Enhanced Recovery Protocols & Optimization of Perioperative Outcomes

 A well-functioning enhanced recovery program (ERP) uses evidence based practices that ensure
continuity of care, decrease variation in clinical management, minimize organ dysfunction, decrease
postoperative complications, and accelerate convalescence.
 The perioperative surgical home (PSH) is defined by interdisciplinary, team-based global
management of the surgical patient throughout the surgical care continuum. PSH management begins
following the initial surgical diagnosis and patient preparation, and ends when the patient is returned
to the care of his or her primary health care provider after full recovery. It includes several
perioperative enhanced recovery program (ERP) elements that are adapted to the local clinical care
environment.
 Persistent postsurgical pain (chronic pain that continues beyond the typical healing period of 1 to 2
months following surgery, or well past the normal period for postoperative follow-up) is increasingly
acknowledged as a common and significant problem following surgery.
 The magnitude of the surgical stress response is related to the intensity of the surgical stimulus,
hypothermia, and psychological stress. It can be moderated by perioperative interventions, including
neural blockade and reduction in procedural invasiveness.
 Neuraxial blockade of nociceptive stimuli by epidural and spinal local anesthetics has been shown to
blunt the metabolic, inflammatory, and neuroendocrine stress response to surgery. In major open
abdominal and thoracic procedures, thoracic epidural blockade with local anesthetic provides
excellent analgesia, facilitates mobilization, and decreases the incidence and severity of ileus.
 Epidural blockade using a solution of local anesthetic and low-dose opioid provides better
postoperative analgesia at rest and with movement than systemic opioids. By sparing opioid use and
minimizing the incidence of systemic opioid-related side effects, epidural analgesia facilitates both
earlier mobilization and earlier resumption of oral nutrition, expediting exercise activity and
attenuating loss of body mass.
 Peripheral nerve blocks (PNBs) with local anesthetics (single-shot or continuous infusion) block
afferent nociceptive pathways and are an excellent way to minimize the need for systemic opioids and
thereby reduce the incidence of opioid-related side effects.
 Lidocaine (intravenous bolus of 100 mg or 1.5–2 mg/kg, followed by continuous intravenous infusion
of 1.5–3 mg/kg/h or 2–3 mg/min) has analgesic, antihyperalgesic, and antiinflammatory properties.
 Multimodal analgesia combines different classes of medications that have different (multimodal)
pharmacological mechanisms of action, resulting in additive or synergistic effects to reduce
postoperative pain and its sequelae.
 The addition of nonsteroidal antiinflammatory drugs (NSAIDs) to systemic opioid analgesia
diminishes postoperative pain intensity, reduces opioid requirements, and decreases opioid-related
side effects such as postoperative nausea and vomiting (PONV), sedation, and urinary retention.
However, NSAIDs may increase the risk of gastrointestinal and wound bleeding, decrease kidney
function, and impair wound healing.
 Opioid administration by patient-controlled analgesia provides better pain control, greater patient
satisfaction, and fewer opioid side effects when compared to nurse-administered on-request (PRN)
parenteral opioid administration.
 Single-shot and continuous peripheral nerve blockade is frequently utilized for fast-track ambulatory
and inpatient orthopedic surgery, and can accelerate recovery from surgery and improve analgesia
and patient satisfaction.
 Postoperative ileus delays postoperative resumption of enteral feeding, is often a source of
considerable patient discomfort, and is one of the most common causes of prolonged postoperative
hospital length of stay and preventable hospitalization costs. Nasogastric tubes should be discouraged
whenever possible or used for only a very short period of time, even with gastrointestinal surgery.
The opioid-sparing effects of multimodal analgesia shorten the duration of postoperative ileus or may
preempt it entirely.
 Because either excessive, or excessively restricted, perioperative fluid therapy increases the incidence
and severity of postoperative ileus, a goal-directed fluid administration strategy may be beneficial,
especially in patients undergoing major surgery associated with large fluid shifts or patients at high
risk of developing postoperative gastrointestinal complications.

Evolution of Enhanced Recovery Programs

Major advances in surgical and anesthetic management have progressively decreased risk-
adjusted perioperative mortality and morbidity. Continued improvement in perioperative outcomes,
including accelerated postoperative convalescence and decreased perioperative complications, depends
upon the continued evolution of integrated, multidisciplinary team approaches to perioperative care. The
goal of team-based care is to combine individual evidence-based elements of perioperative care (eg,
analgesic regimens, nutritional interventions, and physical therapy), each of which may have modest
benefits when used in isolation into a tightly coordinated effort that has significant synergistic, beneficial
effects upon surgical outcomes (the theory of aggregation of marginal gains).
Such coordinated, multidisciplinary perioperative care programs are termed enhanced recovery
programs (ERPs), fast-track surgery, or enhanced recovery after surgery (ERAS) (Figure 48–1). A well-
functioning ERP uses evidence-based practices that ensure continuity of care, decrease variation in
clinical management, minimize organ dysfunction, decrease postoperative complications, and accelerate
convalescence (Figure 48–2). The success of ERPs relies upon the additive or synergistic effects of the
interventions included in these programs. Adherence to ERP pathways is associated with better
postoperative outcomes, accelerated convalescence, and lower costs.

FIGURE 48–1 Perioperative elements contributing to enhanced recovery after surgery (ERAS). CHO,
carbohydrate; DVT, deep vein thrombosis; PONV, postoperative nausea and vomiting.
FIGURE 48–2 Multimodal interventions to attenuate the surgical stress response.

