Be a Surgical “Multiplier” in MIGS Inspire Brilliance Through Teamwork

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Scientific Program ChairJubilee Brown, MD

Honorary ChairBarbara S. Levy, MD

PresidentMarie Fidela R. Paraiso, MD

SYLLABUSPANEL SESSION 1:

Enhanced Recovery After Surgery (ERAS): Building the Ultimate

ERAS Protocol!

Professional Education Information

Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure of Relevant Financial Relationships As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Anti-Harassment Statement AAGL encourages its members to interact with each other for the purposes of professional development and scholarly interchange so that all members may learn, network, and enjoy the company of colleagues in a professional atmosphere. Consequently, it is the policy of the AAGL to provide an environment free from all forms of discrimination, harassment, and retaliation to its members and guests at all regional educational meetings or courses, the annual global congress (i.e. annual meeting), and AAGL-hosted social events (AAGL sponsored activities). Every individual associated with the AAGL has a duty to maintain this environment free of harassment and intimidation. AAGL encourages reporting all perceived incidents of harassment, discrimination, or retaliation. Any individual covered by this policy who believes that he or she has been subjected to such an inappropriate incident has two (2) options for reporting:

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Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 ERAS at Scripps Clinic: It’s about Value… and Narcotics B.S. Kahn ....................................................................................................................................................... 3 Mayo Clinic Has the Best Protocol in the Country, a Humble Opinion S. Dowdy ....................................................................................................................................................... 5 ERAS at Cedars: Stop the Void to Change an Institution K.N. Wright .................................................................................................................................................... 8 ERAmiS From the AAGL Task Force- the Best Pathway Unveiled R.B. Rosenfield, R.L. Stone ......................................................................................................................... 10 Cultural and Linguistics Competency ......................................................................................................... 14

Panel Session 1: Enhanced Recovery After Surgery (ERAS): Building the Ultimate ERAS Protocol!

Moderator: Bruce S. Kahn Faculty: Sean Dowdy, Richard B. Rosenfield, Rebecca L. Stone, Kelly N. Wright

Course Description During this presentation and panel discussion, panelists will discuss how implementation of Enhanced Recovery Pathways have improved patients’ perioperative experience, length of stay, as well as how the need for and use of narcotic medication has been minimized or eliminated. Panelists will also share their experiences working with hospital administrators, anesthesiologists and peri-operative staff to begin ERAS programs and suggest tips for success in starting new or expanding existing programs. The economic impact and future areas for development of ERAS pathways will be explored from several perspectives.

Course Objectives At the conclusion of this activity, the participant will be able to: 1) Discuss the benefits of ERAS pathways for patients, surgeons and hospital administrators; 2) use ERAS pathways to optimize patients’ peri-operative experience and length-of-stay; and 3) interact with hospital administrators to implement a successful ERAS program.

Course Outline

2:00 Welcome, Introductions, and Course Overview B.S. Kahn 2:05 ERAS at Scripps Clinic: It’s about Value… and Narcotics B.S. Kahn 2:10 Mayo Clinic Has the Best Protocol in the Country, a Humble Opinion S. Dowdy2:15 ERAS at Cedars: Stop the Void to Change an Institution K.N. Wright 2:20 ERAmiS From the AAGL Task Force- the Best Pathway Unveiled R.B. Rosenfield/

R.L. Stone2:25 An Audience Participation Event to Create the ULTIMATE ERAS

Protocol… All Faculty

3:00 Adjourn

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Director, AAGL* Linda D. Bradley, Medical Director, AAGL* Erin T. Carey Consultant: MedIQ Mark W. Dassel Contracted Research: Myovant Sciences Erica Dun* Adi Katz* Linda Michels, Executive Director, AAGL* Erinn M. Myers Speakers Bureau: Laborie Medical Technologies, Teleflex Medical Other: Unrestricted educational grant to support NC FPMRS Fellow Cadaver Lab: Boston Scientific Corp. Inc. Amy Park* Grace Phan, Professional Education Specialist, AAGL* Harold Y. Wu* Linda C. Yang Other: Ownership Interest: KLAAS LLC Bruce S. Kahn Contracted Research: Boston Scientific Corp. Speakers Bureau: AbbVie, Douchenay

