The role of the anaesthesiologist in enhanced recovery programs

Casans Francés, R.; Ripollés Melchor, J.; Abad-Gurumeta, A.; Longás Valién, J.; Calvo Vecino, J.M.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fast-Track Surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> also known as Enhanced Recovery After Surgery &#40;ERAS&#41;&#44; is a combination of intraoperative measures and strategies designed to reduce surgery-induced stress response in patients scheduled for elective surgery&#46; By speeding up postoperative recovery time&#44; this approach greatly reduces procedure-related complications&#44; morbidity and mortality<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> and improves the patient&#39;s quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The endocrine-metabolic response to surgical aggression has always been extensively studied in the field of surgery&#44; since an understanding of this phenomenon could pave the way towards reducing postoperative morbidity and mortality&#46; Scientists&#44; such as Claude Bernard and Walter Cannon&#44; studied the concept&#44; while Francis Moore and Douglas Wilmore offered detailed descriptions of the biological response to surgical lesions and the importance of optimal nutritional and metabolic support&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2000&#44; Henrik Kehlet set out to determine which factors prevented early hospital discharge in patients undergoing major abdominal surgery&#44; identifying pain&#44; ileus&#44; and inability to walk and the 3 main culprits&#46; Postoperative recovery time and mean length of hospital stay are prolonged by the persistence and interaction of these factors&#44; together with the onset of postoperative complications&#46; Kehlet decided to develop a clinical pathway centred on these 3 factors that would accelerate recovery after colonic resection by optimising pain relief with administration of local analgesia&#44; early enteral nutrition to reduce the risk of ileus&#44; and early mobilisation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This program has been shown to improve morbidity and mortality and reduce mean length hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The endocrine-metabolic response to surgical aggression is usually regarded as inevitable and inherent to the intraoperative process&#46; Nevertheless&#44; a well-structured multimodal approach can substantially prevent this response&#46; Similarly&#44; in contrast to the traditional notion of the need for complete bed rest after surgery&#44; early mobilisation can help speed up recovery of the patient&#39;s preoperative functional capacity&#46; These 2 approaches come together in ERAS or multimodal rehabilitation &#40;MMR&#41; programs that speed up postoperative recovery and reduce surgery-related morbidity&#44; and ultimately&#44; length of hospital stay and healthcare costs&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The importance of these ERAS programs does not lie in creating new clinical practices or changing existing ones&#44; but rather in bringing together in a single program all the professionals involved in the intraoperative process&#44; starting with the patient and his or her family&#44; who are actively involved from the moment of diagnosis&#44; and ending with multidiscplinary strategies supported by evidence-based medicine&#46; The ultimate aim is the patient&#39;s full recovery and return to their family and social activities in the shortest time possible&#46; A key element in the multidisciplinary enhanced recovery program is the anaesthesiologist&#44; who is directly responsible for or oversees over 60&#37; of the items included in the strategy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patient education</span><p id="par0030" class="elsevierStylePara elsevierViewall">Surgical patients are under a great deal of psychological stress caused by the fear of a procedure that could severely undermine their social interactions&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The fear of not being able to carry out their family or job-related responsibilities&#44; the possibility of having a stoma&#44; or of no longer being a &#8220;normal person&#8221;&#44; can lower their self-esteem and lead to depression&#44; both of which can hinder intraoperative progress in an ERAS program&#46; These obstacles can be overcome with adequate patient education&#44; and it is up to the anaesthesiologist to answer all the patient&#39;s questions regarding anaesthesia and the surgical procedure&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Providing detailed information about the intervention can help improve postoperative rehabilitation&#44; particularly in patients with a high level of anxiety&#44; while a clear explanation of what will happen during their stay in hospital will facilitate compliance with the ERAS program and shorten both rehabilitation time and mean length of hospital stay&#46; Patient education must include a detailed description of the intraoperative process and the analgesic strategy&#44; together with a rough indication of their physical condition during their stay in hospital&#46; Several meta-analyses have shown that patients provided with detailed information on the intraoperative process require shorter postoperative rehabilitation time&#44; have less stress and pain and are better prepared to take care of themselves and manage postoperative symptoms&#46; This is particularly true of extremely anxious and fearful patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Evidence suggests that patient education is most effective when given before the start of the preoperative workup&#44; instead of immediately before the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In oncology patients in particular&#44; it has been found that information regarding the ERAS program is most effective when given in an interview held after diagnosis and before the start of ERAS preparation&#46; From the start&#44; it is important for patients to understand their active involvement in the process and what they will be expected to do to optimise their condition both before and immediately after surgery&#44; such as eating and walking about&#46; They must also understand the hospital&#39;s discharge criteria&#44; as misunderstandings in this regard could delay the patient&#39;s discharge from hospital&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The preliminary interview should also be used to identify any social factors that may delay discharge&#46; It is common for patients to be clinically fit for discharge from hospital&#44; but to be reluctant to leave due to their social circumstances&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> As far as possible&#44; these factors should be addressed before surgery with the help of the patient&#39;s primary care doctor&#44; social workers and occupational therapists&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">There is as yet no ideal method for educating patients in the ERAS program&#44; although basic patient guides to FT surgery seem to be useful&#46; Patients should be given both verbal and written information that is easily understandable&#46; During the preadmission process it also helps to show the patient and their family members the actual room or facilities where they will be hospitalised&#46; Evidence suggests that patients recover faster in a setting where only elective surgical procedures are performed&#46; The layout and design of the hospital ward should make