Table 1.

Detailed Laryngectomy Pathway Orders

Intervention Type	Postoperative Day 0	Postoperative Day 1	Postoperative Day 2	Postoperative Day 3	Postoperative Day 4	Postoperative Day 5	Postoperative Day 6	Postoperative Day 7
Outcomes	Mechanical vent weaned in OR	Out of bed to chair once	Out of bed 3 × Lary tube worn at all times (if applicable)	Out of bed 3 × HME and lary tube worn at all times	Out of bed 3 × Ambulate 3 × HME and lary tube worn at all times	Ambulate 3 × HME and lary tube worn at all times Discharge planning	Ambulate 3 × HME removal and replacement Stoma suctioning Stoma care	Caregiver in room with patient overnight and provides care Patient and family demonstrate that patient can safely go home Patient and family verbalize understanding of discharge/medication instructions
Diagnostics	Chest and abdominal x-rays CBC CMP PTH Prealbumin Ionized calcium	Chest x-ray CBC CMP PTH Ionized calcium				CBC
Treatments	SLP evaluation and treatment PT/OT evaluation and treatment No ties around neck (if flap) Keep head in neutral position (if flap) Flap checks every hour Tracheostomy tube in stoma Stoma care by RT Strip bulb suction and record Neurovascular checks on donor site	Humidified air via tracheostomy collar Clean incisions with saline and apply bacitracin Inpatient consult to hematology/oncology psychology Continue impaired communication protocol	Place HME and change daily Flap checks every 2 hours All medications per tube Discontinue arterial line	Place HME and change daily All medications per PEG tube		OK for ties No ties around neck sign may be taken down Flap checks every 4 hours Neurovascular checks on donor site every shift Tegaderm off STSG donor site		Start rooming in Staples/sutures removed prior to discharge if patient not previously radiated
	Supplies needed at bedside: suction, Ambu bag, duplicate trach obturator, gauze, suture removal kit RT evaluation Answer all call lights in person Communication board in patient room Sign above bed No neck ties Patient is a neck breather; no oral intubation Start impaired communication protocol No pressors unless cleared by surgeon PEG to gravity
Medications	Duo nebs q4h Morphine or Dilaudid PRN Unasyn or clindamycin and ciprofloxacin Famotidine Synthroid Ondansetron Metoclopramide PRN Promethazine PRN IVF infusion	Bacitracin ointment PCA if needed Melatonin or zolpidem		Hycet via tube	Stop antibiotics
Activity	Bed rest Head of bed elevated	Progressive mobility protocol
Diet/Nutrition	Diet NPO	Inpatient consult to dietitian/nutritionist Daily recorded weight	Start continuous TF at 10 mL/h for 24 hours Decrease IVF to keep constant total intake	Increase TF to target
Prophylaxis	TED hose SCD Heparin or Lovenox
Education			Laryngectomy training	Stoma care HME PEG care Wound care	Continue stoma, HME, PEG, and wound care	Twice daily: placing and removing HME, stoma suctioning, stoma care

CBC, complete blood count; CMP, comprehensive metabolic panel; duo nebs q4h, nebulized ipratropium bromide and albuterol sulfate every 4 hours; HME, heat moisture exchange; IVF, intravenous fluid; lary tube, laryngectomy tube; NPO, nothing by mouth; OR, operating room; PCA, patient-controlled anesthesia; PEG, percutaneous gastrostomy tube; PRN, as needed; PT/OT, physical therapy/occupational therapy; PTH, parathyroid hormone level; RT, respiratory therapist; SCD, sequential compression device; SLP, speech and language pathology; STSG, split thickness skin graft; TED, thromboembolic deterrent; TF, tube feeding.