Table 1.
Enhanced recovery program
| Perioperative care and discharge criteria |
| Preoperative care |
| Preadmission information and counselling |
| Preoperative bowel preparation |
| Preoperative fasting: 2 h for liquids and 6 h for solids |
| Preanesthesia medication |
| From midnight prior to surgery, patients did not receive medications known to cause long-term sedation. Patients chronically taking benzodiazepines were allowed to continue until the night prior to surgery |
| Short-acting medications given to facilitate insertion of the epidural catheter were accepted |
| Prophylaxis against thromboembolism |
| Subcutaneous enoxaparin 40 mg were given 12 h before the expected time of thoracic epidural catheter insertion. It was continued at 40 mg daily until discharge. |
| Antimicrobial prophylaxis |
| Patients received single-dose antibiotic prophylaxis against both anaerobes and aerobes about 1 h before surgery. |
| Perioperative management |
| Standard anesthesia protocol |
| Long-acting intravenous/epidural opioids were avoided in all patients unless epidural anesthesia was contraindicated. |
| A load dose of intravenous ketorolac (1 mg per kg body weight, calculated according to Ideal Body Weight) and a load dose of dipyrone sodium (20 mg per kg, calculated according to Ideal Body Weight) were given if not contraindicated to provide a multimodal analgesic regimen. |
| A midthoracic epidural commenced preoperatively containing a local anesthetic (lidocaine 2 % without epinephrine) was used unless contraindicated. Intraoperative epidural low dose fentanyl (0.5–1 μg per kg of body weight, calculated according to Ideal Body Weight) and clonidine (0.5–1 μg per kg, calculated according to Ideal Body Weight) were added to provide postoperative analgesia. |
| Preventing and treating postoperative nausea and vomiting |
| Intravenous dexamethasone 8 mg (g dose) and ondansetron 8 m (single dose) given after induction of anesthesia |
| Metoclopramide hydrochloride or droperidol was given if nausea or vomiting actually occurred. |
| Nasogastric intubation |
| Preventing intraoperative hypothermia |
| Intraoperative maintenance of normothermia with an upper-body forced-air heating cover was used routinely. |
| Perioperative fluid management and hemodynamic management |
| Preload of 500 mL of colloid was given routinely before epidural administration of local anesthetics. |
| Intraoperatively, lactated Ringer’s solution, 4 ml/kg per hour according to ideal body weight. |
| Blood loss was replaced 1:1 with colloids . |
| Transfusion (red cells) was given according to a preoperative target hematocrit that was defined according to age (older or younger than 65 years of age) and the presence or absence of cardiopathy. If neither of these determinants were present (cardiopathy or age older than 65) target hematocrit was 26. If only one of these factors was present, the target hematocrit was 28. Finally, if both factors were present (age older than 65 and presence of cardiopathy) the target hematocrit was 30. |
| Urinary drainage |
| Urrinay catheterization was maintained routinely for 24 h after operation |
| Prevention of postoperative ileus |
| Midthoracic epidural analgesia and avoidance of fluid overload were used to prevent postoperative ileus. |
| Posptoerative care |
| Postoperative analgesia |
| During the time patients stayed in the Post Anesthesia Care Unit (PACU) they received a continuous epidural midthoracic low-dose local anesthetic (0.125 % bupivacaine) and a low-dose opioid (2 mg per mL of the analgesic solution). Epidural catheters were removed before discharge from PACU. |
| Ketorolac 1 mg/kg (calculated according to Ideal Body Weight) was given every 8 h throughout the postoperative course. |
| Oral analgesia was provided when the patient was able to tolerate oral intake. |
| Postoperative nutritional care |
| Liquid diet postoperative day (POD) 1 |
| Soft diet POD 2 |
| Early mobilization |
| Patients were nursed in an environment that encouraged independence and mobilization. |
| Patients were strongly encouraged to be out of bed longer than 2 h beginning on the day after operation |
| Discharge criteria |
| Passing flatus or stool |
| Afebrile, and without tachycardia |
| Tolerance of oral feeding |
| Adequate control of pain with oral analgesia |
| Patient ambulating independently |
| Adequate support at home |