Anesthetic Management For Enhanced Recovery After Major Noncardiac Surgery (ERAS) - UpToDate

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Anesthetic management for enhanced recovery after

major noncardiac surgery (ERAS)
Author: Girish P Joshi, MB, BS, MD, FFARCSI
Section Editor: Roberta Hines, MD
Deputy Editor: Nancy A Nussmeier, MD, FAHA
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: May 23, 2022.
INTRODUCTION
Multimodal, multidisciplinary fast-track surgery, also known as enhanced recovery after surgery
(ERAS) or enhanced recovery pathways (ERPs), can hasten functional recovery after various
types of surgical procedures [1]. ERAS/ERP protocols involve evidence-based therapeutic
interventions in the preoperative, intraoperative, and postoperative periods [2,3].
This topic discusses management of components (elements) of anesthetic care for enhanced
recovery after major abdominal surgical procedures such as gastrointestinal surgery (eg,
colorectal surgery, liver resection, gastrectomy, pancreaticoduodenal surgery). Many of the
principles discussed in this topic are applicable to other types of major surgical procedures such
as urologic surgery (eg, radical nephrectomy and cystectomy), orthopedic surgery (eg, total
joint replacement, complex spine surgery), or breast surgery (eg, radical mastectomy).
Other topics discuss anesthetic management for enhanced recovery after cardiothoracic
surgical procedures. (See "Anesthetic management for enhanced recovery after thoracic
surgery" and "Anesthetic management for enhanced recovery after cardiac surgery (ERACS)".)
Details regarding surgical management of enhanced recovery after colorectal surgery or

gynecologic surgery are found in separate topics. (See "Enhanced recovery after colorectal
surgery" and "Enhanced recovery after gynecologic surgery: Components and
implementation".)
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DEFINITION OF ERAS
ERAS refers to evidence-based protocols that standardize care to minimize surgical stress
response and postoperative pain, reduce complications, improve outcomes, decrease hospital
length of stay, and expedite recovery following elective procedures.
The overall principles of perioperative care for major surgical procedures, particularly
preoperative and intraoperative management, remain the same with a few procedure-specific
variations (eg, procedure-specific pain management). (See "Enhanced recovery after colorectal
surgery", section on 'Elements of ERAS' and "Enhanced recovery after gynecologic surgery:
Components and implementation", section on 'Definition'.)
ERAS ELEMENTS
This table provides an overview of ERAS elements (interventions) ( table 1).
Early ERAS protocols in 1990s proposed approximately 20 perioperative elements, which were
selected based on the evidence obtained in other surgical settings. Subsequent studies
suggested that not all ERAS elements are equally weighted for influence on postoperative
complications and recovery [3]. For example, in patients undergoing colorectal surgery,
intraoperative minimally invasive approaches and postoperative elements such as early oral
intake and early ambulation had the greatest impact to speed recovery [4,5]. However, the
overall impact of compliance with ERAS protocols was greatest for procedures performed with
an open surgical approach, particularly compliance with postoperative elements [5]. Although
achievement of postoperative compliance was more difficult compared with the preoperative
and intraoperative phases of ERAS protocols in this study, such postoperative elements may be
most important once the surgical stress response has occurred.
Several other ERAS elements including preoperative optimization of comorbid conditions,

avoiding prolonged preoperative fasting, routine antiemetic prophylaxis, use of opioid-sparing
analgesic techniques, maintenance of normothermia, lung-protective mechanical ventilation,
antibiotic prophylaxis, and venous thromboembolism (VTE) prophylaxis have become standard
of care based on extensive evidence [3]. These elements are briefly discussed below, and
further detail can be found in separate topics:
● (See "Preoperative evaluation for anesthesia for noncardiac surgery".)

● (See "Preoperative fasting in adults".)
● (See "Postoperative nausea and vomiting", section on 'Prevention'.)

● (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

● (See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective
ventilation during anesthesia'.)
● (See "Perioperative temperature management".)
● (See "Approach to the management of acute pain in adults".)
● (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical
patients" and "Prevention of venous thromboembolism in adults undergoing hip fracture
repair or hip or knee replacement".)
Other perioperative ERAS elements such as avoidance of mechanical bowel preparation,

carbohydrate loading, goal-directed fluid management, or use of epidural analgesia may be
unnecessary [3].
PREOPERATIVE CONSIDERATIONS
Preanesthesia consultation — Important goals during the preanesthesia consultation are to

[6]:
● Identify comorbidities and opportunities to optimize the patient's preoperative condition,

which may improve postoperative outcomes. (See "Preoperative evaluation for anesthesia
for noncardiac surgery", section on 'Patient risk factors' and "Preoperative evaluation for
anesthesia for noncardiac surgery", section on 'Conditions that increase perioperative
risk'.)
● Emphasize minimizing the fasting period and maintaining hydration during the fasting
period. For example, ERAS protocols for patients undergoing colorectal surgery include
advice to patients to hydrate during the fasting period, with consumption of two glasses
of water prior to going to bed and two glasses of water before traveling to the hospital on
the morning of surgery. There is no evidence that restriction of the volume of clear liquids
is beneficial [7]. However, we do not use complex carbohydrate loading, as the evidence of
benefit in the ERAS setting is weak [8]. Rather, patients are given an option to consume a
simple carbohydrate drink (eg, apple juice or Gatorade) instead of two glasses of water,
but the drink must be consumed at least two hours prior to surgery. (See "Preoperative
fasting in adults" and "Enhanced recovery after colorectal surgery", section on 'Fasting
guidelines'.)
● Educate the patient and family to set expectations regarding the patient's own role in the
recovery process, and reduce patient anxiety. In particular, preoperative planning for pain

management emphasizes realistic expectations regarding postoperative pain relief [6,9-

11]. Such efforts lead to increased patient satisfaction [9]. (See 'Postoperative anesthetic
management' below.)
Prehabilitation efforts such as nutritional supplementation, physical exercise programs,

interventions to improve cognitive function, smoking cessation, and stress reduction are
addressed separately. (See "Overview of prehabilitation for surgical patients".)
Medications administered in the preoperative period — Medications administered in the

immediate preoperative period include:
● Oral acetaminophen 1 g, administered at least two hours preoperatively if there are no

contraindications.
● Oral cyclooxygenase (COX)-2 specific inhibitor (eg, celecoxib 400 mg) at least two hours
preoperatively, if no contraindications.
● For selected patients undergoing surgical procedures with a high likelihood of persistent
postoperative pain, oral gabapentin 300 to 600 mg may also be administered at least two
hours preoperatively [12,13]. However, we avoid gabapentin in patients who are >65 years
old or have sleep-disordered breathing (eg, obstructive sleep apnea) due to concerns
regarding excessive sedation, ventilatory depression, and dizziness, particularly if
gabapentin is combined with opioids [14-17]. In a 2020 meta-analysis of nearly 25,000
patients participating in 281 trials, gabapentinoids were associated with reductions in pain
intensity that were clinically insignificant at 6, 12, 24, and 48 postoperative hours, with no
effect by 72 postoperative hours, compared with controls who did not receive
gabapentinoids [17]. Postoperative nausea and vomiting (PONV) occurred less frequently
in patients receiving gabapentinoids (risk ratio [RR] 0.77, 95% CI 0.72-0.82; 17,145
participants). However, a higher incidence of dizziness was noted after gabapentinoid
administration (risk ratio [RR] 1.25, 95% CI 1.13-1.39; 12,054 participants) [17].
● For selected surgical procedures, thromboprophylaxis with subcutaneous heparin 5000

