(ERAS) For Gastrointestinal Surgery For Anaesthesia Practice

REVIEW ARTICLE
Enhanced Recovery After Surgery (ERAS) for gastrointestinal

surgery, part 2: consensus statement for anaesthesia practice
A. Feldheiser1, O. Aziz2, G. Baldini3, B. P. B. W. Cox4, K. C. H. Fearon5, L. S. Feldman6, T. J. Gan7,
R. H. Kennedy8, O. Ljungqvist9, D. N. Lobo10, T. Miller7, F. F. Radtke1, T. Ruiz Garces11, T. Schricker12,
M. J. Scott13, J. K. Thacker14, L. M. Ytrebø15 and F. Carli3
1
Department of Anesthesiology and Intensive Care Medicine Campus Charite , Mitte and Campus Virchow-Klinikum Charit
e, University Medicine,
Berlin, Germany
2
St. Mark’s Hospital, Harrow, Middlesex, UK
3
Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
4
Department of Anesthesiology and Pain Therapy, University Hospital Maastricht (azM), Maastricht, The Netherlands
5
University of Edinburgh, The Royal Infirmary, Clinical Surgery, Edinburgh, UK
6
Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
7
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
8
St. Mark’s Hospital/Imperial College, Harrow, Middlesex/London, UK
9 €
Department of Surgery, Faculty of Medicine and Health, Orebro €
University, Orebro, Sweden
10
Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University
Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
11
Anestesiologa y Reanimacin, Hospital Clinico Lozano Blesa, Universidad de Zaragoza, Zaragoza, Spain
12
Department of Anesthesia, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada
13
Royal Surrey County Hospital NHS Foundation Trust, University of Surrey, Surrey, UK
14
Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
15
Department of Anaesthesiology, University Hospital of North Norway, Tromso, Norway
Correspondence Background: The present interdisciplinary consensus review

F. Carli, Department of Anesthesia, McGill
University Health Centre, Room D10.165.2, 1650 proposes clinical considerations and recommendations for anaes-
Cedar Ave, Montreal, Quebec H3G 1A4, Canada thetic practice in patients undergoing gastrointestinal surgery
E-mail: franco.carli@mcgill.ca with an Enhanced Recovery after Surgery (ERAS) programme.
Current Address Methods: Studies were selected with particular attention being
T. J. Gan, Department of Anesthesiology, paid to meta-analyses, randomized controlled trials and large
Stony Brook University, New York, USA
prospective cohort studies. For each item of the perioperative
Conflicts of interest
Dr Olle Ljungqvist is founder, shareholder,
treatment pathway, available English-language literature was
board member Encare AB, Sweden; board examined and reviewed. The group reached a consensus recom-
member Nutricia A/S The Netherlands; he also mendation after critical appraisal of the literature.
receives speaker’s honoraria from Fresenius
Kabi, B/Braun, Nutricia, Merck. Dr Dileep N Lobo
Results: This consensus statement demonstrates that anaesthesi-
has received speaker’s honoraria and ologists control several preoperative, intraoperative and postoper-
unrestricted research funding from Fresenius ative ERAS elements. Further research is needed to verify the
Kabi, Baxter & BBraun, and has served on
advisory boards of AbbVie & Baxter. strength of these recommendations.
Funding Conclusions: Based on the evidence available for each element of
None. perioperative care pathways, the Enhanced Recovery After Sur-
Submitted 23 September 2015; accepted 25 gery (ERAS ) Society presents a comprehensive consensus
September 2015; submission 23 January 2015. review, clinical considerations and recommendations for anaesthe-
Citation
sia care in patients undergoing gastrointestinal surgery within an
Feldheiser A, Aziz O, Baldini G, Cox BPBW, ERAS programme. This unified protocol facilitates involvement of
Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, anaesthesiologists in the implementation of the ERAS pro-
Ljungqvist O, Lobo DN, Miller T, Radtke FF,
Ruiz Garces T, Schricker T, Scott MJ, Thacker
grammes and allows for comparison between centres and it even-
JK, Ytrebø LM, Carli F. Enhanced Recovery tually might facilitate the design of multi-institutional prospective
After Surgery (ERAS) for gastrointestinal and adequately powered randomized trials.
surgery, Part 2: consensus statement for
anaesthesia practice. Acta Anaesthesiologica
Scandinavica 2016
doi: 10.1111/aas.12651
Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

ª 2015 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,
distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. 289
A. FELDHEISER ET AL.
Editorial comment: what this article tells us

This consensus paper includes a number of recommendations to enhance recovery in patients
undergoing gastrointestinal surgery. Preoperatively, optimization of medical disease and cessation
of smoking and alcohol intake are emphasized. Prevention of nausea and vomiting is important.
Careful titration of anaesthetics and ensuring full recovery of neuromuscular blockade are recom-
mended. During surgery, there should be normal values of arterial oxygen level, intraoperative
temperature and glucose concentration. The article also includes recommendations regarding fluid
therapy, opioid-sparing analgesia and mobilization.
Over 234 million major surgical procedures are sively, specifically for different types of surgical
performed globally each year1 and despite procedures, as well the quality of evidence sup-
advances in surgical and anaesthetic care, mor- porting each ERAS element15–19. It must be
bidity after abdominal surgery is still high2. acknowledged that evidence supporting some of
Fast-track or enhanced recovery after surgery the ERAS elements still remains controversial.
(ERAS) clinical pathways have been proposed
to improve the quality of perioperative care with
Methods
the aim of attenuating the loss of functional
capacity and accelerating the recovery process3. An interdisciplinary group of physicians, anaes-
The ERAS pathways reduce the delay until full thesiologists and surgeons who are experts in
recovery after major abdominal surgery by atten- the field of ERAS programmes were invited to
uating surgical stress and maintaining postopera- participate in the preparation of this consensus
tive physiological functions. The implementation statement.
of the ERAS pathways has been shown to impact
positively in reducing postoperative morbidity,
Literature search
and as a consequence, length of stay in hospital
The authors met in October 2012 and the topics
(LOSH) and its related costs4–9.
for inclusion were agreed upon and allocated. The
In recent years, several studies have high-
principal literature search utilized MEDLINE,
lighted the impact of the anaesthetic management
Embase and Cochrane databases to identify contri-
on postoperative morbidity and mortality10–13. In
butions related to the topic published between
view of the evidence that many elements of the
January 1966 and May 2014. Medical Subject
ERAS programme published by the ERAS Soci-
Headings (MeSH) terms were used, as were
ety in 2009 are of related to anaesthetic care, it is
accompanying entry terms for the patient group,
imperative that guidelines on perioperative care
interventions and outcomes. Key words included
include recommendations approved by an inter-
“‘anesthesia’’, “anaesthesia”, “analgesia”, “sur-
disciplinary team comprising anaesthesiologists
gery”, “‘enhanced recovery’’ and “‘fast track’’. Ref-
and surgeons3.
erence lists of all eligible articles were checked for
As a follow-up of the previous manuscript14
other relevant studies. Conference proceedings
where the pathophysiological basis of the ERAS
were not searched. Expert contributions came
were analysed, this article represents an effort of
from within the ERAS Society Working Party.
the ERAS Society (www.erassociety.org) to pre-
sent a consensus review of clinical considera-
tions, including recommendations, for optimal Study selection, assessment and data analyses of the
anaesthesia care for patients undergoing gas- identified trials
trointestinal surgery within the ERAS pro- Based on the literature search, titles and
gramme. It is not the purpose of this manuscript abstracts were screened by individual reviewers
to provide detailed information about each sin- to identify reviews, case series, non-randomized
gle ERAS element and for each type of gastroin- studies, randomized control studies, meta-ana-
testinal surgical procedure. Most of the ERAS lyses and systematic reviews that were consid-
elements have been already discussed exten- ered for each individual topic. Discrepancies in

290 ª 2015 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation
ERAS AND ANAESTHESIA CONSIDERATIONS
judgment were resolved by the senior author view of the most common scoring system use in
and during committee meetings of the ERAS clinical practice beside the well known Ameri-
Society Working Party. can Society of Anesthesiologists (ASA) physical
status score.
POSSUM scores: in 1991, Copeland et al.
Recommendations
described the POSSUM (Physiological and
Recommendations were made by the panel based
Operative Severity Scoring for the enUmeration
on the evidence supporting each ERAS element.
of Mortality and morbidity) scoring system for
Specifically, “Strong recommendations” indicate
general surgical patients22. This is a two part
that the panel was confident that the desirable
scoring system based on physiological assess-
effects of adherence to a recommendation out-
ment (12 variables) and operative severity (six
weighed the undesirable effects. “Weak recom-
variables). Each variable has a 1–4 point range
mendations” indicate that the desirable effects of
depending on severity. The system predicts 30-
adherence to a recommendation probably out-
day risk for mortality (matrix for the 50% pre-
weighed the undesirable effects, but the panel
diction of risk of mortality: specificity = 99.3%
was less confident. Recommendations were based
and sensitivity = 54.1%) and morbidity (matrix
on the balance between desirable and undesirable
for the 50% prediction of risk of morbidity:
effects, and on values and preferences.
specificity = 92.4% and sensitivity = 52.1%).
The Portsmouth POSSUM (P-POSSUM) better
Part A. Preoperative ERAS elements predicts postoperative mortality23, as the origi-
nal POSSUM logistic regression equation over-
An ERAS approach to preoperative predicts mortality especially in low-risk
evaluation patients. POSSUM has been also modified
slightly for different specialties such as colorec-
Pre-admission risk stratification tal24, oesophageal25 and vascular surgery26 to try
Risk scoring systems have been used to try and improve sensitivity and specificity for these
and identify which patients are at higher risk specialties.
of death and complications from major surgery.
Up to 80% of postoperative deaths come from
Assessing cardiac risk in non-cardiac surgery—Cardio-
this high-risk group20. It is imperative not
vascular risk can be predicted by multivariate
only to provide patients with an overview of
risk incidences that include clinical and surgi-
the risk of surgery but also to select those
cal criteria, and biological markers27–29. These
patients for further investigation and optimiza-
tools have been incorporated in the recent
tion and decide which perioperative care path-
ACC/AHA 2014 guidelines on perioperative
way the patients should be on for resource
cardiovascular evaluation and care for non-car-
allocation. In a major retrospective study in
diac surgery.30
the USA, Khuri et al. analysed data on
105,951 patients undergoing a variety of differ-
ent specialty major surgical procedures. The The Lee index—The Lee Index is a modification
striking result was that if patients had a major of the original Goldman cardiac risk index31. It
complication within 30 days of surgery then it comprises six independent clinical determinants
reduced median survival by 69% at 8 years21. of major perioperative cardiac events:
Therefore, identification for risk factors for any
major complication of surgery is also impor- 1. History of ischaemic heart disease (IHD)
tant. 2. History of cerebrovascular disease
3. Heart failure
4. Preoperative insulin treatment for diabetes
Scoring systems for surgery. Many different scoring mellitus
systems, some of them procedure-specific, have 5. Serum creatinine > 177 lmol/l
been developed for patients undergoing surgery. 6. High-risk type of surgery
The purpose of this section is to give an over-

ª 2015 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation 291
All factors contribute 1 point equally to the Dynamic Tests

index, and for patients with an index of 0, 1, 2 Walk Tests—(2 min, 6 min, shuttle) All these
and 3 points the incidence of major cardiac com- tests measure the distance covered over a set
plications is estimated at 0.4%, 0.9%, 7% and period of time by the patient. They have been
11% respectively.31 validated in clinical practice and are easy to
administer.35,36 Norms according to age and
gender have been created. Although they corre-
Cardiovascular Risk Calculator—A similar tool
lated with cardiopulmonary testing, they have
to determine the postoperative probability of
not been used to determine whether to operate
myocardial infarct or cardiac arrest has been val-
or not on patients undergoing high-risk surgery.
idated by Gupta and colleagues in 211,410
patients undergoing surgery. It contains five
independent predictors28: Cardiopulmonary Exercise Testing (CPET)—
This is a dynamic non-invasive objective test
1. Type of surgery
that evaluates the ability of a patient’s car-
2. Dependent functional status (inability to per-
diopulmonary system to adapt to a sudden
form activities of daily living in the 30 days
increase in oxygen demand. The ramped exer-
before surgery, partially independent or
cise test is performed on a cycle ergometer with
totally independent)
ECG monitoring and analysis of expired carbon
3. Abnormal serum creatinine
dioxide and oxygen consumption, the later
4. American Society of Anesthesiologists class
being directly related to oxygen delivery and a
(ASA)
linear function of cardiac output when exercis-
5. Increasing age
ing. With increasing exercise, oxygen consump-
More recently there has been increasing tion will eventually exceed oxygen delivery.
awareness that perioperative myocardial injury Aerobic metabolism becomes inadequate to
does not always present with any of the typical meet the metabolic demands and blood lactate
ischaemic features of chest pain, electrocardio- rises reflecting supplementary anaerobic meta-
gram changes, rhythm disturbance or heart fail- bolism. The value for oxygen consumption at
ure. The VISION study measured troponins and this point is known as the anaerobic threshold
showed a spectrum of results with 44% of tro- (AT), expressed as ml/kg/min VO2 peak/max
ponin rises fulfilling the criteria for myocardial can also be measured. Both values have been
injury without fulfilling a traditional definition used to try and predict the risk of complications.
of perioperative myocardial infarction32. Older’s original work in colorectal patients
showed that if a patient’s AT was less than
11 ml/kg/min, the patients was at higher risk of
Assessment of functional capacity. Estimating func- complications which was increased if there was
tional capacity is an important start of assessing a the presence of ischaemic heart disease.37,38
patient. Functional capacity is measured in meta- Snowden et al. showed that an AT cut-off value
bolic equivalents (METs). One MET equals the of 10.1 ml/kg/min predicts complications better
basal metabolic rate at rest. Climbing one flight than an algorithm-based activity assessment
of stairs demands 4 METs and strenuous activity (Veterans Activity Questionnaire Index
such as playing tennis or swimming is > 10 [VASI]).39 Similarly, in patients undergoing
METS. The inability to perform 4 METS indicates pancreatic, hepatic and vascular surgery and AT
poor functional capacity and is associated with < 10 ml/kg/min predicts complications and
an increased incidence of postoperative cardiac early postoperative death40–43. VO2 max has also
events.33 The presence of good functional capac- been studied to predict outcome and has been
ity, even in the presence of stable IHD or other shown to be a sensitive marker for cardiopul-
risk factors is associated with a good outcome.34 monary complications in patients undergoing
As patients poorly estimate their functional oesophageal resection44. Despite its high sensi-
capacity, it is important to obtain an independent tivity, the specificity of the CPET is not high
assessment using dynamic testing. enough to identify patients with a significant

retrospective study, it should be also considered

Table 3 Risk factors, prevention and management of primary
that some patients might have a higher risk to
POI.
develop prolonged primary POI (Table 3). These
results need to be confirmed when adopting Patients risk factors333
• Male
multiple interventions to attenuate postoperative
• Cerebrovascular diseases
gastrointestinal dysfunctions as in a context of • Respiratory diseases
an ERAS programme.333 Nasogastric decompres- • Peripheral vascular diseases
sion should be considered to prevent complica-
Intraoperative strategies to accelerate the recovery of
tions such as pulmonary aspiration and
gastrointestinal function
arrhythmias.164 • Laparoscopic surgery5
• Thoracic epidural analgesia241
Summary and recommendation: Primary POI is • Opioid-sparing strategies332
an inevitable consequence after gastrointestinal o Intravenous Lidocaine
surgery and its pathogenesis is multifactorial. o NSAIDs/COX-2
Multimodal preventing strategies should be o Ketamine
• Avoid fluid excess and splanchnic hypoperfusion332
adopted to facilitate the recovery of gastroin-
testinal function. Postoperative strategies to accelerate the recovery of
Recommendation grade: moderate • Thoracic epidural analgesia241
• Opioid-sparing strategies332
o NSAIDs/COX-2
Early mobilization • Opioid antagonists358
Although the tradition of prolonged postopera- o Alvimopam
o Metiltrexone
tive bed rest was abandoned over 75 years
• Mobilization332
ago334 and the dangers of staying in bed • Laxative332
acknowledged,335 modern surgical patients actu- • Gum-chewing359
ally spend very little time out of bed.336 Early • Administer IV fluids only if clinical indicated (surgical losses,
“enforced” or “structured” mobilization is a key inadequate hydration) (ref)
component of virtually all ERAS pro- • Early feeding332
grammes.16,337 Patients cared for with the ERAS • Avoidance prophylactic and routine use of NGT
paradigms mobilize more and achieve indepen- Treatment of primary POI

dent mobilization earlier than those cared for NGT insertion332
without ERAS.7 Mobilization helps preserve
Fig. 1. Identification of patients with primary

or secondary postoperative Ileus (POI). SIRS,
systemic inflammmatory response; WBC,
white blood cell; Hb, hemoglobin; K+,
potassium; HPO42 , phospate.

disease that can increase the risk of periopera- morbidity.58–60 These effects seem to be dose-
tive complications independently. Smokers dependent.58 The risk of transfusion-related
without these comorbidities still have an complications and the effect of blood transfusion
increased perioperative risk, mainly due to poor on the immune system must be also consid-
wound and tissue healing which can lead to ered.56,57,61 Evidence suggesting that normaliz-
wound infection48 as well as cardiopulmonary ing preoperative haemoglobin levels prior to
complications such as chest infection. Studies surgery reduces postoperative morbidity and
have been undertaken to assess whether short- mortality is lacking and studies evaluating the
term abstinence from smoking can improve out- role of preoperative anaemia optimization are
come. The cessation of smoking for 4 weeks warranted.57,62 Implementation of perioperative
prior to surgery has been shown to improve blood management protocols can reduce the risk
wound healing.48–50 The use of nicotine replace- of allogenic blood transfusions.56,57
ment therapy (NRT) and counselling facilitate
preoperative smoking cessation.49 Other phar-
Cardiovascular risk reduction. It is not the intent of
macological interventions are also available.
this manuscript to discuss in detail periopera-
Varenicline, in combination with two preopera-
tive cardiovascular strategies to reduce cardio-
tive 15-minute standardized counselling ses-
vascular risk. These interventions are
sions, started 1 week before surgery and
extensively discussed in the recent ACC/AHA
followed up for 12 weeks, was shown to
2014 guidelines.30
improve long-term smoking abstinence (RR
1.45, 95% CI 1.01–2.07, P = 0.04) but not reduce
postoperative complications in comparison with Asthma, COPD and diabetes. Chronic conditions
placebo. However, nausea occurred more fre- such as asthma, chronic obstructive airways dis-
quently in patients treated with varenicline ease63, diabetes mellitus64 malnutrition65–67 and
(13.3% vs. 3.7%, P = 0.004).51 Antidepressants frailty68 should be optimized prior to surgery.
such as bupropion also seem beneficial to
improve smoking cessation, but limited data are Summary and recommendation: cessation of
available in the perioperative setting.52,53 smoking and alcohol intake at least 4 weeks
before surgery is recommended. Encouraging
patients is not enough; pharmacological support
Preoperative anaemia. Haemoglobin is one of the and individual counselling should be offered to
main determinants of oxygen delivery. Preopera- every patient who smokes and to alcohol abu-
tive anaemia is common and is an independent sers undergoing elective surgery. Optimization
predictor of mortality and postoperative compli- of medical conditions, such as cardiovascular
cations.54,55 Haemoglobin levels should be cor- diseases, anaemia, chronic obstructive airways
rected preoperatively, as it is common to expect disease, diabetes, nutritional status and frailty
a drop of haemoglobin concentrations due to and should follow international recommenda-
blood loss and to the dilution effect of intra- tions.
venous fluids. Correction of preoperative anae-
mia should take in consideration its
Recommendation grade:
aetiology.56,57 Iron, folate, vitamin B12 supple-
Smoking cessation: high
ments and/or erythropoietin should be used
Nicotine replacement therapy and counselling:
when appropriate. Medical management of pre-
high
operative anaemia takes time and should be
Alcohol cessation: low
planned at least 3–4 weeks before elective sur-
Medical optimization: strong
gery. Although preoperative blood transfusion
corrects anaemia rapidly and could be used in
severely anaemic patients and/or in patients Pre-anaesthetic medications
undergoing surgery with expected profound Patients undergoing major surgery are, as
blood loss, caution should be used as it has expected, anxious. Anxiety has also been shown
been associated with increased mortality and in many studies to be the most common predic-

tor for postoperative pain and positively corre- of patients fasting after midnight.77,78 Imaging
lates with postoperative pain intensity.69 Fur- studies have further supported the safety of
thermore, preoperative pain is also a significant allowing clear fluids up to 2 h before the induc-
predictor for postoperative pain.70 Therefore, tion of anaesthesia, showing complete gastric
education and counselling, and preoperative emptying with 90 min.79 Recently, the Euro-
analgesic and anxiolytic medication must be pean and American Anesthesia Society have
specifically addressed during the preoperative revised their fasting guidelines and have not
assessment of the patient. Short-acting anxiolyt- changed their previous recommendations.80,81
ics and analgesics can be administered to facili- Preoperative treatment with oral complex carbo-
tate regional anaesthetic procedures and hydrates (CHO) (maltodextrin) with a relatively
insertion of intravascular lines, provided they high concentration (12.5%), with 100 g
are used in adequate doses based on age and (800 ml) administered the night before of sur-
patients’ comorbidities.71 Short-acting benzodi- gery and 50 g (400 ml) 2–3 h before induction
azepines should be avoided in older patients of anaesthesia, reduces the catabolic state
(age > 60).72 Long-acting sedatives and opioids induced by overnight fasting and surgery.
should be avoided as they may hinder recovery, Indeed, overnight fasting before surgery inhibits
thus impairing postoperative mobilization and insulin secretion and promotes the release of
direct participation, resulting in prolonged catabolic hormones such as glucagon and corti-
length of stay.71 sol. By increasing insulin levels preoperative
treatment with oral CHO reduces postoperative
Summary and recommendation: long-acting anxi- insulin resistance, maintains glycogen reserves,
olytic and opioids should be avoided as they decreases protein breakdown and improves
may delay discharge. Short-acting benzodi- muscle strength.82 Faster surgical recovery and
azepine should be avoided in the elderly. better postoperative well-being still remains
controversial83,84. Delayed gastric emptying
Recommendation grade: strong should be suspected in patients with docu-
mented gastroparesis, patients on prokinetic
agents such as metoclopramide and/or domperi-
Preoperative fasting and carbohydrate loading
done, patients scheduled for gastrointestinal
Although fasting guidelines of various anaesthe-
operations such oesophageal, gastric, fundopli-
sia societies support the safety of allowing clear
cation, paraesophageal hernia repair, gastro-jeju-
fluids up to 2 h and solid food up to 6 h before
nostomy, in patients who underwent previous
the induction of anaesthesia, patients scheduled
Whipple’s procedure, in patients with achalasia
for elective surgery are commonly asked to fast
and in patients with neurological diseases with
from midnight. The evidence supporting this
dysphagia. Patients with diabetes with neuropa-
practice, with the belief to ensure an empty
thy and, less clearly, obese patients85 are con-
stomach before the induction of anaesthesia and
sidered to have delayed gastric emptying.
decrease the risk of aspiration is lacking.73 On
However, gastric emptying after 300 ml of clear
the contrary, it has been shown that fasting from
fluids 2–3 h before the induction of anaesthesia
midnight increases insulin resistance, patient’s
in obese patients has been shown to be similar
discomfort and potentially decreases intravascu-
to those of lean patients86,87 and gastric empty-
lar volume, especially in patients receiving
ing after CHO administration in patients with
mechanical bowel preparation.74 In fact, func-
uncomplicated diabetes is normal.88,89 The clini-
tional intravascular deficit after fasting time, as
cal relevance of preoperative CHO drinks in
indicated by guidelines75 or after 8 h fasting76 is
these specific populations remains to be estab-
minimally affected in patients undergoing
lished.
elective surgeries without mechanical bowel
preparation.75,76 Results from two Cochrane
meta-analyses have shown that gastric content Summary and recommendation: Intake of clear
of patients following anaesthesia fasting guide- fluids should be allowed until 2 h before induc-
lines is the same or lower of the gastric content tion of anaesthesia. Solids should be allowed

until 6 h. Preoperative treatment with oral on the antagonism of different kinds of central
CHOs can be administered safely except in receptors that are all involved in the pathophys-
patients with documented delayed gastric emp- iology of PONV and all have shown to be supe-
tying or gastrointestinal motility disorders and rior to placebo in the prevention of PONV.98
as well in patients undergoing emergency sur- Newer drugs as the neurokinin-1 receptor antag-
gery. onists show encouraging results in initial tri-
als.99 Unfortunately, none of the available
pharmacological agents when used alone are
Recommendation grade:
effective in reducing the incidence of PONV by
Adherence to fasting guidelines (avoid over-
more than 25%. Antiemetic combinations are
night fasting): strong
recommended for patients at higher risk of
Administration of preoperative CHOs: strong
PONV. Combination therapy is more effective
Administration of preoperative CHOs in dia-
than monotherapy, and for high-risk patients,
betic and obese patients: weak
combination with 2–3 antiemetics in addition to
propofol based total intravenous anaesthetic
Part B. Intraoperative and postoperative ERAS (TIVA) has the greatest likelihood of reducing
elements PONV.
Examples of antiemetic drugs are serotonin
Preventing and treating postoperative antagonists like ondansetron 4 mg i.v. or dopa-
nausea and vomiting mine antagonists like droperidol 0.625–1.25 mg
i.v. given at the end of surgery or a transdermal
Despite significant advances in our knowledge patch of scopolamine placed the evening prior to
of PONV and the introduction of new agents, or 2 h before surgery. Dexamethasone 4–5 mg i.v.
the overall incidence of PONV is currently esti- after induction of anaesthesia has also been
mated to be 20–30%. In high-risk patients, the shown to be effective, but its immunosuppressive
incidence in still as high as 70%,90 and it is one effects on long-term oncological outcome are
of the most unpleasant experiences in the peri- unknown. Higher doses of dexamethasone have
operative period.91 no additional effect and are associated to sleep
There are many risk factors that predispose disturbances. It should not be used in diabetic
patients to PONV.92 The most widely used scor- patients requiring insulin and not given prior to
ing system was developed by Apfel et al.,93 induction of anaesthesia due to perineal pain.
who created a simplified scoring system using If PONV is present postoperatively, rescue
only four risk factors – female gender, a history therapy should be with an antiemetic from a
of motion sickness or PONV, non-smoking sta- different class unless the elapsed time from the
tus and the use of postoperative opioids.92 previous antiemetic administration is greater
The multimodal approach to PONV within an than 6 h,100 After prophylactic administration of
ERAS programme contains the use of antiemet- 4 mg ondansetron re-dosing for established
ics and a total intravenous anaesthesia with PONV was shown to be no more effective than
propofol instead of inhalational agents. Avoid- placebo.101
ance of nitrous oxide is also important.94 Other
factors like the reduction of preoperative fasting, Summary and recommendation: Aggressive PONV
carbohydrate loading and adequate hydra- prevention strategy should be included in an
tion95,96 and high inspired oxygen concentra- ERAS protocol.102 All patients with 1–2 risk fac-
tions97 may influence the prevalence of PONV. tors should receive as PONV prophylaxis a com-
The use of regional anaesthetic techniques and bination of two antiemetics. Patients with 3–4
the use of non-steroidal anti-inflammatory drugs risk factors should receive 2–3 antiemetics and
(NSAIDs) as opioid-sparing strategies may have total intravenous anaesthesia (TIVA) with
an additional indirect influence on the preva- propofol and opioid-sparing strategies should
lence of PONV. be encouraged.93,102
Classes of antiemetics (serotonergic, dopamin-
ergic, cholinergic and histaminergic) are based Recommendation grade: strong.
(NMDA) receptor antagonist, has been shown to