SCIENTIFIC PROGRAM COMMITTEE Linda D. Bradley, Medical Director, AAGL* Jubilee Brown* Nichole Mahnert* Shanti Indira Mohling* Fariba Mohtashami Consultant: Hologic Marie Fidela R. Paraiso* Shailesh P. Puntambekar* Matthew T. Siedhoff Consultant: Applied Medical, Caldera Medical, CooperSurgical, Olympus Amanda C. Yunker Consultant: Olympus Linda Michels, Executive Director, AAGL*

FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Sean Dowdy* Bruce S. Kahn Contracted Research: Boston Scientific Corp. Speakers Bureau: AbbVie, Douchenay Richard B. Rosenfield* Rebecca L. Stone Consultant: AstraZeneca Kelly N. Wright Consultant: Acessa, Applied Medical, Boston Scientific Corp. Inc., Hologic, Karl Storz

Content Reviewer has nothing to disclose.

Asterisk (*) denotes no financial relationships to disclose.

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ERAS at Scripps Clinic: It’s about Value… and Narcotics

Bruce Kahn, MDFemale Pelvic Medicine and Reconstructive SurgeryDirector, Scripps Fellowship in Minimally Invasive Gynecologic SurgeryScripps Clinic Medical Group, La Jolla, CAProfessor (Adj), Uniformed Services University of the Health Sciences

Disclosure

● Contracted Research: Boston Scientific Corp.● Speakers Bureau: AbbVie, Douchenay

Objectives

● Define the value in ERAS protocols● Examine strategies to reduce narcotic use

Value in ERAS

● Value = Improved Outcomes / Reduced Cost (V=I/R)

● Outcome measures: quicker recovery, increased patient satisfaction● Cost measures: Decreased morbidity, length of stay, etc.

● Is your ERAS program measuring these variables?

1. Kahn, B., Brown, A. Contemp Ob/Gyn, 63(4): 5-19, 2018

Strategies to reduce narcotic use

● Use of non-narcotic analgesia

○ Pre-operatively?

○ Intraoperatively?

■ Narcotics cause nausea, hypotension requiring treatment during case, and possibly the need for more pain medicine postoperatively.2

○ Post-operatively

2. Kim SH, Stoicea N, Soghomonyan S, Bergese SD. Am J Ther. 2015 May-Jun;22(3):e62-74

Managing Your Pain After Surgery Without Opioids

● Take 650 mg of Tylenol (2 pills of 325 mg) and 600 mg of Motrin (3 pills of 200 mg) four times per day.

● We recommend that you follow this schedule around-the-clock for at least 3 days after surgery, or until you feel that it is no longer needed.

● Important: Do not take more than 3000mg of Tylenol or 3200mg of Motrin in a 24-hour period.

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References

1. Kahn, B., Brown, A. Enhanced recovery in gynecologic surgery. Contemp Ob/Gyn, 63(4): 5-19, 2018. https://www.contemporaryobgyn.net/modern-medicine-feature-articles/enhanced-recovery-gynecologic-surgery.2. Kim SH, Stoicea N, Soghomonyan S, Bergese SD. Remifentanil-acute opioid tolerance and opioid-induced hyperalgesia: a systematic review. Am J Ther. 2015 May-Jun;22(3):e62-74. https://www.ncbi.nlm.nih.gov/pubmed/25830866.