patients feel safe and encourage self-care&#46; By way of example&#44; instead of serving patients their meals in bed&#44; they should be expected to walk to an adjacent dining room&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Preoperative evaluation</span><p id="par0055" class="elsevierStylePara elsevierViewall">High-risk patients account for 13&#37; of the surgical population&#44; but 80&#37; of postoperative mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Complications arising within the first 30 days post-surgery will to a large extent determine the long-term survival of high-risk patients&#59; therefore&#44; reducing or eliminating these complications is of primary importance in ERAS programs&#46; The pivotal role of anaesthesiologist in detecting and improving comorbidities before surgery in the ERAS preoperative evaluation can reduce morbidity and the need for complex care&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The preoperative evaluation allows anaesthetists to realistically assess surgical risks&#44; and to modify the patient&#39;s bodily functions and general physical condition&#46; This evaluation should be carried out 4 weeks prior to surgery&#44; although this may be brought forward in the case of emergency cancer surgery&#46; As the complications most frequently associated with major abdominal surgery are cardiovascular morbidity&#44; postoperative ileus&#44; surgical wound infection and the need for blood transfusion&#44; assessment of comorbidities should focus&#44; albeit not exclusively&#44; on determining cardiovascular risk&#44; nutritional status&#44; and anaemia&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows an overview of the preoperative evaluation algorithm&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Major abdominal surgery is associated with a marked inflammatory response&#44; with oxygen consumption increasing in proportion to the extent of tissue damage and surgical aggression&#46; This activates the neuroendocrine and fibrinolytic systems&#44; which predispose high-risk patients to coronary ischaemia or heart failure&#46; The incidence of cardiovascular complications in non-cardiac surgery patients is approximately 1&#37;&#8211;2&#37;&#46; High-risk patients are those that cannot spontaneously increase cardiac output to the level required by the neuroendocrine response&#46; These patients can be identified in the preoperative evaluation&#44; and will benefit from preoperative pre-habilitation strategies&#46; AHA Clinical Practice Guidelines<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> recommend that patients with active heart disease&#44; unstable angina&#44; uncompensated heart failure&#44; symptomatic arrhythmia or severe aorticstenosis or mitral regurgitation be evaluated by a cardiologist before surgery&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Patients with pulmonary comorbidities are at high risk for intraoperative morbidity&#46; Generally&#44; when the clinical history or physical examination raises suspicion of an underlying&#44; unidentified pulmonary disease&#44; spirometry with bronchodilator response and arterial blood gas testing can be considered&#44; and appropriate background therapy started&#46; In these cases&#44; it is particularly important to contact the patient&#39;s general practitioner&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> From the moment the patient is diagnosed&#44; it is important to stress the need to stop smoking and start exercising before surgery&#44; as this will help reduce atelectasis and respiratory complications&#46; Clinicians should also recommend that patients engage in exercises requiring deep breathing&#44; such as breathing exercises or chest physiotherapy&#44; as there is solid evidence that these are effective in reducing intraoperative respiratory morbidity&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Preoperative malnutrition increases surgical morbidity&#44; mortality and mean length of hospital stay&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> because surgery increases nutritional requirements and the risk of malnutrition&#46; Patients scheduled for major elective surgery should be screened to identify those at risk for nutritional problems&#46; Screening parameters should include body mass index&#44; recent weight loss&#44; and the patient&#39;s normal eating habits&#44; and patients with suspected malnutrition should undergo more detailed studies&#46; If the diagnosis is confirmed&#44; they should be referred to the Endocrinology and Nutrition department for nutrition therapy&#44; and monitored to determine tolerance and response to therapy&#46; Likewise&#44; patients with poorly controlled blood glucose levels and those with previously undetected hyperglycaemia should be referred to a specialist for evaluation&#44; because there is evidence to suggest that intraoperative hyperglycaemia is an independent risk factor for intraoperative morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Preoperative anaemia&#44; either due to absolute or functional iron deficiency or iron sequestration&#44; is a common diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This is why early determination of intraoperative haemoglobin levels is so important&#46; This should be done at least 28 days before surgery for oral ferrous sulphate therapy to be effective&#44; taking as a reference the World Health Organisation normal Hb levels &#40;13<span class="elsevierStyleHsp" style=""></span>g&#47;dl in men and 12<span class="elsevierStyleHsp" style=""></span>gd&#47;l in women&#41;&#46; Intravenous iron therapy is reserved for situations where oral therapy would not be effective in the time available before surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The preoperative evaluation should also be used to explain the detrimental effects of smoking and alcohol consumption in the immediate postoperative period&#44; and to advise patients to abstain from these activities&#46; Smoking has been associated with 50&#37; increase in pulmonary morbidity and mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and abstinence from smoking 1 month prior to surgery can reduce the risk of surgical wound infection&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally&#44; certain hospitals are starting to introduce more complex preoperative strategies&#44; called &#8220;surgical prehabilitation&#8221;&#44; the aim of which is to reduce intraoperative complications by optimising the patient&#39;s physical status and quality of life prior to surgery&#46; Prehabilitation strategies are tailored to the needs of each patient&#44; and include nutrition therapy&#44; chest physiotherapy&#44; physical exercise and behavioural psychology sessions to reduce the patient&#39;s intraoperative stress&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Prehabilitation improves the patient&#39;s preoperative physical condition by reducing morbidity&#44; and promotes speedier postoperative recovery&#46; Prehabilitation programs have been shown to be effective in cardiovascular surgery&#44; and are likely to be equally beneficial in abdominal surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Immediate preoperative period</span><p id="par0090" class="elsevierStylePara elsevierViewall">Aside from antibiotic and antithrombotic prophylaxis&#44; elimination of the need for bowel preparation&#44; bathing&#44; and elimination of bodily hair&#44; the 2 most important issues facing anaesthesiologists in the immediate preoperative period