Box 1.

Enhanced Recovery Pathway

I. Preoperative diet	Evening before surgery: carbohydrate loading drink; may eat until midnight May ingest fluids up to 4 h before procedure Eliminate use of mechanical bowel preparation; rectal enemas still performed
II. Intraoperative
Analgesia before operative  room entry	Celecoxib 400 mg orally once Acetaminophen 1,000 mg orally once Gabapentin 600 mg orally once
Postoperative nausea and  vomiting prophylaxis	Before incision (±30 min): dexamethasone 4 mg IV once plus droperidol 0.625 mg IV once Before incision closure (±30 min): granisetron 0.1 mg IV once
Fluid balance	Goal: maintain intraoperative euvolemia ○ Decrease crystalloid administration ○ Increase colloid administration if needed
Analgesia	Opioids IV at discretion of anesthesiologist supplemented with ketamine, ketorolac, or both After incision closure: injection of bupivacaine at incision site
Anesthesia in pelvic organ  prolapse surgery	Subarachnoid block containing bupivacaine and hydromorphone (40−100 micrograms) Sedation vs “light” general anesthetic at the discretion of the anesthesiologist Ketorolac 15 mg IV at the end of the procedure for patients able to tolerate it No wound infiltration with bupivacaine in this cohort
III. Postoperative
Activity	Evening of surgery: out of bed greater than 2 h, including one or more walks and sitting in chair Day after surgery and until discharge: out of bed greater than 8 h including four or more walks and sitting in chair Patient up in chair for all meals
Diet	No nasogastric tube; if nasogastric tube used intraoperatively, remove at extubation Patient encouraged to start low residual diet 4 h after procedure Day of surgery: one box of liquid nutritional supplement; encourage oral intake of at least 800 mL of fluid, but no more than 2,000 mL by midnight Day after surgery until discharge: two boxes of liquid nutritional supplement; encourage daily oral intake of 1,500–2,500 mL of fluids Osmotic diarrhetics: senna and docusate sodium; magnesium oxide; magnesium hydroxide as needed
Analgesia	Goal: no IV patient-controlled analgesia Oral opioids ○ Oxycodone 5–10 mg orally every 4 h as needed for pain rated 4 or greater or greater than patient stated comfort goal (5 mg for pain rated 4–6 or 10 mg for pain rated 7–10); for patients who received intrathecal analgesia, start 24 h after intrathecal dose given Scheduled acetaminophen* ○ Acetaminophen 1,000 mg orally every 6 h for patients with no or mild hepatic disease; acetaminophen 1,000 mg orally twice daily for patients with moderate hepatic disease; maximum acetaminophen should not exceed 4,000 mg/24 h from all sources Scheduled NSAIDs ○ Ketorolac 15 mg IV every 6 h for four doses (start no sooner than 6 h after last intraoperative dose); then, ibuprofen 800 mg orally every 6 h (start 6 h after last ketorolac dose administered) If patient unable to take NSAIDs ○ Tramadol 100 mg orally 4 times a day (start at 6:00 am day after surgery) for patients younger than 65 years of age and no history of renal impairment or hepatic disease; tramadol 100 mg orally twice daily (start at 6:00 am day after surgery) for patients 65 years of age or older or creatinine clearance less than 30 mL/min or history of hepatic disease Breakthrough pain (pain greater than 7 more than 1 h after receiving oxycodone) ○ Hydromorphone 0.4 mg IV once if patient did not receive intrathecal medications; may repeat once after 20 min if first dose ineffective IV patient-controlled analgesia ○ Hydromorphone patient-controlled analgesia started only if continued pain despite 2 doses of IV hydromorphone
Fluid balance	Operating room fluids discontinued on arrival to floor Fluids at 40 mL/h until 8:00 am on day after surgery and then discontinued Peripheral lock IV when patient had 600 mL orally intake or at 8:00 am on day after surgery, whichever came first

IV, intravenous; NSAIDs, nonsteroidal anti-inflammatory drugs.

^*Doses for patients greater than 80 kg and younger than 65 years of age; doses adjusted as appropriate for patients less than 80 kg or 65 years of age or older.