Enhanced Recovery After Surgery

1. Preoperative Recommendations
  1. Preoperative recommendations
    1. Patients and their families should receive education about the surgery and expected recovery prior to their operation (Level of evidence: Low)
      1. Patients and their families should receive information on: expected length of stay assuming there are no complications; length of preoperative fasting; pain control; early ambulation and feeding; and smoking cessation prior to surgery
      2. Patients should be assessed for history of gastroesophageal reflux disease, dysphagia symptoms, or other gastrointestinal motility disorders preoperatively. If present, patients may require individual recommendations for perioperative fasting
    2. Patients should be allowed to eat solid foods until midnight the night before surgery (Level of evidence: Low)
    3. Patients should be encouraged to drink clear fluids up to 2 hours before anesthesia administration. Clear fluids include coffee and tea (without milk), and drinks that are high in carbohydrates (i.e. apple juice and pulp-free orange juice) (Level of evidence: High)
    4. Infants can consume breast milk up to 4 hours prior to anesthesia administration (Level of evidence: Low)
2. Intraoperative Recommendations
  1. Intraoperative recommendations
    1. Perioperative pain control should be multimodal (Level of evidence: Moderate)
      1. Multimodal opioid-sparing analgesia should be considered for all patients. This should include considering acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, ketamine, lidocaine, epidurals and regional anesthesia
      2. Analgesia should be customized to enable the earliest possible transition to oral medications including early removal of patient controlled analgesia (PCA) if used
    2. Prophylactic use of nasogastric tubes for decompression should be avoided. (Level of evidence: High)
    3. See guideline recommendations for surgical site infection prevention
3. Postoperative Recommendations
  1. Postoperative recommendations
    1. Patients should be encouraged to participate in early mobilization once extubated with the exception of patients having spine surgery who should be assessed individually (Level of evidence: Moderate)
      1. Patients should be encouraged to dangle on the side of their bed, walk, or sit in a chair on postoperative day (POD) 0
      2. Patients should be encouraged to walk at least twice on POD1 and everyday until discharge
      3. Patients should be encouraged to sit up in a chair while awake during the day
    2. Patients should resume eating and drinking as soon as possible after surgery (Level of evidence: Moderate)
      1. Patients should be offered clear fluids 2 hours postoperatively provided they are awake, alert and capable of swallowing
      2. Patients should be offered solid food beginning POD1
      3. Patients who undergo abdominal surgery should be encouraged to chew gum 3x/day for 5 minutes until they are tolerating solid food
    3. The routine use of Foley catheters should be avoided with the exception of patients undergoing urologic or pelvic surgery; there is an anticipated prolonged duration of surgery; patient is anticipated to receive large volume infusions of fluid or diuretics; or the patient requires monitoring
      1. If used, the Foley catheter should be removed within 24 hours except if the patient underwent rectal or urologic surgery
      2. For patients who undergo rectal surgery the catheter should be removed at or before 48 hours
      3. For patients who undergo urologic surgery the catheter should be removed at the discretion of the treating urologist based on the nature of the surgery