Assessing outcomes following ERP adoption is critical. Hospital length of stay is a commonly
used measure of success, although in many health care systems the timing of hospital discharge is more
directly related to administrative and organizational issues than to discrete surgical and medical
milestones in the patient’s postoperative recovery. Little research has been undertaken to define the
process of postoperative recovery, and few outcome measures are currently available to confirm that
postoperative recovery has been
accomplished for a given surgical disease. Other measures of successful implementation of ERPs include
reduced rates of hospital readmission and reduced rates and severity of perioperative complications.
Promising data suggest that ERPs may improve oncologic outcomes after surgery.
Anesthetic interventions that reduce pain, facilitate earlier postoperative mobilization, and allow
earlier resumption of oral feeding accelerate the pace of perioperative recovery. In this context, the
anesthesia provider must not only provide ideal anesthetic management throughout the procedure, but
must also help improve overall perioperative care. These goals are achieved through optimizing the
patient’s preoperative medical condition, avoiding prolonged fasting, moderating the adverse effects of
the intraoperative neuroendocrine stress response, and providing multimodal pain and symptom
management to accelerate postoperative recovery.
Initially developed for patients undergoing colorectal and cardiac surgery, ERPs have also been
developed for patients undergoing esophageal, bariatric, pancreatic, liver, head and neck, breast,
orthopedic, bariatric, and pediatric abdominal surgery. Many ERP guidelines and consensus statements
are available from the various specialty societies.
The perioperative surgical home (PSH) has been defined as a “patient centered, innovative model
of delivering health care during the entire patient surgical/procedural experience; from the time of the
decision for surgery until the patient has recovered and returned to the care of his or her patient centered
medical home or primary health care provider.” The PSH “provides coordination of care throughout all of
the clinical microsystems of care.” PSH programs can be considered an evolution of ERPs, because they
include several perioperative ERP elements but are adapted to the local clinical environment. Based on
their unique clinical skills, anesthesiologists are called to play a pivotal, coordinating care role in the
PSH. To accomplish this, anesthesia providers must integrate with the surgical and medical teams with
whom they jointly provide perioperative care. Accordingly, anesthesiology training programs must
expand their curricula to include the entire continuum of perioperative care.
 Persistent postsurgical pain (chronic pain that continues beyond the typical healing period of 1–2
months following surgery) is increasingly acknowledged as a common and significant issue following
surgery. The incidence of persistent postsurgical pain may exceed 30% after some operations, especially
amputations, thoracotomy, mastectomy, and inguinal herniorrhaphy. Although the cause is unclear,
several risk factors have been identified (Figure 48–3). Multimodal perioperative pain control is often
suggested as a fundamental preemptive strategy to reduce the incidence of persistent postsurgical pain
(see Chapter 47).

FIGURE 48–3 Risk factors for persistent postsurgical pain.

Anesthetic Management–Related Factors Contributing to Enhanced Recovery

PREOPERATIVE PERIOD
Patient Education
Cooperation from the patient and family is essential if an ERP is to be effectively implemented.
Preoperative teaching must use plain language and avoid medical jargon. Well-designed print, video, and
online materials presented in the patient’s native language are useful to introduce ERPs. Smartphone text
messaging and patient navigation apps are increasingly utilized to help organize and coordinate the
patient’s perioperative care continuum.
Preoperative Risk Assessment & Optimization of Functional Status
Reducing the likelihood of perioperative complications improves surgical recovery. Preoperative
assessment is discussed in detail in Chapter 18. Although international guidelines evaluating the risk for
developing cardiovascular, respiratory, or metabolic complications have been extensively reviewed and
published, less attention has been given to assessment and optimization of preoperative functional and
physiological status. Nonetheless, some recommendations can be made. For example, perioperative β-
blockers should be continued in patients already receiving this therapy. Perioperative statins appear to
decrease postoperative cardiovascular complications and should not be abruptly discontinued
perioperatively. Several procedure-specific scoring systems based on patient comorbidity, type of
surgery, and biochemical data are being used to predict postoperative mortality and morbidity. In
addition, risk adjusted
scoring systems, such as the American College of Surgeons’ National Surgical Quality Improvement
Program (NSQIP) and the Society of Thoracic Surgeons’ National Database, can be used to compare
outcomes among institutions.

Smoking & Alcohol Cessation

Preoperative evaluation of surgical risk and optimization of medical comorbidities also provides
opportunity to modify habits that may significantly impact the patient’s short-term and long-term health
and quality of life.
Smoking, drug abuse, and excessive alcohol use are risk factors for the development of
postoperative complications. Perioperative interventions aimed at risk modification can reduce risks of
complications, accelerate surgical recovery, and reduce perioperative costs. A recent meta-analysis found
that preoperative smoking cessation, for any type of surgery, reduced postoperative complications by
41%, especially those related to wound healing and the lungs.
Intense preoperative smoking cessation programs of 3 to 4 weeks’ duration that include
pharmacological interventions (eg, nicotine replacement therapy) and patient counseling produce better
results than brief and isolated preoperative smoking cessation interventions. Many psychological and
pharmacological strategies are also available to help patients stop excessive alcohol consumption
and reduce the risk of alcohol withdrawal.

