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Table 2 Enhanced recovery for radical cystectomy pathway

From: Impact of an enhanced recovery pathway on length of stay and complications in elective radical cystectomy: a before and after cohort study

Preoperative management
 Patient educated about the pathway in the surgical clinic
 Preoperative bowel preparation is not routinely used
 Patients allowed clear fluids until 2 h before the start of surgery
 500 mL carbohydrate drink 2 h before surgery (Clearfast)
 Oral adjunctive analgesics given preoperatively: acetaminophen, gabapentin
 Alvimopan given preoperatively
 Transdermal scopolamine patch applied in preoperative holding unless contraindicated
 Low thoracic epidural placed with small amount of IV fentanyl and/or midazolam for sedation
 Heparin 5000u SC given after epidural placement and before incision
 Antibiotic prophylaxis: cefazolin or clindamycin if penicillin allergic
Intraoperative management
 Induction: lidocaine, propofol, fentanyl up to 150 μg, neuromuscular blocking drug of choice
 Goal is to avoid IV opioids, no IV opioids after induction without discussion with attending anesthesiologist
 Dexamethasone 4 mg IV after induction
 ASA standard monitors and arterial line with cardiac output monitor
 Volatile anesthetic titrated to keep BIS 40–60
 Option for epidural hydromorphone 0.4 mg at induction
 Epidural infusion bupivacaine 0.0625–0.25% ± hydromorphone 10 μg/mL run at 3–6 mL/h
 Ketamine infusion 4 μg/kg/min may be used in chronic pain patients
 Ondansetron 4 mg IV given at the end of surgery
 Acetaminophen 1 g IV and ketorolac 15 mg IV given towards end of the case if appropriate
 Fluid management:
  Maintenance crystalloid infusion (LR) 3 mL/kg based on ideal body weight
  Goal-directed fluid therapy—colloid boluses to maximize stroke volume
   Record initial stroke volume (SV)
   After incision, give 250 mL colloid bolus over < 15 min
    If SV increases by > 10%, repeat bolus
    If SV increases by < 10%, patient does not require a further bolus
    Record peak value achieved
    If still hypotensive, consider phenylephrine bolus or infusion
    Give a further colloid bolus when SV drops 10% from peak value
    Repeat cycle
  Blood products transfused as needed
Postoperative management
 Epidural bupivacaine 0.0625–0.125% ± hydromorphone 10 μg/mL run at 4–6 mL/h for up to 72 h
  (Hydromorphone 10 μg/mL alone may be used in hypotension is a problem)
 Scheduled adjunctive analgesia with acetaminophen and NSAIDs whenever possible
 Patients transitioned to oral opioids after removal of epidural catheter
 Patients encouraged to drink liquids immediately after surgery
 Alvimopan given postoperatively for 5 days or until first stool
 IV fluids discontinued once adequate oral intake is achieved, usually the first morning after surgery
 All preoperative medications are restarted when patients tolerate oral intake
 Patients cared for in an environment that encourages early mobilization
 Encouraged to be out of bed on the day after surgery and for at least 6 h on every subsequent day
 Patients are asked to maintain a diary of their activity and sleep