are probably&#44; on the one hand&#44; preoperative fasting and administration of carbonated drinks&#44; and on the other&#44; the use of glucocorticoids and sedatives&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Conventional postoperative fasting causes dehydration&#44; increases incidence of postoperative nausea and vomiting&#44; and heightens the risk of postoperative insulin resistance&#44; a common metabolic response to surgical aggression&#46; Administration of 12&#46;5&#37; oral maltodextrin up to 2<span class="elsevierStyleHsp" style=""></span>h before surgery does not increase gastric volume and is not associated with any risks&#44; but has been shown to reduce insulin resistance and postoperative complications&#44; and improve the patient&#39;s perception of well-being by reducing their feeling of thirst and hunger&#46; It has also been shown to contribute to reducing mean hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Administration of a single dose of glucocorticoids prior to surgery reduces postoperative complications by diminishing the inflammatory response and prostaglandin synthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The use of short-acting sedatives&#44; such as midazolam&#44; facilitates patient management during delivery of local analgesia without increasing intraoperative risks&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Intraoperative period</span><p id="par0105" class="elsevierStylePara elsevierViewall">This&#44; in a ERAS program&#44; is obviously the period of maximum activity for the anaesthesiologist&#44; who is responsible for analgesia&#44; fluid management&#44; the choice of induction drugs and nausea and vomiting prophylaxis&#44; maintaining the patient&#39;s body temperature&#44; or administering and reversing neuromuscular blockade&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Patients should initially be monitored in accordance with the World Federation of Societies of Anaesthesiologists &#40;WFSA&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> international recommendations&#44; which include fraction of inspired oxygen&#44; pulse oximetry&#44; electrocardiography&#44; non-invasive arterial pressure&#44; and central temperature&#46; In addition to these measure&#44; the following should also be monitored&#58; &#40;a&#41; depth of anaesthesia using the bispectral index &#40;BIS&#41; or equivalent device in order to prevent anaesthesia overdose&#44; particularly in geriatric patients and in patients in whom excessive hypnosis is known to increase the risk of postoperative delirium<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#59; &#40;b&#41; TOF response or T1&#47;T4 ratio to maintain a moderate level of neuromuscular blockage for adequate surgical field visualisation&#44; particular during laparoscopic surgery&#59; and &#40;c&#41; intraoperative blood glucose levels to detect hyper- or hypoglycaemia&#44; which have been associated with an increase in postoperative comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> If an urinary bladder catheter is needed&#44; it should be removed as soon as possible&#44; and should never remain in place for more than 24<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Among non-standard monitoring techniques&#44; invasive arterial pressure monitoring should be reserved for patients with severe cardiovascular disease&#44; or whenever intraoperative or postoperative problems are expected&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> unless it is unavoidable in the context of goal directed fluid management&#46; Use of a central venous catheter should be reserved for patients requiring continuous infusion of vasopressors or inotropes&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> or total parenteral nutrition solution to prevent malnutrition&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The anaesthetist should choose short-acting agents that allow relatively rapid awakening&#44; such as propofol in combination with short- or ultra-short-acting opioids&#44; such as fentanyl or remifentanil&#44; and hypnosis should be maintained with either inhalatory anaesthetics&#44; such as sevoflurane or desflurane&#44; or total intravenous anaesthesia &#40;TIVA&#41;&#46; The latter could be more beneficial in patients that are prone to postoperative nausea and vomiting &#40;PONV&#41;&#46; No studies have as yet compared different hypnosis techniques in the context of ERAS&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Measures should be taken to maintain intraoperative normothermia&#44; as this has been shown to reduce wound site pain and the risk of infection&#44; and prevent hypothermia-induce coagulopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> It is also important to maintain an intraoperative inspired oxygen fraction of 0&#46;5&#46; Hyperoxia improves neutrophil function&#44; thus reducing incidence of surgical wound infection without increasing incidence of pulmonary atelectasis&#44; and also reduces incidence of PONV&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> To prevent PONV&#44; the patient&#39;s Apfel<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> score should be calculated and PONV prevention measures taken accordingly&#46; In patients at high risk for PONV&#44; TIVA should be used instead of nitrous oxygen and volatile anaesthetics&#46; Nasogastric tubes should not be routinely used&#44; as they delay tolerance&#44; do not improve intestinal function or prevent postoperative complications&#44; and prolong hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">As intraoperative fluid management directly affects surgical outcomes&#44; it must be individualised in order to maintain circulatory volume and&#44; as far as possible&#44; prevent overload&#46; The aim must be zero balance and adequate tissue oxygenation during the intraoperative period&#46; Goal directed &#40;GD&#41; fluid management can reduce postoperative complications and the length of hospital stay&#44; although it has not been associated with a reduction in intraoperative mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a> Although NICE guidelines from 2011 recommend oesophageal Doppler monitoring in patients undergoing high-risk surgery or other surgical patients in whom invasive monitoring would be considered&#44; the authors of the guidelines themselves conclude that&#44; as invasive arterial monitoring in high-risk patients is justifiable&#44; GD fluid management algorithms should be drawn up in accordance with the monitoring techniques available in each hospital&#44; the patient&#39;s morbidity&#44; and the type of surgery performed&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> There is no single ideal monitoring technique for GD fluid management&#59; each technique has its advantages and drawbacks&#46; Very few studies have compared different monitoring systems in this context&#44; but what little evidence is available has shown that these devices are not interchangeable&#44; as results differed among different devices used within the same goal-directed algorithm&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> GD algorithms that combine fluid&#44; vasoconstrictor and inotrope therapies are the most beneficial&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows a basic GD fluid management algorithm&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Pain management has always been an essential aspect of ERAS strategies&#46; The search for an analgesia technique that can control the patient&#39;s