Guidelines for Food & Fluid Intake Preoperative fasting and surgical stress induce insulin resistance.
Furthermore, patients who are not allowed to drink fluids after an overnight fast and those who receive a
mechanical bowel preparation experience dehydration, which may increase discomfort and cause
drowsiness and orthostatic lightheadedness. Although fasting has been advocated as a preoperative
strategy to minimize the risk of pulmonary aspiration during induction of anesthesia, this benefit must be
weighed against the detrimental aspects of this practice.
Research suggests that avoiding preoperative fasting and ensuring adequate hydration and energy
supply may moderate postoperative insulin resistance. Preliminary evidence has shown that preoperative
administration of carbohydrate (CHO) drinks (eg, 50 g of maltodextrin 2–3 h before induction of
anesthesia) is safe and reduces insulin resistance, hunger, fatigue, and postoperative nausea and vomiting
(PONV). Moreover, CHO drinks positively influence recovery of bowel and immune function. However,
these results have been achieved mainly with maltodextrin CHO drinks, and the metabolic and clinical
impacts of simple sugar CHO drinks are unknown. It is important to educate patients to drink
preoperative CHO over a short time, as sipping these beverages over hours does not induce a sufficient
insulin response to reduce insulin resistance.
Contemporary international fasting guidelines allow clear fluids up to 2 h prior to induction of
anesthesia in patients at low risk for pulmonary aspiration (see Chapter 18). The safety of allowing clear
fluids, CHO drinks, or both, 2 h before induction of anesthesia has been demonstrated by magnetic
resonance imaging studies in healthy volunteers. Residual gastric volume 2 h after 400 mL of oral
carbohydrate (12.5% maltodextrins) was found to be similar to the residual gastric volume following an
overnight fast (mean volume 21 mL). The safety of this practice has been tested in patients with
uncomplicated type 2 diabetes mellitus, none of whom showed evidence of worsened risk of aspiration.
Despite several clinical trials demonstrating that prolonged fasting impairs postoperative recovery,
compliance with evidence-based fasting guidelines remains low, as physicians continue to order nil per
os (NPO) after midnight.

INTRAOPERATIVE PERIOD
Antithrombotic Prophylaxis
Antithrombotic prophylaxis reduces perioperative venous thromboembolism risk and related morbidity
and mortality. Both pneumatic compression devices and anticoagulant medications are now commonly
used. Because neuraxial anesthesia techniques are commonly employed for many patients undergoing
major abdominal, vascular, thoracic, and orthopedic procedures, appropriate timing and administration of
antithrombotic agents in these cases is of critical importance in order to avoid the risk of epidural
hematoma. International recommendations on the management of anticoagulated patients receiving
regional anesthesia are discussed in Chapter 45.

Antibiotic Prophylaxis
Appropriate selection and timing of preoperative antibiotic prophylaxis reduces the risk of surgical site
infections. Antibiotics should be administered intravenously within 1 h before skin incision and, based on
their plasma half-life and estimated blood loss, should be repeated during lengthy surgeries to ensure
adequate tissue concentrations. Recent data from large national databases have demonstrated that
administration of oral antibiotics 24 h prior to colorectal surgery in patients receiving mechanical bowel
preparation (MBP) reduces the risk of surgical site infections, when compared with patients receiving
MBP alone or those not receiving MBP. Antibiotic prophylaxis for surgical site infections should be
discontinued within 24 h following surgery, although current guidelines permit cardiothoracic patients to
receive antibiotics for 48 h following surgery.

Strategies to Minimize the Surgical Stress Response

The surgical stress response is characterized by neuroendocrine, metabolic, inflammatory, and
immunological changes initiated by the physiological trespass of the surgical incision and subsequent
invasive procedures. The stress response can adversely affect organ function and perioperative outcomes,
and may include induction of a catabolic state as well as a transient, but reversible, state of insulin
resistance, characterized by decreased peripheral glucose uptake and increased endogenous glucose
production. The magnitude of the surgical stress response is related to the intensity of the surgical
stimulus, hypothermia, and psychological stress. It can be moderated by perioperative interventions,
including neural blockade and reduction in procedural invasiveness. Much recent effort has focused on
developing surgical and anesthetic techniques that reduce the surgical stress response, with the goal of
lowering the risk of stress-related organ dysfunction and perioperative complications. An overview of
several techniques that have proved effective in ERP protocols follows.
A. Minimally Invasive Surgery
It is well established that minimally invasive surgical procedures are associated with significantly less
surgical stress when compared with corresponding “open” procedures. Published data highlight the safety
of minimally invasive procedures in the hands of adequately trained and experienced surgeons. Moreover,
a longer term salutary impact is achieved when laparoscopic techniques are included in ERPs. For
example, laparoscopic procedures are associated with a reduced incidence of surgical complications,
especially surgical site infections, when compared with the same procedures performed in “open” fashion.
A laparoscopic approach is also associated with less postoperative surgical pain, better postoperative
respiratory function, and less morbidity in elderly surgical patients. Over the past 15 years, further
advancements in surgical care, such as robotic surgery, natural orifice specimen extraction during
laparoscopic surgery, endoscopic surgical approaches, and minimally invasive orthopedic surgery,
have further moderated the impact of surgery on surgical stress, and such progress is expected to
continue.

B. Regional Anesthesia/Analgesia Techniques

A variety of fast-track surgical procedures have taken advantage of the beneficial clinical and metabolic
effects of regional anesthesia/analgesia techniques (Table 48–1). Neuraxial blockade of nociceptive
stimuli by epidural and spinal local anesthetics has been shown to blunt the metabolic, inflammatory, and
neuroendocrine stress responses to surgery. In major open abdominal and thoracic procedures, thoracic
epidural blockade with local anesthetic is a recommended anesthetic component of a postoperative ERP,
providing excellent analgesia, facilitating mobilization and physical therapy, and decreasing the incidence
and severity of ileus. However, the advantages of epidural blockade in such cases are not as evident when
minimally invasive surgical techniques are used, and in certain cases, epidural blockade has even been
shown to delay recovery and prolong hospital stay. Lumbar epidural anesthesia/analgesia should be
discouraged for abdominal surgery because it often does not provide adequate segmental analgesia for an
abdominal incision. In addition, it frequently causes urinary retention and lower limb sensory and motor
blockade, increasing the need for urinary drainage catheters (with accompanying increased risk of urinary
tract infection), delaying mobilization and recovery, and increasing the risk of falls.
TABLE 48–1 Enhanced recovery programs that incorporate regional anesthesia/analgesia
techniques.

