1. Preadmission education (4-5 weeks before surgery, at least one week before surgery)
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• Meeting with Anesthesiologist, ERAS nurse specialist, Nutritionist, Stoma counseling, and Physiatrist; |
• Booklet describing the protocol. |
2. Preoperative screening
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• Nutritional deficiency: Malnutrition Universal Screening Tool - MUST and the Scored Patient-Generated Subjective Global Assessment (PG-SGA); |
• Prescription of a diet; |
• Tobacco and ethanol: referred preoperatively for counseling. |
3. Prehabilitation
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• Physical exercises according to Physiatrist. |
4. Fasting and carbohydrate loading guidelines
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• Normal diet until midnight and hydration encouraged; |
• One carbohydrate drink (200 mL) until 21 h and half until 23 h the day before surgery; |
• Half carbohydrate drink (100 mL) until 2 h before surgery; |
• Fasting is according to international guidelines. |
5. Bowel preparation
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• Colonic surgery: administration of laxative therapy only; |
• Rectal surgery: bowel preparation with a 2-L electrolytic solution the day before surgery. |
6. Thromboembolic prophylaxis
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• Prophylactic-dose enoxaparin subcutaneously 12 h before surgery and regular administration at the same schedule (starting 6 h after surgery); |
• Use of compression socks since the day of surgery until discharge day. |
7. Antibiotic prophylaxis
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• Cefoxitin 2 g and metronidazole 1 g, 60-30 min before surgical incision; |
• Intraoperatively, cefoxitin 1 g is administered every 2 h and metronidazole 500 mg every 6 h. |
8. Preemptive analgesia
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• We usually do not administer preemptive analgesia. |
9. Anti-emetic prophylaxis
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• According to Apfel score; |
• All patients are administered at least on anti-emetic; common agents are dexamethasone and ondansetron. |
10. Standard Anesthetic protocol - general principles
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• Avoiding pre-medication and long-acting opioids; |
• Monitoring neuromuscular block; |
• Use of cerebral monitoring for depth of anesthesia. |
11. Intraoperative fluid management strategy
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• Restrictive fluid approach with “zero balance”; |
• Hypotension is preferably approached according to etiology. If patient is not hypovolemic, vasopressors are preferred; |
• If high risk patient, or expected relevant blood loss, goal-directed therapy is encouraged. |
12. Patient warming strategy
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• The warming measures start at the induction room; |
• Forced air heating and intravenous fluids warming; |
• Esophageal temperature monitorization to T ≥ 36.1 °C. |
13. Surgical access
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• Preferably minimal invasive approaches. |
14. Plan for intraoperative opioid minimization
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• Open surgery: thoracic epidural (colonic surgery - T7/T9 level; rectum surgery - T10/T11 level); |
• Laparoscopic surgery: Other locoregional techniques can be useful (in our institution, a transverse abdominis plane (TAP) block is the most frequent option). |
15. Drain and line management
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• No routine wound drains; |
• Nasogastric tube is removed in the operating room; |
• Foley catheter: If colonic surgery, removal at day 1 postoperative; if rectal surgery, its removal is decided individually. |
16. Postoperative fluids
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• Balanced solutions until 24 h post-surgery at 1 mL.kg-1.h-1. |
17. Postoperative analgesia
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• Visual Analogue Scale (VAS) punctuation < 4; |
• Open surgery: epidural analgesia. The catheter is removed by postoperative day 2, if colonic surgery, and by postoperative day 4, if rectal surgery; |
• Open surgery and laparoscopic surgery: non-opioid adjuvants (paracetamol and metamizol) during first 48 h at 6 h-intervals; after which NSAIDs or COX-2 inhibitors can be added. Tramadol can also be administered, if needed; |
• In the first 24 h, analgesics are administered intravenously. |
18. Early mobilization strategy
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• Ambulation to chair at day 0 postoperative, for 2 h; |
• At day 1 postoperative, the patient starts to walk in hallways (3 times during the day, minimum 2 h). |
19. Postoperative diet and bowel regimen management
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• Gut motility stimulation with Bisacodyl 5 mg. |
• On the day of surgery: liquid diet, 2-4 h after surgery. Goal: 600 mL and 300 Kcal; End of first day: low-residue diet. |
20. Criteria for discharge
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• Postoperative autonomy guaranteed; |
• Pain well controlled on oral medication (VAS < 4); |
• Gastrointestinal transit recovered. |
21. Tracking of post-discharge outcomes
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• Follow-up at 48 h and at 30-days; |
• Phone call by the ERAS team nurse. |