Table 1 Enhanced recovery after surgery protocol for open liver resection

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