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Mayo Clinic has the best ERAS protocol in the country:

A humble opinion

Sean C. Dowdy, MDProfessor and Chair, Gynecologic OncologyMidwest Chair of Quality and AffordabilityMayo Clinic, Rochester, MN

Disclosure

“I have no financial relationships to disclose”

Objectives

● Summarize relevant literature on ERAS● Explain the collateral impact that implementation of an ERAS pathway

has on other quality measures● Describe the importance of standardization, auditing, and diffusion

Basic Tenets of ERAS

● Nutritional optimizationGreat nutrition = Great healing = Great outcomes

● Opioid-sparing analgesiaEase suffering

● EuvolemiaGoldilocks

Hypothesis• Review of past experienceTrial• Individual or small group

investigationLocal Change• Adoption of practice

division-wide or in other surgical subspecialties

Regional/National • Diffusion to outside

organizations/hospitalsAssess Impact• National Databases

Cycle of continuous improvement and spread

Hypothesis

Trial

Local Change

Regional/National

Assess Impact

Continuous improvement(Complex cytoreduction, ovarian cancer)

“Conservative management”

1Enhanced Recovery 1.0

2ERAS 2.0 (Liposomal

Bupivacaine)ERAS 3.0

2013-20172011-2013Until 2011

LOS: 8 daysPCA: 99%

1Kalogera and Dowdy, et al. Obstet Gynecol, 20132Kalogera and Dowdy, et al. Obstet Gynecol, 2016

2017- 2018

LOS: 5 days PCA: 30%Narcotics at 48 hours: 80%>$800,000 savings>90% pt satisfaction

LOS: 5 daysPCA: 4%Narcotics at 48 hours: 90% Ileus: 50%Cost neutral

Targeted to LBRReduction in variation of LOS IQR 5-10.5 daysIQR 5-7 days(p=0.01)

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Does ERAS increase AKI?

● At least 1 serum creatinine in 510 patients with ovarian cancer376 ERAS, 134 historical controls

● No difference in AKI despite less IVF, more NSAIDsKDIGO definition

15% ERAS19% historical controls

NSQIP definition 0.5% ERAS1.5% historical controls

Glaser, Dowdy et al. Manuscript in preparation

Impact of bowel preps in gyn surgery(n=224,687)

Kalorgera, Dowdy et al. Manuscript in review

>70,000 downloads

>15,000downloads

AHRQ Safety Program Improving Surgical Care and Recovery: A National Collaborative to Enhance the Recovery of Surgical Patients

10

Impact of ERAS compliance* on LOS(n=2101)

*Compliance does not include elements which could be considered endpoints

Wijk, Dowdy, Nelson. Am J Obstet Gynecol. 2019

ERAS and Inpatient Opioid Requirements:Complex cytoreductions

● Opioid use first 48 hours after surgery (OME)Conservative management 351 (47 x 5mg oxy)Enhanced recovery 1.0 69Enhanced recovery 2.0 37.5 (5 x 5mg oxy)

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Steps to Achieve Opioid Standardization

● Query historical prescribing data to learn current statePills prescribed (2500 patients, 25 procedures, 10 subspecialties)

● Survey outpatient opioid requirementsPills used (2500 patients, 25 procedures, 10 subspecialties)

● Create procedure-specific guidelines for each surgical subspecialty

Thiels et al., Ann Surg. 2017 Thiels et al., Ann Surg 2018

Impact of Data-driven Standardization

● Excess 5mg oxycodone pillsPerioperative standardization for ovarian cancer: 40,000 pillsPostoperative prescriptions for gyn surgery: 35,000 pills/yearOrthopedic surgery: 200,000 pills/year Across House of Surgery: 1.5 million pills/year

Collateral impact of ERAS:Culture change, continuous QI

● Anastomotic leak rate: 50% reduction● Surgical site infection rate: 80% reduction● Transfusion rate: 72% reduction

● Standardized perioperative decision-makingTesting and imaging, surgical approach, NAC vs. PDS,

sentinel node, postoperative chemo and/or RT

Kalogera and Langstraat, et al. Gynecol Oncol. 2016.Johnson and Bakkum-Gamez, et al. Obstet Gynecol. 2016.Wallace and Bakkum-Gamez et al. Obstet Gynecol 2018.

