre-op drinks prescribed by FY1 for 06:00 on the day of surgery (given to patient to take at home). 

Following the above, patients may elect to return home for the night prior to surgery. They are asked to return to ward 18 at 07:00 on the day of surgery. 

Theatre

Patients having bilateral surgery will be transferred to the anaesthetic room for 08:00-08:15 by the theatre team. Standard start time for unilateral cases.

Based on consensus review, the following is appropriate for most patients:

• Large bore IV access.
• Consider an arterial line- especially for bilateral surgery.
• Urinary catheter with urometer. 
• Flowtrons and TEDS.
• Maintain patient temperature >36degrees - core temp probe and underbody blanket. 
• Preferably use TIVA (+/- BIS monitoring) or volatile anaesthetic and remifentanil. 
• Co-amoxiclav 1.2g or Clindamycin 300mg at induction + 8 hourly if prolonged surgery.
• Use goal directed fluid balance. Avoid under and over resuscitation. Vasopressors safe to use. Surgeon may request controlled hypotension during dissection and normotension for anastomosis. 
• PONV prophylaxis (e.g 5-HT3 antagonist +/- other). NB some evidence of increased metastasis with steroid. 
• Multimodal intra-operative analgesia:

Remifentanil + Morphine/oxycodone 10-20mg

Paracetomol + NSAID

Wound catheter(s) placed by surgeons.

• Patient in crucifix position. Arms abducted <90 degrees to prevent brachial plexus injury. Fix forearms in neutral position. Use heel pads + may need pillows under knees to prevent hyper-extension. Surgeons will request bed break after rectus fascia closure.
• Massage and gentle mobilisation of joints and pressure areas intra-operatively as surgery allows. 

Post-operative

Please prescribe the following post-operative medications (unless contraindicated)

Analgesia:

• Regular paracetomol
• Regular Ibuprofen/ diclofenac (if tolerated) when eating and drinking. 
• Morphine PCA (100mg in 50mls) with Droperidol 2.5-5mg/50mls. Prescribed 1mg PRN, 5 min lockout. Please complete the PCA chart.
• Elastomeric pump infusion via wound catheter(s):

- Unilateral surgery: single pump 400l x 5mg/ml levobupivicaine

- Bilateral surgery: two pumps 800ml x 2.5mg/ml Levobupivicaine- split between pumps (i.e 400ml per pump). 

• The pain nurses will see the patient the following day to review their ongoing analgesia and discharge prescription. If the patient has surgery on a Friday, please liaise with the weekend anaesthetic team to request a pain review over the weekend on Level 1 post op ward (19A). Anti-emetics:
• Ondansetron 4mg orally TDS (not PRN) + Droperidol with PCA as above. 
• Rescue antiemetics e.g cyclizine &/or Prochlorperazine. 

• Lactulose 10mls BD starting on the day of surgery. 
• Dalteparin sc at 22:00 on the day of operation or as discussed with the surgical team

Please complete the wound drain charts

Patients are transferred to Level 1 Ward 19A post-op. Flowtrons should remain on until the patient mobiles out of bed on Level 1. TEDS to remain on until discharge home.