units, administered 30 to 60 minutes before surgery. Prophylaxis also includes placement
of bilateral sequential compression devices prior to induction of anesthesia. (See
"Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients",
section on 'Selecting thromboprophylaxis' and "Prevention of venous thromboembolism in
adults undergoing hip fracture repair or hip or knee replacement".)
● We avoid routine administration of benzodiazepine premedication. Many

anesthesiologists administer a small intravenous (IV) dose of a benzodiazepine, typically
midazolam 1 to 2 mg, just before transfer of the patient from the holding area to the
operating room. Perceived benefits include anxiolysis, sedation, amnesia, and improved
patient satisfaction [18], although these benefits are controversial [19]. Potential adverse
effects of benzodiazepines include postoperative amnesia, drowsiness, and cognitive
dysfunction [20], increased incidence of pharyngeal dysfunction and discoordinated
breathing and swallowing [21,22], and occasional unpredictable paradoxical reactions (eg,
irritability, aggressiveness, delirium) [23-25]. In one large randomized trial in 1062 adults
<70 years of age, premedication with a long-acting benzodiazepine (lorazepam) was
associated with modestly prolonged time to tracheal extubation, delayed cognitive
recovery, and no improvement in self-reported postoperative patient experiences [26].
INTRAOPERATIVE ANESTHETIC MANAGEMENT
Anesthetic agents and techniques are selected to provide optimal operating conditions with
consistent and rapid recovery of cognition and physical functions such as oral intake and
ambulation, ideally with minimal or no adverse effects. Other aspects of perioperative ERAS
management protocols that are managed by anesthesiologists include fluid administration,
temperature control, mechanical ventilation, and prophylaxis against pain and nausea/vomiting
can affect both short- and long-term postoperative outcomes [2,27-29].
Induction of anesthesia — Major surgical procedures are typically performed under general

anesthesia. For ERAS protocols, an intravenous (IV) anesthetic induction sequence is typically
used including IV fentanyl approximately 0.5 to 1 mcg/kg ideal body weight (IBW), given three
to five minutes prior to lidocaine 20 to 30 mg, followed by propofol 1 to 1.5 mg/kg to achieve
loss of eyelash reflex and/or response to verbal command. In addition, a nondepolarizing
neuromuscular blocking agent (NMBA) such as rocuronium 0.6 to 1 mg/kg IBW may be
administered to provide muscle relaxation that facilitates laryngoscopy and insertion of an
endotracheal tube (ETT). As with other intraoperative settings, it may be necessary to modify
selection and dosing of anesthetic induction agents due to patient-specific factors (eg, difficult
airway, aspiration risk). (See "Induction of general anesthesia: Overview".)
● Intravenous induction agents – Propofol is usually the IV induction agent of choice for
ERAS protocols due to its unique recovery profile, antiemetic properties, and euphoria on
emergence.
Commonly used adjuvants include lidocaine to minimize the pain associated with propofol
injection and an opioid (usually fentanyl) to blunt the sympathetic responses to
laryngoscopy and tracheal intubation as well as reduce the propofol dose required to

achieve loss of consciousness [30,31]. (See "Induction of general anesthesia: Overview",

section on 'Intravenous anesthetic induction'.)
Dosing of anesthetic induction agents and adjuvants should be judicious; large bolus
doses may result in significant post-induction hypotension and need for vasopressor
support [32,33]. (See "General anesthesia: Intravenous induction agents", section on
'Dosing considerations' and "Hemodynamic management during anesthesia in adults",
section on 'Selection and dosing of anesthetic agents'.)
● Neuromuscular blocking agents – An intermediate-acting non-depolarizing NMBA such

as rocuronium is typically selected for the induction sequence. In patients with a high risk
for pulmonary aspiration or a potentially difficult airway, we select succinylcholine if there
are no contraindications. Further details regarding selection of a muscle relaxant for use
during induction are available in separate topics:
• (See "Induction of general anesthesia: Overview", section on 'Neuromuscular blocking

agents'.)
• (See "Clinical use of neuromuscular blocking agents in anesthesia", section on
'Endotracheal intubation'.)
• (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Adverse
effects of succinylcholine'.)
Antibiotic prophylaxis — Routine IV antibiotic prophylaxis is administered 30 to 60 minutes

before the surgical incision as standard of care. To achieve this timing goal, we typically
administer prophylactic antibiotics immediately after induction of general anesthesia. The
choice and dose of the antibiotics are discussed separately. (See "Antimicrobial prophylaxis for
prevention of surgical site infection in adults".)
Maintenance of anesthesia
Inhalation versus total intravenous anesthesia techniques — Maintenance of general

anesthesia using either inhalation anesthesia or a total intravenous anesthesia (TIVA) technique
is acceptable for patients participating in ERAS protocols. For either technique, it is prudent to
use short-acting agents administered at the lowest possible doses since residual effects of
inhalation anesthetics and IV hypnotic-sedatives, opioids, and muscle relaxants can delay
recovery or result in other adverse effects. Goals for emergence from general anesthesia
include planning a rapid clearheaded awakening, with adequate analgesia. (See "Maintenance
of general anesthesia: Overview", section on 'Inhalation anesthetic agents and techniques' and
"Maintenance of general anesthesia: Overview", section on 'Total intravenous anesthesia'.)

However, we avoid deep levels of general anesthesia. (See "Maintenance of general anesthesia:
Overview", section on 'Anesthetic depth'.)
● Inhalation anesthesia – For most patients, we prefer an inhalation-based technique with

a potent volatile agent (desflurane or sevoflurane) plus nitrous oxide (N2O) 50 percent in
oxygen to achieve an age-adjusted minimum alveolar concentration (MAC) value of
approximately 0.8 to 1.0. (See "Inhalation anesthetic agents: Clinical effects and uses",
section on 'MAC and MAC-awake values for inhalation agents'.)
Advantages of the potent volatile inhalation anesthetics include (see "Inhalation

anesthetic agents: Clinical effects and uses"):
• Some degree of muscle relaxation, allowing minimized dosing of NMBA. (See

"Inhalation anesthetic agents: Clinical effects and uses", section on 'Skeletal and
smooth muscle relaxation'.)
• Ease of titration. (See "Inhalation anesthetic agents: Properties and delivery", section
on 'Factors affecting inhalation anesthetic delivery'.)
• Availability of end-tidal anesthetic concentration (ETAC) to aid in maintenance of

adequate anesthetic depth without awareness. We set alarms to detect low ETAC (eg,
age-adjusted MAC <0.7). Also, we sometimes employ neuromonitoring such as
processed electroencephalography (EEG) such as the bispectral index [34]. (See
"Accidental awareness during general anesthesia", section on 'End-tidal anesthetic
concentration' and "Accidental awareness during general anesthesia", section on 'Brain
monitoring'.)
However, there is insufficient evidence to recommend use of EEG monitoring to

prevent postoperative delirium or other neurocognitive disorders [34]. (See
"Perioperative neurocognitive disorders in adults: Risk factors and mitigation
strategies", section on 'Avoid excessive depth during general anesthesia' and
"Inhalation anesthetic agents: Clinical effects and uses", section on 'Continuum of
effect: sedation to general anesthesia'.)
• Rapid recovery, particularly with use of the short-acting inhalation anesthetics