Epidural blockade using a solution of local anesthetic and low-dose opioid provides better
postoperative analgesia at rest and with movement than systemic opioids (Figure 48–4 and Table 48–2).
By sparing opioid use and minimizing the incidence of systemic opioid-related side effects, epidural
analgesia facilitates both earlier mobilization and earlier resumption of oral nutrition,expediting exercise
activity and attenuating loss of body mass. It minimizes postoperative insulin resistance by attenuating the
postoperative hyperglycemic response and by facilitating utilization of exogenous glucose, thereby
preventing postoperative loss of amino acids and conserving lean body mass.

FIGURE 48–4 Optimal regions for placing an epidural catheter in the adult spine when administering
epidural anesthesia/analgesia for thoracic and abdominal procedures.
TABLE 48–2 Options for composition of thoracic epidural infusion analgesia solutions.

If spinal anesthesia is used for fast-track (and especially ambulatory) surgery, attention must be
paid to delayed recovery due to prolonged motor blockade. The use of smaller doses of intrathecal local
anesthetics (lidocaine, 30–40 mg; bupivacaine, 3–10 mg; or ropivacaine, 5–10 mg) with lipophilic
intrathecal opioids (fentanyl, 10–25 mcg, or sufentanil, 5–10 mcg) can prolong postoperative analgesia
and minimize motor block without delaying recovery from anesthesia. The introduction of ultra-short-
acting intrathecal agents such as 2-chloroprocaine (still controversial at present) may further speed the
fast-track process. Spinal opioids are associated with side effects such as nausea, pruritus, and
postoperative urinary retention. Adjuvants such as clonidine are effective alternatives to intrathecal
opioids, with the goal of avoiding opioid side effects that may delay hospital discharge. For example,
intrathecal clonidine added to spinal local anesthetic provides effective analgesia with less urinary
retention than intrathecal morphine. In a recent study, lower cortisol and glucose levels were observed in
colorectal patients receiving spinal anesthesia with intrathecal local anesthetic and morphine compared
with patients receiving systemic opioids; however, the inflammatory response did not differ between the
two analgesic techniques. Further studies are needed to define the safety and efficacy of regional
anesthesia techniques in fast-track cardiac surgery. Although some cardiac surgery studies have shown
that spinal analgesia with intrathecal morphine decreases extubation time, decreases length of stay in the
intensive care unit (ICU), reduces pulmonary complications and arrhythmias, and provides analgesia with
less respiratory depression, other studies have shown no benefit to this approach. continuous infusion)
block afferent nociceptive pathways and are an excellent way to minimize the need for systemic opioids
and thereby reduce the incidence of opioid-related side effects and facilitate recovery (see Chapter 46).
The choice of local anesthetic, dosage, and concentration should be made with the goal of avoiding
prolonged motor blockade and delayed mobilization and discharge.

C. Intravenous Lidocaine Infusion

Lidocaine (intravenous bolus of 100 mg or 1.5–2 mg/kg, followed by continuous intravenous infusion of
1.5–3 mg/kg/h or 2–3 mg/min) has analgesic, antihyperalgesic, and antiinflammatory properties. In
patients undergoing colorectal and radical retropubic prostate surgeries, intravenous lidocaine has been
shown to reduce requirements for opioids and general anesthetic agents, provide satisfactory analgesia,
facilitate early return of bowel function, and accelerate hospital discharge. Although lidocaine infusion
potentially may replace neuraxial blockade and regional anesthesia in some circumstances, more studies
are needed to confirm the advantage of this technique in the context of ERPs. The most effective dose and
duration of infusion for various surgical procedures remains to be determined; even short duration of
lidocaine infusion may have benefit.
D. β-Blockade Therapy
β-Blockers have been used to blunt the sympathetic response during laryngoscopy and intubation and to
attenuate the surgical stress-induced increase in circulating catecholamines. They also have been shown
to prevent perioperative cardiovascular events in at-risk patients undergoing non cardiac surgery and to
help maintain hemodynamic stability during the intraoperative period and during emergence from
anesthesia. They possess anti catabolic properties, which may be explained by reduced energy
requirements associated with decreased adrenergic stimulation. Intravenous esmolol reduces the
requirement of volatile anesthetic agents and decreases minimum alveolar concentration values; it has
also been shown to reduce postoperative pain intensity, opioid consumption, and PONV. A positive
protein balance has been reported in critically ill patients when β-blockade is combined with parenteral
nutrition. However, the precise role of β-blockers as adjuvant analgesics in the context of ERPs remains
undetermined.

E. Intravenous α2-Agonist Therapy

Both clonidine and dexmedetomidine have anesthetic and analgesic properties. Clonidine decreases
postoperative pain, reduces opioid consumption and opioidrelated side effects, and prolongs neuraxial and
peripheral nerve local anesthetic blockade. In patients undergoing cardiovascular fast-track surgery,
spinal morphine with clonidine decreases extubation time, provides effective analgesia, and improves
quality of recovery. The role of dexmedetomidine in ERP pathways has not been extensively studied.

Use of Short-Acting Intravenous & Inhalation Agents

A. Intravenous Anesthetics
Intravenous propofol is the deep sedation and general anesthesia induction agent of choice for most
surgical procedures. Propofol total intravenous anesthesia (TIVA) is often used as part of a multimodal
regimen for patients at high risk for PONV.

