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Table 1 Enhanced recovery after surgery protocol for open liver resection

From: Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: a single centre retrospective observational study

Preoperative - Preoperative multidisciplinary evaluation
- Cardiac risk stratification with transthoracic echocardiography and stress thallium if clinically indicated
- Optimization of medical comorbidities
- Education of patients and families and informed consent
- Urea, creatinine, electrolytes, estimated glomerular filtration rate, albumin, liver function tests, ferritin, hemoglobin, platelet white cell count, prothrombin time, fasting glucose, activated partial thromboplastin time, fibrinogen, chest x-ray, EKG
Intraoperative Day of surgery
 - Two hours fasting for clear fluids, 6 h fasting for light meal
Anesthesia protocol
 - No preoperative IV fluid loading
 - Spinal analgesia: intrathecal morphine (200-400μg)
 - Induction: propofol (1 mg/kg), fentanyl (3 μg/kg)
 - Maintenance: volatile or propofol infusion (BIS of 40–60)
 - Intraoperative analgesia: remifentanil infusion (0.1–0.3 μg/kg/hr)
 - Prophylactic thromboembolic prophylaxis (enoxaparin 40 mg SC)
 - Antibiotic prophylaxis (ceftriaxone/ampicillin/metronidazole)
 - Pre-hepatic transection phase: fluid restriction
 - Hepatic transection phase: fluid restriction, low central venous pressure (< 8 mmHg) using reverse Trendelenburg positioning and glyceryl trinitrate IVI infusion (5–20 μg/min) if required
 - Post-hepatic transection phase: restoration of euvolemia
 - Paracetamol 1 g IV
 - Removal of nasogastric tube at completion of surgery
Day of surgery and & Postoperative Day 1 Analgesia
 - Patient controlled analgesia with fentanyl or oxycodone
 - Fentanyl infusion (10 μg/hr) IV
 - Ketamine infusion 0.05–0.1 mg/kg//hr. IV
 - Paracetamol 1 g IV/po TDS
Fluid intervention
 - Oral fluids encouraged and soft diet
 - Balanced crystalloid maintenance therapy: 125 ml/hr
 - Albumex 4% 250 ml boluses at discretion of clinicians
Other
 - Metoclopramide 15 mg IV TDS
 - Potassium and magnesium supplementation
 - Vitamin K 10 mg daily
 - Continue antibiotics for 24 h
 - Dihydrogen phosphate ions (14.5 mmol IV TDS)
 - Pantoprazole 40 mg IV/po daily
 - Heparin 5000 IU SC BD
 - Physiotherapy: early mobilization within 6 h of surgery
Postoperative Day 2 Analgesia
 - Patient controlled analgesia with fentanyl or oxycodone
 - Ketamine infusion ceased
 - Paracetamol 1 g po TDS
 - Tramadol 50–100 mg IV/po QID prn
Fluid intervention
 - Oral fluids encouraged and soft diet
 - Maintenance fluid therapy reduced to 83 mls/hr
Other
 - Metoclopramide 15 mg IV TDS
 - Pantoprazole 40 mg po daily
 - Vitamin K 10 mg daily
 - Dihydrogen phosphate ions (14.5 mmol IV TDS)
 - Potassium and magnesium supplementation
 - Physiotherapy: early mobilization TDS
 - Antithrombotic prophylaxis
 - Urinary catheter removed
Analgesia
 - Patient Controlled Analgesia with fentanyl or oxycodone
 - Stop ketamine infusion
 - Strict QID paracetamol
 - PRN tramadol
Fluid intervention
 - Aim for neutral fluid balance
 - Reduce maintenance fluid therapy to 42 mls/hr.
 - Soft ward diet
Other
 - Removal of central venous catheter
 - Removal of urinary catheter
 - Daily weight
 - Strict metoclopramide 15 mg IV TDS
 - Potassium and magnesium supplementation
 - Pantoprazole 40 mg daily
 - Use of diuretic if positive fluid balance (frusemide 10–20 mg)
 - Vitamin K 10 mg daily
 - Dihydrogen phosphate ions (14.5 mmol IV TDS)
 - Continue antithrombotic prophylaxis
 - Physiotherapy: continue mobilization TDS
Postoperative Day 3 to hospital discharge Analgesia
 - Patient controlled analgesia ceased
 - Oxycodone (IR) 10 mg 4 hourly prn
 - Paracetamol 1 g prn TDS
 - Tramadol 50–100 mg prn TDS
Fluid intervention
 - Advance oral diet
Other
 - Daily weight
 - Potassium and magnesium supplementation
 - Pantoprazole 40 mg PO
 - Continue antithrombotic prophylaxis
 - Coloxyl 100 mg BD
 - Physiotherapy: continue mobilization TDS