(sevoflurane or desflurane plus N2O) [35]. Clinical differences between desflurane and
sevoflurane appear to be small, although several studies have reported slightly more
rapid emergence with desflurane [36,37]. (See "Inhalation anesthetic agents: Clinical
effects and uses", section on 'Sevoflurane' and "Inhalation anesthetic agents: Clinical
effects and uses", section on 'Desflurane'.)
● Total intravenous anesthesia – A TIVA technique may be employed in selected patients

participating in an ERAS protocol, particularly those at very high risk for postoperative
nausea and vomiting (PONV) [38]. Although a propofol-based TIVA technique may result in
a reduced incidence of PONV compared with inhalation anesthesia [39,40], data are not
consistent. One 2016 meta-analysis found no overall difference in risk of PONV when TIVA
was compared with an inhalation technique if at least one prophylactic antiemetic agent
was administered [41]. (See "Postoperative nausea and vomiting", section on 'Prevention'.)
A typical TIVA technique includes infusion of propofol 75 to 150 mcg/kg/minute, with

titration based on neuromonitoring of the processed or unprocessed EEG, with alarms set
to detect high EEG indices that indicate possible awareness. A remifentanil infusion is
typically selected for the opioid component of a TIVA technique for ERAS procedures, with
titration to achieve hemodynamic stability. (See "Maintenance of general anesthesia:
Overview", section on 'Total intravenous anesthesia' and "Accidental awareness during
general anesthesia", section on 'Brain monitoring'.)
Nitrous oxide — We routinely use N2O for ERAS procedures. The amnestic and analgesic
properties of N2O reduce the requirements of other anesthetic and adjuvant agents [42].
Furthermore, N2O facilitates both uptake and removal of the potent volatile inhalation
anesthetics via its "second gas effect," thereby allowing rapid changes in anesthetic depth and
rapid emergence from anesthesia [43]. (See "Inhalation anesthetic agents: Clinical effects and
uses", section on 'Advantages' and "Inhalation anesthetic agents: Properties and delivery",
section on 'Second gas effect'.)
Despite these beneficial effects, some clinicians avoid N2O due to concerns regarding increased
risk of PONV. However, the emetic effects of N2O can be mitigated with use of prophylactic
antiemetics [43-46]. Other concerns include the possibility of bowel distention during colorectal
procedures due to expansion of closed spaces. However, several studies have noted that
surgeons do not recognize a difference between conditions in patients receiving N2O during
colorectal surgery compared with patients not receiving N2O [47-49]. (See "Inhalation
anesthetic agents: Clinical effects and uses", section on 'Disadvantages and adverse effects'.)
Opioids — Opioids may increase risk for postoperative opioid-related adverse events such as
nausea, vomiting, sedation, bladder dysfunction, and respiratory depression, and may increase
potential for acute tolerance, delayed hyperalgesia, and paradoxical increases in postoperative
pain and opioid dosing requirements [50,51]. Therefore, we avoid high doses of opioids and use
opioid-sparing approaches to perioperative pain management. (See "Perioperative uses of
intravenous opioids in adults: General considerations", section on 'Prevention and management
of adverse opioid effects'.)
As noted above, a remifentanil infusion is typically selected for the opioid component of a TIVA
technique. For other techniques, small bolus doses of an opioid (eg, fentanyl 25 to 50 mcg) may
be administered during the intraoperative period if indicated (eg, when increased heart rate
and/or blood pressure are noted), but we typically limit the dose (eg, ≤1 mcg/kg per hour of
fentanyl). Once fentanyl requirements have exceeded 1 mcg/kg per hour, we typically treat
hypertension (and/or tachycardia) with vasoactive agents such as beta blockers or vasodilators
rather than with additional doses of an opioid.
Notably, intraoperative tachycardia and hypertension often occur due to causes other than
pain. For example, during laparoscopic surgical procedures, factors such as increased intra-
abdominal pressure, absorption of carbon dioxide (CO2), and effects of surgical positioning may
lead to tachycardia and/or hypertension. Increasing opioid dosing to treat such hyperdynamic
responses is not appropriate, as discussed in a separate topic. (See "Anesthesia for patients with
hypertension", section on 'Prevention and treatment of intraoperative hypertension'.)
Neuromuscular blocking agents — An NMBA is often administered to facilitate surgical

exposure during laparoscopic or open surgical procedures [52,53]. We avoid profound muscle
paralysis by using a peripheral nerve stimulator to aim for a moderate level of neuromuscular
blockade during laparoscopic procedures (eg, a train-of-four [TOF] count of 2 to 3). Even during
laparoscopic abdominal surgery, we administer NMBAs as required by the clinical situation,
aiming for the least degree of block necessary for the clinical situation. Detailed discussions
regarding dosing and monitoring the effects of NMBAs are found in separate topics:
● (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Facilitation

of surgery'.)
● (See "Monitoring neuromuscular blockade", section on 'Train-of-four'.)
● (See "Anesthesia for laparoscopic and abdominal robotic surgery in adults", section on
'Neuromuscular blockade'.)
We avoid maintenance of deep neuromuscular blockade as this results in use of high doses of
NMBAs and increased risk of residual muscle weakness at the end of the procedure (defined as
a TOF ratio <0.9), even after reversal [54-56] (see "Clinical use of neuromuscular blocking agents
in anesthesia", section on 'Avoidance of residual neuromuscular blockade'). Furthermore, one
study noted that persistent impairment of the peripheral chemoreflex with blunting of the
ventilatory response to hypoxia often occurs despite complete reversal of rocuronium with
neostigmine or sugammadex [57]. These effects may increase the risk for serious adverse
respiratory events [55,58]. Approaches to reducing residual effects of NMBAs include using the
smallest dose of an NMBA that provides optimal surgical conditions, avoiding use of long-acting
NMBAs, and ensuring complete reversal of any residual neuromuscular blockade near the end
of the surgical procedure. Dosing of the reversal agents neostigmine or sugammadex is based
on the degree of residual neuromuscular block at the time the agent is administered. Details
regarding timing and adequacy of reversal of neuromuscular block are found in separate
topics:
● (See "Emergence from general anesthesia", section on 'Assess and reverse effects of
neuromuscular blocking agents'.)
● (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Reversal of
neuromuscular block'.)
● (See "Respiratory problems in the post-anesthesia care unit (PACU)", section on
'Neuromuscular blocking agents'.)
Mechanical ventilation — Intraoperative lung protective mechanical ventilation reduces

postoperative pulmonary complications, length of hospital stay, and mortality after major
surgery [59]. (See "Ventilator-induced lung injury" and "Physiologic and pathophysiologic
consequences of mechanical ventilation".)
● Maintenance phase of general anesthesia – Optimal lung protective parameters include

