Building Blocks: Intraoperative

Click on the title to get more information about this element of the SMART pathway.

Laparoscopic surgery

Both laparoscopic surgery and ERPs result in improved outcomes when used in isolation. But additional benefits are seen when they are combined. In a large multicenter trial where patients were allocated to four groups combining surgical approach (laparoscopic or open) and perioperative care (enhanced recovery or standard), the combination of MIS and ERP resulted in […]

Nerve Blocks

Multimodal analgesia: Optimal pain management while avoiding opioids is a key enabler of patient recovery. Furthermore, poor acute pain management is a strong risk factor for the development of chronic pain. A multimodal approach is recommended, using multiple strategies before, during and after surgery. Intraoperatively: For open surgery, neuraxial blockade via thoracic epidural combining local […]

Fluid Balance

There is a narrow range for optimal fluid therapy with a goal of maintaining euvolemia and avoiding both underhydration and salt and water excess. The complication rate goes up with fluid overload of as little as 3L in elective bowel surgery, especially with crystalloids (1). Use of a balanced crystalloid solution (eg Ringer’s lactate) is […]


Mild hypothermia through shivering and vasoconstriction elicits a stress response and increases rates of surgical site infection. Passive and active warmers are used to maintain normothermia (>35.5°). (1) For more information, see Chapter 7: Prevention of Hypothermia in The SAGES / ERAS® Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery References 1. Forbes SS, […]

PONV prophylaxis

Enhanced recovery programs depend greatly on the ability to support patients with early nutrition, multimodal analgesia and ambulation, none of which can be achieved unless the GI tract is functioning well. PONV prophylaxis begins in the operative room. Laparoscopic surgery may increase the risk of PONV while adequate hydration and opioid minimization are protective. A […]

Anesthesia protocol

There are many key aspects of ERPs under the primary responsibility of the anesthesiology team including attenuation of surgical stress, fluid therapy, analgesia, and maintenance of normothermia and euglycemia. An anesthesia protocol allowing for rapid awakening is used. Deep neuromuscular blockade may help with exposure during laparoscopic surgery at lower pressures of pneumoperitoneum. For more […]

Avoid tubes, drains, lines

Nasogastric tubes: Prophylactic NG tubes are not inserted routinely after bowel surgery. Meta-analyses of trials in mainly lower GI surgery found that bowel function was accelerated and pulmonary complications reduced when NGs were not used (1). NG tube insertion postoperatively may be required in up to 15% of patients. After gastrectomy, a meta-analysis comparing routine […]

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