1. Preoperative Recommendations
- Preoperative recommendations
- Patients and their families should receive education about the surgery and expected recovery prior to their operation (Level of evidence: Low)
- 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
- 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
- Patients should be allowed to eat solid foods until midnight the night before surgery (Level of evidence: Low)
- 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)
- Infants can consume breast milk up to 4 hours prior to anesthesia administration (Level of evidence: Low)
- Patients and their families should receive education about the surgery and expected recovery prior to their operation (Level of evidence: Low)
2. Intraoperative Recommendations
- Intraoperative recommendations
- Perioperative pain control should be multimodal (Level of evidence: Moderate)
- 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
- Analgesia should be customized to enable the earliest possible transition to oral medications including early removal of patient controlled analgesia (PCA) if used
- Prophylactic use of nasogastric tubes for decompression should be avoided. (Level of evidence: High)
- NG tubes may be used in patients having gastric or pancreatic surgery as per the surgeon’s clinical judgement
- See guideline recommendations for surgical site infection prevention
- Perioperative pain control should be multimodal (Level of evidence: Moderate)
3. Postoperative Recommendations
- Postoperative recommendations
- 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)
- Patients should be encouraged to dangle on the side of their bed, walk, or sit in a chair on postoperative day (POD) 0
- Patients should be encouraged to walk at least twice on POD1 and everyday until discharge
- Patients should be encouraged to sit up in a chair while awake during the day
- Patients should resume eating and drinking as soon as possible after surgery (Level of evidence: Moderate)
- Patients should be offered clear fluids 2 hours postoperatively provided they are awake, alert and capable of swallowing
- Patients should be offered solid food beginning POD1
- Patients who undergo abdominal surgery should be encouraged to chew gum 3x/day for 5 minutes until they are tolerating solid food
- 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
- If used, the Foley catheter should be removed within 24 hours except if the patient underwent rectal or urologic surgery
- For patients who undergo rectal surgery the catheter should be removed at or before 48 hours
- 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
- 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)