pain without interfering with other key elements of the program has led to the development of a number of intraoperative analgesia strategies suitable for ERAS&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Most studies in intraoperative analgesia have compared intravenous opioids against the use of a catheter for continuous infusion of local anaesthetic into the thoracic epidural space&#44; either with or without additional opioids&#46; The latter has been shown to be clearly superior to the former in major abdominal surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> Nevertheless&#44; although thoracic continuous epidural infusion is still the technique of choice in open abdominal surgery&#44; new developments that include minimally invasive surgical techniques and local anaesthetic infiltration of trocar insertion sites&#44; and ultrasound-guided nerve block techniques&#44; such a transversus abdominis plane block<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> or rectus sheath block&#44; together with the proven safety of epidural catheter placement&#44; have called into question the benefit of thoracic epidural infusion in major laparoscopic abdominal surgery&#44; and this approach is now reserved for patients with pulmonary comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Adjuvants to anaesthesia are also an important factor in enhanced recovery programs&#46; Although some of these are more common&#44; such as nonsteroidal anti-inflammatory drugs&#44; others&#44; including ketamine&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> gabapentin or pregabalin&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> are more recent or controversial&#46; However&#44; they should also be considered within the analgesia protocol of an ERAS program&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows an example of an intraoperative analgesia algorithm&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">During awakening&#44; the T1&#47;T4 ratio must be above 0&#46;9 before extubation&#46; A lower ratio has been associated with residual neuromuscular block&#44; increased mortality&#44; and postoperative&#44; particularly respiratory&#44; complications&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> Sugarmmadex can be used to reverse any type of residual blockade induced by aminosteroid agents&#44; adjusting the dose to the depth of the block&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> while neostigmine and atropine can be used to reverse mild residual blockade in patients with no myopathy or myasthenia gravis&#44; tachyarrhythmias&#44; malnutrition&#44; pulmonary pathology or morbid obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> Neostigmine and atropine should be used to reverse residual benzylisoquinoline alkaloid-induced blockade&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Finally&#44; other intraoperative measures that have less to do with anaesthesia and more with surgery are also important in ERAS programs&#46; These include skin preparation&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> the type of surgical approach &#40;minimally invasive or transverse vs midline incision in laparotomy<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>&#41; or whether or not drainage is needed&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Postoperative period and hospital discharge</span><p id="par0155" class="elsevierStylePara elsevierViewall">Patient management in the post-anaesthesia care unit should conform to standard care measures for all patients according to the type of surgery and anaesthesia used&#46; After transfer to the ward&#44; every effort should be made to help the patient recover their functional autonomy&#44; i&#46;e&#46;&#44; ability to eat and walk unaided&#46; This will speed up rehabilitation and improve their overall functional status&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Although strict postoperative fasting is widely used to prevent postoperative nausea and vomiting&#44; reduce the effect of paralytic ileus or prevent anastomotic leak&#44; ERAS recommends early oral nutrition instead of the traditional strict postoperative fasting approach&#44; as it reduces mortality&#44; morbidity and length of hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> Bed-rest increases insulin resistance&#44; and also leads to loss of muscle mass and strength&#44; diminished lung function and poor cellular oxygenation&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Early mobilisation has been strongly associated with a lower incidence of pressure ulcers&#44; deep vein thrombosis&#44; pneumonia and pulmonary complications&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Despite abundant evidence&#44; early postoperative mobilisation is not common practice in abdominal surgery patients&#46; Early mobilisation is only possible with good postoperative pain management and limited use of catheters and drainage&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> Patients should start ambulation on the same day of surgery&#46; Other measures that are neither invasive or pharmacological&#44; such as the use of chewing gum in the postoperative period&#44; also seems to have beneficial effects on intestinal function&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Hospital discharge should be planned and individualised to each patient&#39;s needs&#46; The use of standardised information leaflets helps patients understand the instructions given to them on discharge&#46; Delayed discharge due to the need to train patients in stoma management is considerably reduced when patients have been introduced to these techniques prior to surgery and during their hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Individualised recommendations at discharge have a positive effect on mean hospital stay&#44; readmission rates&#44; and patient satisfaction ratings&#44; although their effect on mortality&#44; healthcare outcomes and medical costs is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Outcomes in enhanced recovery programs</span><p id="par0170" class="elsevierStylePara elsevierViewall">Enhanced recovery programs have been shown to be superior to conventional approaches in terms of both shorter hospital stay and in reducing the overall incidence of complications&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> not only in ideal patients&#44; but also in populations traditionally considered &#8220;at risk&#8221;&#44; such as the geriatric population&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a> These improvements are not limited to colorectal surgery&#44; but also extend to other abdominal procedures&#44; such as pancreaticoduodenectomy<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> or liver surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">It stands to reason that the reduction in mean length of hospital stay and incidence of morbidity associated with ERAS programs will also affect overall hospital costs&#46; Unfortunately&#44; cost-effectiveness studies are usually inconsistent and poorly conducted&#46; According to a recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> comparing enhanced recovery colorectal surgery to the traditional approach&#44; ERAS protocols could save from &#8364;135 to &#8364;6537 per patient&#44; although these results were not statistically significant&#46; In Spain&#44; the study published by Salvans<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> reported a statistically significant reduction