Table 1.
Components of modified enhanced recovery after surgery (ERAS) program.
| Preoperative |
| Education and counseling: verbal and written information on postoperative expectationsa |
| Preoperative optimization (e.g., address smoking, alcohol use, anemia, and diabetes) |
| Antimicrobial prophylaxis and skin preparation consistent with SCIP guidelines |
| Pre-treatment pain control and nausea (acetaminophen, gabapentin, scopolamine) |
| Regional anesthesia for open cases (transversus abdominis plane block or epidural) |
| Bowel preparation with magnesium citrate or GoLYTELY at 4 pm 1 day prior to surgeryb |
| Clear liquids 2–4 h prior to surgery |
| Intraoperative |
| Short-acting anesthetic agents allowing for rapid awakening (e.g., propofol and sevoflurane) |
| Opioid-sparing anesthesia with limited use of long-acting opioids |
| Maintain tidal volume 5–7 ml/kg (usually <500 ml) and PEEP at 4–6 cm H2O |
| Multimodal antiemetics (ondansetron, metoclopramide, scopolamine) |
| Maintain intraoperative temperature above 36°C |
| Perioperative fluid management: maintain euvolemia |
| Postoperative |
| Multimodal approach to postoperative nausea and vomiting with >2 antiemetics |
| VTE prophylaxis: with extended prophylaxis for laparotomy for pelvic malignancy |
| Termination of IV fluids within 24 h after surgery |
| Regular diet within the first 24 h of surgery |
| Multi-agent bowel regimen of docusate oral or suppository and polyethylene glycol 3350 |
| Postoperative glucose control <180 |
| Multimodal analgesiac |
| Urinary catheter removed within 24 h of surgery |
| Early mobilization within 24 h of surgery |
| Postoperative day 0 discharge minimally invasive surveryd |
| Postoperative day 1 discharge open surgeryd |
| Discharge regimen: tramadol × 3 days, ibuprofen × 10 days, docusate × 30 daysd |
| Simplified discharge criteria |
| Stable vital signs |
| Appropriate and stable postoperative hemoglobin or hematocrit |
| Adequate urine output with normal or stable kidney function |
| Ability to tolerate a solid diet without vomiting, abdominal distension, or pain |
| Ability to ambulate or move sufficiently enough to manage at current home environment |
| Ability to tolerate pain with a multimodal pain regimen |
| Voiding spontaneously unless a Foley catheter is clinically indicated |
| No social barrier for postoperative recovery after discharge |
SCIP, Surgical Care Improvement Project; PEEP, positive end-expiratory pressure; VTE, venous thromboembolism.
Postoperative expectations include information on the procedure, pain, and length of stay.
GoLYTELY [polyethylene glycol 3350 227.1 g, sodium sulfate (anhydrous) 21.5 g, sodium bicarbonate 6.36 g, sodium chloride 5.53 g, potassium chloride 2.82 g]—patients were instructed to drink a total of up to 1 gal at a rate of 240 ml (8 oz.) every 10 min until 1 gal is consumed or the rectal effluent is clear. Magnesium citrate—patients were instructed to drink one bottle with four glasses of water at 4 pm on 1 day prior to surgery. Patients who underwent laparoscopic surgery at our department did not have bowel preparation.
Including acetaminophen, ketorolac or ibuprofen, lidocaine patch, gabapentin, abdominal binder, and tramadol.
If no contraindication.