Standard anaesthetic protocol and depth of
reduce the risk of awareness118 with one study
anaesthesia monitoring
showing an NNT of 46,119 however, there were
Although there are no studies comparing gen- two cases of awareness in the ENIGMA study in
eral anaesthetic techniques for gastrointestinal patients having nitrous oxide.120 Recent studies
surgery, it is sensible to assume that within the have highlighted that patients with BIS levels
ERAS protocol efforts have to be made to mini- < 45 under anaesthesia (reflecting increased sup-
mize the impact of anaesthetic agents and tech- pression of brain activity) have an increased risk
niques on organ function, and to facilitate rapid of death by up to 1.24-fold (95% CI 1.06–
awakening from anaesthesia thus accelerating 1.44).121 Subsequent analysis suggests this may
recovery of the patient’s gastrointestinal and be a reflection of elderly patients who have mul-
motor functions. As such particular attention tiple problems and cognitive dysfunction and
can be drawn to the type of agents used and the may have a reduced life expectancy prior to sur-
monitoring of vital functions. gery more likely to have low BIS values. More
Traditionally the anaesthesiologist has relied studies are needed to clarify this point. There is
on clinical signs to try and ensure appropriate increasing interest in anaesthetic drugs and anal-
depth of anaesthesia and avoidance of awareness gesic techniques. (e.g. morphine and thoracic
but also avoiding overdose and the resultant epidural analgesia) and their effect on cancer
depression of a patient’s physiological status. outcome but there is currently not enough con-
Depth of anaesthesia can now be measured by sistent data to support making specific recom-
many devices but in terms of clinical evaluation mendations.122,123
the data on Bispectral Index (BIS) far exceeds
other devices.103 Recent focus has been on using Summary and recommendation: anaesthetic depth
depth of anaesthesia monitoring not just to avoid should be guided either maintaining an end
awareness during surgery but also to titrate the tidal concentration of 0.7–1.3 MAC or BIS index
minimum amount of anaesthetic necessary to between 40 and 60 with the aim not only to
avoid complications.103–116 This appears to have prevent awareness but also to minimize anaes-
particular significance in the elderly population thetic side effects and facilitate rapid awakening
with cognitive dysfunction.117 Unfortunately BIS and recovery. Avoid too deep anaesthesia (BIS
is not infallible. Many things can affect the BIS < 45), especially in elderly patients
value, in particular neuromuscular relaxation,
which is commonly used in anaesthesia. The Recommendation grade: strong
specificity seems to be lower when using total
intravenous anaesthesia (TIVA).106 There is also
Neuromuscular blockade (NMB) and
a lag time between EEG interpretation and the
neuromuscular monitoring
displayed BIS value.
When compared with clinical signs alone, BIS This section discusses the importance of neuro-
obtains lower rates of awareness during muscular blockade and neuromuscular monitor-
surgery.112–114,116 Anaesthetic depth guided by ing, and their potential implications specifically
BIS may also help reduce the amount of drug in the context of an ERAS programme. Neuro-
given,107,116 with more rapid immediate recovery muscular blockade agents (NMBA) paralyse
although the time to discharge home appears to skeletal muscles, allowing optimal conditions
be unaffected116. In Myles’ study, 138 patients for surgery. The level of NMB needed to obtain
needed to have BIS monitoring to avoid one case optimal surgical conditions can differ depending
of awareness.112 Avidan’s studies104,105 have on the surgical approach. A deep NMB might be
demonstrated that maintaining anaesthetic depth particularly useful when a laparoscopic
with an end tidal concentration (EATC) between approach is used.124,125 A recent systematic
0.7 and 1.3 MAC equivalents can prevent intra- review showed that during certain laparoscopic
operative awareness as effectively as anaesthesia procedures deep NMB (e.g. Post-Tetanic Count
guided by a BIS value between 40 and 60. The 1 or more; but Train of Four (TOF) Count of
use of nitrous oxide, a N-methyl-D-aspartate 0126) provide better surgical conditions than
of transversus abdominis plane block. J Clin analgesia following upper abdominal surgery.
Anesth 2011; 23: 7–14. Anaesthesia 2011; 66: 465–71.
283. Johns N, O’Neill S, Ventham NT, Barron F, Brady 294. De Oliveira GS Jr, Castro-Alves LJ, Nader A,
RR, Daniel T. Clinical effectiveness of transversus Kendall MC, McCarthy RJ. Transversus
abdominis plane (TAP) block in abdominal abdominis plane block to ameliorate postoperative
surgery: a systematic review and meta-analysis. pain outcomes after laparoscopic surgery: a meta-
Colorectal Dis 2012; 14: e635–42. analysis of randomized controlled trials. Anesth
284. Bharti N, Kumar P, Bala I, Gupta V. The efficacy of Analg 2014; 118: 454–63.
a novel approach to transversus abdominis plane 295. Walter CJ, Maxwell-Armstrong C, Pinkney TD,
block for postoperative analgesia after colorectal Conaghan PJ, Bedforth N, Gornall CB, Acheson
surgery. Anesth Analg 2011; 112: 1504–8. AG. A randomised controlled trial of the efficacy
285. Owen DJ, Harrod I, Ford J, Luckas M, Gudimetla of ultrasound-guided transversus abdominis plane
V. The surgical transversus abdominis plane (TAP) block in laparoscopic colorectal surgery.
block–a novel approach for performing an Surg Endosc 2013; 27: 2366–72.
established technique. BJOG 2011; 118: 24–7. 296. Niraj G, Kelkar A, Hart E, Horst C, Malik D,
286. Favuzza J, Brady K, Delaney CP. Transversus Yeow C, Singh B, Chaudhri S. Comparison of
abdominis plane blocks and enhanced recovery analgesic efficacy of four-quadrant transversus
pathways: making the 23-h hospital stay a abdominis plane (TAP) block and continuous
realistic goal after laparoscopic colorectal surgery. posterior TAP analgesia with epidural analgesia in
Surg Endosc 2013; 27: 2481–6. patients undergoing laparoscopic colorectal
287. Favuzza J, Delaney CP. Outcomes of discharge surgery: an open-label, randomised, non-
after elective laparoscopic colorectal surgery with inferiority trial. Anaesthesia 2014; 69: 348–55.
transversus abdominis plane blocks and enhanced 297. Abdallah FW, Chan VW, Brull R. Transversus
recovery pathway. J Am Coll Surg 2013; 217: 503– abdominis plane block: a systematic review. Reg
6. Anesth Pain Med 2012; 37: 193–209.
288. Keller DS, Stulberg JJ, Lawrence JK, Delaney CP. 298. Kahokehr A, Sammour T, Shoshtari KZ, Taylor M,
Process control to measure process improvement Hill AG. Intraperitoneal local anesthetic improves
in colorectal surgery: modifications to an recovery after colon resection: a double-blinded
established enhanced recovery pathway. Dis randomized controlled trial. Ann Surg 2011; 254:
Colon Rectum 2014; 57: 194–200. 28–38.
289. Brady RR, Ventham NT, Roberts DM, Graham C, 299. Kahokehr A, Sammour T, Srinivasa S, Hill AG.
Daniel T. Open transversus abdominis plane Systematic review and meta-analysis of
block and analgesic requirements in patients intraperitoneal local anaesthetic for pain reduction
following right hemicolectomy. Ann R Coll Surg after laparoscopic gastric procedures. Br J Surg
Engl 2012; 94: 327–30. 2011; 98: 29–36.
290. Allcock E, Spencer E, Frazer R, Applegate G, 300. Wu CL, Rowlingson AJ, Partin AW, Kalish MA,
Buckenmaier C 3rd. Continuous transversus Courpas GE, Walsh PC, Fleisher LA. Correlation
abdominis plane (TAP) block catheters in a of postoperative pain to quality of recovery in the
combat surgical environment. Pain Med 2010; 11: immediate postoperative period. Reg Anesth Pain
1426–9. Med 2005; 30: 516–22.
291. Kadam RV, Field JB. Ultrasound-guided 301. Marret E, Kurdi O, Zufferey P, Bonnet F. Effects
continuous transverse abdominis plane block for of nonsteroidal antiinflammatory drugs on patient-
abdominal surgery. J Anaesthesiol Clin Pharmacol controlled analgesia morphine side effects: meta-
2011; 27: 333–6. analysis of randomized controlled trials.
292. Bjerregaard N, Nikolajsen L, Bendtsen TF, Anesthesiology 2005; 102: 1249–60.
Rasmussen BS. Transversus abdominis plane 302. Klein M. Postoperative non-steroidal anti-
catheter bolus analgesia after major abdominal inflammatory drugs and colorectal anastomotic
surgery. Anesthesiol Res Pract 2012; 2012: 596536. leakage. NSAIDs and anastomotic leakage. Dan
293. Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Med J 2012; 59: B4420.
Williams O, Darbar A, Maheshwaran A, Powell R. 303. Burton TP, Mittal A, Soop M. Nonsteroidal anti-
Comparison of analgesic efficacy of subcostal inflammatory drugs and anastomotic dehiscence in
transversus abdominis plane blocks with epidural bowel surgery: systematic review and meta-

associated with 1-year mortality in an older clinical trial of multimodal optimization of

intensive care unit population. Am J Respir Crit surgical care in patients undergoing major colonic
Care Med 2009; 180: 1092–7. resection. Br J Surg 2005; 92: 1354–62.
325. Radtke FM, Heymann A, Franck M, Maechler F, 337. Kehlet H, Wilmore DW. Evidence-based surgical
Drews T, Luetz A, Nachtigall I, Wernecke KD, care and the evolution of fast-track surgery. Ann
Spies CD. How to implement monitoring tools for Surg 2008; 248: 189–98.
sedation, pain and delirium in the intensive care 338. Browning L, Denehy L, Scholes RL. The quantity
unit: an experimental cohort study. Intensive Care of early upright mobilisation performed following
Med 2012; 38: 1974–81. upper abdominal surgery is low: an observational
326. Skrobik Y, Ahern S, Leblanc M, Marquis F, study. Aust J Physiother 2007; 53: 47–52.
Awissi DK, Kavanagh BP. Protocolized intensive 339. Henriksen MG, Jensen MB, Hansen HV,
care unit management of analgesia, sedation, and Jespersen TW, Hessov I. Enforced mobilization,
delirium improves analgesia and subsyndromal early oral feeding, and balanced analgesia
delirium rates. Anest Analg 2010; 111: 451–63. improve convalescence after colorectal surgery.
327. Radtke FM, Franck M, MacGuill M, Seeling M, Lutz Nutrition 2002; 18: 147–52.
A, Westhoff S, Neumann U, Wernecke KD, Spies 340. Pashikanti L, Von Ah D. Impact of early
CD. Duration of fluid fasting and choice of analgesic mobilization protocol on the medical-surgical
are modifiable factors for early postoperative inpatient population: an integrated review of
delirium. Eur J Anaesthesiol 2010; 27: 411–6. literature. Clin Nurse Spec 2012; 26: 87–94.
328. Lonergan E, Britton AM, Luxenberg J, Wyller T. 341. Pitkethly M, Macgillivray S, Ryan R. Recordings
Antipsychotics for delirium. Cochrane Database or summaries of consultations for people with
Syst Rev 2007; CD005594. cancer. Cochrane Database Syst Rev 2008; 3:
329. Lonergan E, Luxenberg J, Areosa Sastre A, Wyller CD001539.
TB. Benzodiazepines for delirium. Cochrane 342. Li C, Ferri LE, Mulder DS, Ncuti A, Neville A,
Database Syst Rev 2009; 1: CD006379. Lee L, Kaneva P, Watson D, Vassiliou M, Carli F,
330. Delaney CP, Kehlet H, Senagore A. Postoperative Feldman LS. An enhanced recovery pathway
ileus: profiles, risk factors and definitions – a decreases duration of stay after esophagectomy.
framework for optimizing surgical outcomes in Surgery 2012; 152: 606–14; discussion 14-6.
patients undergoing major abdominal and 343. Li C, Carli F, Lee L, Charlebois P, Stein B,
colorectal surgery. Clinical Consensus Update in Liberman AS, Kaneva P, Augustin B,
General Surgery 2006. Available at: http:// Wongyingsinn M, Gamsa A, Kim do J, Vassiliou
www.clinicalwebcasts.com/updates/index.htm. MC, Feldman LS. Impact of a trimodal
(accessed 15 September 2015) prehabilitation program on functional recovery
331. van Bree SH, Bemelman WA, Hollmann MW, after colorectal cancer surgery: a pilot study. Surg
Zwinderman AH, Matteoli G, El Temna S, The Endosc 2013; 27: 1072–82.
FO, Vlug MS, Bennink RJ, Boeckxstaens GE. 344. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen
Identification of clinical outcome measures for K, Andersen J, Kessels AG, Revhaug A, Kehlet H,
recovery of gastrointestinal motility in Ljungqvist O, Fearon KC, von Meyenfeldt MF. A
postoperative ileus. Ann Surg 2014; 259: 708–14. protocol is not enough to implement an enhanced
332. Kehlet H. Postoperative ileus–an update on recovery programme for colorectal resection. Br J
preventive techniques. Nat Clin Pract Surg 2007; 94: 224–31.
Gastroenterol Hepatol 2008; 5: 552–8. 345. Bravata DM, Smith-Spangler C, Sundaram V,
333. Chapuis PH, Bokey L, Keshava A, Rickard MJ, Gienger AL, Lin N, Lewis R, Stave CD, Olkin I,
Stewart P, Young CJ, Dent OF. Risk factors for Sirard JR. Using pedometers to increase physical
prolonged ileus after resection of colorectal cancer: activity and improve health: a systematic review.
an observational study of 2400 consecutive JAMA 2007; 298: 2296–304.
patients. Ann Surg 2013; 257: 909–15. 346. Papaspyros S, Uppal S, Khan SA, Paul S, O’Regan
334. Brieger GH. Early ambulation. A study in the DJ. Analysis of bedside entertainment services’
history of surgery. Ann Surg 1983; 197: 443–9. effect on post cardiac surgery physical activity: a
335. Brower RG. Consequences of bed rest. Critical prospective, randomised clinical trial. Eur J
Care Med 2009; 37: S422–8. Cardiothorac Surg 2008; 34: 1022–6.
336. Gatt M, Anderson AD, Reddy BS, Hayward- 347. Moiniche S, Hjortso NC, Blemmer T, Dahl JB,
Sampson P, Tring IC, MacFie J. Randomized Kehlet H. Blood pressure and heart rate during

centrations which result in hyperoxia should Summary and recommendation: Intraoperative

be avoided. hypothermia should be avoided by using active
warming devices.
Recommendation grade: strong
2). 100% inspired oxygen concentrations can be
Recommendation grade: strong.
used for pre-oxygenation prior to anaesthesia
or for short periods to overcome hypoxia.
Surgical techniques
Recommendation grade: strong
The short-term benefits of laparoscopic vs. open
surgery for abdominal surgery have been well
Preventing intraoperative hypothermia established in the literature to date and include
Perioperative hypothermia, defined as a core shorter length of stay, reduced postoperative
temperature below 36°C is a common adverse morbidity, earlier passage of flatus and less nar-
consequence of anaesthesia and surgery.146 The cotic analgesic requirements.157 However, long-
prevalence of inadvertent hypothermia ranges term outcomes have shown equivalence
from 50% to 90%147 independently whether between laparoscopic and open surgery.158 The
patients undergo laparoscopic or open sur- fact that laparoscopic practice has improved
gery.148 Older adults are more prone to heat since these trials were initiated, further consoli-
loss, whereas obesity has a protective effect.149 dates the role played by this technique as the
Hypothermia in most patients undergoing preferable one for abdominal surgery. In the
general anaesthesia is the result of an internal context of an enhanced recovery programme, the
core-to-peripheral redistribution of body heat multicentre randomized LAFA study has shown
that usually reduces core temperature by 0.5– positive benefits when laparoscopic resection is
1.5°C in the first 30 min after induction of optimized within an ERAS protocol.5
anaesthesia.150 The main goal of enhanced recovery strategy
Several meta-analyses and RCTs have demon- should not be based on the choice of laparo-
strated that preventing inadvertent hypothermia scopic vs. open, but less surgical invasiveness as
during major abdominal surgery significantly the surgical technique should minimize wound
reduces wound infections,151,152 cardiac compli- trauma, tissue distraction and bleeding.
cations,151,153 bleeding and transfusion require- A recently updated Cochrane review compar-
ments,153,154 and improves immune function,151 ing transverse with midline laparotomy incisions
the duration of post-anaesthetic recovery155 and for abdominal surgery found less postoperative
overall survival.156 Therefore, it makes sense to opiate analgesic use with transverse incisions159
prevent the loss of body heat as also recom- but no differences in visual analogue pain scores
mended by the ERAS society. reported by patients. Pooled data for spirometry
Use of active warming devices is highly rec- after the operation showed that a transverse inci-
ommended in all cases lasting more than sion had less effect on vital capacity and FEV1.
30 min151 and this can be achieved by using However, these benefits on pulmonary function
different warming devices (forced air warming did not result in reduced pulmonary complica-
systems, circulating water garments or warmed tions or hospital stay. A trend towards a lower
i.v. solutions). Combined strategies, and among incidence of wound dehiscence was shown in the
the others preoperative warming, should be con- transverse incision group. Finally there was a
sidered in vulnerable groups such as older reduction in incisional hernias with transverse
patients with cardiorespiratory diseases, and incisions, but the studies showed a high variety
surgery of long duration.147 Rewarming should of time to follow-up.
be performed to a core temperature of 35.5– A number of new minimally invasive surgical
36.0°C before emergence from anaesthesia, and technologies have emerged over the past decade.
every effort should be made to avoid shivering A recent meta-analysis of non-randomized con-
by using meperidine 0.25–0.5 mg/kg. Alterna- trolled trials has indicated that robotic total
tively clonidine 1–2 lg/kg i.v. can be used. mesorectal excision (TME) did not reduce opera-