(see "Mechanical ventilation during anesthesia in adults", section on 'Lung protective
ventilation during anesthesia'):
• Low tidal volumes (ie, 6 to 8 mL/kg IBW). (See "Mechanical ventilation during
anesthesia in adults", section on 'Tidal volume'.)
• Initial positive end-expiratory pressure (PEEP) 5 cm H2O (or 8 to 10 cm H2O during

laparoscopic procedures). However, as surgery progresses, PEEP should be
individualized based on patient and surgical factors, in an attempt to avoid both
alveolar overdistention and atelectasis. In addition to patients undergoing laparoscopic
procedures, those who are obese or undergoing surgery performed in steep
Trendelenburg position may need levels of PEEP >5 cm H2O. (See "Mechanical
ventilation during anesthesia in adults", section on 'Positive end-expiratory pressure'
and "Mechanical ventilation during anesthesia in adults", section on 'Individualized
PEEP'.)
• Plateau pressure ≤16 mmHg and driving pressure (defined as the difference between
plateau pressure and PEEP) ≤16 mmHg. (See "Mechanical ventilation during anesthesia
in adults", section on 'Plateau pressure' and "Mechanical ventilation during anesthesia
in adults", section on 'Driving pressure' and "Mechanical ventilation during anesthesia
in adults", section on 'Monitoring driving pressure'.)
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• Fraction of inspired oxygen (FiO2) 0.4 to 0.5. (See "Mechanical ventilation during
anesthesia in adults", section on 'Fraction of inspired oxygen'.)
• Initial respiratory rate of 8 breaths/minute, subsequently adjusted to maintain end-

tidal carbon dioxide (ETCO2) levels at approximately 40 mmHg (rather than traditional
values of 30 to 35 mmHg). These higher CO2 level may increase tissue perfusion and
oxygenation, due to an increase in cardiac output and vasodilation, and a rightward
shift of the oxyhemoglobin dissociation curve. (See "Mechanical ventilation during
anesthesia in adults", section on 'Respiratory rate' and "Mechanical ventilation during
anesthesia in adults", section on 'Goal end-tidal carbon dioxide'.)
• Performance of recruitment maneuvers only when indicated to improve oxygenation

(eg, in an obese patient), or in specific circumstances (eg, after insufflation for
laparoscopy or disconnection from the ventilator for suctioning). (See "Mechanical
ventilation during anesthesia in adults", section on 'Recruitment maneuvers'.)
During laparoscopic procedures, high peak airway pressures and/or desaturation may
necessitate temporary modifications in these ventilator settings. (See "Anesthesia for
laparoscopic and abdominal robotic surgery in adults", section on 'Mechanical
ventilation'.)
● Emergence from general anesthesia – During emergence, we maintain minute

ventilation in an effort to eliminate inhalation anesthetics and facilitate rapid emergence.
Although some clinicians reduce the respiratory rate near the end of the procedure in an
effort to increase ETCO2 levels to simulate respiration, this reduction of respiratory rate
and minute ventilation can delay removal of inhalation anesthetic agents, thereby
delaying emergence. (See "Emergence from general anesthesia", section on 'Preparations
for emergence'.)
Fluid management — Intraoperative fluid management is aimed at restoring and maintaining

euvolemia. (See "Intraoperative fluid management", section on 'Choosing a fluid management
strategy'.)
We typically use a zero-balance fluid therapy approach that minimizes fluid administration for
minimally or moderately invasive surgery for patients participating in an ERAS protocol. We
administer a balanced electrolyte solution (eg, Ringer's lactate) at 3 mL/kg/hour. We do not
"preload" fluid prior to neuraxial block or induction of general anesthesia, or replace urine
output, calculated insensible losses, or nonanatomic "third space" losses [60]. (See
"Intraoperative fluid management", section on 'Restrictive (zero-balance) strategy' and
"Intraoperative fluid management", section on 'Minimally/moderately invasive surgery'.)
For high-risk patients undergoing major surgical procedures that dictate arterial catheter
placement, this approach is supplemented with goal-directed fluid therapy, particularly if
significant blood losses (eg, >500 mL) and/or fluid shifts are expected. With this approach,
supplemental fluid boluses (typically 200 to 250 mL) are administered based on information
derived from invasive dynamic hemodynamic parameters such as manual estimation or
automated calculation of variations in systolic blood pressure or pulse pressure in the
intraarterial waveform tracing, or variations in stroke volume. Further details are available in a
separate topic:
● (See "Intraoperative fluid management", section on 'Major invasive surgery'.)

● (See "Intraoperative fluid management", section on 'Goal-directed fluid therapy'.)
● (See "Intraoperative fluid management", section on 'Dynamic parameters to assess
volume responsiveness'.)
For patients participating in ERAS protocols and other surgical patients, evidence suggests that
these fluid management strategies (zero-balance or goal-directed approaches) are superior to
traditional approaches that use liberal fluid administration based on a fixed volume resulting in
administration of excessive volumes of crystalloid solution and increased risk for tissue edema
and associated adverse outcomes. (See "Intraoperative fluid management", section on 'Avoid
traditional liberal or fixed-volume approaches'.)
Temperature control — Core body temperature is routinely monitored at the esophageal or

nasopharyngeal site, and warming devices are employed to maintain normothermia
(temperature ≥35.5°C) [61-64]. These include upper- and lower-body forced-air warming devices
and blankets, insulation water mattresses, and devices for warming all IV fluids. (See
"Perioperative temperature management", section on 'Intraoperative hypothermia'.)
Hypothermia is avoided because of potential complications in the immediate- and long-term

postoperative periods (eg, shivering, coagulopathy, prolonged duration of stay in the post-
anesthesia care unit (PACU), surgical site infection, adverse cardiac events) [64]. (See
"Perioperative temperature management", section on 'Postoperative temperature
derangements'.)
Glycemic control — Perioperative glycemic control is initiated in the preoperative period,

including appropriate advice to diabetic patients regarding hypoglycemic drugs and insulin
administration. Perioperative blood glucose levels are monitored and maintained between 140
and 200 mg/dL (7.8 to 11 mmol/L) in both diabetic and nondiabetic patients throughout the
perioperative period. More aggressive control is avoided as this incurs risk of hypoglycemia and
associated perioperative complications. (See "Perioperative management of blood glucose in

adults with diabetes mellitus".)
Antiemetic prophylaxis — We routinely use multimodal antiemetic prophylaxis in all patients

participating in ERAS protocols to facilitate early recovery [38]. Although selective risk-based
approaches for antiemetic therapy have been proposed, compliance with these strategies may
be poor [65]. (See "Postoperative nausea and vomiting", section on 'Risk stratification'.)
We typically use a combination of IV dexamethasone 8 to 10 mg administered after induction of

anesthesia, as well as a 5-hydroxytryptamine type 3 (5-HT3) antagonist such as IV ondansetron
4 mg administered at the end of the surgical procedure. Administration of a higher
perioperative dose of dexamethasone 0.2 mg/kg did not reduce a composite of serious
complications (eg, organ failure) compared with placebo in a trial of more than 1200 patients
undergoing major noncardiac surgery, but increased risk for hyperglycemia requiring insulin
therapy [66].
For patients at very high risk of PONV (eg, history of motion sickness, history of previous PONV,
known high opioid requirements for pain relief), we administer an additional antiemetic agent
such as preoperative transdermal scopolamine or intraoperative IV haloperidol 0.5 to 1 mg
administered shortly after induction of anesthesia. Notably, use of more than three antiemetics
has not been shown to confer additional clinical benefit [67]. In addition, a TIVA technique may
be used for such high-risk patients. (See "Postoperative nausea and vomiting", section on
'Antiemetics'.)
Pain prophylaxis — Postoperative multimodal pain management is patient-specific and

