Building Blocks: Postoperative

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

Immediate diet

After colorectal surgery, metaanalyses comparing early nutrition (within 24 hours) compared to traditional step-wise introduction of oral intake after return of bowel function conclude that early feeding decreases complications without increasing the risk of leak or affecting bowel function; NG tube reinsertion was not significantly increased (10% versus 7%) (1). After laparoscopic bowel surgery, patients […]

Ileus prophylaxis

Multiple elements of the pathway may have an impact in supporting normal bowel function including laparoscopic surgery, fluid balance and opioid sparing analgesia. Chewing sugar free gum is a simple low cost intervention that decreases time to first flatus, bowel movement and hospital stay after colorectal surgery overall and reduces time to first BM when […]

Heplock IV

As part of a complete ERP approach, with immediate oral intake, PONV prophylaxis, ileus prevention and multimodal analgesia, the “maintenance” IV infusions are stopped within 24 hours of surgery and the IV line heparin-locked to encourage mobilization and functional independence. For more information, see Chapter 11: Fluid Management in The SAGES / ERAS® Society Manual […]

Immediate mobilization

Staying in bed leads to deconditioning that can largely be prevented by physical activity (1). In the context of ERPs, being out of bed on POD0 and POD1 are independent predictors of shorter hospital stay (2). There is little available evidence to suggest what amount of mobilization improves outcomes. Patients are helped to be out […]

No foley or out POD1

Urinary catheter: For routine laparoscopic right colectomy, the urinary catheter is removed in the operating room. Even in the presence of a thoracic epidural, urinary catheters can be removed on POD1 in patients at low risk for urinary retention. A bladder scan based protocol is used to monitor for urinary retention in patients who do […]

Multimodal analgesia

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. Postoperatively: patients are prescribed routine (not PRN) acetominophen 1gm q6hours and […]

Daily care maps, Discharge criteria

Beginning in the surgeon’s office and continued with the preoperative clinic education, the patient and their family are provided with the daily plan for each day of hospitalization. These include milestones to achieve for diet and activities, information about management of pain and drains and the target discharge day if all goes well. These are […]