tion time, length of hospital stay, time to resume benefits of routinely avoiding nasogastric intu-
regular diet, postoperative morbidity or mortal- bations overcome the risks.
ity160 and is a technique that requires evaluation Delayed gastric emptying can occur in a small
through high-quality randomized research. proportion of patients, leading to vomiting and
While single-incision laparoscopic resections fatal aspiration if not treated promptly by insert-
may improve recovery, no robust data have yet ing a nasogastric tube.172,173 The recognition
appeared and these techniques are at an early and avoidance of this complication is essential.
stage in their development.161 Furthermore, Teams should be taught to positively identify
transvaginal and transrectal specimen extraction these changes, particularly when patients are
to avoid abdominal wounds has been described, failing to progress between 2 and 5 days after
but with little data on short- and long-term surgery.
results.162,163 At this stage, no recommendation
can be made on these procedures. However, the Summary and recommendation: Prophylactic use
negative intraoperative pathophysiological con- of nasogastric tubes is not recommended for
sequences (e.g. head-down-position, longer patients undergoing elective colorectal surgery,
operation time) have to be balanced to the bene- while its use in patients undergoing gastrec-
fits of the minimal-invasive approaches and the tomy and oesophagectomy is still debatable.
use of an ERAS protocol. Patients with delayed gastric emptying after sur-
gery should be treated by inserting a nasogastric
Summary and recommendation: Laparoscopic sur- tube.
gery for gastrointestinal resections is recom-
mended when the expertise is available. Recommendation grade: strong.
Transverse incisions for colonic resections
should be preferred.
Intraoperative glycaemic control
Recommendation grade: Blood glucose levels increase during and after
Laparoscopic approach: strong; elective surgery with the magnitude of hyper-
Transverse incisions: low. glycaemia depending upon the patient’s meta-
bolic state (fasting, fed, diabetes), the type of
anaesthesia and analgesia and the severity of
Nasogastric intubation
surgical tissue trauma.174
There is strong evidence that routine nasogastric Strong evidence indicates that even moderate
decompression following elective laparotomy increases in blood glucose are associated with
should be avoided.164 Prophylactic nasogastric adverse outcomes.175–177 Patients with fasting
tubes placed during surgery (to evacuate air) glucose levels > 7 mmol/l or random blood glu-
should be removed before reversal of anaesthe- cose levels > 11.1 mmol/l on general surgical
sia. Fever, oropharyngeal and pulmonary com- wards showed an 18-fold increased in-hospital
plications are more frequent in patients with mortality.175
nasogastric tubes.164–166 Even death and other More recent observations suggest that the
serious complications resulting from nasogastric quality of preoperative glycaemic control also is
tubes are reported.167,168 Avoidance of nasogas- important. In fact elevated HbA1c levels have
tric decompression is associated with an earlier been found to be predictive of complications
return of bowel function164–166,169 while gastroe- after cardiac and abdominal surgery.178–181
sophageal reflux is increased during laparotomy Mere associations between two variables, i.e.
if nasogastric tubes are placed.170 Even in gas- glycaemia and clinical outcomes, do not prove a
troduodenal and pancreatic surgery, there direct cause–effect relationship. At present there
appears to be no evidence of a beneficial effect is insufficient evidence to demonstrate superior-
from the prophylactic use of nasogastric ity of strict glycaemic control (blood glucose
tubes.164,171 However, the incidence of vomiting levels within a normal and narrow range) over
has been shown to be higher in patients with- conventional management in surgical patients.
out nasogastric tubes.164–166 Nevertheless, the As in the ICU situation, it remains a balance
between the benefits of bringing down glucose preoperative carbohydrate (CHO) drinks83 have
levels vs. the risks of hypoglycaemia. For the substantially reduced intraoperative fluid
surgical patient on the ward, there is also the requirements. However, when MBP is indicated
issue of the nursing staffing and their capacity fluid and electrolytes derangements occur even
to monitor patients on intensive insulin treat- if patients are encouraged to drink.74,189,190 The
ment to take into account. A review of the effect replacement of preoperative intravascular defi-
of glycaemic control on the incidence of surgical cits should be based on individualized intraop-
site infections was inconclusive, mainly because erative fluid administration strategies75 rather
of the small number of studies (n = 5), the than administering fluid based on anecdotal
heterogeneity in patient populations, the route “textbook recipes”.
of insulin administrations, the definition of out- Intraoperative period: intraoperative fluid ther-
comes measures and the fact that glycaemic tar- apy aims to administer balanced crystalloid
gets were different and/or were not achieved.182 solutions to cover the needs derived from the
Hence, to date, the optimal glucose level for salt–water homoeostasis. This is in contrast to
enhancing clinical outcomes is unknown. volume therapy where goal-directed boluses of
This uncertainty is reflected by the diversity of intravenous solutions are administered to treat
recommendations issued by Medical Associa- objective evidence of hypovolaemia, and conse-
tions concerning blood glucose control in criti- quently improve intravascular volume and cir-
cally ill and surgical patients.64,183–185 Overall culatory flow.
most of the Associations recommend treatment Intraoperative fluid therapy should aim to
of random blood glucose concentrations maintain a near-zero fluid balance191 and substan-
> 10 mmol/l. A large randomized controlled trial tial weight gain of more than 2.5 kg should be
of aggressive preservation of normoglycaemia vs. avoided.192. Intraoperative fluid requirements can
conventional glycaemic control is necessary to be met with a basal crystalloid infusion rate of
identify target blood glucose concentrations in 3 2 ml/kg/h (also called restrictive app-
patients undergoing major surgery. roach11).192–194 Crystalloid excess increases the
In the meantime, it is important to emphasize risk of pulmonary complications,193 prolonged
that there are a range of elements in the ERAS ileus192,195,196 and delayed recovery.197
protocol that will reduce insulin resistance and Crystalloid isotonic balanced solutions should be
hence reduce the risk of hyperglycaemia and preferred and 0.9% saline solutions avoided.198,199
that should be employed.186 These include pre- Hyperchloraemia caused by the use of 0.9% saline
operative carbohydrates, an active mid thoracic solutions has been associated with kidney dysfunc-
epidural, early feeding and good pain control. tion200–202, prolonged hospital stay and increased
30-day mortality (OR = 1.58, 95% CI 1.25–1.98).200
Summary and recommendation: Glucose concen- Intraoperative volume therapy should be per-
trations should be kept as close to normal as formed by bolus administration of an intra-
possible without compromising safety. Employ- venous solution based on objective measures of
ing perioperative treatments that reduce insulin hypovolaemia. Goal-directed fluid therapy
resistance without causing hypoglycaemia is (GDFT) aims to maintain central normovolaemia
recommended. by utilizing changes in stroke volume measured
by a minimally invasive cardiac output monitor
Recommendation grade: strong. to optimize the patients on their individual
Frank–Starling curve.96,203
Trans-oesophageal Doppler (TOD)-guided
Perioperative haemodynamic management
GDFT has been shown to reduce the length of
Preoperative period: preoperative hydration deficit hospital stay and postoperative complications in
can vary according to patients’ comorbidities, several RCTs of patients undergoing non-cardiac
preoperative fasting and use of preoperative surgery96,204–206 and in a hospital quality
mechanical bowel preparation (MBP). The improvement project.207 Similarly, GDFT based
avoidance of prolonged preoperative fasting,80,81 on pulse contour analysis and aiming to mini-
MBP187,188 and as well the administration of mize stroke volume variations during the respi-
ratory cycle of mechanically ventilated patients these results have not been consistently repro-
has also shown to decrease morbidity and accel- duced in the perioperative setting.224,225 A
erate recovery203,208–210. These findings are in recent study has found a dose-dependent associ-
agreement with the results of 2 recent meta-ana- ation between the volume of HES administered
lysis209,211. and the development of AKI. The Pharmacovigi-
However, the benefits of GDFT seem to be off- lance Risk Assessment Committee of the Euro-
set by the optimization of perioperative surgical pean Medicines Agency has recommended that
care. In fact, in two recent RCTs, TOD-guided HES should only be used for the treatment of
GDFT showed no benefits on postoperative out- hypovolaemia caused by acute blood loss when
comes in low-risk patients treated within an crystalloids alone are not considered sufficient
ERAS protocol.191,212. These results could be and that it should be used at the lowest effec-
also explained by a judicious fluid management tive dose for the shortest period of time. It also
in patients not treated with GDFT, as the states that treatment should be guided by con-
amount of intravenous fluid received in patients tinuous haemodynamic monitoring so that the
randomized in these patients was significantly infusion is stopped as soon as appropriate
less than the amount received by the same pop- haemodynamic goals have been achieved. The
ulation in previous studies.213 committee also observed that there is a lack of
The benefits of GDFT become more clinically robust long-term safety data in patients under-
meaningful in high-risk patients214,215, and in going surgical procedures and in patients with
patients undergoing surgery associated with lar- trauma.226 Moreover, the use of large volumes
ger intravascular fluid loss (blood loss and pro- of colloids (2605 512 ml) hydroxyethyl starch
tein/fluid shift)213,216. In the largest multicentre (HES) 130/0.4 during major urological proce-
RCT (734 patients), Pearse et al. found a non- dures has shown to impair haemostasis and
significant trend towards decreased complica- increase surgical blood loss compared with crys-
tions (36% vs. 43.4% respectively, P = 0.07) and talloids.227 Nevertheless, crystalloid-based
180-day mortality (7.7% vs. 11.6% respectively, GDFT can significantly increase the risk of fluid
P = 0.08) in high-risk patients receiving GDFT overload.227
compared with patients receiving usual care.215 Arterial hypotension should be treated with
Auditing internal data (amount of intraoperative vasopressors when administering intravenous
fluid given, surgical loss, complications, fluid boluses fails to significantly improve the
mortality, length of stay and readmission rate) is stroke volume (stroke volume > 10%).13,203
essential to determine if GDFT should be imple- Inotropes should be considered in patients with
mented as routine strategy to improve postoper- reduced contractility (Cardiac Index < 2.5 l/min)
ative outcomes.213 to guarantee adequate oxygen delivery.203
Colloidal solutions have been mainly used to Postoperative period. Early oral intake of fluids
optimize stroke volume during GDFT.96,204–206 and solids following abdominal surgery should
Colloids improve circulatory flow to a greater be encouraged171,228,229. If oral intake is toler-
extent,217,218 produce better blood volume ated, routine intravenous fluid administration
expansion and less interstitial space overload should be discontinued after PACU discharge
than crystalloids219 and could reduce the inci- and restarted only if clinically indicated. In the
dence of postoperative nausea and vomiting and absence of surgical losses to cover physiological
postoperative pain.220 Recently, Yates et al. needs patients should be encouraged to drink
showed that in moderate–high-risk patients 25–35 ml/kg of water per day (1.75–2.75 l for an
GDFT with colloid boluses does not accelerate average person).11 After ensuring the patient is
the recovery of bowel function, reduce compli- normovolaemic, hypotensive patients receiving
cations or impair haemostasis compared with epidural analgesia should be treated with vaso-
crystalloids.221 Recent data have suggested that pressors.230,231
the use of large volumes of colloids adminis-
tered post-resuscitation in critically ill patients Summary and Recommendation: The goal of peri-
can increase the risk of death and acute kidney operative fluid therapy is to maintain fluid
injury (AKI) in critically ill patients,222,223 but homeostasis avoiding fluid excess and organ
hypoperfusion. Fluid excess leading to perioper- There are two relatively small randomized
ative weight gain more than 2.5 kg should be clinical trials in humans comparing 0.9% saline
avoided, and a perioperative near-zero fluid bal- with Ringer’s lactate in the perioperative period,
ance approach should be preferred. The need of showing that 0.9% saline caused more side
GDFT should be determined based on clinical effects.235,236 One of these studies, involving
and surgical factors. GDFT should be adopted patients undergoing renal transplantation, had
especially in high-risk patients and in patients to be stopped prematurely because, compared
undergoing surgery with large intravascular with none in those receiving Ringer’s lactate,
fluid loss (blood loss and protein/fluid shift). 19% of patients in the saline group had to be
Inotropes should be considered in patients with treated for hyperkalaemia and 31% for meta-
poor contractility CI < 2.5 l/min). 0.9% saline bolic acidosis.235 In the other study, involving
and saline-based solutions should be avoided, patients undergoing abdominal aortic aneurysm
with balanced solutions preferred. Colloids repair, those receiving saline needed more blood
should be used to treat objective evidence of products and bicarbonate therapy.236 Three
hypovolaemia. In patients receiving epidural recent large observational studies200–202 have
analgesia, arterial hypotension should be treated suggested that 0.9% saline, because of the high
with vasopressors after ensuring the patient is chloride content, may cause harm, especially to
normovolaemic. In the absence of surgical the kidney. In a study using a validated and
losses, postoperative intravenous fluid should quality assured database, evaluation of out-
be discontinued and oral intake (1.5 l/day) comes in 2,788 adults undergoing major open
encouraged. abdominal surgery who received only 0.9% sal-
ine and 926 who received only a balanced crys-
Recommendation grade: GDFT: Strong in high- talloid on the day of surgery and showed that
risk patients and for patients undergoing sur- unadjusted in-hospital mortality (5.6% vs.
gery with large intravascular fluid loss (blood 2.9%) and the percentage of patients developing
loss and protein/fluid shift) complications (33.7% vs. 23%) were signifi-
GDFT: low in low-risk patients and in cantly greater in the 0.9% saline group than in
patients undergoing low-risk surgery the balanced crystalloid group.202 Patients
Perioperative near-zero fluid balance: moderate receiving 0.9% saline had significantly greater
Use of advanced haemodynamic monitoring: blood transfusion requirements and more
strong in high-risk patients and for patients infectious complications, and were 4.8 times
undergoing surgery with large intravascular more likely to require dialysis than those receiv-
fluid loss (blood loss and protein/fluid shift) ing balanced crystalloids. Another recent study
provides support for chloride-restrictive fluid
strategies in critically ill patients.201 In an open-
Balanced crystalloids vs. 0.9% saline
label prospective sequential manner, 760
Healthy volunteer studies have suggested that patients consecutively admitted to intensive care
the excretion of an acute saline load is slower (30% of whom were admitted after elective sur-
when compared with balanced crystalloid infu- gery) received either traditional chloride-rich
sions232–234, and saline tends to overload the solutions (0.9% sodium chloride, 4% succiny-
interstitial space to a greater extent, with a ten- lated gelatin solution or 4% albumin solution)
dency to result in more oedema than balanced or chloride-restricted (Hartmann’s solution,
crystalloids.232 Mechanisms for excreting this Plasma-Lyte 148 or chloride-poor 20% albu-
saline excess are inefficient, depending on a min). After adjusting for confounding variables,
slow and sustained suppression of the renin– the chloride-restricted group had decreased inci-
angiotensin–aldosterone axis.219 In addition, dence of acute kidney injury [odds ratio 0.52
0.9% saline produces a hyperchloraemic acido- (95% CI 0.37–0.75), P < 0.001] and the use of
sis, which along with renal oedema, can lead renal replacement therapy [odds ratio 0.52 (95%
to a reduction in renal blood flow and renal CI 0.33–0.81), P = 0.004]. However, there were
cortical perfusion, even in healthy human vol- no differences in hospital mortality, hospital or
unteers.232 ICU length of stay.201 A third study on 22,851
surgical patients with normal preoperative unclear if epidural analgesia improves postopera-
serum chloride concentration and renal function tive outcomes. Although the results of a large
showed that the incidence of acute postoperative multicentre RCT failed to show a significant ben-
hyperchloraemia (serum chloride > 110 mmol/l) efit of using epidural analgesia in association
was 22%.200 Patients with hyperchloraemia with general anaesthesia in reducing 30-day mor-
were at increased risk of 30-day postoperative tality and postoperative morbidity in high-risk
mortality (3.0% vs. 1.9%; odds ratio 1.58 (95% patients240 a recent meta-analysis of 9044
CI 1.25–1.98) and had a longer median hospital patients undergoing surgery with general anaes-
stay [7.0 days (IQR 4.1–12.3) vs. 6.3 days (IQR thesia and receiving epidural analgesia (4525
4.0–11.3)] than patients with normal postopera- patients) found that epidural analgesia is associ-
tive serum chloride concentrations.200 Patients ated with a 40% reduction of mortality.241 Initia-
with postoperative hyperchloraemia were also tion of neuroaxial blockade before surgery and
more likely to have postoperative renal dysfunc- its maintenance throughout surgery decreases the
tion. need for anaesthetic agents, opioids and muscle
There is a strong signal suggesting that 0.9% relaxants.242 Compared with parenteral opioids,
saline is harmful, particularly in the periopera- epidural blockade has shown to provide better
tive period when compared with balanced solu- postoperative static and dynamic analgesia for
tions199. However, there are currently no large- the first 72 h,10, to accelerate the recovery of gas-
scale randomized controlled trails that confirm trointestinal function,243–245 to reduce insulin
this finding. Nevertheless, it may be preferable resistance246 and impact positively on cardiovas-
to use balanced crystalloids in the perioperative cular and respiratory complications.241,247. How-
period and restrict the use of saline to patients ever, hypotension, urinary retention pruritus and
who have alkalosis or have a hyperchloraemia motor blockade are common side effects.248
secondary to conditions such as vomiting or Although detrusor function can be impaired in
high nasogastric tube aspirates, and in neuro- patients receiving TEA, a recent RCT has shown
surgical patients because of the relative hypo- that early removal of a urinary catheter (on post-
osmolarity of some of the balanced crystalloids. operative day 1) does not increase the risk blad-
der recatheterization and urinary infection.249.
Summary and Recommendations: 0.9% saline Also TEA does not influence the duration of hos-
should be avoided and balanced crystalloids pital stay.250
used in the preoperative period. The use of The same benefits have not been observed
0.9% saline should be restricted in hypochlo- after laparoscopic procedures,59 especially in a
raemic and acidotic patients. context of an ERAS programme.251–253 However,
TEA might still be valuable in patients at risk
Recommendation: strong of respiratory complications, in those with high
probability of conversion to laparotomy, or
requiring transverse or Pfannenstiel-like inci-
Pain management
sions.254 Furthermore, TEA may be useful to
Multimodal, evidence-based and procedure-spe- facilitate the recovery of bowel function even
cific analgesic regimens should be standard of after laparoscopic colorectal surgery.243
care, with the aim to achieve optimal analgesia
with minimal side effects and to facilitate the
Clinical management
achievement of important ERAS milestones such
Epidural blockade should be tested before sur-
as early mobilization and oral feeding
gery or in the immediate postoperative period
(Table 2).237,238
(post-anaesthesia care unit) to avoid non-func-
tioning epidurals and unnecessary opioid
Thoracic epidural analgesia (TEA) administration.255 The addition of opioids to
TEA (T6-T11) remains the gold standard for post- local anaesthetic has shown to improve postop-
operative pain control in patients undergoing erative analgesia.248,256 Although a paucity of
open abdominal surgery.239 It still remains studies have compared the analgesic efficacy of

Table 2 Non-analgesic outcomes and current issues reported after abdominal surgery with different analgesic techniques.
Analgesia technique Outcomes ERAS Control group Complications/issues
Laparotomy TEA (low dose of LA ; PONV250 – SO Hypotension, pruritus,

and opioids) ↑Recovery of bowel function244 – SO bladder dysfunction248,249
;Insulin resistance246 – SO
;Respiratory complications247 – SO
↑Health-related quality of life353 – SO
= LOSH250 – SO
IT morphine Health-related quality of life354 ✓ SO Respiratory depression,
pruritus, bladder dysfunction265
IVLI Anti-inflammatory269 – SO LA toxicity270
↑Recovery of bowel function269 – SO
;LOSH269 – SO
= LOSH254 ✓ TEA
CWI LA ;/↑/= Recovery of bowel ✓/– SO;TEA Ideal anatomic location not
function275–277,355 determined274
;/↑/= LOSH273,275,276 – SO;TEA
Abdominal trunks ;Postoperative sedation284,289 – SO Timing, dose, volume of LA,
blocks ;PONV283 – SO technique297
Laparoscopy TEA ↑/=/; Recovery of bowel ✓/– SO;IVLI;IT/TAP Hypotension, pruritus, bladder
function243,253,254 dysfunction248,249
↑/= LOSH253,254 ✓ SO;IT;TAP
IT morphine = Recovery of bowel ✓ SO;TEA Respiratory depression, pruritus,
function253,268,356 bladder dysfunction265
Facilitate mobilization356 ✓ TEA
;/= LOSH253,268 ✓ SO;TEA
23-h LOSH after laparoscopic ✓ –
colectomy357
IVLI Anti-inflammatory269(; IL-6, IL1-R) – SO LA toxicity270
↑/= Recovery of bowel ✓ SO;TEA
function254,272
= LOSH254 ✓ TEA
Abdominal 23-h LOSH after laparoscopic ✓ SO Timing, dose and volume of LA,
trunksblocks colectomy286 technique297
= LOSH295 ✓ SO
= LOSH, earlier urinary catheter ✓ TEA
removal296
;, decreasing; ↑, accelerating; =, no effect. SO, systemic opioids; TEA, thoracic epidural analgesia; IVLI, intravenous lidocaine infusion; CWI,
continuous wound infusion; LA, local anaesthetic; LOSH, length of hospital stay in hospital; (ERAS), study within an ERAS programme.
epidural solutions combining local anaesthetic opioids to increase segmental analgesia spread
with lipophilic opioids vs. those containing and could be recommended for long midline
local anaesthetic combined with hydrophilic incisions.259 Epidural infusions can be contin-
opioids, epidural solution containing morphine ued for 48-72, gradually reducing infusion rates
increase the risk of urinary retention.257,258 and until the recovery of gastrointestinal func-
However, the use of low dose of local anaesthet- tion. Adding adrenaline (1.5–2.0 lg/ml) to
ics (bupivacaine 0.1 mg/ml) and lipophilic opi- epidural mixture of local anaesthetic and fen-
oids (e.g. fentanyl 3 lg/ml) seem to provide tanyl improves postoperative analgesia, espe-
optimal analgesia with minimal side effects257. cially during mobilization and coughing, and
Epidural morphine (0.02 mg/ml) in adjunct to reduces pruritus and nausea.248,256,260–262 Evi-
local anaesthetic can be preferred to lipophilic dence on the analgesic efficacy of epidural cloni-

dine is inconclusive and the risk of hypotension shown to improve postoperative analgesia,
and sedation is increased.263 Hypotension reduce opioid consumption and speed surgical
induced by epidural blockade should be treated recovery.269,270 Similar benefits have been
with vasopressors as first choice provided the observed after laparoscopic abdominal surgeries
patient is not hypovolaemic. Orthostatic when compared with systemic opioids,271 but
hypotension associated with postoperative not when compared with TEA254, and especially
epidural analgesia does not impair the ability to in the absence of an ERAS programme.254,272
ambulate.264 Institutional policies on how to
manage epidural side effects, terminate epidural
Clinical management
infusions, and how transition to oral multi-
A loading dose of 1.5 mg/kg (IBW) should be
modal analgesia are recommended.
initiated 30 min before or at the induction of
anaesthesia and continued until the end of
Intrathecal (IT) analgesia. IT morphine is a valu- surgery or in the recovery room (2 mg/kg/h
able analgesic technique to improve early post- IBW). The exact duration of the infusion provid-
operative analgesia265 and facilitates surgical ing optimal analgesia and facilitating also recov-
recovery.266 However, compared with systemic ery remains unknown. Systemic toxicity is rare,
opioids, the incidence of pruritus (OR 3.85, but continuous cardiovascular monitoring is
95% CI 2.40–6.15) and respiratory depression required.270
(although rare) is increased (OR 7.86, 95% CI
1.54–40.3). Postoperative urinary retention is
Continuous wound infusion (CWI) of local
also slightly more frequent (OR 2.35, 95% CI
anaesthetic. CWI of local anaesthetic after open
1.00–5.51).265 Hypotension in the first 12 h,
abdominal surgery has been shown to improve
especially in a context of an enhanced recovery
postoperative analgesia and reduce opioid con-
pathway and a restrictive fluid management, has
sumption,273,274 however the effect on the
been also associated with the use of intrathecal
recovery of bowel function is unclear.273,275
hydromorphone (with bupivacaine or cloni-
Two recent RCTs have compared the analgesic
dine).267
efficacy of CWI of local anaesthetic with TEA
In the light of these side effects, in the con-
but the results are contrasting.276,277 A recent
text of an multimodal analgesic regimen other
feasibility study has compared the analgesic
regional anaesthesia technique could be
efficacy of CWI of local anaesthetic with epidu-
favoured especially in elderly patients. Behind
ral analgesia after laparoscopic abdominal sur-
providing excellent analgesia,268 IT morphine
gery. Pain intensity was similar among patients
seems an appealing technique to shorten hospi-
receiving epidural and CWI of local anaes-
tal stay in low-risk patients undergoing laparo-
thetic.278
scopic colorectal surgery with an ERAS
Despite promising results the analgesic effi-
protocol.253
cacy of CWI of local anaesthetic remains incon-
clusive and several aspects related to this
Clinical management techniques need to be clarified. For example,
Reported IT morphine dosage range between although preperitoneal multihole catheters have
200 and 250 lg in patients aged ≤ 75 years to lg consistently provided satisfactory analgesia, and
150 in patients > 75 years of age. Isobaric or subfascial catheters have provided better results
hyperbaric bupivacaine (10–12.5 mg) have been than suprafascial catheters,279 the anatomical
used in conjunction with IT morphine.253,268 location associated with optimal recovery
remains undetermined.274,279 Furthermore, it
remains to be established if the analgesic effect
Intravenous lidocaine (IVL) infusion
observed in different trials is mainly driven by
In view of its antinociceptive and anti-inflam- the bolus of local anaesthetic commonly given
matory properties, systemic administration of at the end of surgery or by the infusion of local
IVL as adjuvant to systemic opioids has been anaesthetic during the postoperative period.280