procedure-specific, with the goal of minimizing pain during rest and also during early
mobilization and physical therapy. Combinations of the following agents and techniques may
be used to balance analgesic efficacy with overall side effects in multimodal strategies [13] (see
"Approach to the management of acute pain in adults", section on 'Creating a plan for
analgesia'):
● Nonopioid analgesics – We employ combinations of acetaminophen and a nonsteroidal

antiinflammatory drug (NSAID) or a cyclooxygenase (COX)-2 specific inhibitor in
multimodal pain management protocols for all patients who have no contraindications
(see "Nonselective NSAIDs: Overview of adverse effects" and "Anesthesia for the patient
with liver disease", section on 'Other analgesics') [13,68-71]. We typically administer oral
acetaminophen two hours preoperatively; IV acetaminophen 1 g is administered after
induction of anesthesia only if the patient did not receive preoperative acetaminophen.
Administration of NSAIDs is typically avoided until the surgical procedure itself has been
completed (late during the intraoperative period or in the postoperative period) due to
antiplatelet effects that may increase risk of perioperative bleeding. We typically
administer IV ketorolac 15 to 30 mg (if no contraindications) near the end of the surgical
procedure. However, COX-2 specific inhibitors spare the COX-1 enzyme and have no
antiplatelet effects; thus, these agents may be administered earlier (in the preoperative
period) if desired. Oral or IV preparations of acetaminophen and NSAIDs or COX-2 specific
inhibitors are then continued in the postoperative period with regular scheduled dosing.
Although most experts recommend such combinations of an NSAID plus acetaminophen

[13,68], only heterogeneous evidence of the efficacy of this approach exists because of
differences in the types of surgical procedures studied, specific agents used, and dosing
and timing of administration of these agents. One 2013 meta-analysis included three trials
with 1647 total patients who received a combination of differing doses of ibuprofen and
acetaminophen, ibuprofen alone, or placebo, with agent(s) administered only once in the
perioperative period during various types of surgical procedures [69]. The proportion of
patients achieving at least 50 percent maximum pain relief over six postoperative hours
ranged from 69 to 73 percent with this combination (depending on the dose of each drug)
compared with only 7 percent of those receiving placebo, and only 52 percent of those
receiving ibuprofen alone. No significant adverse events were reported in any of the
included studies [69]. Similarly, an older meta-analysis of 21 trials (2909 patients) that
compared acetaminophen alone or in combination with one of several NSAIDs (ibuprofen,
diclofenac, ketoprofen, ketorolac, aspirin, tenoxicam, or rofecoxib), noted that
combinations of these agents were more effective than either agent alone [71].
Additional considerations regarding administration of NSAIDs and acetaminophen are

discussed in other sections of this topic and elsewhere:
• (See 'Medications administered in the preoperative period' above.)

• (See 'Management of pain' below.)
• (See "Nonopioid pharmacotherapy for acute pain in adults", section on
'Acetaminophen'.)
• (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal
anti-inflammatory drugs'.)
● Local or regional anesthetic techniques – A local or regional anesthetic technique is

often employed as a primary component of a multimodal analgesic regimen [13,72,73].
• Local infiltration or surgical field block – Infiltration of the surgical wound with local
anesthetic provides excellent analgesia that outlasts the duration of action of the drug;
therefore, this technique is used whenever possible [74]. Attention to proper infiltration
technique (ie, infiltration into the peritoneal, musculofascial, and subdermal tissue
planes) is essential to attain the maximum benefits. Catheters may be placed by the
surgeon directly at the site of the incision and can be left in place for days [73]. (See
"Approach to the management of acute pain in adults", section on 'Wound infiltration'.)
An alternative is an interfascial plane block such as the transversus abdominis plane

(TAP) blocks, which provide excellent pain relief after laparoscopic or open lower (below
the umbilicus) abdominal surgical procedures such as total abdominal hysterectomy.
However, a TAP block is unlikely to be superior to surgical site infiltration after a
laparoscopic procedure with a small incision [72]. (See "Abdominal nerve block
techniques", section on 'Transversus abdominis plane (TAP) blocks'.)
New interfascial plane blocks are emerging (eg, quadratus lumborum, serratus plane,
and erector spinae plane blocks). Erector spinae plane blocks provide somatic as well
as visceral analgesia, and may be superior to peripheral interfascial plane blocks (eg,
the TAP block) [72]. Details regarding placement of these blocks are available in
separate topics:
- (See "Thoracic nerve block techniques", section on 'Erector spinae plane block'.)
- (See "Thoracic nerve block techniques", section on 'Serratus plane block'.)
- (See "Quadratus lumborum block procedure guide".)
Some clinicians use long-acting liposomal bupivacaine, which has been approved by
the US Food and Drug Administration, for local infiltration at the surgical wound site.
(See "Clinical use of local anesthetics in anesthesia", section on 'Sustained release
bupivacaine'.)
• Peripheral nerve blocks – Peripheral nerve blocks for the lower extremity (eg, femoral
nerve block) are not used commonly due to concern regarding delays in ambulation
and recovery. Furthermore, since single injection peripheral nerve blocks have a short
duration of action, rebound pain may occur after the block has resolved. However,
brachial plexus blocks are still used for upper extremity surgery, and popliteal sciatic
nerve block are suitable for selected foot and ankle procedures [13]. (See "Approach to
the management of acute pain in adults", section on 'Regional anesthesia techniques'.)
• Neuraxial analgesia – We do not use epidural analgesia in ERAS patients undergoing

minimally invasive procedures (eg, laparoscopic surgery) because of potential delays in
ambulation and hospital discharge due to adverse side effects that may include
postural hypotension, need for a urinary catheter, or inadequate muscle strength. Also,
there is little additional benefit for pain control since alternative analgesic techniques
provide similar pain relief (eg, interfascial plane blocks) [13]. In particular, we avoid
administration of an intrathecal opioid such as morphine for any ERAS procedure due
to high risk for adverse effects including nausea, vomiting, pruritus, urinary retention,
and respiratory depression.
Although epidural analgesia provides excellent pain relief after major open thoracic
and abdominal surgical procedures, it is unnecessary after less invasive surgical
approaches [13]. Rarely, thoracic epidural analgesia is used to prevent or treat pain
after an open procedure with a long midline incision (eg, from the xiphoid process to
the pubis). Such use is typically supplemented with a TAP block for the subumbilical
portion of the incision.
● Fixed dose of a long-acting opioid – For patients who did not receive a regional
anesthetic technique, ERAS protocols include a precalculated dose of a long-acting opioid
for most open surgical procedures. We use morphine 0.05 to 0.1 mg/kg IBW or
hydromorphone 5 to 10 mcg/kg IBW administered approximately 20 minutes prior to the
expected time of extubation (eg, when the surgeon starts closing the abdomen). This
approach does not delay awakening or tracheal extubation [75]. Some clinicians attempt
to titrate a long-acting opioid to produce a respiratory rate of approximately 12 to 15
breaths per minute during emergence from anesthesia, but potential residual effects of
anesthetic agents and NMBAs make this approach challenging.
Long-acting opioids are always used sparingly due to opioid-related adverse effects that
delay recovery and return to activities of daily living (eg, delayed emergence from
anesthesia, postoperative respiratory depression, delirium, PONV, urinary retention
necessitating bladder catheterization, pruritus, development of acute tolerance or
hyperalgesia) [25,50,51]. (See "Perioperative uses of intravenous opioids in adults: General
considerations", section on 'Dosing considerations' and "Perioperative uses of intravenous
opioids in adults: General considerations", section on 'Prevention and management of
adverse opioid effects'.)
● Adjunct agents
• Dexamethasone – As noted above, we routinely administer IV dexamethasone 8 to 10