B. Inhalational Anesthetics
When compared with other volatile anesthetic agents, desflurane and sevoflurane may shorten anesthesia
emergence, reduce postanesthesia care unit (PACU) length of stay, and decrease recovery-associated
costs. There is evidence that avoidance of deep general anesthesia by use of bispectral index (BIS)
monitoring may improve outcomes, including a reduction of the incidence of postoperative delirium and
cognitive dysfunction. Nitrous oxide, because of its anesthetic- and analgesic-sparing effects, rapid
pharmacokinetic profile, and low cost, is sometimes administered with other inhalation agents. However,
routine administration of nitrous oxide has declined recently, as it may cause bowel distention and impair
the laparoscopic surgeon’s view of anatomic structures, and may increase the risk of PONV (Chapter 8).

C. Opioids
Short-acting opioids such as fentanyl, alfentanil, and remifentanil are commonly used during fast-track
surgery in combination with inhalation agents or propofol, and with regional or local anesthesia/analgesia
techniques. However, intraoperative administration of remifentanil to patients who will experience
extensive postoperative pain has been associated with opioid-induced hyperalgesia, acute opioid
tolerance, and increased analgesic requirements during the postoperative period. There is increasing
evidence that the use of opioids should be minimized in all phases of the perioperative course as part of a
multimodal analgesia technique to reduce opioid side effects and optimize recovery. Opioid-free
anesthesia has been shown to reduce PONV and postoperative opioid use when compared with opioid-
based anesthesia and may be an alternative technique, especially in patients at high risk for PONV, sleep
apnea, or respiratory depression.

Maintenance of Normothermia
The inhibitory effects of anesthetic agents on thermoregulation, exposure to the relatively cool surgical
environment, and intraoperative heat loss can lead to hypothermia in all patients undergoing surgical
procedures. The duration and extent of the surgical procedure directly correlates with hypothermia risk.
Perioperative hypothermia increases cardiovascular morbidity and wound infection risk by increasing
sympathetic discharge and inhibiting the immune cellular response. A decrease in core body temperature
of 1.9°C triples the incidence of surgical wound infection. The risk of bleeding and blood transfusion
requirement are also increased with hypothermia. Furthermore, by impairing the metabolism of many
anesthetic agents, hypothermia may significantly prolong anesthesia recovery (see Chapter 52).

Maintenance of Adequate Tissue Oxygenation

Surgical stress leads to impaired pulmonary function and to peripheral vasoconstriction, resulting in
arterial and local tissue hypoxemia, respectively. Perioperative hypoxia can increase cardiovascular and
cerebral complications, and many strategies should be adopted during the perioperative period to prevent
its development. Maintenance of adequate perioperative oxygenation by oxygen supplementation has
been associated with the improvement of some clinically relevant outcomes. Intraoperative and
postoperative (for 2 h) inspired oxygen concentration of 80% increases arterial and subcutaneous oxygen
tension and may decrease the rate of wound infection and lower the incidence of PONV, without
increasing potential complications associated with high inspired oxygen fraction, such as atelectasis and
hypercapnia. Regional anesthesia techniques decrease vascular resistance and may improve peripheral
tissue perfusion and oxygenation. Finally, early mobilization and avoidance of bed rest improve
postoperative central and peripheral tissue oxygenation.

Postoperative Nausea & Vomiting Prophylaxis

PONV is a frequent complication that delays early feeding and postoperative recovery. Preemptive
strategies minimizing the risk of PONV are strongly advocated for any type of surgery, and consensus
guidelines for prevention and management of PONV are available in the current literature (see Chapters
17 and 56).

Goal-Directed Fluid & Hemodynamic Therapy

There is increasing evidence that perioperative fluid administration affects patient outcome following
major surgery, with the quantity of fluid administered either too restrictive or too liberal—being
associated with increased incidence of postoperative complications. Observational studies reveal large
variation in practitioners’ fluid management strategies. Most attention is focused on avoiding
hypovolemia, whereas excessively liberal fluid administration and its attendant adverse effects, though
more difficult to observe in the operating room, are probably more common. Fluid overload, especially of
crystalloid, has been associated with reduced tissue oxygenation, anastomotic leakage, pulmonary edema,
pneumonia, wound infection, postoperative ileus, and prolonged hospitalization. Furthermore, excess
fluids commonly increase body weight by 3 to 6 kg and may impair postoperative mobilization.
The concept of goal-directed fluid therapy (GDFT) is based on optimization of hemodynamic
measures such as heart rate, blood pressure, stroke volume, pulse pressure variation, and stroke volume
variation obtained by noninvasive cardiac output devices such as pulse-contour arterial waveform
analysis, transesophageal echocardiography, or esophageal Doppler (see Chapter 5).
GDFT aims to avoid both hypovolemia and fluid excess, and has been shown to be the optimal
approach for fluid administration in high-risk surgical patients. The type of fluid infused is also
important: isotonic balanced crystalloid should be used to replace extracellular losses, whereas iso-
oncotic colloids are commonly used to replace intravascular volume (Table 48–3).

TABLE 48–3 Physiologically based first-line fluid replacement for goaldirected therapy.1
POSTOPERATIVE PERIOD
Immediate Postoperative Care
A. Strategies to Minimize Postoperative Shivering
The primary cause of postoperative shivering is perioperative hypothermia, although other, non-
thermoregulatory, mechanisms may be involved. Postoperative shivering can greatly increase oxygen
consumption, catecholamine release, cardiac output, heart rate, blood pressure, and intracranial and
intraocular pressure. It increases cardiovascular morbidity, especially in elderly patients, and increases
PACU length of stay and cost. Shivering is uncommon in elderly and hypoxic patients: the efficacy of
thermoregulation decreases with aging, and hypoxia can directly inhibit shivering. Many drugs, notably
meperidine, clonidine, and tramadol, can be used to reduce postoperative shivering; however, prevention
via strategies intended to minimize thermal loss is optimal (see Chapter 52).