Clinical management Clinical management

Preperitoneal continuous infusion of ropiva- Optimal timing, choice of local anaesthetic, dos-
caine 0.2% (10 ml/h) for 48–72 h has been ing and volumes remain unknown.297 However,
used in the majority of the studies. Other it seems that a minimal volume of 15 ml is
amide-local anaesthetics have also been used. required to achieve satisfactory analgesia with
Systemic opioids are still required to control single-shot TAP block.297 Ropivacaine 0.2% (8–
visceral pain. 10 ml/h) can be infused for 48–72 h trough a
multihole catheter. A bilateral infusion (8–
10 ml/h each side) is required with a midline
Abdominal trunk blocks: transversus abdominis plane
incision. Systemic opioids are needed to control
(TAP) block and rectus sheath block. Significant
visceral pain.
reduction of pain intensity and opioid consump-
More studies that further validate the anal-
tion after ultrasound-guided single-shot TAP
gesic efficacy of TAP blocks are warranted.
blocks has been observed but it is limited to the
first 24 h after surgery.281–283 TAP blocks can
also be performed by surgeons from the peri- Intraperitoneal local anaesthetic (IPLA) . The results
toneal cavity before closing the abdominal of a meta-analysis including eight RCTs have
wall,284,285 or laparoscopic guided.286–288 Few shown that IPLA after open abdominal surgery
studies have reported a reduction of some of the reduce postoperative pain scores but not opioid
opioids side effects such as nausea and vomit- consumption. However, in the latest randomized
ing283 or sedation,284,289 but these results have control trial conducted in a context of an
not been reproduced consistently.281 Continuous enhanced recovery programme, IPLA improved
infusion or intermittent administration of local surgical recovery, reduced postoperative pain
anaesthetics through multihole catheters placed and opioid consumption in patients undergoing
in the transversus abdominis plane have been open colectomy and receiving thoracic epidural
used to improve and prolong opioid-based post- analgesia.298
operative analgesia up to 48–72 h after abdomi- IPLA has been shown to improve postopera-
nal surgery, but the evidence supporting the tive analgesia, reduce shoulder pain and opioid
analgesic efficacy of TAP-infusion of local anaes- consumption after laparoscopic gastric sur-
thetic remains scarce and inconclusive.290–292 gery299.
Niraj et al. found that epidural analgesia did
not provide better visual analogue scores dur-
ing coughing than intermittent local anaesthetic Multimodal analgesia (MMA). A MMA regimen
boluses through bilateral subcostal TAP cathe- based on routine use of NSAIDs, COX-2 and
ters in the first 72 h after upper abdominal acetaminophen (paracetamol) (PO or intra-
surgery.293 However, epidural failure rate venously when available) should adopted if not
were high (22%) and almost half of the TAP contraindicated in patients undergoing open
catheters had to be replaced in the postoperative and laparoscopic abdominal procedures with
period. the aim to reduce opioid consumption and their
Similar benefits have been reported in abdom- dose-dependent side effects that impair recov-
inal laparoscopic procedures282,294 and in a con- ery.300 NSAIDs and COX-2 inhibitors have been
text of an ERAS programme.286,295 Despite shown to improve postoperative analgesia,
facilitating hospital discharge,286 bilateral sin- reduce opioid consumption and some of their
gle-shot TAP blocks seem to do not reduce hos- side effects by 30%.301 There have been recent
pital stay after laparoscopic colorectal concerns about the risk of anastomotic leakage
surgery.295 A recent RCT has shown that the and the use of NSAIDs or COX-2 inhibitors
analgesic efficacy of four-quadrant TAP blocks after colorectal surgeries based on experimental,
in adjunct to bilateral posterior continuous TAP retrospective and case-series studies.302. Large
blocks, was not inferior to TEA after laparo- RCTs are needed to confirm these results. The
scopic colorectal surgery.296 risk of anastomotic leakage after bowel surgery

was not significantly increased in a recent meta- might offset the reported advantages of different
analysis of six RCTs (480 patients) of patients analgesic techniques.242 The synergistic effect of
receiving at least one dose of NSAIDs or COX-2 combining different analgesic medications
inhibitors within 48 h of surgery (Peto OR 2.16 remains unknown and the impact of MMA
[95% CI 0.85–5.53, P = 0.11])303. This effect on long- term outcomes still remains to be
seems to be molecule-specific (diclofenac is determined318.
associated with the highest risk)302 and class-
specific (risk of anastomotic leakage with Summary and Recommendation: Analgesic tech-
NSAIDs, OR 2.13 [95% CI 1.24–3.65], niques should aim to not only provide optimal
P = 0.006, risk of anastomotic leakage with pain control but also to facilitate the achieve-
selective COX-2 inhibitors OR 1.16 [95% CI ment of important milestones such as tolerance
0.49–2.75] P = 0.741)304. Furthermore, the risk of oral intake, and early mobilization. Opioid
varies with duration of the treatment, and it is side effects are dose-dependent and delay recov-
higher after 3 days or more of NSAIDs than after ery. Opioid-sparing analgesic strategies, includ-
1 or 2 days only304. Acetaminophen (paraceta- ing regional analgesia techniques, should be
mol) has shown to improve postoperative anal- implemented in a context of a multimodal anal-
gesia, have an opioid-sparing effect, but not gesic regimen. Postoperative pain management
reduce opioids side effects.305 However, a recent should be procedure-specific.
meta-analysis has demonstrated that intravenous
paracetamol reduces the risk of postoperative Recommendation grade: MMA: strong
nausea and vomiting, but this effect seems more
related to an improvement in postoperative pain
Open abdominal surgery. TEA: strong for using
rather than to a reduction in opioid consump-
it
tion.306 Concerns have been raised about the
IVLI: moderate for using it
cardiovascular risk and delayed bone healing
CWI: weak for using it
associated with the use of NSAIDs and COX-2
TAP blocks: moderate for using it
inhibitors307. Overall, the evidence is inconclu-
sive307 and does not support the avoidance of
short perioperative NSAIDs and COX-2 inhibi- Laparoscopic abdominal surgery. TEA: weak for
tors treatment in patients with low cardiovascu- using it
lar risk.307,308 High-dose of systemic steroids IVLI: moderate for using it
have also shown promising results309,310, also in Intrathecal morphine: moderate for using it
patients not undergoing gastrointestinal sur- TAP blocks: moderate for using it
gery.311,312 Perioperative intravenous ketamine
and gabapentinoids have also shown opioid-
Postoperative delirium
sparing properties.313,314 However, the risk of
side effects such as dizziness and sedation Postoperative delirium is increasingly recognized
should be considered. An opioid-free ultimodal in surgical practice, particularly in the elderly
analgesic strategy based mainly on analgesic population who have pre-existing cognitive dys-
adjuvants would be appealing but more studies function. While delirium can be a symptom of a
are warranted to establish the feasibility, effi- surgical or medical complication it is important
cacy and safety of such analgesic approaches.315 to be recognized instantly.
Wound infiltration with long-acting multivesic- The prevalence is underestimated and under-
ular liposome formulation of bupivacaine as part diagnosed if no systematic monitoring is
of multimodal analgesic regimens has also applied.319 It is defined as a condition of
shown promising results.316,317 It must be altered consciousness, orientation, memory,
acknowledged that most of the following recom- thought, perception, behaviour and possibly
mendations come from studies not using sleep pattern which develops acutely and
enhanced recovery after surgery (ERAS) shows a fluctuating clinical course.320 Delirium
programmes. It might be possible that the can be classified into three subtypes: the hyper-
well-proven benefits of ERAS programmes active delirium, the hypoactive delirium and a
mixed form.321 Delirium as a symptom of acute

Attenuation and treatment of postoperative
cerebral dysfunction should not solely be per-
ileus
ceived as a strictly binary phenomenon which
is either present or absent. Detection of delir- Postoperative ileus (POI) is defined as a tran-
ium also at pre-delirium or sub-syndromal sient reduction of bowel motility that prevents
levels could prevent further deterioration of effective transit of bowel content and tolerance
cerebral function. of oral intake following surgical interven-
Undetected and untreated or delayed treat- tions.330 POI has been associated with pro-
ment of delirium does increase the rate of com- longed hospital stay and higher risk of
plications, the length of hospital stay as well as complications. POI can be classified in primary
mortality322,323 and is associated with long-term POI that occurs in the absence of surgical com-
cognitive dysfunction.324 plications, and in secondary POI in the presence
Early detection in the postoperative setting is of surgical complications such as anastomotic
a prerequisite for finding and treating the leakage, abscess, peritonitis, etc.330 Primary POI
underlying causes. Numerous validated Delir- is considered an inevitable consequence after
ium Instruments have been validated for clinical abdominal surgery. However, its clinical presen-
use.325,326 tation and duration can significantly vary among
Delirium promoting factors such as pro- patients depending on the severity of the gas-
longed preoperative fluid fasting times, deep trointestinal dysfunction. Some patients can be
anaesthesia time as well as disturbing the totally asymptomatic and tolerate oral intake in
sleep–wake cycle and the use of sedatives and the immediate postoperative period, while
other delirogenic medications should be others experience gastrointestinal symptoms,
avoided.117,327 cannot tolerate any oral intake for several days
If postoperative delirium is detected, the early and might require insertion of a nasogastric tube
symptomatic therapy based on pharmacological (NGT).330 The definitions of primary POI
and non-pharmacological measures, is associ- remains elusive and many clinical trials still uti-
ated with a decreased mortality323. Psychotic lize personal definitions in view of the difficulty
symptoms should be treated with neuroleptics. on how to clinically identify patients with a
A systematic review that a low-dose haloperidol clinically relevant impairment of gastrointestinal
therapy compared with a therapy with atypical dysfunction. In a recent study measuring the
neuroleptics has a similar effectiveness and side gastrointestinal transit after colorectal surgery,
effect rate.328 Van Bree et al. showed that the combination of
If there is the necessity to apply substances tolerance of solid food and passage of stool best
with sedative properties, non-benzodiazepines correlates with the recovery of gastrointestinal
should be preferred (e.g. alpha-2-agonists) due function (area under the curve 0.9, SE 0.04,
to international guidelines for sedation. Benzo- 95% CI 0.79–0.95, P < 0.001), with a positive
diazepines are known to be an independent risk predictive value of 93% (95% CI 78–99).331 It
factor for delirium and should therefore be also best predicts hospital stay.331 Others clini-
avoided if possible.329 cal indicators commonly used to assess POI,
such as the time to first flatus, poorly correlate
Summary and recommendation: Preventive with the recovery of the gastrointestinal func-
measure as avoidance of prolonged fasting, tion.331 A list of clinical indicators commonly
deep anaesthesia, disturbance of sleep–wake used in clinical practice to evaluate the recovery
cycle or delirogenic medications like benzodi- of the gastrointestinal function is reported in
azepines, atropine should be implemented. Sys- Fig. 1. Non-ileus-related nausea and intra-
tematic delirium screening and symptom- abdominal surgical complications leading to sec-
oriented treatment should be performed and ondary POI should be excluded.
potential underlying medical causes should be Due to its multifactorial pathogenesis several
ruled out. perioperative preventive strategies can be imple-
mented to reduce the severity and duration of
Recommendation grade: strong. primary POI.332 Based on the results of a large
retrospective study, it should be also considered

Table 3 Risk factors, prevention and management of primary
that some patients might have a higher risk to
POI.
develop prolonged primary POI (Table 3). These
results need to be confirmed when adopting Patients risk factors333
• Male
multiple interventions to attenuate postoperative
• Cerebrovascular diseases
gastrointestinal dysfunctions as in a context of • Respiratory diseases
an ERAS programme.333 Nasogastric decompres- • Peripheral vascular diseases
sion should be considered to prevent complica-
Intraoperative strategies to accelerate the recovery of
tions such as pulmonary aspiration and
arrhythmias.164 • Laparoscopic surgery5
• Thoracic epidural analgesia241
Summary and recommendation: Primary POI is • Opioid-sparing strategies332
an inevitable consequence after gastrointestinal o Intravenous Lidocaine
surgery and its pathogenesis is multifactorial. o NSAIDs/COX-2
Multimodal preventing strategies should be o Ketamine
• Avoid fluid excess and splanchnic hypoperfusion332
adopted to facilitate the recovery of gastroin-
testinal function. Postoperative strategies to accelerate the recovery of
Recommendation grade: moderate • Thoracic epidural analgesia241
• Opioid-sparing strategies332
o NSAIDs/COX-2
Early mobilization • Opioid antagonists358
Although the tradition of prolonged postopera- o Alvimopam
o Metiltrexone
tive bed rest was abandoned over 75 years
• Mobilization332
ago334 and the dangers of staying in bed • Laxative332
acknowledged,335 modern surgical patients actu- • Gum-chewing359
ally spend very little time out of bed.336 Early • Administer IV fluids only if clinical indicated (surgical losses,
“enforced” or “structured” mobilization is a key inadequate hydration) (ref)
component of virtually all ERAS pro- • Early feeding332
grammes.16,337 Patients cared for with the ERAS • Avoidance prophylactic and routine use of NGT
paradigms mobilize more and achieve indepen- Treatment of primary POI

dent mobilization earlier than those cared for NGT insertion332
without ERAS.7 Mobilization helps preserve
Fig. 1. Identification of patients with primary

or secondary postoperative Ileus (POI). SIRS,
systemic inflammmatory response; WBC,
white blood cell; Hb, hemoglobin; K+,
potassium; HPO42 , phospate.

muscle function and prevent complications Achieving early mobilization on the ward
associated with bed rest, but also aligns with requires integration between the patient and the
the message of empowerment of patients to play various health care providers working in a multi-
an active role in their own recovery after sur- disciplinary fashion form the beginning. Pain and
gery; this term is used instead of “convales- drains inhibit ambulation.338 Ideally a dedicated
cence”, which implies a passive process. pain service is involved in the ERAS team to opti-
Protocols differ between pathways and there mize pain control and reduce side effects.337
is no standard definition of early mobilization Epidural analgesia provides excellent analgesia
which may include exercising in bed, sitting out after open abdominal or thoracic surgery but it is
of bed, standing, walking in the room, walking associated with postoperative hypotension and
in the hallway or exercising.338 Different with lower limb weakness if the epidural block is
successful pathways set different mobilization extended to the lumbar nerve roots.248 Epidural
goals using different benchmarks such as time7 systems that reduce interference with ambulation
(hours out of bed, hours sitting or walking) or should be used if possible. There is a tendency to
distance (e.g. number of times to walk a hall- bed rest patients experiencing orthostatic intoler-
way or ward).339 These begin early, on the day ance or hypotension, and to consider the epidural
of surgery, and increase each day to reach prede- responsible for this effect. However, in patients
termined targets. There are no data to support with thoracic epidural analgesia hypotension is a
the use of one plan over another or suggestion relatively common side effect on postoperative
of a “dose–response” curve related to outcomes. day 1 but is often asymptomatic and does not pre-
Unfortunately, there is little evidence avail- dict the ability to walk.264 Furthermore, epidural
able to guide how to best achieve early mobi- analgesia is not associated with higher risk of
lization and even within established ERAS orthostatic intolerance or hypotension than sys-
programmes adherence to mobilization targets temic opioids.347 Orthostatic intolerance seems to
may be quite low, suggesting a need for specific be more related to an impairment of the auto-
studies in this area.197 A review of the impact of nomic system and to an alteration of the barore-
early mobilization for medical and surgical ceptor reflex348,349 rather than to other factors such
patients found that the use of a more standard- as hypovolaemia,350 anaemia and pain.349 The
ized and structured approach beginning as early underlying mechanisms are not yet fully
as possible had the most favourable results.340 understood.
This begins in the preoperative setting with Most pathways rely on nurses to assist with
clear and explicit instructions detailing daily “enforcing” mobilization7 with physiotherapists
mobilization goals. These instructions are rein- involved in some programmes, suggesting an
forced with written material which improves increased need for resources. Nurses should be
recall341 and which is brought by the patient to involved in the creation of the mobilization plan
the hospital. Posters on the ward may help rein- from the beginning in order for the team to
force daily goals.342 Patients who begin an exer- understand potential barriers to ambulation.351
cise programme in the preoperative period may Although there may be concern from nurses that
also be more likely to be physically active post- ERAS will increase their daily workload related
operatively.343 Compliance may be improved by to these physical tasks, this has not been shown
the use of a patient diary344 or when a pedome- to be the case, perhaps because of increased
ter is worn, which has been shown in other patient independence.352
contexts to be associated with increased physi-
cal activity.345 Creation of separate ERAS “reha- Summary and recommendation: Achievement of
bilitation” wards344 or having a separate ward mobilization goals requires a multidisciplinary
dining room may help337 but are not feasible in approach. Patients should be given written
all settings. The absence of an in-room enter- information setting daily targets for ambulation
tainment system may promote increased walk- in hospital. Patients should be encouraged to
ing.346 Having an audit tool available recording increase their physical activity in the preopera-
compliance with mobilization is important to tive period. Patients should use a diary or
identify and address barriers. pedometer to record their daily physical activity.
Table 4 ERAS elements: summary and recommendations.
Perioperative element Summary and recommendation Recommendation grade
Risk assessment Preoperative scoring tools and functional capacity tests can be POSSUM: strong
used to identify patients at risk of complications and to stratify Lee Index: strong
perioperative risk. Cardiovascular Risk Calculator: strong
Walk tests: strong
CPET: strong
General Surgery Acute Kidney Injury
Risk Index: strong
Preoperative Cessation of smoking and alcohol intake at least 4 weeks before Smoking cessation: high
optimization surgery is recommended. Encouraging patients is not enough; NRT and counselling: high
pharmacological support and individual counselling should be Alcohol cessation: low
offered to every patient who smokes and to alcohol abusers Medical optimization: strong
undergoing elective surgery. Optimization of medical conditions, Optimize preoperative anaemia
such as cardiovascular diseases, anaemia, COPD, nutritional reduces morbidity and mortality:
status and diabetes should follow international moderate
recommendations.
Pre-anaesthetic Long-acting anxiolytic and opioids should be avoided as they may Strong.
medication delay discharge. Short-acting benzodiazepine should be avoided
in the elderly.
Preoperative fasting Intake of clear fluids should be allowed until 2 h before induction Adherence to fasting guidelines (avoid
and carbohydrates of anaesthesia. Solids should be allowed until 6 h. Preoperative overnight fasting): strong
(CHOs) loading treatment with oral CHOs should be routinely administered Administration of preoperative CHOs:
except in patients with documented delayed gastric emptying or strong
slow gastrointestinal motility and as well in patients undergoing Administration of preoperative CHOs
emergency surgery. in diabetic and obese patients: weak
Preventing and Aggressive PONV prevention strategy should be included in an Strong
treating ERAS protocol102. All patients with 1–2 risk factors should
postoperative receive a combination of two antiemetics. Patients with 3–4 risk
nausea and factors should receive 2–3 antiemetics. Total intravenous
vomiting (PONV) anaesthesia (TIVA) with propofol and opioid-sparing strategies
should be encouraged.
Standard anaesthetic Anaesthetic depth should be guided either maintaining an end Strong
protocol tidal concentration of 0.7–1.3 MAC or BIS index between 40 and
60 with the aim not only to prevent awareness but also to
minimize anaesthetic side effects and facilitate rapid awakening
and recovery. Avoid too deep anaesthesia (BIS < 45), especially
in elderly patients
Neuromuscular It remains controversial if deep neuromuscular blockade during Monitoring neuromuscular function:
blockade (NMB) and laparoscopic surgery improves operating conditions. strong
neuromuscular Neuromuscular function should be always monitored when Reversing neuromuscular blockade:
monitoring using NMBA to avoid residual paralysis. Long-acting NMBA strong
should be avoided. When NMBA are administered
neuromuscular function should be monitored by using a
peripheral nerve stimulator to ensure adequate muscle
relaxation during surgery and optimal restoration of
neuromuscular function at the end of surgery. A TOF ratio of
0.9 must be achieved to ensure adequate return of muscle
function and thus preventing complications.
Inspired Oxygen 1) The inspired fractional concentration of oxygen should be 1) Strong
Concentration titrated to produce normal arterial oxygen levels and 2) Strong
saturations. Prolonged periods of high inspired oxygen
concentrations which result in hyperoxia should be avoided.

Table 4 (Continued)
2) 100% inspired oxygen concentrations can be used for pre-

oxygenation prior to anaesthesia or for short periods to
overcome hypoxia.
Preventing Intraoperative hypothermia should be avoided by using active Strong.
intraoperative warming devices.
hypothermia
Surgical techniques Laparoscopic surgery for gastrointestinal surgery is recommended Laparoscopic approach: strong
when the expertise is available. Transverse incisions for colonic Transverse incisions for colonic
resections can be preferred. surgery: low
Nasogastric intubation Prophylactic use of NGTs is not recommended for patients Strong.
undergoing elective colorectal surgery, while its use in patients
undergoing gastrectomy and oesophagectomy is still debatable.
Patients with delayed gastric emptying after surgery should be
treated by inserting a NGT.
Intraoperative Glucose levels should be kept as close to normal as possible Strong.
glycaemic control without compromising safety. Employing perioperative
treatments that reduce insulin resistance without causing
hypoglycaemia is recommended.
Perioperative The goal of perioperative fluid therapy is to maintain fluid GDFT: Strong in high-risk patients and
haemodynamic homeostasis avoiding fluid excess and organ hypoperfusion. for patients undergoing surgery with
management Fluid excess leading to perioperative weight gain more than large intravascular fluid loss (blood
2.5 kg should be avoided, and a perioperative near-zero fluid loss and protein/fluid shift)
balance approach should be preferred. GDFT should be adopted GDFT: low in low-risk patients and in
especially in moderate–high-risk patients. Inotropes should be patients undergoing low-risk surgery
considered in patients with poor contractility CI < 2.5 l/min). Perioperative near-zero fluid balance:
Colloids should not be used in septic patients and in patients moderate
with reduced renal function. Large amount of colloids can Use of advanced hemodynamic
impair haemostasis. In patients receiving epidural analgesia monitoring: strong in high-risk patients
arterial hypotension should be treated with vasopressors, and for patients undergoing surgery
ensuring the patient is normovolaemic. In the absence of with large intravascular fluid loss
surgical losses postoperative intravenous fluid should be (blood loss and protein/fluid shift)
discontinued and oral intake (1.5 l/day) encouraged.
Balanced crystalloids 0.9% saline should be avoided and balanced crystalloid solution Strong
vs. 0.9% saline used in the preoperative period. The use of 0.9% saline should
be restricted in hypochloraemic and acidotic patients.
Pain management Analgesic techniques should aim to not only provide optimal pain MMA: strong
control, but also to facilitate the achievement of important Open abdominal surgery
milestones such as tolerance of oral intake, and early TEA: strong for using it
mobilization. Opioids side effects are dose-dependent and delay IVLI: moderate for using it
recovery. Opioid-sparing analgesic strategies, including regional CWI: weak for using it
analgesia techniques, should be implemented in a context of a TAP blocks: moderate for using it
multimodal analgesic regimen. Postoperative pain management Laparoscopic abdominal surgery
should be procedure-specific TEA: weak for using it
IVLI: moderate for using it
Intrathecal morphine: moderate for
using it
TAP blocks: moderate for using it
Postoperative Preventive measure as avoidance of prolonged fasting, deep Strong
Delirium anaesthesia, disturbance of sleep-wake cycle or delirogenic
medications like benzodiazepines, atropine should be
implemented. Systematic delirium screening and symptom-

Table 4 (Continued)
oriented treatment should be performed and potential

underlying medical causes should be ruled out.
Attenuation and Primary POI is an inevitable consequence after gastrointestinal Moderate
treatment of surgery and its pathogenesis is multifactorial. Multimodal
postoperative ileus preventing strategies should be adopted to facilitate the
recovery of gastrointestinal function.
Early mobilization Achievement of mobilization goals requires a multidisciplinary Weak.
approach. Patients should be given written information setting
daily targets for ambulation in hospital. Patients should be
encouraged to increase their physical activity in the
preoperative period. Patients should use a diary or pedometer
to record their daily physical activity.
Recommendation grade: weak. considerations and recommendations for each of

the ERAS elements are listed in Table 4.
Comment
References
The practice of surgery and anaesthesia is con-
tinuously evolving and there is a need to offer 1. Weiser TG, Regenbogen SE, Thompson KD,
the knowledge base for continuous training of Haynes AB, Lipsitz SR, Berry WR, Gawande AA.
those involved in the treatment of surgical An estimation of the global volume of surgery: a
patients. The ERAS Society (www.erassoci- modelling strategy based on available data. Lancet
ety.org) was initiated by the former ERAS Study 2008; 372: 139–44.
Group and was formed in 2010 to support these 2. Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz
processes. The multidisciplinary Society partici- P, Spies C, Vallet B, Vincent JL, Hoeft A, Rhodes
pates in the improvement of perioperative care A. European Surgical Outcomes Study group for
by developing new knowledge through the Trials groups of the European Society of
Intensive Care Medicine, the European Society of
research, education and also by being involved
Anaesthesiology. Mortality after surgery in Europe:
in the implementation of best practice.
a 7 day cohort study. Lancet 2012; 380: 1059–65.
The current manuscript presents a consensus
3. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO,
review from the ERAS Society, discuss clinical
Spies C, von Meyenfeldt MF, Fearon KC, Revhaug
considerations, and provide recommendations, A, Norderval S, Ljungqvist O, Lobo DN, Dejong
for optimal anaesthesia care within the ERAS CH, Enhanced Recovery After Surgery G.
programme for patients undergoing gastroin- Consensus review of optimal perioperative care in
testinal surgery. The quality of evidence sup- colorectal surgery: Enhanced Recovery After
porting each ERAS element has been already Surgery (ERAS) Group recommendations. Arch
evaluated according to the GRADE system and Surg 2009; 144: 961–9.
previously published15–19. The evidence-based 4. Khoo CK, Vickery CJ, Forsyth N, Vinall NS,
recommendations present the ERAS protocol Eyre-Brook IA. A prospective randomized
interventions separately and overall, and are controlled trial of multimodal perioperative
intended to be used by units undertaking to management protocol in patients undergoing
implement and upgrade to what the current lit- elective colorectal resection for cancer. Ann Surg
erature shows to be best practice: the ERAS pro- 2007; 245: 867–72.
tocol. It must be acknowledged that, not being a 5. Vlug MS, Wind J, Hollmann MW, Ubbink DT,
systematic review, all articles quoted in the Cense HA, Engel AF, Gerhards MF, van
manuscript have been selected by the expert in Wagensveld BA, van der Zaag ES, van Geloven
each area, resulting in potential bias. Clinical AA, Sprangers MA, Cuesta MA, Bemelman WA,