mg after induction of anesthesia to all patients unless there are contraindications, due
to its antiemetic prophylactic effects (see 'Antiemetic prophylaxis' above), but it also has
analgesic properties [76,77]. Potential concerns regarding increases in blood glucose

and surgical site infections have not been observed in large observational studies
[78,79].
• Ketamine – We do not routinely use intraoperative ketamine to achieve postoperative

analgesia. Although administration of a low dose of ketamine (25 to 50 mg) after
induction of anesthesia has been reported to improve postoperative pain relief [80],
adverse psychotomimetic effects such as hallucinations, nightmares, or vivid dreams
during and shortly after emergence from anesthesia limit its use in ERAS protocols
[13,81,82].
POSTOPERATIVE ANESTHETIC MANAGEMENT
Postoperative goals in ERAS protocols include prevention and relief of pain and postoperative
nausea or vomiting (PONV), as well as facilitation of early nutrition and mobilization [83].
Management of pain — While the patient is in the post-anesthesia care unit (PACU), pain is
treated with small bolus doses of either intravenous (IV) morphine 1 to 2 mg doses (up to 10
mg) or IV hydromorphone 0.1 to 0.2 mg (up to 1 mg).
Subsequently, we use scheduled doses of oral acetaminophen 1 g four times per day and an
oral nonsteroidal antiinflammatory drug (NSAID; eg, meloxicam 15 mg once per day) or oral
cyclooxygenase (COX)-2 specific inhibitor (eg, celecoxib 200 mg twice per day) [13,68-70]. For
patients who do not yet tolerate oral liquids, acetaminophen, ibuprofen, and ketorolac are each
available in an IV formulation. (See "Nonopioid pharmacotherapy for acute pain in adults".)
For major open surgical procedures with a high likelihood of persistent postoperative pain, we
also use oral gabapentin 300 mg three times per day [12,13]. As noted above (see 'Medications
administered in the preoperative period' above), we avoid gabapentin in older patients and
those with sleep-disordered breathing (eg, obstructive sleep apnea) due to concerns regarding
excessive sedation, ventilatory depression, and dizziness [14-17].
We administer oral oxycodone 5 to 10 mg four times per day as needed for breakthrough pain.
For patients unable to take oxycodone, we use tramadol 50 mg four times per day as needed. If
a patient is unable to take oral medications or has severe pain, small bolus doses of IV
morphine (2 to 3 mg) or hydromorphone (0.5 mg) may be administered as needed. In rare
circumstances, it may be necessary to administer IV opioids via IV patient-controlled analgesia
to achieve control of postoperative pain. (See "Use of opioids for postoperative pain control".)
Management of nausea and vomiting — For patients requiring postoperative rescue

antiemetic therapy to treat PONV, we typically administer IV promethazine 6.25 mg and/or
ondansetron 4 mg (no earlier than four hours after an intraoperative ondansetron dose) and/or
dimenhydrinate 1 mg/kg. (See "Postoperative nausea and vomiting".)
Observation for cardiopulmonary problems — Even after minimally invasive surgery and

adherence to an ERAS protocol, observation and prompt treatment of postoperative problems
such as hypoxemia or orthostatic hypotension is necessary [84,85].
OUTCOMES
Data from observational studies and randomized trials in patients undergoing colorectal
surgery show that ERAS protocols are associated with reduced hospital length of stay and
morbidity, reduced postoperative pain, faster recovery, comparable or reduced readmission
rate, and cost savings compared with traditional care. Adherence to a standardized ERAS
protocol impacts outcomes such as complications and length of hospital stay [27,86,87]. Further
discussion regarding these outcomes is available in a separate topic. (See "Enhanced recovery
after colorectal surgery", section on 'Outcomes'.)
Similarly, studies in various types of gynecologic surgery have noted that ERAS protocols are
associated with decreased pain, length of stay, use of nursing time, and overall costs, thereby
improving patient satisfaction and quality of life. (See "Enhanced recovery after gynecologic
surgery: Components and implementation", section on 'Outcomes'.)
Short- and long-term postoperative outcomes are influenced by anesthesia-related

management as part of a multidisciplinary team effort during the preoperative, intraoperative,
and postoperative periods [3,6,28].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Postoperative nausea
and vomiting" and "Society guideline links: Enhanced recovery after surgery".)
SUMMARY AND RECOMMENDATIONS
● Preoperative considerations – Management to facilitate enhanced recovery after surgery

(ERAS) emphasizes ( table 1) (see 'Preoperative considerations' above):
• Identifying comorbidities and opportunities to optimize preoperative condition

• Minimizing the fasting period and maintaining hydration during the fasting period
• Educating patient and family to reduce patient anxiety and set realistic expectations,
particularly regarding plans for pain management
● Preoperative medications – Medications for ERAS protocols given in the preoperative

period typically include oral acetaminophen 1 g and a cyclooxygenase (COX)-2 specific
inhibitor (eg, celecoxib 400 mg) administered at least two hours preoperatively for
patients without contraindications to these agents. Oral gabapentin is reserved for
selected patients undergoing surgical procedures with a high risk of persistent
postoperative pain (300 to 600 mg administered at least two hours preoperatively). Also,
thromboprophylaxis with subcutaneous heparin 5000 units is administered 30 to 60
minutes before surgery. We avoid routine administration of benzodiazepine
premedication. (See 'Medications administered in the preoperative period' above.)
● Anesthetic induction – A typical anesthetic induction sequence includes intravenous (IV)

fentanyl approximately 0.5 to 1 mcg/kg ideal body weight (IBW), given three to five
minutes prior to lidocaine 20 to 30 mg, followed by propofol 1 to 1.5 mg/kg to achieve loss
of eyelash reflex and/or response to verbal command. In addition, a nondepolarizing
neuromuscular blocking agent (NMBA) such as rocuronium 0.6 to 1 mg/kg IBW may be
administered to facilitate laryngoscopy and endotracheal intubation. (See 'Induction of
anesthesia' above.)
● Anesthetic maintenance – During maintenance of anesthesia, we prefer an inhalation-