B. PONV Treatment
Pharmacological treatment of PONV should be promptly initiated once medical or surgical causes of
PONV have been ruled out (see Chapters 17 and 56).

C. Multimodal Analgesia
Multimodal analgesia combines different classes of medications that have different (multimodal)
pharmacological mechanisms of action, resulting in additive or synergistic effects to reduce postoperative
pain and its sequelae. Such an approach may achieve desired analgesic effects while reducing analgesic
dosage and associated side effects. Multimodal pain management often includes utilization of regional
analgesic techniques, including local anesthetic wound infusion, epidural/intrathecal analgesia, or single-
shot/continuous peripheral nerve blockade. Multimodal analgesia is routinely utilized in ERPs to improve
postoperative outcomes. Discussion here focuses on principal analgesic interventions used in
perioperative multimodal analgesia regimens.
1. NSAIDs—The addition of nonsteroidal antiinflammatory drugs (NSAIDs) to systemic opioid analgesia
diminishes postoperative pain intensity, reduces opioid requirements, and decreases opioid-related side
effects such as PONV, sedation, and urinary retention. However, NSAIDs may increase the risk of
gastrointestinal and wound bleeding, decrease kidney function, and impair wound healing. There is also a
concern that NSAIDs may have a detrimental effect on anastomotic healing of the gastrointestinal tract
and increase the risk of anastomotic leak, although this is controversial and further research is needed.
Perioperative administration of selective cyclooxygenase-2 (COX-2) inhibitor NSAIDs likewise
reduces postoperative pain and decreases both opioid consumption and opioid-related side effects, and
although their use reduces the incidence of NSAID-related platelet dysfunction and gastrointestinal
bleeding, the potential adverse effects of COX-2 inhibitors on kidney function remain controversial.
Concerns have also been raised, primarily with rofecoxib and valdecoxib, regarding COX-2 safety for
patients undergoing cardiovascular surgery. Increased cardiovascular risk associated with the
perioperative use of celecoxib or valdecoxib in patients with minimal cardiovascular risk factors and
undergoing nonvascular surgery is unproven. Further studies are needed to establish the analgesic
efficacy and safety of COX-2 inhibitors, their clinical impact on postoperative outcomes, and precise role
in ERPs.

2. Acetaminophen (paracetamol)—Oral, rectal, and parenteral acetaminophen is a common component

of multimodal analgesia. Acetaminophen’s analgesic effect is 20% to 30% less than that of NSAIDs, but
its pharmacological profile is safer. Analgesic efficacy improves when the drug is administered together
with NSAIDs, and it significantly reduces pain intensity and spares opioid consumption after orthopedic
and abdominal surgery. However, acetaminophen may not reduce opioid-related side effects. Routine
administration of acetaminophen in combination with regional anesthesia and analgesia techniques
may allow NSAIDs to be reserved for control of breakthrough pain, thus limiting the incidence of
NSAID-related side effects.

3. Gabapentinoids—Oral gabapentin and pregabalin given as a single dose preoperatively have been
shown to decrease postoperative pain and opioid consumption in the first 24 h following surgery. There is
debate about the dose and duration of perioperative use of these drugs, and whether they may potentially
alter the incidence of chronic pain after surgery. Common side effects include sedation and dizziness,
especially in elderly patients.

4. N-methyl-D-aspartate (NMDA) receptor antagonists—Ketamine: Perioperative low-dose ketamine

(bolus, infusion) has been associated with significant reduction in pain, opioid consumption, and PONV.
Ketamine has also been shown to be of particular benefit in patients on chronic opioids. Magnesium:
Magnesium may also reduce postoperative pain and opioid consumption, although the optimal dosing is
uncertain. Side effects include hypotension and potentiation of neuromuscular blockade.

5. Intravenous lidocaine—Intravenous lidocaine infusion analgesia has recently increased in popularity

because there is good evidence to support its use as a component of multimodal analgesia. In major
abdominal surgery, it is associated with faster return of bowel function and decreased hospital length of
stay. Continuous cardiovascular monitoring is frequently advocated for patients receiving intravenous
lidocaine, and therefore its use is currently limited to settings such as the PACU, ICU, or a monitored
hospital ward. However, several centers have developed and implemented perioperative protocols to
safely use intravenous lidocaine on surgical wards without continuous cardiovascular monitoring.

6. Opioids—Despite the increasing use of new, nonopioid analgesic medications and adjuvants and of
regional anesthesia and analgesia techniques intended to minimize opioid requirements and opioid-related
side effects (Table 48–4), the use of systemic opioids remains a cornerstone in the management of
surgical pain. Parenteral opioids are frequently prescribed in the postoperative period during the
transitional phase to oral analgesia. Opioid administration by patientcontrolled analgesia (PCA) provides
better pain control, greater patient satisfaction, and fewer opioid side effects when compared to nurse-
administered, on-request (PRN) parenteral opioid administration. Oral administration of opioids, such as
oxycodone or hydrocodone, in combination with NSAIDs or acetaminophen, or both, is common in the
perioperative period.
TABLE 48–4 Analgesic adjuvants in the perioperative period.1,2