References

● Kalogera and Langstraat, et al. Gynecol Oncol. 2016.● Johnson and Bakkum-Gamez, et al. Obstet Gynecol. 2016.● Wallace and Bakkum-Gamez et al. Obstet Gynecol 2018.● Thiels et al., Ann Surg. 2017 ● Thiels et al., Ann Surg 2018● Wijk, Dowdy, Nelson. Am J Obstet Gynecol. 2019● Kalogera and Dowdy, et al. Obstet Gynecol, 2013● Kalogera and Dowdy, et al. Obstet Gynecol, 2016● Neslon and Dowdy et al., Gynecol Oncol, 2016● Nelson and Dowdy et al., International Journal of Gynecologic Cancer 2019

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Stop the void to change an institutionKelly Wright, MD, FACOG, FACSDirector, Center for Minimally Invasive Gynecologic SurgeryAssistant Professor, Obstetrics and GynecologyCedars-Sinai ®UCLA David Geffen School of Medicine

2

Disclosures

Consultant: Acessa, Applied Medical, Boston Scientific Corp. Inc., Hologic, Karl Storz

Objectives

• Describe how to circumvent barriers to ERAS implementation

• Review risk of post-op urinary retention (POUR)

• Share why you should stop requiring patients to void after surgery

4

Cedars-Sinai Medical Center

• 1000 beds• 2000 surgeons

Less than 5% faculty• Private anesthesia group without

standard practices

5

Overcoming barriers

6

Implementing ERAS

• Went to nursing and asked what their biggest barrier was• “Waiting for patients to void”

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7

• Boccola et al: Patients undergoing active TOV had faster time to decision and higher void rate 135 min vs. 247 min RR 1.56

• Foster et al: Backfill TOV independent predictor for successful bladder emptying after vaginal surgery

What’s the evidence?

• Chao et al: Partial backfill reduces time to void but not time to discharge 181 vs. 206 min (p=.04)

• Moawad et al: Partial backfill reduces time to void and time to discharge 65 min earlier void (p=.01), 64

min earlier discharge (p=.006)

The infusion method trial of void vs standard catheter removal in the outpatient setting: a prospective randomized trial.  BJU Int. 2011 Apr;107 Suppl 3:43‐6.A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery. Am J Obstet Gynecol 2007;197:627.Postoperative Bladder Filling After Outpatient Laparoscopic Hysterectomy and Time to Discharge: A Randomized Controlled Trial. Obstet Gynecol. 2019 May;133(5):879‐887.Effect of postoperative partial bladder filling after minimally  invasive hysterectomy on postanesthesia care unit discharge and cost: a single‐blinded, randomized controlled trial. Am J ObstetGynecol. 2019 Apr;220(4):367.e1‐367.e7.

What’s the evidence?

• Urinary retention is rare 10,274 undergoing benign hysterectomy 23 urinary retention (0.2%)

40 patients undergoing vaginal or pelvic surgery 0% retention All had low bladder volumes on first void

Risk Factors for Emergency Department Visits After Hysterectomy for Benign Disease. Obstet Gynecol. 2017 Aug;130(2):296‐304.Management of Bladder Function after Outpatient Surgery, Anesthesiology 7 1999, Vol.91, 42‐50.

Should we have patients void at all after hysterectomy?

• Samimi et al: Retrospective study of 4743 patients

undergoing outpatient gynecologic surgery

1557 had an order to void; 3186 had no order to void

3 patients returned with urinary retention All had an order to void

Our own data on POUR

• Siedhoff et al: Retrospective study of 487 laparoscopic

hysterectomies and myomectomies Patients assigned to liberal (no requirement

to void) vs. strict voiding protocols (active or passive requirement to void)

POUR 2.8% vs 5.3% (p=0.17)

UTI 2.4% vs 4.7% (p=.28)

LOS 9.4 vs 10.6 hrs (p<.01)

Results

10

Comparison Groups CasesIP 

CasesOP 

CasesAge

Avg Hours in Hospital per Case

Cases Discharged from PACU

Same Calendar 

Day Discharge

All‐Cause Readmissions

Control Group 42 36% 64% 52 26.3 52% 52% 2%

ERAS Group 35 9% 91% 47 12.2 87% 88% 0%

• Enhanced Recovery After Surgery: Implementation Strategies, Barriers and Facilitators. Surg Clin North Am. 2018 Dec;98(6):1201-1210.

• Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017 Mar 1;152(3):292-298.

• Nursing Perspectives on Enhanced Recovery After Surgery. Surg Clin North Am. 2018 Dec;98(6):1211-1221.

• The infusion method trial of void vs standard catheter removal in the outpatient setting: a prospective randomized trial. BJU Int. 2011 Apr;107 Suppl 3:43-6.

• A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery. Am J Obstet Gynecol 2007;197:627.

• Postoperative Bladder Filling After Outpatient Laparoscopic Hysterectomy and Time to Discharge: A Randomized Controlled Trial. Obstet Gynecol. 2019 May;133(5):879-887.

• Effect of postoperative partial bladder filling after minimally invasive hysterectomy on postanesthesia care unit discharge and cost: a single-blinded, randomized controlled trial. Am J Obstet Gynecol. 2019 Apr;220(4):367.e1-367.e7.

• Risk Factors for Emergency Department Visits After Hysterectomy for Benign Disease. Obstet Gynecol. 2017 Aug;130(2):296-304.

• Management of Bladder Function after Outpatient Surgery, Anesthesiology 7 1999, Vol.91, 42-50.

References

• 18 junior doctors compared to ICU patients they were caring for 23% of the doctors were oliguric More likely to be oliguric than

patients (OR 1.99) Lower mortality rate (0 vs. 18%)

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ERAmiS From the AAGL Task Force- the Best

Pathway Unveiled

Rebecca Stone, MDJohns Hopkins School of Medicine

Disclosure

Consultant: AstraZeneca

Objectives

● To review the key components and goals of the recently formalized ERAS guidelines for MIGS

‘If I say enhanced recovery, you say’:

2018 Annual Meeting Survey Results

AAGL ERAS Taskforce

Rebecca Stone, MD - Johns Hopkins Amanda Nickles Fader, MD - Johns HopkinsErica Weston, MD - Johns Hopkins SOMStacey Scheib, MD - Tulane University Erin Carey, MD - University of North Carolina, Chapel HillAmy Park, MD - Georgetown UniversityJocelyn Fitzgerald, MD - Georgetown UniversityStephanie Ricci, MD - Cleveland ClinicRick Rosenfield, MD – Portland Oregon

What is ERAS?

● evidence-based, best practice guidelines applied across the perioperative continuum to mitigate the physiological stress response to surgery, decreasecomplications and accelerate recovery

● five canonical components:

Patient Education and Optimization

Multimodal, Opioid-sparing Analgesia

Nausea, Infection and VTE Prevention

Maintenance of Euvolemia

Activity

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Preoperative Optimization

● Cessation of smoking and alcohol consumption ≥ 4 weeks preoperativelyis associated with decreased morbidity and strongly recommended

● There is no evidence that delaying surgery to improve glycemic controlimproves outcomes

● Strong evidence supports correction of iron deficiency anemia preoperatively, this is recommended and can be achieved with PO or IV iron to a goal hemoglobin of

Preoperative Hydration & Carbohydrate Loading

Prevents dehydration

Reduces insulin resistance and catabolism

Preserves muscle function (mobility & respiratory effort)

Reduces need for IVF, decreasing complication rates

Improves patient well-being, decreases anxiety

Solid food up to 6h and clear liquids (50gm oralcarbohydrate load) up to 2h prior to induction of anesthesia

Preop Multimodal Opioid-Sparing Med Bundle:Recommendation

Evidence Level

Grade of Recommendation

Should be tailored to the patient and surgery performed andinclude non-opioid adjuncts such as NSAIDs, acetaminophen, anticonvulsants and steroids. Preoperative dosing of non-opioid adjuncts is synergistic and translates into opioid sparing effects postoperatively.