based technique with a potent volatile agent (desflurane or sevoflurane) and nitrous oxide
(N2O) 50 percent in oxygen to achieve an age-adjusted minimum alveolar concentration
(MAC) value of approximately 0.8 to 1.0, and we avoid deep anesthesia. A total intravenous
anesthesia (TIVA) technique is a reasonable alternative for selected patients (eg, those at
very high risk for postoperative nausea and vomiting [PONV]). (See 'Inhalation versus total
intravenous anesthesia techniques' above.)
We use short-acting agents administered at the lowest possible doses:
• Small bolus doses of an opioid (eg, fentanyl 25 to 50 mcg) may be administered as

needed, but we typically limit the dose (eg, ≤1 mcg/kg per hour fentanyl). For TIVA
techniques, a remifentanil infusion is typically selected for the opioid component. (See
'Opioids' above.)
• We routinely use N2O for ERAS procedures. Its amnestic and analgesic properties
reduce the requirements of other anesthetic and adjuvant agents, and its "second gas
effect" facilitates both uptake and removal of the potent volatile inhalation anesthetics.
(See 'Nitrous oxide' above.)
• An NMBA is often administered to facilitate surgical exposure, but we monitor the

effects of the NMBA with a peripheral nerve stimulator to avoid profound muscle
paralysis. (See 'Neuromuscular blocking agents' above.)
● Lung-protective ventilation – We use lung protective ventilatory parameters including

low tidal volumes (ie, 6 to 8 mL/kg IBW), initial positive end-expiratory pressure (PEEP) 5
cm H2O (or 8 to 10 cm H2O during laparoscopic procedures), plateau pressures ≤16
mmHg, driving pressure (defined as the difference between plateau pressure and PEEP)
≤16 mmHg, fraction of inspired oxygen (FiO2) 0.4 to 0.5, and an initial respiratory rate of 8
breaths/minute, subsequently adjusted to maintain end-tidal carbon dioxide (ETCO2) levels
at approximately 40 mmHg. (See 'Mechanical ventilation' above.)
● Fluid management – We typically use a zero-balance fluid therapy approach that

minimizes fluid administration for minimally or moderately invasive surgery with
administration of a balanced electrolyte solution at 3 mL/kg/hour. For high-risk patients
undergoing major surgical procedures, this approach is supplemented with goal-directed
fluid therapy with administration of fluid boluses (typically 200 to 250 mL) based on
dynamic hemodynamic parameters. (See 'Fluid management' above.)
● Maintenance of normothermia – Core body temperature is routinely monitored and

warming devices are employed to maintain normothermia (temperature ≥35.5°C). (See
'Temperature control' above.)
● Glycemic control – Perioperative blood glucose levels are monitored and maintained
between 140 and 200 mg/dL (7.8 to 11 mmol/L) in both diabetic and nondiabetic patients.
(See 'Glycemic control' above.)
● Antiemetic prophylaxis – Antiemetic prophylaxis includes IV dexamethasone 8 to 10 mg

after induction of anesthesia and ondansetron 4 mg at the end of surgery. For patients at
very high risk of PONV, we add a third antiemetic (eg, preoperative transdermal
scopolamine patch or intraoperative IV haloperidol 0.5 to 1 mg shortly after induction).
Postoperative rescue antiemetic therapy to treat PONV includes IV promethazine 6.25 mg
and/or ondansetron 4 mg (no earlier than four hours after an intraoperative ondansetron
dose) and/or dimenhydrinate 1 mg/kg. (See 'Antiemetic prophylaxis' above and
'Management of nausea and vomiting' above.)
● Multimodal pain management – We employ intraoperative and postoperative

multimodal pain prophylaxis and management strategies that minimize perioperative
opioid use including (see 'Pain prophylaxis' above and 'Management of pain' above):
• We suggest administration of a combination of acetaminophen and a nonsteroidal

antiinflammatory drug (NSAID) or a COX-2 specific inhibitor (Grade 2B). We typically
administer acetaminophen 1 g IV shortly after induction of anesthesia (if not previously
administered in the preoperative period), as well as a NSAID such as ketorolac 15 to 30
mg IV at the end of surgery.
• Local or regional techniques, such as surgical site infiltration and interfascial plane
blocks. However, we avoid epidural analgesia and intrathecal morphine because of
potential delays in ambulation and hospital discharge without additional benefits for
pain control.
• For patients undergoing open procedures without a regional anesthetic technique,

administration of a precalculated dose of a long-acting opioid approximately 20
minutes before extubation (eg, morphine 0.05 to 0.1 mg/kg IBW or hydromorphone 5
to 10 mcg/kg IBW).
• For pain while the patient is in the post-anesthesia care unit (PACU), administration of
small bolus doses of either IV morphine 1 to 2 mg doses (up to 10 mg) or IV
hydromorphone 0.1 to 0.2 mg (up to 1 mg).
• Subsequently, we use scheduled doses of oral acetaminophen 1 g four times per day
and an oral NSAID (eg, meloxicam 15 mg once per day) or oral COX-2 specific inhibitor
(eg, celecoxib 200 mg twice per day). For patients who do not yet tolerate oral liquids,
acetaminophen, ibuprofen, and ketorolac are each available in an IV formulation.
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Topic 113724 Version 25.0
GRAPHICS
Overview of enhanced recovery pathway*
Preoperative considerations
Identification and optimization of comorbid conditions

Prehabilitation, if necessary
Patient and family education and discharge planning
Avoidance of prolonged preoperative fasting
Pain management planning (procedure-specific multimodal opioid-sparing pain prophylactic
agents administered at least two hours before surgery)
Oral acetaminophen 1 g ¶
Oral cyclooxygenase (COX)-2 specific inhibitor ¶
Oral gabapentin in selected patients undergoing procedures with a high risk for persistent
postoperative pain Δ
For selected procedures, thromboembolism prophylaxis with subcutaneous heparin 5000 units
administered 30 to 60 minutes before surgery
Intraoperative considerations
Use of a minimally invasive surgical approach, when feasible

Antibiotic prophylaxis administered 30 to 60 minutes before the surgical incision
Use of short-acting anesthetic agents (inhalation and/or IV agents) during induction and
maintenance of general anesthesia
Avoidance of fluid overload
Lung protective mechanical ventilation
Maintenance of normothermia
Glycemic control
Multimodal antiemetic prophylaxis
IV dexamethasone 8 mg after induction of anesthesia ¶
IV 5-HT3 antagonist (eg, ondansetron 4 mg at the end of the surgical procedure) ¶
For patients at very high risk for PONV, use of a third antiemetic agent (eg, preoperative
transdermal scopolamine, intraoperative IV haloperidol 0.5 to 1 mg shortly after anesthetic
induction, and/or use of TIVA anesthetic technique)
Procedure-specific multimodal opioid-sparing pain prophylaxis
Use of local or regional analgesic techniques (ie, peripheral nerve block, interfascial plane
blocks, surgical site infiltration), when feasible
IV acetaminophen 1 g after induction of anesthesia (if it was not administered
preoperatively) ¶
IV ketorolac 15 to 30 mg near the end of the surgical procedure ¶
Administration of a long-acting IV opioid (eg, morphine 0.05 to 0.1 mg/kg IBW,

hydromorphone 5 to 10 mcg/kg IBW) approximately 20 minutes before extubation ¶
Postoperative considerations
Rescue therapy for PONV using one or more IV agents

