Table 1 Modified ERAS (mERAS) protocol for patients undergoing elective awake craniotomy using MAC. Modified ERAS protocol created at university hospitals Cleveland medical center for awake craniotomy procedures
Phase of care | Item(s) | mERAS protocol |
|---|---|---|
Preoperative | Patient and family counseling and education | • Routine consultation for awake craniotomy in surgeon’s office, preoperative anesthesia clinic and preoperative unit • Patients were explained the risk and benefit of the awake craniotomy. The full procedure and recovery process were described to the patient and family • The operative staff including surgical staff, anesthesia team, nursing and neurology/neuro monitoring team introduce themselves to the patient to establish connection and trust |
Preoperative evaluation | • Patient’s functional capacity, mental status and language capability were assessed prior to the surgery | |
Preemptive analgesia | • Acetaminophen 975 mg p.o. administered at preoperative care unit except for those with allergy or liver dysfunction | |
Infection prevention and control | • Pre-operative MRSA screening • Surgical prophylactic antibiotic administration within 1 h prior to skin incision (weight based cefazolin IV if MRSA negative and vancomycin IV if MRSA positive, alternative for those with allergies) | |
Intraoperative | Local anesthetic | • Scalp block before pinning and subcutaneous local mixture of lidocaine/ bupivacaine/ sodium bicarbonate administered at the incision |
Normothermia | • Forced air warmer, fluid warmer and circuit warmer | |
Fluid management | • Goal-directed fluid therapy | |
Non-opioid analgesia | • Intraoperative scalp block and local incision anesthesia, dexmedetomidine drip intraoperatively | |
Postoperative | Postoperative analgesia | • Multimodal analgesic regimen: acetaminophen, cyclobenzaprine, gabapentin, lidocaine patch, oxycodone, breakthrough hydromorphone, etc. |
Postoperative nausea and vomiting (PONV) | • PONV prophylaxis and treatment with dexamethasone, ondansetron, promethazine, metoclopramide, etc. | |
Delirium precautions | • Address sensory impairments, encourage mobility, regulate sleep-wake cycle with optimizing room environment, avoid noise and light at nights, etc. | |
• Avoiding anticholinergics, antipsychotics, and benzodiazepines | ||
Early mobilization and ambulation | • Regular assessment and nursing care, physical and occupational therapy postop day zero | |
Glycemic control | • Insulin sliding scales • Proton pump inhibitors | |
Discharge | Mobility | • Independent mobility or mobility with minimal assistance |
Destination | • Arrange Safe discharge home or to rehabilitation center | |
Follow-up | Home & clinic follow-up | • Timely follow-up with outpatient clinic visit |
• Two weeks and three month follow up in surgeon’s clinic |