LAFA Study Group. Laparoscopy in combination 15. Cerantola Y, Valerio M, Persson B, Jichlinski P,
with fast track multimodal management is the best Ljungqvist O, Hubner M, Kassouf W, Muller S,
perioperative strategy in patients undergoing Baldini G, Carli F, Naesheimh T, Ytrebo L, Revhaug
colonic surgery: a randomized clinical trial (LAFA- A, Lassen K, Knutsen T, Aarsether E, Wiklund P,
study). Ann Surg 2011; 254: 868–75. Patel HR. Guidelines for perioperative care after
6. Basse L, Raskov HH, Hjort Jakobsen D, Sonne E, radical cystectomy for bladder cancer: enhanced
Billesbolle P, Hendel HW, Rosenberg J, Kehlet H. Recovery After Surgery (ERAS)
Accelerated postoperative recovery programme society recommendations. Clin Nutr 2013; 32:
after colonic resection improves physical 879–87.
performance, pulmonary function and body 16. Gustafsson UO, Scott MJ, Schwenk W, Demartines
composition. Br J Surg 2002; 89: 446–53. N, Roulin D, Francis N, McNaught CE, Macfie J,
7. Basse L, Hjort Jakobsen D, Billesbolle P, Werner Liberman AS, Soop M, Hill A, Kennedy RH, Lobo
M, Kehlet H. A clinical pathway to accelerate DN, Fearon K, Ljungqvist O. Enhanced Recovery
recovery after colonic resection. Ann Surg 2000; After Surgery Society, European Society for
232: 51–7. Clinical Nutrition and Metabolism, International
8. Muller S, Zalunardo MP, Hubner M, Clavien PA, Association for Surgical Metabolism and Nutrition.
Demartines N. A fast-track program reduces Guidelines for perioperative care in elective
complications and length of hospital stay after colonic surgery: Enhanced Recovery After Surgery
open colonic surgery. Gastroenterology 2009; 136: (ERAS ) Society recommendations. World J Surg
842–7. 2013; 37: 259–84.
9. Serclova Z, Dytrych P, Marvan J, Nova K, 17. Mortensen K, Nilsson M, Slim K, Schafer M,
Hankeova Z, Ryska O, Slegrova Z, Buresova L, Mariette C, Braga M, Carli F, Demartines N,
Travnikova L, Antos F. Fast-track in open Griffin SM, Lassen K, Enhanced Recovery After
intestinal surgery: prospective randomized study Surgery G. Consensus guidelines for enhanced
(Clinical Trials Gov Identifier no. NCT00123456). recovery after gastrectomy: Enhanced Recovery
Clin Nutr 2009; 28: 618–24. After Surgery (ERAS ) Society recommendations.
10. Werawatganon T, Charuluxanun S. Patient Br J Surg 2014; 101: 1209–29.
controlled intravenous opioid analgesia versus 18. Nygren J, Thacker J, Carli F, Fearon KC, Norderval
continuous epidural analgesia for pain after intra- S, Lobo DN, Ljungqvist O, Soop M, Ramirez J.
abdominal surgery. Cochrane Database Syst Rev Enhanced Recovery After Surgery Society,
2005; (1): CD004088. European Society for Clinical Nutrition and
11. Varadhan KK, Lobo DN. A meta-analysis of Metabolism, International Association for Surgical
randomised controlled trials of intravenous fluid Metabolism and Nutrition. Guidelines for
therapy in major elective open abdominal surgery: perioperative care in elective rectal/pelvic surgery:
getting the balance right. Proc Nutr Soc 2010; 69: Enhanced Recovery After Surgery (ERAS ) Society
488–98. recommendations. World J Surg 2013; 37: 285–305.
12. Rahbari NN, Zimmermann JB, Schmidt T, Koch 19. Lassen K, Coolsen MM, Slim K, Carli F, deAguilar-
M, Weigand MA, Weitz J. Meta-analysis of Nascimento JE, Schafer M, Parks RW, Fearon KC,
standard, restrictive and supplemental fluid Lobo DN, Demartines N, Braga M, Ljungqvist O,
administration in colorectal surgery. Br J Surg Dejong CH, Enhanced Recovery After Surgery
2009; 96: 331–41. Society fPC, European Society for Clinical N,
13. Bijker JB, van Klei WA, Vergouwe Y, Eleveld DJ, Metabolism, International Association for Surgical
van Wolfswinkel L, Moons KG, Kalkman CJ. M, Nutrition. Guidelines for perioperative care for
Intraoperative hypotension and 1-year mortality pancreaticoduodenectomy: Enhanced Recovery
after noncardiac surgery. Anesthesiology 2009; After Surgery (ERAS ) Society recommendations.
111: 1217–26. World J Surg 2013; 37: 240–58.
14. Scott MJ, Baldini G, Fearon K, Feldheiser A, 20. Pearse RM, Harrison DA, James P, Watson D,
Feldman L, Gan TJ, Ljungqvist O, Lobo DN, Hinds C, Rhodes A, Grounds RM, Bennett ED.
Rockall TA, Schricker T, Carli F. Enhanced Identification and characterisation of the high-risk
Recovery After Surgery (ERAS) for surgical population in the United Kingdom. Crit
gastrointestinal surgery, part 1: Care 2006; 10: R81.
pathophysiological considerations. Acta 21. Khuri SF, Henderson WG, DePalma RG, Mosca C,
Anaesthesiol Scand 2015; 59: 1212–31. Healey NA, Kumbhani DJ, Participants in the

VANSQIP. Determinants of long-term survival Heart Association Task Force on Practice

after major surgery and the adverse effect of Guidelines. Circulation 2014; 130: 2215–45.
postoperative complications. Ann Surg 2005; 242: 31. Lee TH, Marcantonio ER, Mangione CM, Thomas
326–41; discussion 41-3. EJ, Polanczyk CA, Cook EF, Sugarbaker DJ,
22. Copeland GP, Jones D, Walters M. POSSUM: a Donaldson MC, Poss R, Ho KK, Ludwig LE,
scoring system for surgical audit. Br J Surg 1991; Pedan A, Goldman L. Derivation and prospective
78: 355–60. validation of a simple index for prediction of
23. Prytherch DR, Whiteley MS, Higgins B, Weaver cardiac risk of major noncardiac surgery.
PC, Prout WG, Powell SJ. POSSUM and Circulation 1999; 100: 1043–9.
Portsmouth POSSUM for predicting mortality. 32. Botto F, Alonso-Coello P, Chan MT, Villar JC,
Physiological and Operative Severity Score for the Xavier D, Srinathan S, Guyatt G, Cruz P, Graham
enUmeration of Mortality and morbidity. Br J Surg M, Wang CY, Berwanger O, Pearse RM, Biccard
1998; 85: 1217–20. BM, Abraham V, Malaga G, Hillis GS, Rodseth
24. Tekkis PP, Poloniecki JD, Thompson MR, RN, Cook D, Polanczyk CA, Szczeklik W, Sessler
Stamatakis JD. Operative mortality in colorectal DI, Sheth T, Ackland GL, Leuwer M, Garg AX,
cancer: prospective national study. BMJ 2003; 327: Lemanach Y, Pettit S, Heels-Ansdell D, Luratibuse
1196–201. G, Walsh M, Sapsford R, Schunemann HJ, Kurz A,
25. Tekkis PP, McCulloch P, Poloniecki JD, Prytherch Thomas S, Mrkobrada M, Thabane L, Gerstein H,
DR, Kessaris N, Steger AC. Risk-adjusted Paniagua P, Nagele P, Raina P, Yusuf S,
prediction of operative mortality in Devereaux PJ, Devereaux PJ, Sessler DI, Walsh M,
oesophagogastric surgery with O-POSSUM. Br J Guyatt G, McQueen MJ, Bhandari M, Cook D,
Surg 2004; 91: 288–95. Bosch J, Buckley N, Yusuf S, Chow CK, Hillis GS,
26. Neary WD, Heather BP, Earnshaw JJ. The Halliwell R, Li S, Lee VW, Mooney J, Polanczyk
Physiological and Operative Severity Score for the CA, Furtado MV, Berwanger O, Suzumura E,
enUmeration of Mortality and morbidity Santucci E, Leite K, Santo JA, Jardim CA,
(POSSUM). Br J Surg 2003; 90: 157–65. Cavalcanti AB, Guimaraes HP, Jacka MJ, Graham
27. Cohen ME, Bilimoria KY, Ko CY, Hall BL. M, McAlister F, McMurtry S, Townsend D, Pannu
Development of an American College of Surgeons N, Bagshaw S, Bessissow A, Bhandari M, Duceppe
National Surgery Quality Improvement Program: E, Eikelboom J, Ganame J, Hankinson J, Hill S,
morbidity and mortality risk calculator for Jolly S, Lamy A, Ling E, Magloire P, Pare G,
colorectal surgery. J Am Coll Surg 2009; 208: Reddy D, Szalay D, Tittley J, Weitz J, Whitlock R,
1009–16. Darvish-Kazim S, Debeer J, Kavsak P, Kearon C,
28. Gupta PK, Gupta H, Sundaram A, Kaushik M, Mizera R, O’Donnell M, McQueen M, Pinthus J,
Fang X, Miller WJ, Esterbrooks DJ, Hunter CB, Ribas S, Simunovic M, Tandon V, Vanhelder T,
Pipinos II, Johanning JM, Lynch TG, Forse RA, Winemaker M, Gerstein H, McDonald S, O’Bryne
Mohiuddin SM, Mooss AN. Development and P, Patel A, Paul J, Punthakee Z, Raymer K,
validation of a risk calculator for prediction of Salehian O, Spencer F, Walter S, Worster A, Adili
cardiac risk after surgery. Circulation 2011; 124: A, Clase C, Cook D, Crowther M, Douketis J,
381–7. Gangji A, Jackson P, Lim W, Lovrics P, Mazzadi S,
29. Lee TH, Goldman L. Letter by Lee and Goldman Orovan W, Rudkowski J, Soth M, Tiboni M,
regarding article, “Development and validation of Acedillo R, Garg A, Hildebrand A, Lam N,
a risk calculator for prediction of cardiac risk after Macneil D, Mrkobrada M, Roshanov PS, Srinathan
surgery”. Circulation 2012; 125: e385; author reply SK, Ramsey C, John PS, Thorlacius L, Siddiqui
e86. FS, Grocott HP, McKay A, Lee TW, Amadeo R,
30. Fleisher LA, Fleischmann KE, Auerbach AD, Funk D, McDonald H, Zacharias J, Villar JC,
Barnason SA, Beckman JA, Bozkurt B, Davila- Cortes OL, Chaparro MS, Vasquez S, Castaneda A,
Roman VG, Gerhard-Herman MD, Holly TA, Kane Ferreira S, Coriat P, Monneret D, Goarin JP,
GC, Marine JE, Nelson MT, Spencer CC, Esteve CI, Royer C, Daas G, Chan MT, Choi GY,
Thompson A, Ting HH, Uretsky BF, Wijeysundera Gin T, Lit LC, Xavier D, Sigamani A, Faruqui A,
DN. 2014 ACC/AHA guideline on perioperative Dhanpal R, Almeida S, Cherian J, Furruqh S,
cardiovascular evaluation and management of Abraham V, Afzal L, George P, Mala S,
patients undergoing noncardiac surgery: a report Schunemann H, Muti P, Vizza E, Wang CY, Ong
of the American College of Cardiology/American GS, Mansor M, Tan AS, Shariffuddin II,

Vasanthan V, Hashim NH, Undok AW, Ki U, Lai AHA 2007 guidelines on perioperative
HY, Ahmad WA, Razack AH, Malaga G, cardiovascular evaluation and care for noncardiac
Valderrama-Victoria V, Loza-Herrera JD, De Los surgery: a report of the American College of
Angeles Lazo M, Rotta-Rotta A, Szczeklik W, Cardiology/American Heart Association Task Force
Sokolowska B, Musial J, Gorka J, Iwaszczuk P, on Practice Guidelines (Writing Committee to
Kozka M, Chwala M, Raczek M, Mrowiecki T, Revise the 2002 Guidelines on Perioperative
Kaczmarek B, Biccard B, Cassimjee H, Gopalan D, Cardiovascular Evaluation for Noncardiac
Kisten T, Mugabi A, Naidoo P, Naidoo R, Rodseth Surgery): developed in collaboration with the
R, Skinner D, Torborg A, Paniagua P, Urrutia G, American Society of Echocardiography, American
Maestre ML, Santalo M, Gonzalez R, Font A, Society of Nuclear Cardiology, Heart Rhythm
Martinez C, Pelaez X, De Antonio M, Villamor JM, Society, Society of Cardiovascular
Garcia JA, Ferre MJ, Popova E, Alonso-Coello P, Anesthesiologists, Society for Cardiovascular
Garutti I, Cruz P, Fernandez C, Palencia M, Diaz Angiography and Interventions, Society for
S, Del Castillo T, Varela A, de Miguel A, Munoz Vascular Medicine and Biology, and Society for
M, Pineiro P, Cusati G, Del Barrio M, Membrillo Vascular Surgery. Circulation 2007; 116: e418–99.
MJ, Orozco D, Reyes F, Sapsford RJ, Barth J, Scott 34. Morris CK, Ueshima K, Kawaguchi T, Hideg A,
J, Hall A, Howell S, Lobley M, Woods J, Howard Froelicher VF. The prognostic value of exercise
S, Fletcher J, Dewhirst N, Williams C, Rushton A, capacity: a review of the literature. Am Heart J
Welters I, Leuwer M, Pearse R, Ackland G, Khan 1991; 122: 1423–31.
A, Niebrzegowska E, Benton S, Wragg A, 35. Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL,
Archbold A, Smith A, McAlees E, Ramballi C, Pugsley SO, Taylor DW, Berman LB. The 6-minute
Macdonald N, Januszewska M, Stephens R, Reyes walk: a new measure of exercise capacity in
A, Paredes LG, Sultan P, Cain D, Whittle J, Del patients with chronic heart failure. Can Med Assoc
Arroyo AG, Sessler DI, Kurz A, Sun Z, Finnegan J 1985; 132: 919–23.
PS, Egan C, Honar H, Shahinyan A, 36. Moriello C, Mayo NE, Feldman L, Carli F.
Panjasawatwong K, Fu AY, Wang S, Reineks E, Validating the six-minute walk test as a measure
Nagele P, Blood J, Kalin M, Gibson D, Wildes T, of recovery after elective colon resection surgery.
Vascular events In noncardiac Surgery patIents Arch Phys Med Rehabil 2008; 89: 1083–9.
cOhort evaluatioN Writing Group oboTVeInSpceI, 37. Older P, Hall A, Hader R. Cardiopulmonary
Appendix 1. The Vascular events In noncardiac exercise testing as a screening test for
Surgery patIents cOhort evaluatio NSIWG, perioperative management of major surgery in the
Appendix 2. The Vascular events In noncardiac elderly. Chest 1999; 116: 355–62.
Surgery patIents cOhort evaluatio NOC, Vascular 38. Older P, Smith R, Hall A, French C. Preoperative
events In noncardiac Surgery patIents cOhort cardiopulmonary risk assessment by
evaluatio NVSI. Myocardial injury after noncardiac cardiopulmonary exercise testing. Crit Care Resusc
surgery: a large, international, prospective cohort 2000; 2: 198–208.
study establishing diagnostic criteria, 39. Snowden CP, Prentis JM, Anderson HL, Roberts
characteristics, predictors, and 30-day outcomes. DR, Randles D, Renton M, Manas DM.
Anesthesiology 2014; 120: 564–78. Submaximal cardiopulmonary exercise testing
33. Fleisher LA, Beckman JA, Brown KA, Calkins H, predicts complications and hospital length of stay
Chaikof E, Fleischmann KE, Freeman WK, in patients undergoing major elective surgery. Ann
Froehlich JB, Kasper EK, Kersten JR, Riegel B, Surg 2010; 251: 535–41.
Robb JF, Smith SC Jr, Jacobs AK, Adams CD, 40. Ausania F, Snowden CP, Prentis JM, Holmes LR,
Anderson JL, Antman EM, Buller CE, Creager Jaques BC, White SA, French JJ, Manas DM,
MA, Ettinger SM, Faxon DP, Fuster V, Halperin Charnley RM. Effects of low cardiopulmonary
JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, reserve on pancreatic leak following
Ornato JP, Page RL, Tarkington LG, Yancy CW, pancreaticoduodenectomy. Br J Surg 2012; 99:
American College of Cardiology/American Heart 1290–4.
Association Task Force on Practice G, American 41. Chandrabalan VV, McMillan DC, Carter R,
Society of E, American Society of Nuclear C, Heart Kinsella J, McKay CJ, Carter CR, Dickson EJ. Pre-
Rhythm S, Society of Cardiovascular A, Society for operative cardiopulmonary exercise testing
Cardiovascular A, Interventions, Society for predicts adverse post-operative events and non-
Vascular M, Biology, Society for Vascular S. ACC/ progression to adjuvant therapy after major

pancreatic surgery. HPB (Oxford) 2013; 15: 899– smoking before elective surgery: a randomised
907. controlled trial. Anaesthesia 2004; 59: 1053–8.
42. Junejo MA, Mason JM, Sheen AJ, Moore J, Foster 53. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K,
P, Atkinson D, Parker MJ, Siriwardena AK. Lancaster T. Antidepressants for smoking
Cardiopulmonary exercise testing for preoperative cessation. Cochrane Database Syst Rev 2014; 1:
risk assessment before hepatic resection. Br J Surg CD000031.
2012; 99: 1097–104. 54. Leichtle SW, Mouawad NJ, Lampman R, Singal B,
43. Hartley RA, Pichel AC, Grant SW, Hickey GL, Cleary RK. Does preoperative anemia adversely
Lancaster PS, Wisely NA, McCollum CN, Atkinson affect colon and rectal surgery outcomes? J Am
D. Preoperative cardiopulmonary exercise testing Coll Surg 2011; 212: 187–94.
and risk of early mortality following abdominal 55. Musallam KM, Tamim HM, Richards T, Spahn
aortic aneurysm repair. Br J Surg 2012; 99: 1539– DR, Rosendaal FR, Habbal A, Khreiss M,
46. Dahdaleh FS, Khavandi K, Sfeir PM, Soweid A,
44. Nagamatsu Y, Shima I, Yamana H, Fujita H, Hoballah JJ, Taher AT, Jamali FR. Preoperative
Shirouzu K, Ishitake T. Preoperative evaluation of anaemia and postoperative outcomes in non-
cardiopulmonary reserve with the use of expired cardiac surgery: a retrospective cohort study.
gas analysis during exercise testing in patients Lancet 2011; 378: 1396–407.
with squamous cell carcinoma of the thoracic 56. Goodnough LT, Shander A. Patient blood
esophagus. J Thorac Cardiovasc Surg 2001; 121: management. Anesthesiology 2012; 116: 1367–76.
1064–8. 57. Hare GM, Baker JE, Pavenski K. Assessment and
45. Kheterpal S, Tremper KK, Heung M, Rosenberg treatment of preoperative anemia: Continuing
AL, Englesbe M, Shanks AM, Campbell DA Jr. Professional Development. Can J Anaesth 2011;
Development and validation of an acute kidney 58: 569–81.
injury risk index for patients undergoing general 58. Bernard AC, Davenport DL, Chang PK, Vaughan
surgery: results from a national data set. TB, Zwischenberger JB. Intraoperative transfusion
Anesthesiology 2009; 110: 505–15. of 1 U to 2 U packed red blood cells is associated
46. Tonnesen H, Kehlet H. Preoperative alcoholism with increased 30-day mortality, surgical-site
and postoperative morbidity. Br J Surg 1999; 86: infection, pneumonia, and sepsis in general
869–74. surgery patients. J Am Coll Surg 2009; 208: 931–7,
47. Tonnesen H, Rosenberg J, Nielsen HJ, Rasmussen 37 e1-2; discussion 38-9.
V, Hauge C, Pedersen IK, Kehlet H. Effect of 59. Halabi WJ, Kang CY, Nguyen VQ, Carmichael JC,
preoperative abstinence on poor postoperative Mills S, Stamos MJ, Pigazzi A. Epidural analgesia
outcome in alcohol misusers: randomised in laparoscopic colorectal surgery: a nationwide
controlled trial. BMJ 1999; 318: 1311–6. analysis of use and outcomes. JAMA Surg 2014;
48. Sorensen LT, Karlsmark T, Gottrup F. Abstinence 149: 130–6.
from smoking reduces incisional wound infection: 60. Refaai MA, Blumberg N. The transfusion
a randomized controlled trial. Ann Surg 2003; 238: dilemma–weighing the known and newly
1–5. proposed risks of blood transfusions against the
49. Thomsen T, Tonnesen H, Moller AM. Effect of uncertain benefits. Best Pract Res Clin
preoperative smoking cessation interventions on Anaesthesiol 2013; 27: 17–35.
postoperative complications and smoking 61. Hare GM, Freedman J, David Mazer C. Review
cessation. Br J Surg 2009; 96: 451–61. article: risks of anemia and related management
50. Thomsen T, Villebro N, Moller AM. Interventions strategies: can perioperative blood management
for preoperative smoking cessation. Cochrane improve patient safety? Can J Anaesth 2013; 60:
Database Syst Rev 2014; 3: CD002294. 168–75.
51. Wong J, Abrishami A, Yang Y, Zaki A, Friedman 62. Shander A, Javidroozi M, Ozawa S, Hare GM.
Z, Selby P, Chapman KR, Chung F. A What is really dangerous: anaemia or transfusion?
perioperative smoking cessation intervention with Br J Anaesth 2011; 107(Suppl 1): i41–59.
varenicline: a double-blind, randomized, 63. Qaseem A, Snow V, Fitterman N, Hornbake ER,
placebo-controlled trial. Anesthesiology 2012; 117: Lawrence VA, Smetana GW, Weiss K, Owens DK,
755–64. Aronson M, Barry P, Casey DE Jr, Cross JT Jr,
52. Myles PS, Leslie K, Angliss M, Mezzavia P, Lee L. Fitterman N, Sherif KD, Weiss KB, Clinical
Effectiveness of bupropion as an aid to stopping Efficacy Assessment Subcommittee of the

American College of P. Risk assessment for and anaesthesia care unit. Br J Anaesth 2006; 96: 747–
strategies to reduce perioperative pulmonary 53.
complications for patients undergoing 73. Maltby JR. Fasting from midnight–the history
noncardiothoracic surgery: a guideline from the behind the dogma. Best Pract Res Clin
American College of Physicians. Ann Intern Med Anaesthesiol 2006; 20: 363–78.
2006; 144: 575–80. 74. Holte K, Nielsen KG, Madsen JL, Kehlet H.
64. Moghissi ES, Korytkowski MT, DiNardo M, Physiologic effects of bowel preparation. Dis
Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Colon Rectum 2004; 47: 1397–402.
Ismail-Beigi F, Kirkman MS, Umpierrez GE. 75. Bundgaard-Nielsen M, Jorgensen CC, Secher NH,
American Association of Clinical E, American Kehlet H. Functional intravascular volume deficit
Diabetes A. American Association of Clinical in patients before surgery. Acta Anaesthesiol
Endocrinologists and American Diabetes Scand 2010; 54: 464–9.
Association consensus statement on inpatient 76. Muller L, Briere M, Bastide S, Roger C, Zoric L,
glycemic control. Diabetes Care 2009; 32: 1119–31. Seni G, de La Coussaye JE, Ripart J, Lefrant JY.
65. Lawson CM, Daley BJ, Sams VG, Martindale R, Preoperative fasting does not affect haemodynamic
Kudsk KA, Miller KR. Factors that impact patient status: a prospective, non-inferiority, echocardio-
outcome: nutrition assessment. JPEN J Parenter graphy study. Br J Anaesth 2014; 112: 835–41.
Enteral Nutr 2013; 37: 30S–8S. 77. Brady M, Kinn S, Ness V, O’Rourke K, Randhawa
66. McClave SA, Kozar R, Martindale RG, Heyland N, Stuart P. Preoperative fasting for preventing
DK, Braga M, Carli F, Drover JW, Flum D, perioperative complications in children. Cochrane
Gramlich L, Herndon DN, Ko C, Kudsk KA, Database Syst Rev 2009; 4: CD005285.
Lawson CM, Miller KR, Taylor B, Wischmeyer PE. 78. Brady M, Kinn S, Stuart P. Preoperative fasting for
Summary points and consensus recommendations adults to prevent perioperative complications.
from the North American Surgical Nutrition Cochrane Database Syst Rev 2003; 4: CD004423.
Summit. JPEN J Parenter Enteral Nutr 2013; 37: 79. Lobo DN, Hendry PO, Rodrigues G, Marciani L,
99S–105S. Totman JJ, Wright JW, Preston T, Gowland P,
67. Miller KR, Wischmeyer PE, Taylor B, McClave Spiller RC, Fearon KC. Gastric emptying of three
SA. An evidence-based approach to liquid oral preoperative metabolic preconditioning
perioperative nutrition support in the elective regimens measured by magnetic resonance
surgery patient. JPEN J Parenter Enteral Nutr imaging in healthy adult volunteers: a randomised
2013; 37: 39S–50S. double-blind, crossover study. Clin Nutr 2009; 28:
68. Chow WB, Rosenthal RA, Merkow RP, Ko CY, 636–41.
Esnaola NF, American College of Surgeons 80. Smith I, Kranke P, Murat I, Smith A, O’Sullivan
National Surgical Quality Improvement P, G, Soreide E, Spies C, in’t Veld B, European
American Geriatrics S. Optimal preoperative Society of Anaesthesiology. Perioperative fasting
assessment of the geriatric surgical patient: a best in adults and children: guidelines from the
practices guideline from the American College of European Society of Anaesthesiology. Eur J
Surgeons National Surgical Quality Improvement Anaesthesiol 2011; 28: 556–69.
Program and the American Geriatrics Society. J 81. American Society of Anesthesiologists C. Practice
Am Coll Surg 2012; 215: 453–66. guidelines for preoperative fasting and the use of
69. Thompson T, Keogh E, French CC, Davis R. pharmacologic agents to reduce the risk of
Anxiety sensitivity and pain: generalisability pulmonary aspiration: application to healthy
across noxious stimuli. Pain 2008; 134: 187–96. patients undergoing elective procedures: an
70. Ip HY, Abrishami A, Peng PW, Wong J, Chung F. updated report by the American Society of
Predictors of postoperative pain and analgesic Anesthesiologists Committee on Standards and
consumption: a qualitative systematic review. Practice Parameters. Anesthesiology 2011; 114:
Anesthesiology 2009; 111: 657–77. 495–511.
71. Walker KJ, Smith AF. Premedication for anxiety 82. Ljungqvist O. Modulating postoperative insulin
in adult day surgery. Cochrane Database Syst Rev resistance by preoperative carbohydrate loading.
2009; 9: CD002192. Best Pract Res Clin Anaesthesiol 2009; 23: 401–9.
72. Lepouse C, Lautner CA, Liu L, Gomis P, Leon A. 83. Awad S, Varadhan KK, Ljungqvist O, Lobo DN. A
Emergence delirium in adults in the post- meta-analysis of randomised controlled trials on

