Table 1.

Changes in the standard of care with the gradual implementation of an enhanced recovery after surgery (ERAS) protocol

Standard of care at commencement of study	Changes to care by quartile
Preoperative care	No changes
Admission on day of surgery
Oral carbohydrate loading
No bowel preparation or routine use of premedication
Prophylactic antibiotics on induction and at closure if the duration of surgery exceeds 180 min
Intraoperative care	Quartile 1
Anaesthesia with volatile anaesthetic, short-acting opioids and anti-emetics	From hepatic resection 14: switch from epidural analgesia to intrathecal morphine because of inability to provide an appropriate post-epidural care package18
Intravenous fluids: titrated against central venous pressure (central venous pressure targeted at <5 cmH2O intraoperatively, then 8 cmH2O in the early postoperative period)	From hepatic resection 27: introduction of bolus delivery (intermittent) wound catheters with 40 ml 0.2% ropivacaine every 6 h for 3 days with a 3-mg/kg loading dose at the time of closure
Intraoperative hypothermia was minimized by use of upper and lower body warming devices	Quartile 3
All resections were performed by open surgery using transverse incisions	From hepatic resection 79: commercial continuous delivery system of 0.2% ropivacaine
Not used routinely: drains, nasogastric tubes
Postoperative care	Quartile 1
Deep vein thrombosis prophylaxis (20–40 mg enoxaparin subcutaneously from the evening of surgery)	From hepatic resection 8: routine use of NSAIDs with omeprazole cover at 24 h postoperatively
Analgesia: paracetamol 1 g q.i.d.
Opioid-based patient-controlled analgesia
Anti-emetics as required
Not used routinely: laxatives, diuretics, immunonutrition, gabapentin19
Eat and drink as tolerated without restriction from day 0
Early mobilization
Urinary catheter removed at day 1

NSAIDs, non-steroidal anti-inflammatory drugs.