High Strong

Acetaminophen and NSAIDs should be administered in combination perioperatively, provided no contraindications. There is no evidence for IV acetaminophen administration. Celecoxib may be administered preoperatively. Ketorolac iseffective when administered in combination with local anesthetic port site infiltration. NSAIDs do not appear to significantly increase perioperative bleeding.

High Strong

Pregabalin dosed preoperatively has been associated with a reduction in postoperative pain and opioid use. Gabapentin has not shown similar reductions in MIH.

Moderate Moderate

Intraoperative use of -2 adrenergic agonists such as dexmedetomidine has no effect on postoperative pain/opioid use outcomes.

Low Weak

Dexamethasone has both antiemetic and analgesic properties and may be administered preoperatively.

Low Weak

Intraoperative AnalgesiaRecommendation:

Evidence 

Level

Grade of 

RecommendationPhenazopyridine is a relatively low risk, optional intervention. Low WeakKetamine can be considered for patients at high risk for post-operative pain (eg. chronic opioid users); routine use is not recommended

Low Weak

Treating physiologic signs of pain (i.e. tachycardia) with IV opioids intra-operatively should be avoided.

High Strong

Intraop lidocaine infusion should not be used routinely due to limited supporting evidence and concern for toxicity when combined with local anesthetic port-site infiltration. Lidocaine infusion may be considered as an adjunct intervention for patients at high risk for post-op pain (eg. chronic opioid users) as it may reduce pain scores in some.

Low Weak

Laparoscopic port-sites should be injected with short acting local anesthetic for post-operative pain prevention. The decision to inject before or after surgical incision should be based on clinical judgement as evidence is mixed regarding the optimal timing for local anesthetic injection. Liposomal bupivacaine should not be used for post-operative pain prevention in laparoscopic surgical patients due to the lack of evidence to suggest a benefit over short-acting bupivacaine and high cost.

High Strong

Transversus abdominus plane (TAP), paracervical and hypogastric plexus blocks should not be routinely used for post-operative pain management in MIGS due to the lack of evidence that these procedures have a sustained effect on post-operative pain, reduce post-operative opioid use, or are worth the additional cost, time and associated risks.

High Strong

Postoperative AnalgesiaRecommendation:

Evidence 

Level

Grade of 

RecommendationFor opioid naive patients, no more than 15 tablets of oxycodone 5 mg equivalents should be prescribed at discharge.

High Strong

Patients with high opioid intake (greater than 50 morphine milligram equivalents daily), a history of substance abuse, or current treatment with methadone, buprenorphine, or naltrexone, a preoperative referral to a pain medicine physician may be considered. Patients should be discharged on their preoperative regimen with supplemental opioids for postsurgical pain control. Opioid weans should be avoided perioperatively

Moderate Moderate

Consider a tiered approach to prescribing based on inpatient use. If the inpatient opioid pill use 24 hours prior to discharge is 0 pills, then prescribe 0-5 pills; 1-4 pills then 10-15 pills; 5 or more pills 25-30 pills.

Low Weak

MIGS Patient Population Preop Intraop Postop Extended Postop

MIGS for patients with a history of VTE or hereditary thrombophilia

- 5,000 units UFH SC given up to 2 hours (h) before induction of anesthesia

- SCDs - SCDs- Early ambulation- 5,000 units UFH SC q8h or 40 mg LMWH SC q24h beginning within 6 h of surgery

- Frequent ambulation- 40 mg LMWH SC q24h or prophylactic dose DOAC for 28 days

Benign MIGS and no history of VTE, hereditary thrombophilia and not on hormonal therapy

- SCDs - SCDs- Early ambulation

- Frequent ambulation

MIGS for cancer and (1) mCaprini score* of ≥ 7 or (2) mCaprini score* of 5-6 AND high grade histology, stage III/IV disease or lymphadenectomy (SLN bx excluded)

- 5,000 units UFH SC given up to 2 h before induction of anesthesia

- SCDs - SCDs- Early ambulation- 5,000 units UFH SC q8h or 40 mg LMWH SC q24h beginning within 6 h of surgery