7. Epidural analgesia—In addition to providing excellent analgesia, epidural blockade blunts the stress
response associated with surgery, decreases postoperative morbidity, attenuates catabolism, and
accelerates postoperative functional recovery. Compared with systemic opioid analgesia, thoracic
epidural analgesia provides better static and dynamic pain relief. However, these benefits have mainly
been observed in patients undergoing open abdominal and thoracic surgery; its usefulness in patients
undergoing minimally invasive abdominal and thoracic surgery is questionable, as recent trials have
suggested it may actually prolong in-hospital recovery in such cases. Long-acting local anesthetics such
as ropivacaine (0.2%), bupivacaine (0.0625–0.125%), and levobupivacaine (0.1–0.125%) are commonly
administered together with lipophilic opioids by continuous epidural infusion or by patient-controlled
epidural analgesia (PCEA). As previously noted, administering low doses of local anesthetic via thoracic
epidural infusion instead of lumbar levels avoids lower extremity motor blockade that may delay
postoperative mobilization and recovery and will increase the risk of patient falls. Adding opioids to
epidural local anesthetics improves the quality of postoperative analgesia without delaying recovery of
bowel function.
8. Paravertebral nerve blocks—Paravertebral nerve blocks provide similar parietal analgesia to epidural
blockade but without the risk of epidural-related side effects. However, they have been poorly studied in
the context of ERPs.
9. Peripheral nerve blockade—Single-shot and continuous peripheral nerve blockade is frequently
utilized for fast-track ambulatory and inpatient orthopedic surgery, and can accelerate recovery from
surgery and improve both analgesia and patient satisfaction (see Chapters 38 and 46). For some
procedures, blocking multiple nerves can provide analgesic benefits superior to blockade of a single
nerve. The opioid-sparing effect of nerve blocks minimizes the risk of systemic opioid-related side
effects. Appropriate patient selection and strict adherence to institutional clinical pathways helps ensure
the success of peripheral nerve blockade as a fast-track orthopedic analgesia technique and also helps
minimize its risks.
Advances in ultrasound imaging technology and techniques have accelerated interest in
abdominal wall blockade, facilitating the selective localization of specific nerves and the direct deposition
of local anesthetic solutions in proximity to the compartments where specific nerves are located (see
Chapters 38 and 46).
Single-shot perineural administration of liposomal bupivacaine has been used recently to extend
the analgesic duration of peripheral nerve blocks to up to 72 h after surgery. However, preliminary studies
have not consistently shown expected benefits, and the role of liposomal local anesthetic preparations in
postoperative analgesia and ERPs has, therefore, yet to be precisely defined.

10. High-volume local anesthetic infiltration analgesia and wound infusion

High-volume local anesthetic infiltration analgesia with a mixture of local anesthetic and epinephrine,
with or without systemic NSAIDs, has recently gained popularity in patients undergoing total hip and
knee replacements, and is currently replacing peripheral nerve blocks in many institutions, especially in
the context of an ERP (see Chapter 38). However, supporting evidence demonstrating that this technique
is superior to peripheral nerve blockade is currently lacking. Moreover, its impact on metabolic and
inflammatory responses and on non–analgesic-related outcomes remains unknown. The impact of
peripheral nerve blocks and rehabilitation therapy on functional outcomes also remains incompletely
studied. Local anesthetic wound infusions can be used to improve postoperative pain control and reduce
the necessity for opioids, especially in patients undergoing open abdominal surgery and in whom epidural
analgesia is contraindicated. The analgesic efficacy of local anesthetic wound infusion has been also
established for multiple other surgical procedures. Inconsistent results from wound infusion may be
secondary to type, concentration, and dose of local anesthetic employed; catheter placement; and mode of
local anesthetic delivery.

11. Intraperitoneal instillation and nebulization of local anesthetic

Instillation and nebulization of intraperitoneal local anesthetic decreases pain intensity and decreases
opioid consumption following open abdominal and laparoscopic surgery. However, the precise roles of
these techniques in multimodal management remain to be determined.

Strategies to Facilitate Recovery on the Surgical Unit

A. Organization of Multidisciplinary Surgical Care
The multidisciplinary aspect of postoperative care should bring together the surgeon, anesthesia care
team, nurses, nutritionist, physiotherapist, pharmacist, and case manager/social worker in an
interdisciplinary team effort to optimize each patient’s care based upon standardized, procedure-specific
protocols. Comfortable chairs and walkers should be made readily available near each patient bed to
encourage patients to sit, stand, and walk. Routine bedrest after surgery should be avoided. Patients
should be encouraged to sit in a chair the afternoon or evening following surgery, with ambulation
starting the same or next day. If patients are unable to get out of bed, they should be instructed and
encouraged to perform physical and deep breathing exercises in their beds.
B. Optimization of Analgesia to Facilitate Functional Recovery
A well-organized, well-trained, acute pain service (APS) utilizing procedure specific clinical protocols to
optimally manage analgesia and related side effects helps drive ERPs. The quality of pain relief and
symptom control heavily influences postoperative recovery; optimal mobilization and dietary intake
depend upon adequate analgesia with minimal analgesic-related side effects. The surgeon and the APS
must identify and employ optimal analgesic techniques tailored to the specific surgical procedure, and the
quality of analgesia and risk of analgesic-related side effects must be closely and continuously assessed.
The goal is not to achieve “zero pain,” but to make patients comfortable while walking and performing
physiotherapy, with minimal side effects such as lightheadedness, sedation, nausea and vomiting, urinary
retention, ileus, and leg weakness. It should be noted that opioid-related PONV is the most common
cause of unplanned hospital admission following ambulatory surgery, and opioid-related ileus is
one of the most common causes of extended hospital length of stay. Both of these problems
significantly increase perioperative costs.