preoperative oral carbohydrate treatment in general anaesthesia in at-risk patients having

elective surgery. Clin Nutr 2013; 32: 34–44. major non-cardiac surgery (ENIGMA-II): a
84. Smith MD, McCall J, Plank L, Herbison GP, Soop randomised, single-blind trial. Lancet 2014; 384:
M, Nygren J. Preoperative carbohydrate treatment 1446–54.
for enhancing recovery after elective surgery. 95. Holte K, Klarskov B, Christensen DS, Lund C,
Cochrane Database Syst Rev 2014; 8: CD009161. Nielsen KG, Bie P, Kehlet H. Liberal versus
85. Jackson SJ, Leahy FE, McGowan AA, Bluck LJ, restrictive fluid administration to improve
Coward WA, Jebb SA. Delayed gastric emptying recovery after laparoscopic cholecystectomy: a
in the obese: an assessment using the non- randomized, double-blind study. Ann Surg 2004;
invasive (13)C-octanoic acid breath test. Diabetes 240: 892–9.
Obes Metab 2004; 6: 264–70. 96. Gan TJ, Soppitt A, Maroof M, el-Moalem H,
86. Harter RL, Kelly WB, Kramer MG, Perez CE, Robertson KM, Moretti E, Dwane P, Glass PS.
Dzwonczyk RR. A comparison of the volume and Goal-directed intraoperative fluid administration
pH of gastric contents of obese and lean surgical reduces length of hospital stay after major surgery.
patients. Anesth Analg 1998; 86: 147–52. Anesthesiology 2002; 97: 820–6.
87. Maltby JR, Pytka S, Watson NC, Cowan RA, Fick 97. Hovaguimian F, Lysakowski C, Elia N, Tramer
GH. Drinking 300 mL of clear fluid two hours MR. Effect of intraoperative high inspired oxygen
before surgery has no effect on gastric fluid fraction on surgical site infection, postoperative
volume and pH in fasting and non-fasting obese nausea and vomiting, and pulmonary function:
patients. Can J Anaesth 2004; 51: 111–5. systematic review and meta-analysis of
88. Breuer JP, von Dossow V, von Heymann C, randomized controlled trials. Anesthesiology 2013;
Griesbach M, von Schickfus M, Mackh E, Hacker 119: 303–16.
C, Elgeti U, Konertz W, Wernecke KD, Spies CD. 98. Carlisle JB, Stevenson CA. Drugs for
Preoperative oral carbohydrate administration to preventing postoperative nausea and vomiting.
ASA III-IV patients undergoing elective cardiac Cochrane Database Syst Rev 2006; 3:
surgery. Anesth Analg 2006; 103: 1099–108. CD004125.
89. Gustafsson UO, Nygren J, Thorell A, Soop M, 99. Gan TJ, Apfel CC, Kovac A, Philip BK, Singla N,
Hellstrom PM, Ljungqvist O, Hagstrom-Toft E. Minkowitz H, Habib AS, Knighton J, Carides AD,
Pre-operative carbohydrate loading may be used in Zhang H, Horgan KJ, Evans JK, Lawson FC. A
type 2 diabetes patients. Acta Anaesthesiol Scand randomized, double-blind comparison of the NK1
2008; 52: 946–51. antagonist, aprepitant, versus ondansetron for the
90. Gan TJ, Meyer TA, Apfel CC, Chung F, Davis PJ, prevention of postoperative nausea and vomiting.
Habib AS, Hooper VD, Kovac AL, Kranke P, Anesth Analg 2007; 104: 1082–9, tables of contents.
Myles P, Philip BK, Samsa G, Sessler DI, Temo J, 100. Le TP, Gan TJ. Update on the management of
Tramer MR, Vander Kolk C, Watcha M. Society for postoperative nausea and vomiting and
Ambulatory Anesthesia guidelines for the postdischarge nausea and vomiting in ambulatory
management of postoperative nausea and surgery. Anesthesiol Clin 2010; 28: 225–49.
vomiting. Anesth Analg 2007; 105: 1615–28. 101. Kovac AL, O’Connor TA, Pearman MH, Kekoler
91. Gan TJ. Postoperative nausea and vomiting–can it LJ, Edmondson D, Baughman VL, Angel JJ,
be eliminated? JAMA 2002; 287: 1233–6. Campbell C, Jense HG, Mingus M, Shahvari MB,
92. Gan TJ. Risk factors for postoperative nausea and Creed MR. Efficacy of repeat intravenous dosing
vomiting. Anesth Analg 2006; 102: 1884–98. of ondansetron in controlling postoperative nausea
93. Apfel CC, Korttila K, Abdalla M, Kerger H, Turan and vomiting: a randomized, double-blind,
A, Vedder I, Zernak C, Danner K, Jokela R, placebo-controlled multicenter trial. J Clin Anesth
Pocock SJ, Trenkler S, Kredel M, Biedler A, 1999; 11: 453–9.
Sessler DI, Roewer N, Investigators I. A factorial 102. Gan TJ, Diemunsch P, Habib AS, Kovac A,
trial of six interventions for the prevention of Kranke P, Meyer TA, Watcha M, Chung F, Angus
postoperative nausea and vomiting. N Engl J Med S, Apfel CC, Bergese SD, Candiotti KA, Chan MT,
2004; 350: 2441–51. Davis PJ, Hooper VD, Lagoo-Deenadayalan S,
94. Myles PS, Leslie K, Chan MT, Forbes A, Peyton Myles P, Nezat G, Philip BK, Tramer MR. Society
PJ, Paech MJ, Beattie WS, Sessler DI, Devereaux for Ambulatory A. Consensus guidelines for the
PJ, Silbert B, Schricker T, Wallace S, the ATGftE- management of postoperative nausea and
IIi. The safety of addition of nitrous oxide to vomiting. Anesth Analg 2014; 118: 85–113.

103. Gelb AW, Leslie K, Stanski D, Shafer S. Monitoring 115. Liao WW, Wang JJ, Wu GJ, Kuo CD. The effect of
the Depth of Anesthesia, Miller Anesthesia, 7th edn. cerebral monitoring on recovery after sevoflurane
Philadelphia, PA: Elsevier, 2010. anesthesia in ambulatory setting in children: a
104. Avidan MS, Jacobsohn E, Glick D, Burnside BA, comparison among bispectral index, A-line
Zhang L, Villafranca A, Karl L, Kamal S, Torres autoregressive index, and standard practice. J
B, O’Connor M, Evers AS, Gradwohl S, Lin N, Chin Med Assoc 2011; 74: 28–36.
Palanca BJ, Mashour GA. Group B-RR. 116. Punjasawadwong Y, Phongchiewboon A,
Prevention of intraoperative awareness in a Bunchungmongkol N. Bispectral index for
high-risk surgical population. N Engl J Med improving anaesthetic delivery and postoperative
2011; 365: 591–600. recovery. Cochrane Database Syst Rev 2014; 6:
105. Avidan MS, Zhang L, Burnside BA, Finkel KJ, CD003843.
Searleman AC, Selvidge JA, Saager L, Turner MS, 117. Chan MT, Cheng BC, Lee TM, Gin T. BIS-guided
Rao S, Bottros M, Hantler C, Jacobsohn E, anesthesia decreases postoperative delirium and
Evers AS. Anesthesia awareness and the cognitive decline. J Neurosurg Anesthesiol 2013;
bispectral index. N Engl J Med 2008; 358: 25: 33–42.
1097–108. 118. Hopkins PM. Nitrous oxide: a unique drug of
106. Bowdle TA. Depth of anesthesia monitoring. continuing importance for anaesthesia. Best Pract
Anesthesiol Clin 2006; 24: 793–822. Res Clin Anaesthesiol 2005; 19: 381–9.
107. Boztug N, Bigat Z, Akyuz M, Demir S, Ertok E. 119. Tramer M, Moore A, McQuay H. Omitting nitrous
Does using the bispectral index (BIS) during oxide in general anaesthesia: meta-analysis of
craniotomy affect the quality of recovery? J intraoperative awareness and postoperative emesis
Neurosurg Anesthesiol 2006; 18: 1–4. in randomized controlled trials. Br J Anaesth
108. Johansen JW. Update on bispectral index 1996; 76: 186–93.
monitoring. Best Pract Res Clin Anaesthesiol 120. Myles PS, Leslie K, Chan MT, Forbes A, Paech
2006; 20: 81–99. MJ, Peyton P, Silbert BS, Pascoe E, Group ET.
109. Kakinohana M, Nakamura S, Miyata Y, Sugahara Avoidance of nitrous oxide for patients
K. Emergence from propofol anesthesia in a undergoing major surgery: a randomized
nonagenarian at a Bispectral Index of 52. Anesth controlled trial. Anesthesiology 2007; 107: 221–31.
Analg 2005; 101: 169–70. 121. Monk TG, Saini V, Weldon BC, Sigl JC.
110. Messner M, Beese U, Romstock J, Dinkel M, Anesthetic management and one-year mortality
Tschaikowsky K. The bispectral index declines after noncardiac surgery. Anesth Analg 2005; 100:
during neuromuscular block in fully awake 4–10.
persons. Anesth Analg 2003; 97: 488–91. 122. Ash SA, Buggy DJ. Does regional anaesthesia and
111. Morimoto Y, Nogami Y, Harada K, Tsubokawa T, analgesia or opioid analgesia influence recurrence
Masui K. Awareness during anesthesia: the results after primary cancer surgery? An update of
of a questionnaire survey in Japan. J Anesth 2011; available evidence. Best Pract Res Clin
25: 72–7. Anaesthesiol 2013; 27: 441–56.
112. Myles PS, Leslie K, McNeil J, Forbes A, Chan 123. Fawcett WJ, Mythen MG, Scott MJ. Enhanced
MT. Bispectral index monitoring to prevent recovery: more than just reducing length of stay?
awareness during anaesthesia: the B-Aware Br J Anaesth 2012; 109: 671–4.
randomised controlled trial. Lancet 2004; 363: 124. Martini CH, Boon M, Bevers RF, Aarts LP, Dahan
1757–63. A. Evaluation of surgical conditions during
113. Zhang C, Xu L, Ma YQ, Sun YX, Li YH, Zhang L, laparoscopic surgery in patients with moderate vs
Feng CS, Luo B, Zhao ZL, Guo JR, Jin YJ, Wu G, deep neuromuscular block. Br J Anaesth 2014;
Yuan W, Yuan ZG, Yue Y. Bispectral index 112: 498–505.
monitoring prevent awareness during total 125. Madsen MV, Staehr-Rye AK, Gatke MR, Claudius
intravenous anesthesia: a prospective, randomized, C. Neuromuscular blockade for optimising
double-blinded, multi-center controlled trial. Chin surgical conditions during abdominal and
Med J (Engl) 2011; 124: 3664–9. gynaecological surgery: a systematic review. Acta
114. Ekman A, Lindholm ML, Lennmarken C, Sandin Anaesthesiol Scand 2015; 59: 1–16.
R. Reduction in the incidence of awareness using 126. Kopman AF, Naguib M. Laparoscopic surgery and
BIS monitoring. Acta Anaesthesiol Scand 2004; muscle relaxants: is deep block helpful? Anesth
48: 20–6. Analg 2015; 120: 51–8.

127. King M, Sujirattanawimol N, Danielson DR, 138. Abrishami A, Ho J, Wong J, Yin L, Chung F.
Hall BA, Schroeder DR, Warner DO. Sugammadex, a selective reversal medication for
Requirements for muscle relaxants during radical preventing postoperative residual neuromuscular
retropubic prostatectomy. Anesthesiology 2000; blockade. Cochrane Database Syst Rev 2009; 4:
93: 1392–7. CD007362.
128. Brull SJ, Murphy GS. Residual neuromuscular 139. Meyhoff CS, Wetterslev J, Jorgensen LN,
block: lessons unlearned. Part II: methods to Henneberg SW, Hogdall C, Lundvall L, Svendsen
reduce the risk of residual weakness. Anesth PE, Mollerup H, Lunn TH, Simonsen I, Martinsen
Analg 2010; 111: 129–40. KR, Pulawska T, Bundgaard L, Bugge L, Hansen
129. Heier T, Caldwell JE. Impact of hypothermia on EG, Riber C, Gocht-Jensen P, Walker LR,
the response to neuromuscular blocking drugs. Bendtsen A, Johansson G, Skovgaard N, Helto K,
Anesthesiology 2006; 104: 1070–80. Poukinski A, Korshin A, Walli A, Bulut M,
130. Murphy GS, Brull SJ. Residual neuromuscular Carlsson PS, Rodt SA, Lundbech LB, Rask H,
block: lessons unlearned. Part I: definitions, Buch N, Perdawid SK, Reza J, Jensen KV, Carlsen
incidence, and adverse physiologic effects of CG, Jensen FS, Rasmussen LS. Effect of high
residual neuromuscular block. Anesth Analg 2010; perioperative oxygen fraction on surgical site
111: 120–8. infection and pulmonary complications after
131. Butterly A, Bittner EA, George E, Sandberg WS, abdominal surgery: the PROXI randomized
Eikermann M, Schmidt U. Postoperative residual clinical trial. JAMA 2009; 302: 1543–50.
curarization from intermediate-acting 140. Togioka B, Galvagno S, Sumida S, Murphy J,
neuromuscular blocking agents delays recovery Ouanes JP, Wu C. The role of perioperative high
room discharge. Br J Anaesth 2010; 105: 304–9. inspired oxygen therapy in reducing surgical site
132. Murphy GS, Szokol JW, Franklin M, Marymont infection: a meta-analysis. Anesth Analg 2012;
JH, Avram MJ, Vender JS. Postanesthesia care 114: 334–42.
unit recovery times and neuromuscular blocking 141. Meyhoff CS, Jorgensen LN, Wetterslev J,
drugs: a prospective study of orthopedic surgical Christensen KB, Rasmussen LS. Increased long-
patients randomized to receive pancuronium or term mortality after a high perioperative
rocuronium. Anesth Analg 2004; 98: 193–200. inspiratory oxygen fraction during abdominal
133. Murphy GS, Szokol JW, Marymont JH, Greenberg surgery: follow-up of a randomized clinical trial.
SB, Avram MJ, Vender JS, Nisman M. Anesth Analg 2012; 115: 849–54.
Intraoperative acceleromyographic monitoring 142. Kilgannon JH, Jones AE, Parrillo JE, Dellinger
reduces the risk of residual neuromuscular RP, Milcarek B, Hunter K, Shapiro NI, Trzeciak S.
blockade and adverse respiratory events in the Relationship between supranormal oxygen
postanesthesia care unit. Anesthesiology 2008; tension and outcome after resuscitation from
109: 389–98. cardiac arrest. Circulation 2011; 123: 2717–22.
134. Fink H, Hollmann MW. Myths and facts in 143. Pilcher J, Weatherall M, Shirtcliffe P, Bellomo R,
neuromuscular pharmacology. New developments Young P, Beasley R. The effect of hyperoxia
in reversing neuromuscular blockade. Minerva following cardiac arrest - A systematic review and
Anestesiol 2012; 78: 473–82. meta-analysis of animal trials. Resuscitation 2012;
135. Kotake Y, Ochiai R, Suzuki T, Ogawa S, Takagi S, 83: 417–22.
Ozaki M, Nakatsuka I, Takeda J. Reversal with 144. Edmark L, Kostova-Aherdan K, Enlund M,
sugammadex in the absence of monitoring did not Hedenstierna G. Optimal oxygen concentration
preclude residual neuromuscular block. Anesth during induction of general anesthesia.
Analg 2013; 117: 345–51. Anesthesiology 2003; 98: 28–33.
136. Claudius C, Viby-Mogensen J. 145. Staehr AK, Meyhoff CS, Rasmussen LS. Inspiratory
Acceleromyography for use in scientific and oxygen fraction and postoperative complications in
clinical practice: a systematic review of the obese patients: a subgroup analysis of the PROXI
evidence. Anesthesiology 2008; 108: 1117–40. trial. Anesthesiology 2011; 114: 1313–9.
137. Debaene B, Plaud B, Dilly MP, Donati F. Residual 146. The Management of Inadvertent Perioperative
paralysis in the PACU after a single intubating Hypothermia in Adults. London: Royal College of
dose of nondepolarizing muscle relaxant with an Nursing (UK), 2008.
intermediate duration of action. Anesthesiology 147. Moola S, Lockwood C. Effectiveness of strategies
2003; 98: 1042–8. for the management and/or prevention of

hypothermia within the adult perioperative 159. Brown SR, Goodfellow PB. Transverse verses
environment. Int J Evid Based Healthc 2011; 9: midline incisions for abdominal surgery. Cochrane
337–45. Database Syst Rev 2011; 4: CD005199.
148. Stewart BT, Stitz RW, Tuch MM, Lumley JW. 160. Trastulli S, Farinella E, Cirocchi R, Cavaliere D,
Hypothermia in open and laparoscopic Avenia N, Sciannameo F, Gulla N, Noya G, Boselli
colorectal surgery. Dis Colon Rectum 2011; 42: C. Robotic resection compared with laparoscopic
1292–5. rectal resection for cancer: systematic review and
149. Fernandes LA, Braz LG, Koga FA, Kakuda CM, meta-analysis of short-term outcome. Colorectal
Modolo NS, de Carvalho LR, Vianna PT, Braz JR. Dis 2012; 14: e134–56.
Comparison of peri-operative core temperature in 161. Champagne BJ, Papaconstantinou HT, Parmar SS,
obese and non-obese patients. Anaesthesia 2012; Nagle DA, Young-Fadok TM, Lee EC, Delaney CP.
67: 1364–9. Single-incision versus standard multiport
150. Sessler DI. Temperature monitoring and laparoscopic colectomy: a multicenter, case-
perioperative thermoregulation. Anesthesiology controlled comparison. Ann Surg 2012; 255: 66–9.
2008; 109: 318–38. 162. Alba Mesa F, Amaya Cortijo A, Romero
151. Esnaola NF, Cole DJ. Perioperative normothermia Fernandez JM, Komorowski AL, Sanchez Hurtado
during major surgery: is it important? Adv Surg MA, Fernandez Ortega E, Sanchez Margallo FM.
2011; 45: 249–63. Transvaginal sigmoid cancer resection: first case
152. Kurz A, Sessler DI, Lenhardt R. Perioperative with 12 months of follow-up–technique
normothermia to reduce the incidence of description. J Laparoendosc Adv Surg Techn A
surgical-wound infection and shorten 2012; 22: 587–90.
hospitalization. Study of Wound Infection and 163. Cheung TP, Cheung HY, Ng LW, Chung CC, Li
Temperature Group. N Engl J Med 1996; 334: MK. Hybrid NOTES colectomy for right-sided
1209–15. colonic tumors. Asian Journal Endosc Surg 2012;
153. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, 5: 46–9.
Olson KF, Kelly S, Beattie C. Perioperative 164. Nelson R, Edwards S, Tse B. Prophylactic
maintenance of normothermia reduces the nasogastric decompression after abdominal
incidence of morbid cardiac events. A randomized surgery. Cochrane Database Syst Rev 2007; 3:
clinical trial. JAMA 1997; 277: 1127–34. CD004929.
154. Rajagopalan S, Mascha E, Na J, Sessler DI. The 165. Rao W, Zhang X, Zhang J, Yan R, Hu Z,
effects of mild perioperative hypothermia on Wang Q. The role of nasogastric tube in
blood loss and transfusion requirement. decompression after elective colon and rectum
Anesthesiology 2008; 108: 71–7. surgery: a meta-analysis. Int J Colorectal Dis
155. Lenhardt R, Marker E, Goll V, Tschernich H, Kurz 2011; 26: 423–9.
A, Sessler DI, Narzt E, Lackner F. Mild 166. Cheatham ML, Chapman WC, Key SP, Sawyers
intraoperative hypothermia prolongs JL. A meta-analysis of selective versus routine
postanesthetic recovery. Anesthesiology 1997; 87: nasogastric decompression after elective
1318–23. laparotomy. Ann Surg 1995; 221: 469–76;
156. Moslemi-Kebria M, El-Nashar SA, Aletti GD, discussion 76-8.
Cliby WA. Intraoperative hypothermia during 167. Yardley IE, Donaldson LJ. Patient safety matters:
cytoreductive surgery for ovarian cancer and reducing the risks of nasogastric tubes. Clin Med
perioperative morbidity. Obstet Gynecol 2012; 2010; 10: 228–30.
119: 590–6. 168. Ronen O, Uri N. A case of nasogastric tube
157. Abraham NS, Byrne CM, Young JM, Solomon MJ. perforation of the nasopharynx causing a fatal
Meta-analysis of non-randomized comparative mediastinal complication. Ear Nose Throat J 2009;
studies of the short-term outcomes of laparoscopic 88: E17–8.
resection for colorectal cancer. ANZ J Surg 2007; 169. Johnson MD, Walsh RM. Current therapies to
77: 508–16. shorten postoperative ileus. Cleve Clin J Med
158. Kuhry E, Schwenk W, Gaupset R, Romild U, 2009; 76: 641–8.
Bonjer J. Long-term outcome of laparoscopic 170. Manning BJ, Winter DC, McGreal G, Kirwan WO,
surgery for colorectal cancer: a cochrane systematic Redmond HP. Nasogastric intubation causes
review of randomised controlled trials. Cancer gastroesophageal reflux in patients undergoing
Treat Rev 2008; 34: 498–504. elective laparotomy. Surgery 2001; 130: 788–91.

