Building Blocks: Preoperative

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

Optimization of organ dysfunction

An ERP starts in a well functioning preoperative clinic. The goal of preoperative optimization is to improve physiologic reserve to better tolerate the incoming stress of surgery. Nutrition: Patients should be referred to a nutritionist if they are at risk for malnutrition and provided with supplementation to optimize stores preoperatively. Routine use of oral nutritional […]


Prehabilitation is a strategy to increase reserve in anticipation of an upcoming stressor. Patients with poor baseline functional capacity are at increased risk of complications and prolonged recovery (1,2). Emerging evidence suggests that a 4-week period of prehabilitation can increase walking capacity in colorectal cancer patients, and deconditioned patients in general make the biggest gains. […]

Selective bowel preparation

Mechanical bowel preparation has long been thought to reduce infectious complications after colorectal resection. However, mechanical bowel preparation is uncomfortable and results in fluid losses. For colon resection, meta-analyses of randomized trials conclude that mechanical bowel preparation does not decrease infectious complications or leak (1). However, these trials did not include oral antibiotics with the […]

Reduce preoperative fasting

Traditionally patients are “NPO after midnight” to reduce the risk of aspiration of gastric contents at induction of anesthesia. This results in a long period without hydration or nutrition, especially for cases booked later the following day. Oral intake of clear fluids up to 2 hours before surgery does not increase the risk of aspiration […]

Carbohydrate drink

Carbohydrate drink: The administration of a complex carbohydrate-rich drink before surgery (100gm the evening before surgery and 50gm 2-3 hours preop) may increase insulin sensitivity but does not reduce complications or significantly improve other outcomes when compared to placebo fluids (1). Larger trials are required to establish impact on protein catabolism and on clinical outcomes. […]

No long acting sedatives

Long acting benzodiazepines are avoided. Short-acting agents to reduce anxiety during induction of anesthesia or insertion of epidurals are used selectively. « Carbohydrate drinkLaparoscopic surgery »