C. Strategies to Minimize Postoperative Ileus

Postoperative ileus delays postoperative resumption of enteral feeding, is often a source of considerable
patient discomfort, and is one of the most common causes of prolonged postoperative hospital length of
stay and preventable hospitalization costs. Because early enteral nutrition is associated with decreased
postoperative morbidity, interventions and strategies aimed at minimizing the risk and severity of
postoperative ileus are essential for patients in an ERP. Four main mechanisms contribute to ileus:
sympathetic inhibitory reflexes, local inflammation initiated by the operative procedure, intraoperatively-
and postoperatively-administered systemic opioids, and bowel edema caused by administration of excess
intravenous fluid. Nasogastric tubes, frequently inserted after abdominal surgery, do not speed the
recovery of bowel function and may increase pulmonary morbidity by increasing the risk of
aspiration. Therefore, nasogastric tubes should be discouraged whenever possible or used for only a
very short period of time, even with gastrointestinal surgery.
The opioid-sparing effects of multimodal analgesia with minimal or non–opioid analgesia
techniques shorten the duration of postoperative ileus or may preempt it entirely. Minimally
invasive surgical techniques are associated with less surgical stress and inflammation than open
procedures, resulting in more rapid return of bowel function. For open abdominal procedures, thoracic
epidural local anesthetic infusions not only provide superior analgesia, but also speed recovery of bowel
function by suppressing inhibitory sympathetic spinal cord reflexes that promote the development and
severity of postoperative ileus.
Epidural analgesia does not appear to have the same impact following laparoscopic procedures.
Laxatives, such as milk of magnesia and bisacodyl, reduce postoperative ileus duration. Prokinetic
medications such as metoclopramide are ineffective. Neostigmine increases peristalsis but may also
increase the incidence of PONV.
Postoperative chewing gum, by stimulating gastrointestinal reflexes, may decrease ileus duration.
Although its effect has not been evaluated in ERP patients, postoperative chewing gum may be included
in multimodal interventions to decrease postoperative ileus because of its safety and low cost. Peripheral
opioid μ-receptor antagonists methylnaltrexone (Relistor) and alvimopan (Entereg) minimize the adverse
effects of opioids on bowel function without antagonizing systemic opioid analgesia because of their
limited ability to cross the blood–brain barrier. In laparotomy patients receiving high-dose intravenous
morphine analgesia, alvimopan decreases the duration of postoperative ileus by 16 to 18 h, decreases the
incidence of nasogastric tube reinsertion, shortens hospital length of stay, and lowers hospital readmission
of postoperative bowel function in such alvimopan-treated, high-dose systemic morphine analgesia
patients remains slower than that of patients utilizing opioid sparing, multimodal ERPs.
 Excessive perioperative fluid administration commonly causes bowel mucosal edema and delays
postoperative return of bowel function. Because either excessive, or excessively restricted, perioperative
fluid therapy increases the incidence and severity of postoperative ileus, a goal-directed fluid
administration strategy may be beneficial, especially in patients undergoing major surgery associated with
large fluid shifts and patients at high risk of developing postoperative gastrointestinal complications (see
Chapter 51). However, results from a recent randomized double-blind study of liberal versus restricted
fluid administration showed no differences with regard to recovery of bowel function in patients
undergoing fast-track abdominal surgery.

Issues in the Implementation of Enhanced Recovery Programs

The success of ERPs depends upon the ability and willingness of perioperative team stakeholders
to reach evidence-based interdisciplinary consensus. Many traditional aspects of perioperative care, such
as use of drains, dietary and activity restrictions, excessive or excessively restrictive fluid management,
and bedrest, must be extensively revised in ERPs. Patient involvement and patient and family
expectations are fundamentally important, but frequently overlooked, aspects of these programs. New
surgical techniques, such as transverse incisions or minimally invasive surgery, may require surgeons to
acquire and perfect new skills. Similarly, the emphasis on thoracic epidural blockade or peripheral nerve
blocks, pharmacological modulation of the neuroendocrine stress response to surgery, goal-directed fluid
and hemodynamic therapy, and integral involvement of a well-organized and managed APS requires a
substantial expansion of the traditional roles of anesthesiologists and of the anesthesia care team.
Aggressive analgesia and symptom management, early ambulation and physiotherapy, early nutrition
protocols, and early removal or total avoidance of urinary drainage catheters significantly change the way
patients are cared for in the postanesthesia recovery unit and on the surgical unit and require a well-
organized, highly trained, highly motivated nursing staff.
Although there are published studies of successful ERPs, there are no “off the-shelf” protocols
with universal application: Local differences in goals, expertise, experience, resources, and politics
markedly influence the development, implementation, and management of ERPs for each institution or
health care system. Each family of similar surgical procedures requires a standardized interdisciplinary
clinical protocol or pathway, with specialized input from a team with experience in caring for those
patients. Such an interdisciplinary team should include representation from surgery, anesthesiology,
nursing, pharmacy, physiotherapy, nutrition, and administration, and it should be responsible not only for
each clinical protocol’s creation, but also for continuously monitoring its efficacy and cost, and for
instituting continuous improvement-related protocol modifications and provider feedback as indicated by
outcomes data (Figure 48–5).

FIGURE
FIGURE 48–5 Stepwise process for initiating and implementing an enhanced recovery program.

Optimal perioperative care requires the anesthesia provider to be an integral part of the perioperative
surgical care team leadership and management. The skill sets of the anesthesiologist and anesthesia care
team are essential for the success of ERPs and have potential benefits for surgical care delivery on a
global basis, from initial surgical diagnosis, preoperative evaluation, and presurgical preparation through
postoperative recovery and return of the patient to his or her primary healthcare provider. The
perioperative surgical home concept represents an accumulation of developments derived from
ambulatory, minimally invasive, fast-track, enhanced recovery, and interdisciplinary, team-based surgical
care and allows both quality- and cost-related variables to be analyzed and optimized from the patient’s
perspective (eg, incidence and severity of perioperative complications, hospital length of stay, hospital
readmission rate, return to work, and return to chemotherapy). By optimizing these many variables, the
PSH contributes to delivering a higher value surgical experience to the patient. This will require new
standards for clinical education and training.