171. Lassen K, Kjaeve J, Fetveit T, Trano G, Sigurdsson 181. O’Sullivan CJ, Hynes N, Mahendran B, Andrews EJ,
HK, Horn A, Revhaug A. Allowing normal food at Avalos G, Tawfik S, Lowery A, Sultan S.
will after major upper gastrointestinal surgery Haemoglobin A1c (HbA1C) in non-diabetic and
does not increase morbidity: a randomized diabetic vascular patients. Is HbA1C an independent
multicenter trial. Ann Surg 2008; 247: 721–9. risk factor and predictor of adverse outcome? Eur J
172. Balzano G, Zerbi A, Braga M, Rocchetti S, Vasc Endovasc Surg 2006; 32: 188–97.
Beneduce AA, Di Carlo V. Fast-track recovery 182. Kao LS, Meeks D, Moyer VA, Lally KP. Peri-
programme after pancreaticoduodenectomy operative glycaemic control regimens for preventing
reduces delayed gastric emptying. Br J Surg 2008; surgical site infections in adults. Cochrane Database
95: 1387–93. Syst Rev 2009; July 8;(3): CD006806.
173. Berberat PO, Ingold H, Gulbinas A, Kleeff J, 183. Ryden L, Standl E, Bartnik M, Van den Berghe G,
Muller MW, Gutt C, Weigand M, Friess H, Betteridge J, deBoer MJ, Cosentino F, Jonsson B,
Buchler MW. Fast track–different implications in Laakso M, Malmberg K, Priori S, Ostergren J,
pancreatic surgery. J Gastrointest Surg 2007; 11: Tuomilehto J, Thrainsdottir I, Vanhorebeek I,
880–7. Stramba-Badiale M, Lindgren P, Qiao Q, Priori
174. Schricker T, Lattermann R, Schreiber M, Geisser SG, Blanc JJ, Budaj A, Camm J, Dean V, Deckers
W, Georgieff M, Radermacher P. The J, Dickstein K, Lekakis J, McGregor K, Metra M,
hyperglycemic response to surgery: Morais J, Osterspey A, Tamargo J, Zamorano JL,
pathophysiology, clinical implications and Deckers JW, Bertrand M, Charbonnel B, Erdmann
modification by the anaesthetic technique. Clinical E, Ferrannini E, Flyvbjerg A, Gohlke H, Juanatey
Intensive Care 1998; 9: 118–28. JR, Graham I, Monteiro PF, Parhofer K, Pyorala
175. Umpierrez GE, Isaacs SD, Bazargan N, You X, K, Raz I, Schernthaner G, Volpe M, Wood D.
Thaler LM, Kitabchi AE. Hyperglycemia: an Guidelines on diabetes, pre-diabetes, and
independent marker of in-hospital mortality in cardiovascular diseases: executive summary. The
patients with undiagnosed diabetes. J Clin Task Force on Diabetes and Cardiovascular
Endocrinol Metab 2002; 87: 978–82. Diseases of the European Society of Cardiology
176. Ata A, Lee J, Bestle SL, Desemone J, Stain SC. (ESC) and of the European Association for the
Postoperative hyperglycemia and surgical site Study of Diabetes (EASD). Eur Heart J 2007; 28:
infection in general surgery patients. Arch Surg 88–136.
2010; 145: 858–64. 184. Lazar HL, McDonnell M, Chipkin SR, Furnary AP,
177. Eshuis WJ, Hermanides J, van Dalen JW, van Engelman RM, Sadhu AR, Bridges CR, Haan CK,
Samkar G, Busch OR, van Gulik TM, DeVries JH, Svedjeholm R, Taegtmeyer H, Shemin RJ. The
Hoekstra JB, Gouma DJ. Early postoperative Society of Thoracic Surgeons practice guideline
hyperglycemia is associated with postoperative series: Blood glucose management during adult
complications after pancreatoduodenectomy. Ann cardiac surgery. Ann Thorac Surg 2009; 87: 663–9.
Surg 2011; 253: 739–44. 185. Dellinger RP, Levy MM, Rhodes A, Annane D,
178. Sato H, Carvalho G, Sato T, Lattermann R, Gerlach H, Opal SM, Sevransky JE, Sprung CL,
Matsukawa T, Schricker T. The association of Douglas IS, Jaeschke R, Osborn TM, Nunnally
preoperative glycemic control, intraoperative ME, Townsend SR, Reinhart K, Kleinpell RM,
insulin sensitivity, and outcomes after cardiac Angus DC, Deutschman CS, Machado FR,
surgery. J Clin Endocrinol Metab 2010; 95: 4338– Rubenfeld GD, Webb S, Beale RJ, Vincent JL,
44. Moreno R, Surviving Sepsis Campaign
179. Halkos ME, Puskas JD, Lattouf OM, Kilgo P, Guidelines Committee including The Pediatric S.
Kerendi F, Song HK, Guyton RA, Thourani VH. Surviving Sepsis Campaign: international
Elevated preoperative hemoglobin A1c level is guidelines for management of severe sepsis and
predictive of adverse events after coronary artery septic shock, 2012. Intensive Care Med 2013; 39:
bypass surgery. J Thorac Cardiovasc Surg 2008; 165–228.
136: 631–40. 186. Ljungqvist O, Jonathan E. Rhoads lecture 2011:
180. Gustafsson UO, Thorell A, Soop M, Ljungqvist O, Insulin resistance and enhanced recovery after
Nygren J. Haemoglobin A1c as a predictor of surgery. JPEN J Parenter Enteral Nutr 2012; 36:
postoperative hyperglycaemia and complications 389–98.
after major colorectal surgery. Br J Surg 2009; 96: 187. Cao F, Li J, Li F. Mechanical bowel preparation
1358–64. for elective colorectal surgery: updated systematic

review and meta-analysis. Int J Colorectal Dis 197. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O,
2012; 27: 803–10. Soop M, Nygren J. Enhanced Recovery After
188. Guenaga KF, Matos D, Wille-Jorgensen P. Surgery Study G. Adherence to the enhanced
Mechanical bowel preparation for elective recovery after surgery protocol and outcomes after
colorectal surgery. Cochrane Database Syst Rev colorectal cancer surgery. Arch Surg 2011; 146:
2011; CD001544. doi: 10.1002/14651858. 571–7.
CD001544.pub4. 198. Powell-Tuck J, Gosling P, Lobo DN, Allison SP,
189. Sanders G, Mercer SJ, Saeb-Parsey K, Akhavani Carlson GL, Gore M, Lewington AJ, Pearse RM,
MA, Hosie KB, Lambert AW. Randomized clinical Mythen MG. British Consensus Guidelines on
trial of intravenous fluid replacement during Intravenous Fluid Therapy for Adult Surgical
bowel preparation for surgery. Br J Surg 2001; 88: Patients (GIFTASUP). London: NHS National
1363–5. Library of Health, 2009.
190. Holte K. Pathophysiology and clinical implications 199. Lobo DN, Awad S. Should chloride-rich
of peroperative fluid management in elective crystalloids remain the mainstay of fluid
surgery. Dan Med Bull 2010; 57: B4156. resuscitation to prevent’pre-renal’ acute kidney
191. Brandstrup B, Svendsen PE, Rasmussen M, injury?: con. Kidney Int 2014; 86: 1096–105.
Belhage B, Rodt SA, Hansen B, Moller DR, 200. McCluskey SA, Karkouti K, Wijeysundera D,
Lundbech LB, Andersen N, Berg V, Thomassen Minkovich L, Tait G, Beattie WS. Hyperchloremia
N, Andersen ST, Simonsen L. Which goal for after noncardiac surgery is independently
fluid therapy during colorectal surgery is associated with increased morbidity and mortality:
followed by the best outcome: near-maximal a propensity-matched cohort study. Anesth Analg
stroke volume or zero fluid balance? Br J 2013; 117: 412–21.
Anaesth 2012; 109: 191–9. 201. Yunos NM, Bellomo R, Hegarty C, Story D,
192. Brandstrup B, Tonnesen H, Beier-Holgersen R, Ho L, Bailey M. Association between a chloride-
Hjortso E, Ording H, Lindorff-Larsen K, liberal vs chloride-restrictive intravenous
Rasmussen MS, Lanng C, Wallin L, Iversen LH, fluid administration strategy and kidney injury in
Gramkow CS, Okholm M, Blemmer T, Svendsen critically ill adults. JAMA 2012; 308: 1566–72.
PE, Rottensten HH, Thage B, Riis J, Jeppesen IS, 202. Shaw AD, Bagshaw SM, Goldstein SL, Scherer
Teilum D, Christensen AM, Graungaard B, Pott F, LA, Duan M, Schermer CR, Kellum JA. Major
Danish Study Group on Perioperative Fluid T. complications, mortality, and resource utilization
Effects of intravenous fluid restriction on after open abdominal surgery: 0.9% saline
postoperative complications: comparison of two compared to Plasma-Lyte. Ann Surg 2012; 255:
perioperative fluid regimens: a randomized 821–9.
assessor-blinded multicenter trial. Ann Surg 2003; 203. Feldheiser A, Conroy P, Bonomo T, Cox B, Garces
238: 641–8. TR, Spies C, Anaesthesia Working Group of the
193. Holte K, Foss NB, Andersen J, Valentiner L, Lund Enhanced Recovery After Surgery S, Enhanced
C, Bie P, Kehlet H. Liberal or restrictive fluid Recovery After Surgery S. Development and
administration in fast-track colonic surgery: a feasibility study of an algorithm for intraoperative
randomized, double-blind study. Br J Anaesth goaldirected haemodynamic management in
2007; 99: 500–8. noncardiac surgery. J Int Med Res 2012; 40: 1227–
194. Nisanevich V, Felsenstein I, Almogy G, Weissman 41.
C, Einav S, Matot I. Effect of intraoperative fluid 204. Conway DH, Mayall R, Abdul-Latif MS, Gilligan
management on outcome after intraabdominal S, Tackaberry C. Randomised controlled trial
surgery. Anesthesiology 2005; 103: 25–32. investigating the influence of intravenous fluid
195. Chowdhury AH, Lobo DN. Fluids and titration using oesophageal Doppler monitoring
gastrointestinal function. Curr Opin Clin Nutr during bowel surgery. Anaesthesia 2002; 57: 845–
Metab Care 2011; 14: 469–76. 9.
196. Lobo DN, Bostock KA, Neal KR, Perkins AC, 205. Noblett SE, Snowden CP, Shenton BK, Horgan
Rowlands BJ, Allison SP. Effect of salt and AF. Randomized clinical trial assessing the effect
water balance on recovery of gastrointestinal of Doppler-optimized fluid management on
function after elective colonic resection: a outcome after elective colorectal resection. Br J
randomised controlled trial. Lancet 2002; 359: Surg 2006; 93: 1069–76.
1812–8.

206. Wakeling HG, McFall MR, Jenkins CS, Woods Effect of a perioperative, cardiac output-guided
WG, Miles WF, Barclay GR, Fleming SC. hemodynamic therapy algorithm on outcomes
Intraoperative oesophageal Doppler guided fluid following major gastrointestinal surgery: a
management shortens postoperative hospital stay randomized clinical trial and systematic review.
after major bowel surgery. Br J Anaesth 2005; 95: JAMA 2014; 311: 2181–90.
634–42. 216. Mythen MG, Swart M, Acheson N, Crawford R,
207. Kuper M, Gold SJ, Callow C, Quraishi T, King S, Jones K, Kuper M, McGrath JS, Horgan A.
Mulreany A, Bianchi M, Conway DH. Perioperative fluid management: Consensus
Intraoperative fluid management guided by statement from the enhanced recovery partnership.
oesophageal Doppler monitoring. BMJ 2011; 342: Perioper Med (Lond) 2012; 1: 2.
d3016. 217. Feldheiser A, Pavlova V, Bonomo T, Jones A,
208. Benes J, Chytra I, Altmann P, Hluchy M, Kasal Fotopoulou C, Sehouli J, Wernecke KD, Spies C.
E, Svitak R, Pradl R, Stepan M. Intraoperative Balanced crystalloid compared with balanced
fluid optimization using stroke volume variation colloid solution using a goal-directed
in high risk surgical patients: results of haemodynamic algorithm. Br J Anaesth 2013; 110:
prospective randomized study. Crit Care 2010; 231–40.
14: R118. 218. Verheij J, van Lingen A, Beishuizen A, Christiaans
209. Benes J, Giglio M, Brienza N, Michard F. The HM, de Jong JR, Girbes AR, Wisselink W,
effects of goal-directed fluid therapy based on Rauwerda JA, Huybregts MA, Groeneveld AB.
dynamic parameters on post-surgical outcome: a Cardiac response is greater for colloid than saline
meta-analysis of randomized controlled trials. Crit fluid loading after cardiac or vascular surgery.
Care 2014; 18: 584. Intensive Care Med 2006; 32: 1030–8.
210. Pearse R, Dawson D, Fawcett J, Rhodes A, 219. Lobo DN, Stanga Z, Aloysius MM, Wicks C,
Grounds RM, Bennett ED. Early goal-directed Nunes QM, Ingram KL, Risch L, Allison SP. Effect
therapy after major surgery reduces complications of volume loading with 1 liter intravenous
and duration of hospital stay. A randomised, infusions of 0.9% saline, 4% succinylated gelatine
controlled trial [ISRCTN38797445]. Crit Care (Gelofusine) and 6% hydroxyethyl starch
2005; 9: R687–93. (Voluven) on blood volume and endocrine
211. Grocott MP, Dushianthan A, Hamilton MA, responses: a randomized, three-way crossover
Mythen MG, Harrison D, Rowan K. Optimisation study in healthy volunteers. Crit Care Med 2010;
Systematic Review Steering G. Perioperative 38: 464–70.
increase in global blood flow to explicit defined 220. Moretti EW, Robertson KM, El-Moalem H, Gan
goals and outcomes after surgery: a Cochrane TJ. Intraoperative colloid administration reduces
Systematic Review. Br J Anaesth 2013; 111: 535– postoperative nausea and vomiting and improves
48. postoperative outcomes compared with crystalloid
212. Srinivasa S, Taylor MH, Singh PP, Yu TC, Soop administration. Anesth Analgesia 2003; 96: 611–7.
M, Hill AG. Randomized clinical trial of goal- 221. Yates DR, Davies SJ, Milner HE, Wilson RJ.
directed fluid therapy within an enhanced Crystalloid or colloid for goal-directed fluid
recovery protocol for elective colectomy. Br J Surg therapy in colorectal surgery. Br J Anaesth 2014;
2013; 100: 66–74. 112: 281–9.
213. Miller TE, Roche AM, Mythen M. Fluid 222. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass
management and goal-directed therapy as an A, Gattas D, Glass P, Lipman J, Liu B, McArthur
adjunct to Enhanced Recovery After Surgery C, McGuinness S, Rajbhandari D, Taylor CB,
(ERAS). Can J Anaesth 2015; 62: 158–68. Webb SA, Investigators C. Australian, New
214. Hamilton MA, Cecconi M, Rhodes A. A systematic Zealand Intensive Care Society Clinical Trials G.
review and meta-analysis on the use of Hydroxyethyl starch or saline for fluid
preemptive hemodynamic intervention to improve resuscitation in intensive care. N Engl J Med
postoperative outcomes in moderate and high-risk 2012; 367: 1901–11.
surgical patients. Anesth Analg 2011; 112: 1392– 223. Perner A, Haase N, Guttormsen AB, Tenhunen J,
402. Klemenzson G, Aneman A, Madsen KR, Moller
215. Pearse RM, Harrison DA, MacDonald N, Gillies MH, Elkjaer JM, Poulsen LM, Bendtsen A,
MA, Blunt M, Ackland G, Grocott MP, Ahern A, Winding R, Steensen M, Berezowicz P, Soe-
Griggs K, Scott R, Hinds C, Rowan K, Group OS. Jensen P, Bestle M, Strand K, Wiis J, White JO,

Thornberg KJ, Quist L, Nielsen J, Andersen LH, study on the effects of 2-L infusions of 0.9%
Holst LB, Thormar K, Kjaeldgaard AL, Fabritius saline and plasma-lyte(R) 148 on renal blood flow
ML, Mondrup F, Pott FC, Moller TP, Winkel P, velocity and renal cortical tissue perfusion in
Wetterslev J, Group ST, Scandinavian Critical healthy volunteers. Ann Surg 2012; 256: 18–24.
Care Trials G. Hydroxyethyl starch 130/0.42 233. Lobo DN, Stanga Z, Simpson JAD, Anderson JA,
versus Ringer’s acetate in severe sepsis. N Engl J Rowlands BJ, Allison SP. Dilution and
Med 2012; 367: 124–34. redistribution effects of rapid 2-litre infusions of
224. Gillies MA, Habicher M, Jhanji S, Sander M, 0.9% (w/v) saline and 5% (w/v) dextrose on
Mythen M, Hamilton M, Pearse RM. Incidence of haematological parameters and serum
postoperative death and acute kidney injury biochemistry in normal subjects: a double-blind
associated with i.v. 6% hydroxyethyl starch use: crossover study. Clin Sci (Lond) 2001; 101: 173–9.
systematic review and meta-analysis. Br J Anaesth 234. Reid F, Lobo DN, Williams RN, Rowlands BJ,
2014; 112: 25–34. Allison SP. (Ab)normal saline and physiological
225. Kashy BK, Podolyak A, Makarova N, Dalton JE, Hartmann’s solution: a randomized double-blind
Sessler DI, Kurz A. Effect of hydroxyethyl starch crossover study. Clin Sci (Lond) 2003; 104:
on postoperative kidney function in patients 17–24.
having noncardiac surgery. Anesthesiology 2014; 235. O’Malley CM, Frumento RJ, Hardy MA,
121: 730–9. Benvenisty AI, Brentjens TE, Mercer JS, Bennett-
226. Agency EM. Hydroxyethyl-starch solutions (HES) Guerrero E. A randomized, double-blind
no longer to be used in patients with sepsis or comparison of lactated Ringer’s solution and 0.9%
burn injuries or in critically ill patients, 2013. NaCl during renal transplantation. Anesth Analg
[www document] http://www.ema.europa.eu/ 2005; 100: 1518–24.
docs/en_GB/document_library/Referrals_ 236. Waters JH, Gottlieb A, Schoenwald P, Popovich
document/Solutions_for_infusion_containing_ MJ, Sprung J, Nelson DR. Normal saline versus
hydroxyethyl_starch/European_Commission_ lactated Ringer’s solution for intraoperative fluid
final_decision/WC500162361.pdf (accessed 15 management in patients undergoing abdominal
September 2015). aortic aneurysm repair: an outcome study. Anesth
227. Rasmussen KC, Johansson PI, Hojskov M, Kridina Analg 2001; 93: 817–22.
I, Kistorp T, Thind P, Nielsen HB, Ruhnau B, 237. PROcedure SPECific postoperative pain
Pedersen T, Secher NH. Hydroxyethyl starch menagemenT (PROSPECT) [www document]
reduces coagulation competence and increases http://www.postoppain.org/ (accessed 15
blood loss during major surgery: results from a February 2013).
randomized controlled trial. Ann Surg 2014; 259: 238. White PF, Kehlet H. Improving postoperative pain
249–54. management: what are the unresolved issues?
228. Lewis SJ, Andersen HK, Thomas S. Early enteral Anesthesiology 2010; 112: 220–5.
nutrition within 24 h of intestinal surgery versus 239. Wu CL, Cohen SR, Richman JM, Rowlingson AJ,
later commencement of feeding: a systematic Courpas GE, Cheung K, Lin EE, Liu SS. Efficacy
review and meta-analysis. J Gastrointest Surg of postoperative patient-controlled and continuous
2009; 13: 569–75. infusion epidural analgesia versus intravenous
229. Zhuang CL, Ye XZ, Zhang CJ, Dong QT, Chen BC, patient-controlled analgesia with opioids: a meta-
Yu Z. Early versus traditional postoperative oral analysis. Anesthesiology 2005; 103: 1079–88; quiz
feeding in patients undergoing elective colorectal 109-10.
surgery: a meta-analysis of randomized clinical 240. Rigg JR, Jamrozik K, Myles PS, Silbert BS,
trials. Dig Surg 2013; 30: 225–32. Peyton PJ, Parsons RW, Collins KS, Group MATS.
230. Holte K, Foss NB, Svensen C, Lund C, Madsen Epidural anaesthesia and analgesia and outcome
JL, Kehlet H. Epidural anesthesia, hypotension, of major surgery: a randomised trial. Lancet 2002;
and changes in intravascular volume. 359: 1276–82.
Anesthesiology 2004; 100: 281–6. 241. Popping DM, Elia N, Van Aken HK, Marret E,
231. Gould TH, Grace K, Thorne G, Thomas M. Effect Schug SA, Kranke P, Wenk M, Tramer MR.
of thoracic epidural anaesthesia on colonic blood Impact of epidural analgesia on mortality and
flow. Br J Anaesth 2002; 89: 446–51. morbidity after surgery: systematic review and
232. Chowdhury AH, Cox EF, Francis ST, Lobo DN. A meta-analysis of randomized controlled trials. Ann
randomized, controlled, double-blind crossover Surg 2014; 259: 1056–67.

242. Carli F, Kehlet H, Baldini G, Steel A, McRae K, enhanced recovery pathway. Ann Surg 2015; 261:
Slinger P, Hemmerling T, Salinas F, Neal JM. 648–53.
Evidence basis for regional anesthesia in 253. Levy BF, Scott MJ, Fawcett W, Fry C, Rockall TA.
multidisciplinary fast-track surgical care Randomized clinical trial of epidural, spinal or
pathways. Reg Anesth Pain Med 2011; 36: 63– patient-controlled analgesia for patients
72. undergoing laparoscopic colorectal surgery. Br J
243. Khan SA, Khokhar HA, Nasr AR, Carton E, El- Surg 2011; 98: 1068–78.
Masry S. Effect of epidural analgesia on bowel 254. Wongyingsinn M, Baldini G, Charlebois P,
function in laparoscopic colorectal surgery: a Liberman S, Stein B, Carli F. Intravenous
systematic review and meta-analysis. Surg Endosc lidocaine versus thoracic epidural analgesia: a
2013; 27: 2581–91. randomized controlled trial in patients undergoing
244. Jorgensen H, Wetterslev J, Moiniche S, Dahl JB. laparoscopic colorectal surgery using an enhanced
Epidural local anaesthetics versus opioid-based recovery program. Reg Anesth Pain Med 2011; 36:
analgesic regimens on postoperative 241–8.
gastrointestinal paralysis, PONV and pain after 255. Hermanides J, Hollmann MW, Stevens MF, Lirk
abdominal surgery. Cochrane Database Syst Rev P. Failed epidural: causes and management. Br J
2000; 4: CD001893. Anaesth 2012; 109: 144–54.
245. Shi WZ, Miao YL, Yakoob MY, Cao JB, Zhang H, 256. Finucane BT, Ganapathy S, Carli F, Pridham JN,
Jiang YG, Xu LH, Mi WD. Recovery of Ong BY, Shukla RC, Kristoffersson AH, Huizar
gastrointestinal function with thoracic epidural vs. KM, Nevin K, Ahlen KG, Canadian Ropivacaine
systemic analgesia following gastrointestinal Research G. Prolonged epidural infusions of
surgery. Acta Anaesthesiol Scand 2014; 58: 923– ropivacaine (2 mg/mL) after colonic surgery: the
32. impact of adding fentanyl. Anesth Analg 2001; 92:
246. Uchida I, Asoh T, Shirasaka C, Tsuji H. Effect of 1276–85.
epidural analgesia on postoperative insulin 257. Manion SC, Brennan TJ. Thoracic epidural
resistance as evaluated by insulin clamp analgesia and acute pain management.
technique. Br J Surg 1988; 75: 557–62. Anesthesiology 2011; 115: 181–8.
247. Popping DM, Elia N, Marret E, Remy C, Tramer 258. Kim JY, Lee SJ, Koo BN, Noh SH, Kil HK, Kim
MR. Protective effects of epidural analgesia on HS, Ban SY. The effect of epidural sufentanil in
pulmonary complications after abdominal and ropivacaine on urinary retention in patients
thoracic surgery: a meta-analysis. Arch Surg 2008; undergoing gastrectomy. Br J Anaesth 2006; 97:
143: 990–9; discussion 1000. 414–8.
248. Block BM, Liu SS, Rowlingson AJ, Cowan AR, 259. Rawal N, Allvin R. Epidural and intrathecal
Cowan JA Jr, Wu CL. Efficacy of postoperative opioids for postoperative pain management in
epidural analgesia: a meta-analysis. JAMA 2003; Europe–a 17-nation questionnaire study of
290: 2455–63. selected hospitals. Euro Pain Study Group on
249. Zaouter C, Wuethrich P, Miccoli M, Carli F. Acute Pain. Acta Anaesthesiol Scand 1996; 40:
Early removal of urinary catheter leads to greater 1119–26.
post-void residuals in patients with thoracic 260. Sakaguchi Y, Sakura S, Shinzawa M, Saito Y.
epidural. Acta Anaesthesiol Scand 2012; 56: Does adrenaline improve epidural bupivacaine
1020–5. and fentanyl analgesia after abdominal surgery?
250. Marret E, Remy C, Bonnet F, Postoperative Pain Anaesth Intensive Care 2000; 28: 522–6.
Forum G. Meta-analysis of epidural analgesia 261. Niemi G, Breivik H. The minimally effective
versus parenteral opioid analgesia after colorectal concentration of adrenaline in a low-concentration
surgery. Br J Surg 2007; 94: 665–73. thoracic epidural analgesic infusion of
251. Rawal N. Epidural technique for postoperative bupivacaine, fentanyl and adrenaline after major
pain: gold standard no more? Reg Anesth Pain surgery. A randomized, double-blind, dose-finding
Med 2012; 37: 310–7. study. Acta Anaesthesiol Scand 2003; 47: 439–50.
252. Hubner M, Blanc C, Roulin D, Winiker M, Gander 262. Niemi G, Breivik H. Epinephrine markedly
S, Demartines N. Randomized clinical trial on improves thoracic epidural analgesia produced by
epidural versus patient-controlled analgesia for a small-dose infusion of ropivacaine, fentanyl, and
laparoscopic colorectal surgery within an epinephrine after major thoracic or abdominal

surgery: a randomized, double-blinded crossover and meta-analysis. World J Gastroenterol 2008;

