Table 1

Protocol characteristics of the followed enhanced recovery program

Time

Procedure


Preoperative

a. Provision of verbal and written information to patients regarding the ERAS. Collection of signed consent.

b. Malnourished patients to receive hyperproteic supplement at least twice per day during the week before surgery.


Day before surgery

a. No colon preparation.

b. Normal food in the morning. Liquids on demand during the evening. Four bricks of carbohydrate-rich Nutricia Preop® to be taken during the evening (total: 800 ml).

c. Prophylaxis for pulmonary thromboembolism following normal practice.

d. Antibiotic prophylaxis following normal practice.


Day of surgery (before surgery)

a. Two hours before surgery: provision of two bricks of Nutricia Preop® (total: 400 ml).

b. Antibiotic prophylaxis.


Operating room

A. Surgeons: no drainage; nasogastric tube, if needed, to be removed before extubation; if possible use transverse or curved incisions in open surgery.

B Anaesthetists:

-Maintenance: Oxygen/air with FiO2 >80%.

-Monitoring: routine. Only use arterial/central catheter if unavoidable.

-Fluids: maintenance with Hartmann (5 cc/kg/h). Bolus of gelofusine (250 cc).

Maintain Hb > 8.0 g/dl.

- Optimise stroke volume via oesophageal Doppler:

-250 cc of fluid in bolus; if SV > 10% repeat until this figure is not reached. Provide no further bolus unless SV falls or there is blood loss.

-If hypotension remains after SV correction, use a vasoconstrictor.

-Consider use of inotropic agents if peak velocity descends and clinical signs suggest ventricular function deficit.

-Temperature: use liquid heater and heating blanket.


Day of surgery (recovery room)

-Mask with high oxygen flow for 2 h independent of saturation. Follow with nasal cannulae to maintain SpO2 > 95%.

-Maintain mean blood pressure >65 mmHg. If blood pressure low provide 250 cc gelofusine and reassess.


Day of surgery (ward)

-In the evening sit patient in seat for at least 2 h.

-Liquid diet (800-1000 ml). Include two bricks of high protein/high calorie hospital dietary preparation (specific for postoperative period).

-Minimum diuresis (500 cc in first 24 h).

-Analgesia: 1 g paracetamol/6 h.


Postoperative day 1

-Liquid diet, at least 2 l, including 3 bricks of high protein/high calorie hospital dietary preparation.

-Mobilisation; patient seated at least 6 h per day.

-Suspend IV fluid if tolerated. Heparin injection for maintaining patency of intermittent infusion devices.

-Maintain epidural analgesia pump if one in place.

-Paracetamol 1 g/6 h.

-Lactulose 1 sachet/12 h (preferably magnesium-based).

-Assess meeting of discharge criteria: only oral analgesia, mobilisation reaching presurgical level, toleration of solid food, gases passed, stools passed, no nausea, and patient agrees to discharge.


Postoperative day 2

-Suspend epidural catheter; begin with NSAIDS; diet soft/normal; mobilisation on demand; remove urinary catheter and assess meeting of discharge criteria.


Postoperative day 3

-Check general status; assess meeting of discharge criteria and take decision in this respect.


Follow up

-Telephone monitoring for 48 h.

-First out-patient visit 10-14 days after surgery.


SV: stroke volume; IV: intravenous; Hb: haemoglobin.

Ramírez et al. BMC Surgery 2011 11:9   doi:10.1186/1471-2482-11-9

Open Data