in overall costs in patients undergoing enhanced recovery abdominal surgery &#40;treatment group&#58; &#8364;8107<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4117 vs controls&#58; &#8364;9019<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4667&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#46; The most significant savings occurred in costs associated with the hospital unit&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Implementation</span><p id="par0180" class="elsevierStylePara elsevierViewall">Successful implementation of an ERAS program depends on the availability of a multidisciplinary&#44; coordinated team&#44; because this approach usually requires a radical change in attitudes from the time of diagnosis up to postoperative discharge from hospital&#46; The ultimate aim of the actions of each member of the team &#40;which should include surgeons&#44; anaesthesiologists&#44; nurses&#44; nutritionists&#44; hospital managers&#44; stomatherapists&#44; physiotherapists and other experts&#41; must be to optimise the patient&#39;s status at each stage of the intraoperative process&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> The objectives of the team must be to&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Evaluate existing care protocols in respect of the enhanced recovery program to be implemented &#40;evaluating routine clinical practice&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Agree on the changes needed to facilitate implementation &#40;considering changes needed on the basis of scientific evidence&#58; evidence-based medicine&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Identify potential problems &#40;change management&#44; resistance to change&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Estimate the associated cost or the reallocation of funds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Plan the enhanced recovery program implementation process&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Agree on the indicators needed to measure the effectiveness of the program&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Raise awareness of the enhanced recovery program throughout the hospital&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Set an example that will encourage others to make the change&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">A number of subgroups should be created to implement the changes defined by the working group&#44; such a change in patient preparation&#44; pain management&#44; and in the verbal and written information given to the patient&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The success of the enhanced recovery program will depend on the ability of the surgeon and anaesthesiologist to present the changes in a positive light and ensure the new clinical pathway adapts to local requirements&#46; It is also essential for each member of the team to take into account the needs of other team members&#44; and also those of non-medical personnel involved in the pathway&#44; such as management and administrative staff&#46; Groups that have successfully implemented multimodal programs over a short period of time have emphasised the importance of inter-departmental collaboration as well as close cooperation between the medical staff and the departments involved&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The creation of the enhanced recovery clinical pathway must be the focal point of the working group&#46; This document must cover all aspects of the program&#44; from the moment of diagnosis until discharge from hospital&#44; and all stages of the process must be documented&#46; Although clinical pathways can be created from scratch&#44; most teams prefer to adapt protocols used in other hospitals&#44; or to base their program on ERAS-Society recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#8211;73</span></a> The enhanced recovery abdominal surgery &#40;RICA&#44; in its Spanish acronym&#41; pathway presented on 15 September 2015 by the Spanish Ministry of Health&#44; Social Policy and Equality<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> includes 95 recommendations graded according to their strength and quality of evidence &#40;GRADE&#41;&#44; drawn up following a systematic review using PRISMA methodology &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The consensus protocols published by the Spanish Multimodal Rehabilitation Group&#47;ERAS-Spain are also available online at <a id="intr0010" class="elsevierStyleInterRef" href="http://www.grupogerm.es/">www&#46;grupogerm&#46;es</a> &#40;available as supplementary material&#59; see <a class="elsevierStyleCrossRef" href="#sec0070">Appendix</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">The success of enhanced recovery abdominal surgery programs relies on a complex interdisciplinary approach&#46; The anaesthesiologist is one of the key components of these programs&#44; both as a member of the surgical team and as the person responsible for key items&#44; such as intraoperative fluid management and analgesia&#46; In the context of abdominal surgery&#44; enhanced recovery programs have been shown to reduce both the mean length of hospital stay and the cost of the intervention&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Contributors</span><p id="par0245" class="elsevierStylePara elsevierViewall">Contributors&#44; &#40;in alphabetical order&#41; &#8220;P&#46; Casado Dur&#225;ndez&#44; E&#46; del Valle Hern&#225;ndez&#44; A&#46; Frutos P&#233;rez-Surio&#44; J&#46;J&#46; Hern&#225;ndez Aguado&#44; C&#46; Loinaz Segurola&#44; M&#46;A&#46; L&#243;pez Oriva&#44; J&#46;I&#46; Mart&#237;n S&#225;nchez&#44; C&#46; Mart&#237;n Trapero&#44; E&#46; Mart&#237;nez Hurtado&#44; M&#46; Moralejo&#44; C&#46; Nogueiras Quintas&#44; M&#46; Ortega Urbaneja&#44; J&#46;M&#46; Ram&#237;rez Rodr&#237;guez&#44; A&#46; Rodr&#237;guez Antol&#237;n&#44; E&#46; Rodr&#237;guez Cuellar&#44; P&#46; Ruiz L&#243;pez&#44; and A&#46; Suarez de la Rica&#8221;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0250" class="elsevierStylePara elsevierViewall">No funding was received for this manuscript&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0255" class="elsevierStylePara elsevierViewall">RCF&#58; Fees for speaking and imparting courses from Merck Sharp &#38; Dohme and Fresenius-Kabi&#46; Member of the <span class="elsevierStyleSmallCaps">Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n</span> editorial team&#46; Not involved in reviewing the manuscript&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">JRM&#58; Fees for speaking and imparting courses from Merck Sharp &#38; Dohme&#44; Braun&#44; Deltex Medical&#44; Edwards Lifesciences and Fresenius-Kabi&#46; Study grant from Vifor Pharma&#46; Member of the <span class="elsevierStyleSmallCaps">Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n</span> editorial team&#46; Not involved in reviewing the manuscript&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">AAG&#58; Fees for speaking and imparting courses from Merck Sharp &#38; Dohme&#46; Member of the <span class="elsevierStyleSmallCaps">Revista Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n</span> editorial team&#46; Not involved in reviewing the manuscript&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">JLV&#58; Fees for speaking and imparting courses from Merck Sharp &#38; Dohme&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">JMCV&#58; Fees for speaking and imparting courses from Merck Sharp &#38; Dohme&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Casans