| Preoperative considerations |
- Identification and optimization of comorbid conditions
- Prehabilitation, if necessary
- Patient and family education and discharge planning
- Avoidance of prolonged preoperative fasting
- Pain management planning (procedure-specific multimodal opioid-sparing pain prophylactic agents administered at least two hours before surgery)
- Oral acetaminophen 1 g¶
- Oral cyclooxygenase (COX)-2 specific inhibitor¶
- For selected procedures, thromboembolism prophylaxis with subcutaneous heparin 5000 units administered 30 to 60 minutes before surgery
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| Intraoperative considerations |
- Use of a minimally invasive surgical approach, when feasible
- Antibiotic prophylaxis administered within 30 to 60 minutes of the surgical incision
- Use of short-acting anesthetic agents (inhalation and/or IV agents) during induction and maintenance of general anesthesia
- Avoidance of fluid overload
- Lung protective mechanical ventilation
- Maintenance of normothermia
- Glycemic control
- Multimodal antiemetic prophylaxis
- IV dexamethasone 8 to 10 mg after induction of anesthesia¶
- IV 5-HT3 antagonist (eg, ondansetron 4 mg at the end of the surgical procedure)¶
- For patients at very high risk for PONV, use of a third antiemetic agent (eg, preoperative transdermal scopolamine) and/or use of TIVA anesthetic technique
- Procedure-specific multimodal opioid-sparing pain prophylaxis
- Use of local or regional analgesic techniques (ie, peripheral nerve block, interfascial plane blocks, surgical site infiltration), when feasible
- IV acetaminophen 1 g after induction of anesthesia (if it was not administered preoperatively)¶
- IV ketorolac 15 to 30 mg near the end of the surgical procedure, if no COX-2 specific inhibitor given preop¶
- For open procedures, administration of a long-acting IV opioid (eg, morphine 0.05 to 0.1 mg/kg IBW, hydromorphone 5 to 10 mcg/kg IBW) approximately 20 minutes before extubation¶
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| Postoperative considerations |
- Rescue therapy for PONV using one or more IV agents
- IM promethazine 6.25 mg¶
- IV dimenhydrinate 1 mg/kg¶
- IV 5-HT3 antagonist (but no sooner than four hours after previous ondansetron dose)¶
- Procedure-specific multimodal opioid-sparing pain management
- Administration of IV morphine 1 to 2 mg doses (up to 10 mg) or IV hydromorphone 0.1 to 0.2 mg doses (up to 1 mg) while patient is in the PACU
- Subsequent scheduled daily doses of oral acetaminophen plus an oral NSAID (eg, meloxicam 15 mg, PO) once a day or a COX-2 specific inhibitor (eg, celecoxib 200 mg PO twice a day)¶
- For patients who do not tolerate oral agents, acetaminophen, meloxicam, ibuprofen, and ketorolac are available in an IV formulation and should be administered as scheduled daily doses
- For breakthrough postoperative pain, oral oxycodone 5 to 10 mg or oral tramadol 50 mg can be administered as needed
- Resumption of oral feeding as soon as feasible
- Early postoperative mobilization and physical therapy
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