Table 1 Enhanced Recovery Pathway

 Diet

• Evening before surgery: may eat until midnight

• Clear fluids up to 2 h before procedure, including 50 g Carbohydrate in 400 ml (Nutricia ®)

 Bowel preparation

• No systematic use of mechanical bowel preparation; rectal enemas still performed

 Preoperative sedation

• No systematic preoperative sedation, unless anxious crisis

 Nausea and vomiting prophylaxis

• Before incision: Dexamethasone 8 mg IV once (4 mg if age > 80 or weight < 50 kg)

• Before incision closure:

✓ Droperidol 1.25 mg IV once

✓ Ondansetron 4 mg IV once in high risk patient (Apfel score > 3)

 Fluid balance

• Goal: maintain intraoperative Zero Fluid Balance

✓ crystalloid maintenance administration: 3 ml/kg/h for laparoscopy; 5 ml/kg/h for open

✓ In case of blood loss: replacement according to institutional protocol

 Analgesia

• Continuous AIVOC Remifentanyl at discretion of anesthesiologist, supplemented with IV Ketamine (0.5 mg/kg at induction and 0,15 mg/kg hourly boluses)

• IV Lidocaine 1 mg/kg at induction, then 1,5 mg/kg/h until the end of surgery

• Before the end of surgery: IV 1000 mg Acetaminophen, 100 mg Ketoprofen (if no contraindication) and 20 mg Nefopam

• In case of laparoscopy: injection of Naropein (2 mg/kg maximum) at incision site

• In case of laparotomy: bilateral single shot Tap Block with Naropein (2 mg/kg maximum). No epidural analgesia

 Activity

• Evening of POD 0: out of bed more than 2 h, including sitting in chair

• POD 1 and until discharge: out of bed more than 4 h, including deambulation in ward and sitting in chair

• Patient up in chair for all meals

• Removal of urinary catheter by POD 1

 Diet

• No nasogastric tube; if nasogastric tube used intraoperatively, removal at extubation

• Patient encouraged to start clear fluid 2 h after procedure

• POD 0: Patient encouraged to start free diet. In case of difficulties, one to two boxes of liquid nutritional supplement

• POD 1 until discharge: free diet. Encourage daily oral fluid intake (1500–2500 mL)

 Analgesia

• Goal: opioid sparing; no IV morphin patient-controlled analgesia

• Scheduled oral level II opioids

✓ Izalgi® (Acetominophen 500 mg + Opium powder) orally every 6 h

• Scheduled Acetaminophen

✓ Acetaminophen 500 mg orally every 6 h

✓ For patients with no hepatic disease: Maximum Acetaminophen should not exceed 4000 mg/24 h from all sources including Izalgi®

• Scheduled NSAIDs if no contraindication: renal impairment with creatinine clearance less than 40 ml/min or hepatic disease

✓ Ketoprofen 100 mg orally twice daily (start no sooner than 6 h after the intraoperative dose), until POD 2

✓ If patient unable to take NSAIDs: Tramadol 50 mg orally every 6 h.

• Breakthrough pain

✓ Oxycodone 5–10 mg orally every 4 h if needed

 Fluid balance

• Peripheral IV catheter locked on departure from PACU

• In case of laparotomy: Fluid maintenance at 40 mL/h until 8:00 am the day after surgery and then discontinued