study with and without epinephrine. Anesth 14: 5301–5.
Analg 2002; 94: 1598–605. 274. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy
263. Chan AK, Cheung CW, Chong YK. Alpha-2 of continuous wound catheters delivering local
agonists in acute pain management. Expert Opin anesthetic for postoperative analgesia: a
Pharmacother 2010; 11: 2849–68. quantitative and qualitative systematic review of
264. Gramigni E, Bracco D, Carli F. Epidural analgesia randomized controlled trials. J Am Coll Surg
and postoperative orthostatic haemodynamic 2006; 203: 914–32.
changes. Eur J Anaesthesiol 2013; 30: 398–404. 275. Beaussier M, El’Ayoubi H, Schiffer E, Rollin M,
265. Meylan N, Elia N, Lysakowski C, Tramer MR. Parc Y, Mazoit JX, Azizi L, Gervaz P, Rohr S,
Benefit and risk of intrathecal morphine without Biermann C, Lienhart A, Eledjam JJ. Continuous
local anaesthetic in patients undergoing major preperitoneal infusion of ropivacaine provides
surgery: meta-analysis of randomized trials. Br J effective analgesia and accelerates recovery after
Anaesth 2009; 102: 156–67. colorectal surgery: a randomized, double-blind,
266. Levy BF, Scott MJ, Fawcett WJ, Day A, Rockall placebo-controlled study. Anesthesiology 2007;
TA. Optimizing patient outcomes in laparoscopic 107: 461–8.
surgery. Colorectal Dis 2011; 13(Suppl 7): 8–11. 276. Bertoglio S, Fabiani F, Negri PD, Corcione A,
267. Hubner M, Lovely JK, Huebner M, Slettedahl SW, Merlo DF, Cafiero F, Esposito C, Belluco C, Pertile
Jacob AK, Larson DW. Intrathecal analgesia and D, Amodio R, Mannucci M, Fontana V, Cicco MD,
restrictive perioperative fluid management within Zappi L. The postoperative analgesic efficacy of
enhanced recovery pathway: hemodynamic preperitoneal continuous wound infusion
implications. J Am Coll Surg 2013; 216: 1124–34. compared to epidural continuous infusion with
268. Wongyingsinn M, Baldini G, Stein B, Charlebois local anesthetics after colorectal cancer surgery: a
P, Liberman S, Carli F. Spinal analgesia for randomized controlled multicenter study. Anesth
laparoscopic colonic resection using an enhanced Analg 2012; 115: 1442–50.
recovery after surgery programme: better 277. Jouve P, Bazin JE, Petit A, Minville V, Gerard A,
analgesia, but no benefits on postoperative Buc E, Dupre A, Kwiatkowski F, Constantin JM,
recovery: a randomized controlled trial. Br J Futier E. Epidural versus continuous preperitoneal
Anaesth 2012; 108: 850–6. analgesia during fast-track open colorectal
269. Marret E, Rolin M, Beaussier M, Bonnet F. Meta- surgery: a randomized controlled trial.
analysis of intravenous lidocaine and Anesthesiology 2013; 118: 622–30.
postoperative recovery after abdominal surgery. Br 278. Boulind CE, Ewings P, Bulley SH, Reid JM,
J Surg 2008; 95: 1331–8. Jenkins JT, Blazeby JM, Francis NK. Feasibility
270. Vigneault L, Turgeon AF, Cote D, Lauzier F, study of analgesia via epidural versus
Zarychanski R, Moore L, McIntyre LA, Nicole PC, continuous wound infusion after laparoscopic
Fergusson DA. Perioperative intravenous lidocaine colorectal resection. Br J Surg 2013; 100: 395–
infusion for postoperative pain control: a meta- 402.
analysis of randomized controlled trials. Can J 279. Ventham NT, O’Neill S, Johns N, Brady RR,
Anaesth 2011; 58: 22–37. Fearon KC. Evaluation of novel local anesthetic
271. McCarthy GC, Megalla SA, Habib AS. Impact of wound infiltration techniques for postoperative
intravenous lidocaine infusion on postoperative pain following colorectal resection surgery: a
analgesia and recovery from surgery: a systematic meta-analysis. Dis Colon Rectum 2014; 57: 237–
review of randomized controlled trials. Drugs 50.
2010; 70: 1149–63. 280. Moiniche S, Dahl JB. Wound catheters for post-
272. Kaba A, Laurent SR, Detroz BJ, Sessler DI, operative pain management: overture or finale?
Durieux ME, Lamy ML, Joris JL. Intravenous Acta Anaesthesiol Scand 2011; 55: 775–7.
lidocaine infusion facilitates acute rehabilitation 281. Charlton S, Cyna AM, Middleton P, Griffiths JD.
after laparoscopic colectomy. Anesthesiology 2007; Perioperative transversus abdominis plane (TAP)
106: 11–8; discussion 5-6. blocks for analgesia after abdominal surgery.
273. Karthikesalingam A, Walsh SR, Markar SR, Cochrane Database Syst Rev 2010; CD007705.
Sadat U, Tang TY, Malata CM. Continuous doi: 10.1002/14651858.CD007705.pub2.
wound infusion of local anaesthetic agents 282. Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig
following colorectal surgery: systematic review MK. A meta-analysis on the clinical effectiveness

of transversus abdominis plane block. J Clin analgesia following upper abdominal surgery.
Anesth 2011; 23: 7–14. Anaesthesia 2011; 66: 465–71.
283. Johns N, O’Neill S, Ventham NT, Barron F, Brady 294. De Oliveira GS Jr, Castro-Alves LJ, Nader A,
RR, Daniel T. Clinical effectiveness of transversus Kendall MC, McCarthy RJ. Transversus
abdominis plane (TAP) block in abdominal abdominis plane block to ameliorate postoperative
surgery: a systematic review and meta-analysis. pain outcomes after laparoscopic surgery: a meta-
Colorectal Dis 2012; 14: e635–42. analysis of randomized controlled trials. Anesth
284. Bharti N, Kumar P, Bala I, Gupta V. The efficacy of Analg 2014; 118: 454–63.
a novel approach to transversus abdominis plane 295. Walter CJ, Maxwell-Armstrong C, Pinkney TD,
block for postoperative analgesia after colorectal Conaghan PJ, Bedforth N, Gornall CB, Acheson
surgery. Anesth Analg 2011; 112: 1504–8. AG. A randomised controlled trial of the efficacy
285. Owen DJ, Harrod I, Ford J, Luckas M, Gudimetla of ultrasound-guided transversus abdominis plane
V. The surgical transversus abdominis plane (TAP) block in laparoscopic colorectal surgery.
block–a novel approach for performing an Surg Endosc 2013; 27: 2366–72.
established technique. BJOG 2011; 118: 24–7. 296. Niraj G, Kelkar A, Hart E, Horst C, Malik D,
286. Favuzza J, Brady K, Delaney CP. Transversus Yeow C, Singh B, Chaudhri S. Comparison of
abdominis plane blocks and enhanced recovery analgesic efficacy of four-quadrant transversus
pathways: making the 23-h hospital stay a abdominis plane (TAP) block and continuous
realistic goal after laparoscopic colorectal surgery. posterior TAP analgesia with epidural analgesia in
Surg Endosc 2013; 27: 2481–6. patients undergoing laparoscopic colorectal
287. Favuzza J, Delaney CP. Outcomes of discharge surgery: an open-label, randomised, non-
after elective laparoscopic colorectal surgery with inferiority trial. Anaesthesia 2014; 69: 348–55.
transversus abdominis plane blocks and enhanced 297. Abdallah FW, Chan VW, Brull R. Transversus
recovery pathway. J Am Coll Surg 2013; 217: 503– abdominis plane block: a systematic review. Reg
6. Anesth Pain Med 2012; 37: 193–209.
288. Keller DS, Stulberg JJ, Lawrence JK, Delaney CP. 298. Kahokehr A, Sammour T, Shoshtari KZ, Taylor M,
Process control to measure process improvement Hill AG. Intraperitoneal local anesthetic improves
in colorectal surgery: modifications to an recovery after colon resection: a double-blinded
established enhanced recovery pathway. Dis randomized controlled trial. Ann Surg 2011; 254:
Colon Rectum 2014; 57: 194–200. 28–38.
289. Brady RR, Ventham NT, Roberts DM, Graham C, 299. Kahokehr A, Sammour T, Srinivasa S, Hill AG.
Daniel T. Open transversus abdominis plane Systematic review and meta-analysis of
block and analgesic requirements in patients intraperitoneal local anaesthetic for pain reduction
following right hemicolectomy. Ann R Coll Surg after laparoscopic gastric procedures. Br J Surg
Engl 2012; 94: 327–30. 2011; 98: 29–36.
290. Allcock E, Spencer E, Frazer R, Applegate G, 300. Wu CL, Rowlingson AJ, Partin AW, Kalish MA,
Buckenmaier C 3rd. Continuous transversus Courpas GE, Walsh PC, Fleisher LA. Correlation
abdominis plane (TAP) block catheters in a of postoperative pain to quality of recovery in the
combat surgical environment. Pain Med 2010; 11: immediate postoperative period. Reg Anesth Pain
1426–9. Med 2005; 30: 516–22.
291. Kadam RV, Field JB. Ultrasound-guided 301. Marret E, Kurdi O, Zufferey P, Bonnet F. Effects
continuous transverse abdominis plane block for of nonsteroidal antiinflammatory drugs on patient-
abdominal surgery. J Anaesthesiol Clin Pharmacol controlled analgesia morphine side effects: meta-
2011; 27: 333–6. analysis of randomized controlled trials.
292. Bjerregaard N, Nikolajsen L, Bendtsen TF, Anesthesiology 2005; 102: 1249–60.
Rasmussen BS. Transversus abdominis plane 302. Klein M. Postoperative non-steroidal anti-
catheter bolus analgesia after major abdominal inflammatory drugs and colorectal anastomotic
surgery. Anesthesiol Res Pract 2012; 2012: 596536. leakage. NSAIDs and anastomotic leakage. Dan
293. Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Med J 2012; 59: B4420.
Williams O, Darbar A, Maheshwaran A, Powell R. 303. Burton TP, Mittal A, Soop M. Nonsteroidal anti-
Comparison of analgesic efficacy of subcostal inflammatory drugs and anastomotic dehiscence in
transversus abdominis plane blocks with epidural bowel surgery: systematic review and meta-

analysis of randomized, controlled trials. Dis clinical trial. Ann Surg 2014; 260: 540–8;
Colon Rectum 2013; 56: 126–34. discussion 48-9.
304. Gorissen KJ, Benning D, Berghmans T, Snoeijs 313. Bell RF, Dahl JB, Moore RA, Kalso E.
MG, Sosef MN, Hulsewe KW, Luyer MD. Risk of Perioperative ketamine for acute postoperative
anastomotic leakage with non-steroidal anti- pain. Cochrane Database Syst Rev 2006; 1:
inflammatory drugs in colorectal surgery. Br J CD004603.
Surg 2012; 99: 721–7. 314. Weinbroum AA. Non-opioid IV adjuvants in the
305. Remy C, Marret E, Bonnet F. Effects of perioperative period: pharmacological and clinical
acetaminophen on morphine side-effects and aspects of ketamine and gabapentinoids.
consumption after major surgery: meta-analysis of Pharmacol Res 2012; 65: 411–29.
randomized controlled trials. Br J Anaesth 2005; 315. White PF. The changing role of non-opioid
94: 505–13. analgesic techniques in the management of
306. Apfel CC, Turan A, Souza K, Pergolizzi J, postoperative pain. Anesth Analg 2005; 101: S5–
Hornuss C. Intravenous acetaminophen reduces 22.
postoperative nausea and vomiting: a systematic 316. Candiotti KA, Sands LR, Lee E, Bergese SD,
review and meta-analysis. Pain 2013; 154: 677– Harzman AE, Marcet J, Kumar AS, Haas E.
89. Liposome bupivacaine for postsurgical analgesia
307. Mathiesen O, Wetterslev J, Kontinen VK, in adult patients undergoing laparoscopic
Pommergaard HC, Nikolajsen L, Rosenberg J, colectomy: results from prospective phase IV
Hansen MS, Hamunen K, Kjer JJ, Dahl JB, sequential cohort studies assessing health
Scandinavian Postoperative Pain A. Adverse economic outcomes. Curr Ther Res Clin Exp 2014;
effects of perioperative paracetamol, NSAIDs, 76: 1–6.
glucocorticoids, gabapentinoids and their 317. Cohen SM. Extended pain relief trial utilizing
combinations: a topical review. Acta Anaesthesiol infiltration of Exparel , a long-acting
Scand 2014; 58: 1182–98. multivesicular liposome formulation of
308. Nussmeier NA, Whelton AA, Brown MT, Joshi bupivacaine: a Phase IV health economic trial in
GP, Langford RM, Singla NK, Boye ME, Verburg adult patients undergoing open colectomy. J Pain
KM. Safety and efficacy of the cyclooxygenase-2 Res 2012; 5: 567–72.
inhibitors parecoxib and valdecoxib after 318. Dahl JB, Nielsen RV, Wetterslev J, Nikolajsen L,
noncardiac surgery. Anesthesiology 2006; 104: Hamunen K, Kontinen VK, Hansen MS, Kjer JJ,
518–26. Mathiesen O, Scandinavian Postoperative Pain A.
309. Vignali A, Di Palo S, Orsenigo E, Ghirardelli L, Post-operative analgesic effects of paracetamol,
Radaelli G, Staudacher C. Effect of prednisolone NSAIDs, glucocorticoids, gabapentinoids and their
on local and systemic response in laparoscopic vs. combinations: a topical review. Acta Anaesthesiol
open colon surgery: a randomized, double-blind, Scand 2014; 58: 1165–81.
placebo-controlled trial. Dis Colon Rectum 2009; 319. Brown TM, Boyle MF. Delirium. BMJ 2002; 325:
52: 1080–8. 644–7.
310. Waldron NH, Jones CA, Gan TJ, Allen TK, Habib 320. Tucker GJ. The diagnosis of delirium and DSM-
AS. Impact of perioperative dexamethasone on IV. Dement Geriatr Cogn Disord 1999; 10: 359–63.
postoperative analgesia and side-effects: 321. O’Keeffe ST. Clinical subtypes of delirium in the
systematic review and meta-analysis. Br J Anaesth elderly. Dement Geriatr Cogn Disord 1999; 10:
2013; 110: 191–200. 380–5.
311. Lunn TH, Kristensen BB, Andersen LO, Husted H, 322. Leslie DL, Zhang Y, Holford TR, Bogardus ST,
Otte KS, Gaarn-Larsen L, Kehlet H. Effect of high- Leo-Summers LS, Inouye SK. Premature death
dose preoperative methylprednisolone on pain associated with delirium at 1-year follow-up. Arch
and recovery after total knee arthroplasty: a Intern Med 2005; 165: 1657–62.
randomized, placebo-controlled trial. Br J Anaesth 323. Heymann A, Radtke F, Schiemann A, Lutz A,
2011; 106: 230–8. MacGuill M, Wernecke KD, Spies C. Delayed
312. de la Motte L, Kehlet H, Vogt K, Nielsen CH, treatment of delirium increases mortality rate in
Groenvall JB, Nielsen HB, Andersen A, Schroeder intensive care unit patients. J Int Med Res 2010;
TV, Lonn L. Preoperative methylprednisolone 38: 1584–95.
enhances recovery after endovascular aortic repair: 324. Pisani MA, Kong SY, Kasl SV, Murphy TE,
a randomized, double-blind, placebo-controlled Araujo KL, Van Ness PH. Days of delirium are

associated with 1-year mortality in an older clinical trial of multimodal optimization of

intensive care unit population. Am J Respir Crit surgical care in patients undergoing major colonic
Care Med 2009; 180: 1092–7. resection. Br J Surg 2005; 92: 1354–62.
325. Radtke FM, Heymann A, Franck M, Maechler F, 337. Kehlet H, Wilmore DW. Evidence-based surgical
Drews T, Luetz A, Nachtigall I, Wernecke KD, care and the evolution of fast-track surgery. Ann
Spies CD. How to implement monitoring tools for Surg 2008; 248: 189–98.
sedation, pain and delirium in the intensive care 338. Browning L, Denehy L, Scholes RL. The quantity
unit: an experimental cohort study. Intensive Care of early upright mobilisation performed following
Med 2012; 38: 1974–81. upper abdominal surgery is low: an observational
326. Skrobik Y, Ahern S, Leblanc M, Marquis F, study. Aust J Physiother 2007; 53: 47–52.
Awissi DK, Kavanagh BP. Protocolized intensive 339. Henriksen MG, Jensen MB, Hansen HV,
care unit management of analgesia, sedation, and Jespersen TW, Hessov I. Enforced mobilization,
delirium improves analgesia and subsyndromal early oral feeding, and balanced analgesia
delirium rates. Anest Analg 2010; 111: 451–63. improve convalescence after colorectal surgery.
327. Radtke FM, Franck M, MacGuill M, Seeling M, Lutz Nutrition 2002; 18: 147–52.
A, Westhoff S, Neumann U, Wernecke KD, Spies 340. Pashikanti L, Von Ah D. Impact of early
CD. Duration of fluid fasting and choice of analgesic mobilization protocol on the medical-surgical
are modifiable factors for early postoperative inpatient population: an integrated review of
delirium. Eur J Anaesthesiol 2010; 27: 411–6. literature. Clin Nurse Spec 2012; 26: 87–94.
328. Lonergan E, Britton AM, Luxenberg J, Wyller T. 341. Pitkethly M, Macgillivray S, Ryan R. Recordings
Antipsychotics for delirium. Cochrane Database or summaries of consultations for people with
Syst Rev 2007; CD005594. cancer. Cochrane Database Syst Rev 2008; 3:
329. Lonergan E, Luxenberg J, Areosa Sastre A, Wyller CD001539.
TB. Benzodiazepines for delirium. Cochrane 342. Li C, Ferri LE, Mulder DS, Ncuti A, Neville A,
Database Syst Rev 2009; 1: CD006379. Lee L, Kaneva P, Watson D, Vassiliou M, Carli F,
330. Delaney CP, Kehlet H, Senagore A. Postoperative Feldman LS. An enhanced recovery pathway
ileus: profiles, risk factors and definitions – a decreases duration of stay after esophagectomy.
framework for optimizing surgical outcomes in Surgery 2012; 152: 606–14; discussion 14-6.
patients undergoing major abdominal and 343. Li C, Carli F, Lee L, Charlebois P, Stein B,
colorectal surgery. Clinical Consensus Update in Liberman AS, Kaneva P, Augustin B,
General Surgery 2006. Available at: http:// Wongyingsinn M, Gamsa A, Kim do J, Vassiliou
www.clinicalwebcasts.com/updates/index.htm. MC, Feldman LS. Impact of a trimodal
(accessed 15 September 2015) prehabilitation program on functional recovery
331. van Bree SH, Bemelman WA, Hollmann MW, after colorectal cancer surgery: a pilot study. Surg
Zwinderman AH, Matteoli G, El Temna S, The Endosc 2013; 27: 1072–82.
FO, Vlug MS, Bennink RJ, Boeckxstaens GE. 344. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen
Identification of clinical outcome measures for K, Andersen J, Kessels AG, Revhaug A, Kehlet H,
recovery of gastrointestinal motility in Ljungqvist O, Fearon KC, von Meyenfeldt MF. A
postoperative ileus. Ann Surg 2014; 259: 708–14. protocol is not enough to implement an enhanced
332. Kehlet H. Postoperative ileus–an update on recovery programme for colorectal resection. Br J
preventive techniques. Nat Clin Pract Surg 2007; 94: 224–31.
Gastroenterol Hepatol 2008; 5: 552–8. 345. Bravata DM, Smith-Spangler C, Sundaram V,
333. Chapuis PH, Bokey L, Keshava A, Rickard MJ, Gienger AL, Lin N, Lewis R, Stave CD, Olkin I,
Stewart P, Young CJ, Dent OF. Risk factors for Sirard JR. Using pedometers to increase physical
prolonged ileus after resection of colorectal cancer: activity and improve health: a systematic review.
an observational study of 2400 consecutive JAMA 2007; 298: 2296–304.
patients. Ann Surg 2013; 257: 909–15. 346. Papaspyros S, Uppal S, Khan SA, Paul S, O’Regan
334. Brieger GH. Early ambulation. A study in the DJ. Analysis of bedside entertainment services’
history of surgery. Ann Surg 1983; 197: 443–9. effect on post cardiac surgery physical activity: a
335. Brower RG. Consequences of bed rest. Critical prospective, randomised clinical trial. Eur J
Care Med 2009; 37: S422–8. Cardiothorac Surg 2008; 34: 1022–6.
336. Gatt M, Anderson AD, Reddy BS, Hayward- 347. Moiniche S, Hjortso NC, Blemmer T, Dahl JB,
Sampson P, Tring IC, MacFie J. Randomized Kehlet H. Blood pressure and heart rate during

orthostatic stress and walking with continuous 354. Wodlin NB, Nilsson L, Kjolhede P. Health-related
postoperative thoracic epidural bupivacaine/ quality of life and postoperative recovery in fast-
morphine. Acta Anaesthesiol Scand 1993; 37: 65– track hysterectomy. Acta Obstet Gynecol Scand
9. 2011; 90: 362–8.
348. Kehlet H. Fast-track surgery-an update on 355. Beaussier M, El’ayoubi H, Rollin M, Parc Y,
physiological care principles to enhance recovery. Atchabahian A, Chanques G, Capdevila X,
Langenbecks Arch Surg 2011; 396: 585–90. Lienhart A, Jaber S. Parietal analgesia decreases
349. Jans O, Bundgaard-Nielsen M, Solgaard S, postoperative diaphragm dysfunction induced by
Johansson PI, Kehlet H. Orthostatic intolerance abdominal surgery: a physiologic study. Reg
during early mobilization after fast-track hip Anesth Pain Med 2009; 34: 393–7.
arthroplasty. Br J Anaeesth 2012; 108: 436–43. 356. Virlos I, Clements D, Beynon J, Ratnalikar V,
350. Bundgaard-Nielsen M, Jans O, Muller RG, Korshin Khot U. Short-term outcomes with intrathecal
A, Ruhnau B, Bie P, Secher NH, Kehlet H. Does versus epidural analgesia in laparoscopic
goal-directed fluid therapy affect postoperative colorectal surgery. Br J Surg 2010; 97: 1401–6.
orthostatic intolerance?: A randomized trial. 357. Levy BF, Scott MJ, Fawcett WJ, Rockall TA. 23-
Anesthesiology 2013; 119: 813–23. hour-stay laparoscopic colectomy. Dis Colon
351. Rehberg B. Why don’t patients get out of bed Rectum 2009; 52: 1239–43.
postoperatively? Eur J Anaesthesiol 2013; 30: 358. Vaughan-Shaw PG, Fecher IC, Harris S, Knight
395–6. JS. A meta-analysis of the effectiveness of the
352. Sjetne IS, Krogstad U, Odegard S, Engh ME. opioid receptor antagonist alvimopan in reducing
Improving quality by introducing enhanced hospital length of stay and time to GI recovery in
recovery after surgery in a gynaecological patients enrolled in a standardized accelerated
department: consequences for ward nursing recovery program after abdominal surgery. Dis
practice. Qual Saf Health Care 2009; 18: 236–40. Colon Rectum 2012; 55: 611–20.
353. Carli F, Mayo N, Klubien K, Schricker T, Trudel 359. Yin Z, Sun J, Liu T, Zhu Y, Peng S, Wang J. Gum
J, Belliveau P. Epidural analgesia enhances chewing: another simple potential method for
functional exercise capacity and health-related more rapid improvement of postoperative
quality of life after colonic surgery: results of a gastrointestinal function. Digestion 2013; 87: 67–
randomized trial. Anesthesiology 2002; 97: 540–9. 74.


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REVIEW ARTICLE

Enhanced Recovery After Surgery (ERAS) for gastrointestinal

Correspondence Background: The present interdisciplinary consensus review

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Editorial comment: what this article tells us

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

All factors contribute 1 point equally to the Dynamic Tests

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

retrospective study, it should be also considered

paradigms mobilize more and achieve indepen- Treatment of primary POI

Fig. 1. Identification of patients with primary

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

(NMDA) receptor antagonist, has been shown to

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

associated with 1-year mortality in an older clinical trial of multimodal optimization of

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

centrations which result in hyperoxia should Summary and recommendation: Intraoperative

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Analgesia technique Outcomes ERAS Control group Complications/issues

Laparotomy TEA (low dose of LA ; PONV250 – SO Hypotension, pruritus,

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Clinical management Clinical management

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

mixed form.321 Delirium as a symptom of acute

retrospective study, it should be also considered

paradigms mobilize more and achieve indepen- Treatment of primary POI

Fig. 1. Identification of patients with primary

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Table 4 ERAS elements: summary and recommendations.

Perioperative element Summary and recommendation Recommendation grade

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Perioperative element Summary and recommendation Recommendation grade

2) 100% inspired oxygen concentrations can be used for pre-

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Perioperative element Summary and recommendation Recommendation grade

oriented treatment should be performed and potential

Recommendation grade: weak. considerations and recommendations for each of

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

VANSQIP. Determinants of long-term survival Heart Association Task Force on Practice

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

preoperative oral carbohydrate treatment in general anaesthesia in at-risk patients having

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

surgery: a randomized, double-blinded crossover and meta-analysis. World J Gastroenterol 2008;

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Acta Anaesthesiologica Scandinavica 60 (2016) 289–334

Acta Anaesthesiologica Scandinavica 60 (2016) 289–334