Table 1.

Enhanced Recovery Pathway

I. Preoperative
Diet	• Evening before surgery: may eat until midnight • Clear fluids up to 2 h before procedure, including 50 g Carbohydrate in 400 ml (Nutricia ®)
Bowel preparation	• No systematic use of mechanical bowel preparation; rectal enemas still performed
Preoperative sedation	• No systematic preoperative sedation, unless anxious crisis
II. Intraoperative
Nausea and vomiting prophylaxis	• Before incision: Dexamethasone 8 mg IV once (4 mg if age > 80 or weight < 50 kg) • Before incision closure: ✓ Droperidol 1.25 mg IV once ✓ Ondansetron 4 mg IV once in high risk patient (Apfel score > 3)
Fluid balance	• Goal: maintain intraoperative Zero Fluid Balance ✓ crystalloid maintenance administration: 3 ml/kg/h for laparoscopy; 5 ml/kg/h for open ✓ In case of blood loss: replacement according to institutional protocol
Analgesia	• Continuous AIVOC Remifentanyl at discretion of anesthesiologist, supplemented with IV Ketamine (0.5 mg/kg at induction and 0,15 mg/kg hourly boluses) • IV Lidocaine 1 mg/kg at induction, then 1,5 mg/kg/h until the end of surgery • Before the end of surgery: IV 1000 mg Acetaminophen, 100 mg Ketoprofen (if no contraindication) and 20 mg Nefopam • In case of laparoscopy: injection of Naropein (2 mg/kg maximum) at incision site • In case of laparotomy: bilateral single shot Tap Block with Naropein (2 mg/kg maximum). No epidural analgesia
III. Postoperative
Activity	• Evening of POD 0: out of bed more than 2 h, including sitting in chair • POD 1 and until discharge: out of bed more than 4 h, including deambulation in ward and sitting in chair • Patient up in chair for all meals • Removal of urinary catheter by POD 1
Diet	• No nasogastric tube; if nasogastric tube used intraoperatively, removal at extubation • Patient encouraged to start clear fluid 2 h after procedure • POD 0: Patient encouraged to start free diet. In case of difficulties, one to two boxes of liquid nutritional supplement • POD 1 until discharge: free diet. Encourage daily oral fluid intake (1500–2500 mL)
Analgesia	• Goal: opioid sparing; no IV morphin patient-controlled analgesia • Scheduled oral level II opioids ✓ Izalgi® (Acetominophen 500 mg + Opium powder) orally every 6 h • Scheduled Acetaminophen ✓ Acetaminophen 500 mg orally every 6 h ✓ For patients with no hepatic disease: Maximum Acetaminophen should not exceed 4000 mg/24 h from all sources including Izalgi® • Scheduled NSAIDs if no contraindication: renal impairment with creatinine clearance less than 40 ml/min or hepatic disease ✓ Ketoprofen 100 mg orally twice daily (start no sooner than 6 h after the intraoperative dose), until POD 2 ✓ If patient unable to take NSAIDs: Tramadol 50 mg orally every 6 h. • Breakthrough pain ✓ Oxycodone 5–10 mg orally every 4 h if needed
Fluid balance	• Peripheral IV catheter locked on departure from PACU • In case of laparotomy: Fluid maintenance at 40 mL/h until 8:00 am the day after surgery and then discontinued

Abbreviations: IV intra venous, PACU Post anaesthesia care unit, POD post operative day