|
| Pathway component | Benefit—issues |
|
| Preoperative patient education and optimization of medical illness and nutritional status | Reduce preoperative anxiety, minimize perioperative risks, and enhance postoperative recovery [103, 104] |
| (i) Evaluation and discussion of operative anesthetic plan and perioperative pain management program | Assurance of adequate pain control and selection of appropriate pain management techniques will help with process of controlling sympathetic reflexes, afferent pain and stress-released neuropeptides, and multiple factors contributing to motility inhibition [105] |
| (ii) Assessment of pain tolerance, history of current and past opiate use and tolerance | Epidural should be thoracic and utilize local anesthetic infusion initiated early during the surgical procedure to minimize any responsiveness [50] |
| Epidural anesthesia and postoperative analgesia | Insertion and management of epidural must be coordinated with plans for perioperative DVT prophylaxis (e.g., subQ heparin) [11] |
| IV-PCA | Patients with history of chronic opioid use will likely benefit from use of adjuncts or local anesthetic epidural in combination with IV-PCA to avoid acute withdrawal symptoms [108] |
| Opioid-sparing adjuncts such as NSAIDs, dexmedetomidine, lidocaine infusion, and gabapentin | Patients with history of opioid intolerance (e.g., PONV, constipation, POI) may benefit from opioid-sparing technique(s) and the addition of PAM-OR antagonists [27, 102, 111, 115] |
| Patients with planned IV-PCA or opioid tolerance problems evaluated for preoperative initiation of PAM-OR antagonists | PAM-OR antagonists will reverse adverse effects of opioids on GI function without compromising analgesia;
PAM-OR antagonists contraindicated in patients on chronic opioids [83] |
| Preoperative antiemetics and gastric antacids/emptying | Optimize option of early NGT removal at end of procedure;
consider 5HT3, metoclopramide, and dexamethasone [110, 112] |
| Preoperative warming blankets and anxiolysis as needed | Reduce intraoperative hypothermia, and reduce preinduction stresses [35] |
| Laparoscopic surgery | Reduced manipulation and trauma of the bowel leads to less sympathetic activation and inflammation;
reduce postoperative pain and associated opioid use [113] |
| Limited NGT use postoperatively | Utilize intraoperatively but remove at end of procedure as discussed for each case with surgeon;
allows resumption of early oral intake [109] |
| Minimize intraoperative fluids and consider colloid administration | Reduce bowel edema and accelerate GI recovery [43] |
| Early oral/enteral/sham (gum chewing) feeding initiated POD1 | Stimulation of GI hormones [95] |
| Minimize postoperative opioids | Use of nonopioid analgesics and transition from IV-PCA if used to oral agents when possible with IV opioids used only for breakthrough severe pain [89] |
| Advancing of diet as tolerated | If clear liquids tolerated on POD1 then advance to soft diet POD2 [86] |
| Postoperative laxatives | Help to induce bowel movement [114] |
| Early ambulation | Helps to prevent postoperative complications such as thrombosis, atelectasis, and pneumonia [106] |
| Discharge planning communication | Will need to work toward multiple components to have patient achieve toleration of adequate oral intake without PONV, adequate pain control, evidence of lower GI activity (stool or gas per surgeon routine), independent ambulation, and adequate support available at home [107] |
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