IV promethazine 6.25 mg ¶
IV dimenhydrinate 1 mg/kg ¶
IV 5-HT3 antagonist (but no sooner than four hours after previous ondansetron dose) ¶
Procedure-specific multimodal opioid-sparing pain management
Administration of IV morphine 1 to 2 mg doses (up to 10 mg) or IV hydromorphone 0.1 to
0.2 mg doses (up to 1 mg) while patient is in the PACU
Subsequent scheduled daily doses of oral acetaminophen plus an oral NSAID such as
meloxicam 15 mg, PO once a day or a COX-2 specific inhibitor (eg, celecoxib 200 mg PO
twice a day) ¶
For patients who do not tolerate oral agents, acetaminophen, ibuprofen, and ketorolac are
available in an IV formulation and should be administered as scheduled daily doses
For patients with persistent postoperative pain, oral gabapentin can also be administered in
scheduled daily doses Δ
For breakthrough postoperative pain, oral oxycodone 5 to 10 mg or oral tramadol 50 mg
can be administered as needed
Resumption of oral feeding as soon as feasible
Early postoperative mobilization and physical therapy
IV: intravenous; 5-HT3: 5-hydroxytryptamine type 3; PONV: postoperative nausea and vomiting; TIVA:
total intravenous anesthesia; IBW: ideal body weight; PACU: post-anesthesia care unit; NSAID:
nonsteroidal anti-inflammatory agent; PO: per os (by mouth).
* Refer to topics with content discussing enhanced recovery after surgery (ERAS).
¶ If no contraindications to this medication.
Δ Gabapentin is considered only for selected patients with a high likelihood of persistent
postoperative pain, and is avoided in patients >65 years of age, and those who have sleep
disordered breathing (eg, obstructive sleep apnea).
Graphic 127176 Version 2.0
Contributor Disclosures
Girish P Joshi, MB, BS, MD, FFARCSI Consultant/Advisory Boards: Baxter [anesthesia]. All of the relevant
financial relationships listed have been mitigated. Roberta Hines, MD No relevant financial relationship(s)
with ineligible companies to disclose. Nancy A Nussmeier, MD, FAHA No relevant financial relationship(s)
with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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3/3/23, 14:34 Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS) - UpToDate

Official reprint from UpToDate®

Anesthetic management for enhanced recovery after

Details regarding surgical management of enhanced recovery after colorectal surgery or

https://www.uptodate.com/contents/anesthetic-management-for-enhanced-recovery-after-major-noncardiac-surgery-eras/print?search=Anesthetic ma… 1/31

This table provides an overview of ERAS elements (interventions) ( table 1).

Several other ERAS elements including preoperative optimization of comorbid conditions,

● (See "Preoperative evaluation for anesthesia for noncardiac surgery".)

https://www.uptodate.com/contents/anesthetic-management-for-enhanced-recovery-after-major-noncardiac-surgery-eras/print?search=Anesthetic ma… 2/31

● (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Other perioperative ERAS elements such as avoidance of mechanical bowel preparation,

Preanesthesia consultation — Important goals during the preanesthesia consultation are to

● Identify comorbidities and opportunities to optimize the patient's preoperative condition,

https://www.uptodate.com/contents/anesthetic-management-for-enhanced-recovery-after-major-noncardiac-surgery-eras/print?search=Anesthetic ma… 3/31

management emphasizes realistic expectations regarding postoperative pain relief [6,9-

Prehabilitation efforts such as nutritional supplementation, physical exercise programs,

Medications administered in the preoperative period — Medications administered in the

● Oral acetaminophen 1 g, administered at least two hours preoperatively if there are no

● For selected surgical procedures, thromboprophylaxis with subcutaneous heparin 5000

● We avoid routine administration of benzodiazepine premedication. Many

INTRAOPERATIVE ANESTHETIC MANAGEMENT

Induction of anesthesia — Major surgical procedures are typically performed under general

https://www.uptodate.com/contents/anesthetic-management-for-enhanced-recovery-after-major-noncardiac-surgery-eras/print?search=Anesthetic ma… 5/31

achieve loss of consciousness [30,31]. (See "Induction of general anesthesia: Overview",

● Neuromuscular blocking agents – An intermediate-acting non-depolarizing NMBA such

• (See "Induction of general anesthesia: Overview", section on 'Neuromuscular blocking

Antibiotic prophylaxis — Routine IV antibiotic prophylaxis is administered 30 to 60 minutes

Inhalation versus total intravenous anesthesia techniques — Maintenance of general

https://www.uptodate.com/contents/anesthetic-management-for-enhanced-recovery-after-major-noncardiac-surgery-eras/print?search=Anesthetic ma… 6/31

● Inhalation anesthesia – For most patients, we prefer an inhalation-based technique with

Advantages of the potent volatile inhalation anesthetics include (see "Inhalation

• Some degree of muscle relaxation, allowing minimized dosing of NMBA. (See

• Availability of end-tidal anesthetic concentration (ETAC) to aid in maintenance of

However, there is insufficient evidence to recommend use of EEG monitoring to

• Rapid recovery, particularly with use of the short-acting inhalation anesthetics

● Total intravenous anesthesia – A TIVA technique may be employed in selected patients

A typical TIVA technique includes infusion of propofol 75 to 150 mcg/kg/minute, with

Neuromuscular blocking agents — An NMBA is often administered to facilitate surgical

● (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Facilitation

Mechanical ventilation — Intraoperative lung protective mechanical ventilation reduces

● Maintenance phase of general anesthesia – Optimal lung protective parameters include

• Initial positive end-expiratory pressure (PEEP) 5 cm H2O (or 8 to 10 cm H2O during

• Initial respiratory rate of 8 breaths/minute, subsequently adjusted to maintain end-

• Performance of recruitment maneuvers only when indicated to improve oxygenation

● Emergence from general anesthesia – During emergence, we maintain minute

Fluid management — Intraoperative fluid management is aimed at restoring and maintaining

● (See "Intraoperative fluid management", section on 'Major invasive surgery'.)

Temperature control — Core body temperature is routinely monitored at the esophageal or

Hypothermia is avoided because of potential complications in the immediate- and long-term

Glycemic control — Perioperative glycemic control is initiated in the preoperative period,

associated perioperative complications. (See "Perioperative management of blood glucose in

Antiemetic prophylaxis — We routinely use multimodal antiemetic prophylaxis in all patients

We typically use a combination of IV dexamethasone 8 to 10 mg administered after induction of

Pain prophylaxis — Postoperative multimodal pain management is patient-specific and

● Nonopioid analgesics – We employ combinations of acetaminophen and a nonsteroidal

Although most experts recommend such combinations of an NSAID plus acetaminophen

Additional considerations regarding administration of NSAIDs and acetaminophen are

• (See 'Medications administered in the preoperative period' above.)

● Local or regional anesthetic techniques – A local or regional anesthetic technique is

An alternative is an interfascial plane block such as the transversus abdominis plane

• Neuraxial analgesia – We do not use epidural analgesia in ERAS patients undergoing

• Dexamethasone – As noted above, we routinely administer IV dexamethasone 8 to 10

analgesic properties [76,77]. Potential concerns regarding increases in blood glucose