Franc&#233;s R&#44; Ripoll&#233;s Melchor J&#44; Abad-Gurumeta A&#44; Long&#225;s Vali&#233;n J&#44; Calvo Vecino JM&#46; El rol del anestesi&#243;logo dentro de los programas de recuperaci&#243;n intensificada&#46; Rev Esp Anestesiol Reanim&#46; 2016&#59;63&#58;273&#8211;288&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Recommendations approved in February 2015 by the Spanish Ministry of Health&#44; Social Policies and Equality&#46; Using the PRISMA checklist&#44; EMBASE&#44; MEDLINE and the Cochrane Library databases were searched &#40;updated to October 2014&#41; for relevant studies that met the inclusion criteria&#46; No date or language restrictions were applied&#46; The bibliographies of relevant studies were hand-searched to identify all review articles and evidence-based clinical practice guidelines&#46; The title and abstract of the studies retrieved from the systematic review were independently screened by 2 investigators to rule out irrelevant randomised clinical trials &#40;RCT&#41; and select those that were potentially relevant&#46; The RCTs thus selected were analysed and only those that met the inclusion criteria were ultimately selected&#46; Data from the RCTs were extracted by 2 different investigators&#44; and any discrepancies were analysed in greater depth and confirmed by a third investigator&#46; The authors reviewed the data analysis for the purpose of avoiding transcriptional errors&#46; Following a systematic PRISMA-based review&#44; each recommendation was issued by individual members of the enhanced recovery abdominal surgery clinical pathway working group&#44; and subsequently agreed by consensus in the entire group&#46; The GRADE system was used to determine strength of recommendation and grade of evidence&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GRADE strength&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients should receive comprehensive oral and written information regarding what they will be asked to do to improve their postoperative rehabilitation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients with recent onset of uncompensated cardiac disease must be evaluated by a cardiologist prior to surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that patients scheduled for major surgery be screened for nutritional status&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients deemed to be at risk of under-nutrition should undergo a full nutritional evaluation&#44; be given a nutritional program&#44; and be followed up for tolerance and response to this program&#46; Some analytical tests can determine the degree of inflammation associated with the disease &#40;albumin&#44; C reactive protein levels&#44; etc&#46;&#41; and potential nutrient deficiencies &#40;vitamins&#44; minerals&#41;&#46; This will guide clinicians in their classification of the patient&#39;s nutritional profile&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Control of hyperglycaemia is essential&#44; and patients with poorly controlled glucose should be treated at both the primary care level and by an endocrinologist&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is suggested that preoperative HbAIc be determined&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that preoperative anaemia be detected&#44; as this is associated with increased intraoperative mortality&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients scheduled for surgery&#44; it is recommended that Hb level be determined at least 28 days before the intervention to give time for erythropoiesis stimulation&#44; if required&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is suggested that preoperative Hb levels be within WHO limits of normality &#40;men Hb<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#59; women &#8805;12<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is suggested that patients diagnosed with anaemia receive oral iron therapy with 200<span class="elsevierStyleHsp" style=""></span>mg&#47;day ferrous sulphate for 14 days before surgery to increase preoperative Hb levels and reduce SAP in patients with colorectal cancer&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is suggested that intravenous iron be administered in gynaecological or colorectal surgery patients diagnosed with anaemia to increase preoperative Hb and reduce the need for RBC transfusion&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is suggested that intravenous instead of oral iron be administered in cases where the latter is contraindicated or when insufficient time is available&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is suggested that preoperative gonadotrophin releasing-hormone analogues &#40;GnRHa&#41; be administered in cases of anaemia due to blood loss combined with uterine fibroids&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fluids should be allowed up to 2<span class="elsevierStyleHsp" style=""></span>h and solids up to 6<span class="elsevierStyleHsp" style=""></span>h prior to induction&#44; including obese and diabetic patients&#44; as there is solid evidence that fasting for more than 8<span class="elsevierStyleHsp" style=""></span>h provides no benefits&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that preoperative oral carbohydrate treatment &#40;200&#8211;300<span class="elsevierStyleHsp" style=""></span>cc&#41; with 12&#46;5&#37; maltodextrins be routinely administered 2<span class="elsevierStyleHsp" style=""></span>h prior to induction&#44; as this reduces distress and insulin resistance&#46; It can also be administered in diabetic patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients with delayed gastric emptying&#44; measure should be taken to prevent regurgitation during anaesthesia induction&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In diabetic patients&#44; it is suggested that oral carbohydrate treatment be administered along with their usual diabetic medicine&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Smoking and alcohol consumption should stop 1 month prior to surgery&#58; smoking increases the risk of pulmonary complications by 50&#37;&#44; and alcohol consumption has been associated with more complications&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is suggested that preoperative prehabilitation exercises be ordered to improve the functional capacity of surgical patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that patients bathe prior to surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The use of electric razors is recommended when body hair must be removed&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mechanical bowel preparation is not recommended except when colorectal surgery patients are expected to receive a stoma&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong -&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No bowel preparation could hasten recovery of intestinal motility and shorten hospital stay&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Compression stockings are effective in reducing incidence of thromboembolism in surgical patients&#44; and are even more effective when combined with pharmacological agents&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intermittent pneumatic compression reduces incidence of thromboembolism&#44; and is even more effective when combined with pharmacological agents&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unfractionated heparin &#40;UFH&#41; and low molecular weight heparins &#40;LMWH&#41; are equally effective