Enhanced Recovery Pathways: Organization of Evidence-Based, Fast-Track Perioperative Care

Enhanced recovery pathways (ERPs) are standardized coordinated, multidisciplinary perioperative care plans that incorporate evidence-based interventions to minimize surgical stress, improve physiologic and functional recovery, reduce complications, and thereby facilitate earlier discharge from the hospital. Several perioperative elements contribute to enhance surgical recovery. Preoperative elements include patient education, optimization of medical conditions and functional status, nutritional support, smoking cessation programs, minimization of preoperative fasting and preoperative carbohydrate drinks, avoidance of mechanical bowel preparation when not indicated, and avoidance of long-active sedatives as premedication. Intraoperative elements aim to attenuate the surgical stress response and include regional or local anesthesia; pharmacologic adjuvants, nonopioid analgesics, and maintaining normothermia; intravenous fluid management; and opting to favor small incisions when possible. Postoperative elements include considering multimodal analgesia (opioid-sparing strategies); encouraging early postoperative feeding; stressing the importance of early mobilization; restricting the unnecessary use of intravenous fluids, drains, and catheters; and instituting a discharge and follow-up plan for patients. Tables describe the evolution of intraoperative fluid management, organization of a multimodal perioperative care plan for a specific procedure or group of procedures; key elements to include in developing an ERP; sample multimodal perioperative care plans for elective colorectal resection, esophageal resection, and ambulatory laparoscopic cholecystectomy. This review contains 1 figure, 6 tables, and 319 references.