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Preoperative management
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Patient educated about the pathway in the surgical clinic
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Preoperative bowel preparation is not routinely used
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Patients allowed clear fluids until 2 h before the start of surgery
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500 mL carbohydrate drink 2 h before surgery (Clearfast)
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Oral adjunctive analgesics given preoperatively: acetaminophen, gabapentin
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Alvimopan given preoperatively
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Transdermal scopolamine patch applied in preoperative holding unless contraindicated
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Low thoracic epidural placed with small amount of IV fentanyl and/or midazolam for sedation
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Heparin 5000u SC given after epidural placement and before incision
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Antibiotic prophylaxis: cefazolin or clindamycin if penicillin allergic
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Intraoperative management
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Induction: lidocaine, propofol, fentanyl up to 150 μg, neuromuscular blocking drug of choice
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Goal is to avoid IV opioids, no IV opioids after induction without discussion with attending anesthesiologist
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Dexamethasone 4 mg IV after induction
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ASA standard monitors and arterial line with cardiac output monitor
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Volatile anesthetic titrated to keep BIS 40–60
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Option for epidural hydromorphone 0.4 mg at induction
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Epidural infusion bupivacaine 0.0625–0.25% ± hydromorphone 10 μg/mL run at 3–6 mL/h
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Ketamine infusion 4 μg/kg/min may be used in chronic pain patients
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Ondansetron 4 mg IV given at the end of surgery
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Acetaminophen 1 g IV and ketorolac 15 mg IV given towards end of the case if appropriate
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Fluid management:
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Maintenance crystalloid infusion (LR) 3 mL/kg based on ideal body weight
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Goal-directed fluid therapy—colloid boluses to maximize stroke volume
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Record initial stroke volume (SV)
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After incision, give 250 mL colloid bolus over < 15 min
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If SV increases by > 10%, repeat bolus
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If SV increases by < 10%, patient does not require a further bolus
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Record peak value achieved
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If still hypotensive, consider phenylephrine bolus or infusion
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Give a further colloid bolus when SV drops 10% from peak value
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Repeat cycle
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Blood products transfused as needed
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Postoperative management
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Epidural bupivacaine 0.0625–0.125% ± hydromorphone 10 μg/mL run at 4–6 mL/h for up to 72 h
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(Hydromorphone 10 μg/mL alone may be used in hypotension is a problem)
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Scheduled adjunctive analgesia with acetaminophen and NSAIDs whenever possible
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Patients transitioned to oral opioids after removal of epidural catheter
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Patients encouraged to drink liquids immediately after surgery
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Alvimopan given postoperatively for 5 days or until first stool
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IV fluids discontinued once adequate oral intake is achieved, usually the first morning after surgery
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All preoperative medications are restarted when patients tolerate oral intake
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Patients cared for in an environment that encourages early mobilization
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Encouraged to be out of bed on the day after surgery and for at least 6 h on every subsequent day
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Patients are asked to maintain a diary of their activity and sleep
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