- Frequent ambulation- 40 mg LMWH SC q24h or prophylactic dose DOAC for 28 days

MIGS for cancer not meeting criteria (1) or (2) above ORBenign MIGS for patients on hormonal therapy

- 5,000 units UFH SC given up to 2 h before induction of anesthesia

- SCDs - SCDs- Early ambulation- 5,000 units UFH SC q8h or 40 mg LMWH SC q24h beginning within 6 h of surgery

- Frequent ambulation

*modified Caprini score using a BMI of ≥ 40 kg/m2 instead of 25 kg/m2 and surgical time of 180 minutes instead of 45 minutes. SLN = Sentinel Lymph Node. UFH = unfractionated heparin. SC = subcutaneous. SCDs = Sequential Compression Devices. LMWH = low molecular weight heparin. DOAC = direct oral anticoagulant (eg. Apixaban 2.5mg orally twice daily)

VTE Prophylaxis Recommendations for MIGS

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Thromboprophylaxis – Additional ConsiderationsRelevant to MIGS

● Estimated uterine size/weight ≥ 1000 grams● Coincident iron deficiency anemia and/or thrombocytosis● Lower extremity swelling● Hydroureter on imaging

Leiomyomata Candidates for Preop VTE Screening

Hormonal Contraceptives and Replacement Therapy

● Continuation of hormonal contraceptives ● Initiation of hormone replacement therapy on POD1 for premenopausal women

who have undergone minimally invasive BSO in the form of transdermal patch

Poor social network lacking at least one family member or friend reachable by phone and who can provide care in the first 24h after dischargeHistory of anesthesia complicationsAmerican Society of Anesthesiologists (ASA) score of ≥ 3Age ≥ 80 yearsImpaired cognitionImpaired mobility (eg. ECOG ≥ 2)On therapeutic anticoagulation at baselineDistance from hospital > 60 milesSleep apnea Poorly controlled asthma or COPDHistory of arrhythmia, CHF, pacemaker/AICD or HTN requiring > 3 medsType 1 Diabetic or a poorly controlled type 2 diabetic (blood glucose >180 preoperatively)Significant underlying kidney disease (GFR < 30)/DialysisCirrhosis or daily alcohol consumption > 2 drinks

Criteria for Overnight Admission

Case end before 1800 Expected EBL; no intraoperative complicationAdequate pain control with oral medications (Pain Intensity VAS ≤ 4/10)Minimal nausea and absence of vomitingO2 saturation >92%Alert, awake and appropriately conversantAfebrileBlood pressure, heart rate and respiratory rate within normal or baseline rangeAble to ambulate independentlyAble to void volitionally or foley catheter plan in place

Postoperative Criteria for Same Day Discharge Same Day Discharge Metrics

● PACU time 4 to 6 hours or less

● Median re-admission and re-evaluation rates of ≤ 1% and ≤ 7%

● Goal SDD rate for benign MIGSYear 1 = 80%Beyond year 1 = ≥ 90%

● Goal SDD rate for malignant MIGSYear 1 = 50%Beyond year 1 = ≥ 80%

POSTOP

-F/U by nurse-led phone calls POD1; verbal notification of surgeon if concern arises-Surgeon F/U at ~2w

PREOP

-Eligibility screening-Education & counseling setting clear expectations-HRT and urinary catheter planning-Indication for preop VTE screening and extended VTE prophylaxis-Discharge rx including prn anti-emetic & instructions for managing constipation-Secure first/early start-Call patients T(-)1 day preop to review instructions

PACU

-SDD expectationcommunicated to nursing in patient sign-out-Active voiding trial-Offer patient coffee/tea and chewing gum-Criteria based clearancefor DC home by anesthesiologist/surgeon

INTRAOP

-Preop medications-SCDs-TIVA-Port site infiltration with local anesthetic-Toradol and anti-emetic at skin closure-Foley removed in OR and bladder back-filled with 200cc sterile saline

MIGS Same Day Discharge Phases of Care References

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Thank You!

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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