in preventing deep vein thrombosis and pulmonary thromboembolism&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that routine prophylaxis with intravenous antibiotics be administered between 30 and 60<span class="elsevierStyleHsp" style=""></span>minutes before surgical incision &#40;or on transfer to the theatre&#41;&#46; Additional doses should be given during prolonged procedures according to the half-life of the drug used&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that surgical nurses visit the patient before surgery to reduce their anxiety&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Short-acting anxiolytics do not delay immediate postoperative recovery or prolong hospital stay&#44; and can be used to administer local anaesthesia when required&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Administration of a single dose of glucocorticoids can have a significant impact on the length of hospital stay&#44; and does not increase the rate of complications&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Capnography must be used in all procedures to monitor CO<span class="elsevierStyleInf">2</span> levels&#44; particularly during laparascopy&#44; as any change in the end tidal waveform can be a sign of intraoperative complications&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Central temperature monitoring techniques should be used&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depth of anaesthesia should be monitored using the bispectral index &#40;BIS&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular blockade &#40;NMB&#41; must be objectively and continuously monitored &#40;neurostimulation using acceleromyography&#44; mechanomyography&#44; electromyography&#44; kinemyography&#41; using single stimulus&#44; post-tetanic count&#44; TOF and 1&#47;4 ratio techniques to determine the level of NMB&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Glycaemia must be monitored&#44; as intraoperative hyperglycaemia can increase the risk of postoperative complications&#46; However&#44; an intensive insulin regimen should be avoided due to the risk of hypoglycaemia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bladder catheters&#44; when used&#44; should be placed under strict aseptic conditions&#44; and should be removed as soon as possible &#40;within 24<span class="elsevierStyleHsp" style=""></span>h&#44; and no later than 48<span class="elsevierStyleHsp" style=""></span>h of surgery&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Routine invasive monitoring should be avoided&#44; although arterial lines can be useful in certain patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Routine use of a CVC should be avoided&#46; It can be considered in certain cases&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prior to placing of surgical drapes&#44; skin should be prepared using the clean to soiled technique&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chlorhexidine 1&#37; solution in alcohol base is recommended for skin preparation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Short-acting anaesthetic agents allowing rapid awakening are recommended for induction and maintenance&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bispectral index-guided &#40;BIS&#41; anaesthesia induction and maintenance can be used to avoid excessive depth of anaesthesia &#40;BIS<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30&#41;&#44; particularly in geriatric patients and in patients in whom excessive hypnosis is contraindicated and known to increase the risk of postoperative delirium&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Laparoscopic techniques are recommended&#44; if the expertise is available&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">If open surgery is performed&#44; a low transverse incision should be made whenever possible&#46; This is associated with less postoperative pain and pulmonary complications&#44; although there is no clear evidence to show the superiority of this type of incision over others&#46; Whenever a transverse incision is impossible&#44; a midline approach can be used&#44; endeavouring to keep the incision as small as possible&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraoperative administration of high inspired oxygen concentration &#40;at least FiO<span class="elsevierStyleInf">2</span>&#58; 50&#37;&#41; is an additional strategy that reduces the risk of surgical wound infection in abdominal surgery patients receiving antibiotic prophylaxis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High fraction of inspired oxygen reduces the risk of postoperative nausea and vomiting&#44; particularly in patients receiving inhalation anaesthesia without anti-emetic prophylaxis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High oxygen concentration does not increase incidence of postoperative atelectasis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that intraoperative hypothermia during abdominal surgery be avoided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All patients should be screened for PONV using the Apfel scale&#44; and given prophylaxis accordingly&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients with a high risk for PONV&#44; propofol for anaesthesia induction and maintenance is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that nitrous oxide be avoided in patients at high risk for PONV&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It is recommended that inhalational anaesthetics be avoided in patients at high risk for PONV&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intra- and postoperative opioids should be used sparingly&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients at low risk for PONV&#44; prophylaxis should be reserved for those undergoing high-risk surgery&#44; including laparoscopic&#44; laparotomic&#44; urological&#44; breast&#44; plastic and maxilofacial procedures&#46; In these cases&#44; prophylaxis with dexamethasone monotherapy should be administered during anaesthesia induction or droperidol administered at the end of surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients at moderate risk for PONV&#44; measures for reducing baseline risks and administration of combination dexamethasone and droperidol or ondansetron are indicated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients at high risk for PONV&#44; prophylaxis along with measures for reducing baseline risks&#44; and dexamethasone&#44; droperidol and ondansetron should administered&#44; the latter at the end of surgery are indicated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients with moderate to high risk&#44; combination therapy is preferred over monotherapy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">If PONV is present&#44; an anti-emetic from a different family than that used for prophylaxis should be administered&#46; If no prophylaxis has been administered&#44; low-dose ondansetron is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nasogastric tubes are not recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stroke volume &#40;SV&#41; and stroke volume variation &#40;SVV&#41; are recommended to guide intraoperative fluid management&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fluid should be administered if SV or SVV decrease by 10&#37;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Restrictive intraoperative fluid management should be used to prevent fluid overload&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraoperative hypotension should be treated with vasopressors&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean arterial pressure should be around 70<span class="elsevierStyleHsp" style=""></span>mmHg&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac output should be &#62;2&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#44; with administration of inotropes if there is no response to fluids&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Monitoring with CardioQ or validated pulse-wave-based monitoring devices &#40;Flotrac&#44; ProAQT&#44; CNAP&#41; is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deep&#44; train of four &#40;TOF&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0 neuromuscular blockade &#40;NMB&#41; with at least 1 or 2 post-tetanic count responses or&#44; depending on the patient&#44; a moderate blockade with a TOF count of no more than 1 can improve the surgeon&#39;s view of the laparoscopic field&#46; Therefore&#44; NMB depth should be maintained at this level with administration of anaesthetic in bolus or continuous infusion until the end of the intervention with pneumoperitoneum to maintain intra-abdominal pressure<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>8&#8211;10<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neuromuscular blockade &#40;NMB&#41; must be objectively and continuously monitored &#40;neurostimulation using acceleromyography&#44; mechanomyography&#44; electromyography&#44; kinemyography&#41; using single stimulus&#44; post-tetanic count&#44; TOF and 1&#47;4 ratio techniques to determine the level of NMB&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In anaesthesia reversal&#44; TOF ratio must be &#62;0&#46;9 prior to extubation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A TOF ratio &#60;0&#46;9 leads to a risk of respiratory complications&#44; hypoxaemia and oxygen desaturation during transfer to the postoperative intensive care&#44; including the need for re-intubation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To achieve a TOF ratio &#62;0&#46;9 in a patient with deep NMB&#44; blockade should be reversed with sugammadex at a dose of 4<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; or in the case of moderate blockade&#44; with a TOF count of 1 or 2&#44; a dose of 2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg should be used if aminosteroid neuromuscular blockers&#44; such as rocuronium or vecuronium&#44; were used&#46; The patient must not be extubated until a TOF ratio &#62;0&#46;9 is achieved&#46; With a TOF count of at least 3&#8211;4&#44; NMB can be reversed with neostigmine and atropine&#44; and the patient must not be extubated until a TOF ratio &#62;0&#46;9 is achieved&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sugammadex 2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg can be used instead of atropine and neostigmine in the case of residual blockade&#44; with TOF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#44; or moderate blockade with a TOF count of 1&#8211;3 in patients with mitochondrial myopathies&#44; muscular distrophies or myopathies&#44; myasthenia gravis&#44; history of tachyarrhythmias and ischaemic heart disease&#44; in geriatric or severely under-nourished patients&#44; or in patients with chronic bronchitis and asthma&#44; slow NMB metabolisation&#44; OSAS and morbid obesity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">If benzylisoquinoline NMB agents are used&#44; such as atracurium&#44; cisatracurium&#44; or mivacurium&#44; blockade must be reversed with neostigmine &#40;0&#46;05&#8211;0&#46;03<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; and atropine &#40;0&#46;01<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; when TOF count is at least 3&#8211;4&#59; the patient must not be extubated until a TOF ratio &#62;0&#46;9 is achieved&#46; Sugammadex cannot be used to reverse blockade&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients with morbid obesity&#44; NMB can be based on ideal body weight and reversed with sugammadex dose adjusted to ideal body weight&#46; If NMB dose is based on real body weight&#44; sugammadex dose should likewise be based on real body weight&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Naloxone is not recommended for the reversal of opioids&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weak &#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All patients undergoing major open abdominal surgery should receive combined epidural-general anaesthesia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The routine use of epidural analgesia is not recommended in major laparoscopic abdominal surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients with pulmonary comorbidities can benefit from epidural analgesia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Analgesia strategies should be individualised&#44; avoiding opioids and giving preference to transversus abdominis plane block&#44; spinal analgesia or local anaesthetic infiltration of trocar insertion site when epidural analgesia is contraindicated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In major abdominal surgery&#44; continuous infusion of local anaesthetics should be delivered through a thoracic catheter&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Small additional doses of opioids should be added to the local anaesthetic used for epidural infusion&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Administration bilateral transversus abdominis plane block could be beneficial in major abdominal surgery when epidural analgesia is contraindicated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rectus sheath block could be beneficial in major abdominal surgery&#46;when epidural analgesia is contraindicated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-steroidal anti inflammatory drugs &#40;NSAIDS&#41; should be used as an adjuvant in pain management in major abdominal surgery patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intravenous ketamine should be given to patients receiving analgesia with major opioids in major abdominal surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraoperative i&#46;v&#46; magnesium sulphate as an adjuvant analgesic can improve pain management in patients undergoing abdominal surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All patients undergoing major abdominal surgery must receive preoperative oral gabapentin or pregabalin&#46; Gabapentin is preferred in patients aged over 65 years&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients at risk of developing insulin resistance &#40;obese or geriatric patients&#44; prolonged interventions&#41;&#44; glycaemia levels above 180<span class="elsevierStyleHsp" style=""></span>mg&#47;dl should be avoided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postoperative glucose levels should be determined in all patients&#44; keeping blood glucose levels below 110<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Postoperative treatment of hyperglycaemia in diabetic patients is not fully defined&#46; Nevertheless&#44; levels of under 110<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and over 150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl seem to be harmful&#44; and should be avoided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Drainage catheters are not recommended&#44; except in pelvic surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Early oral nutrition &#40;within 24<span class="elsevierStyleHsp" style=""></span>h post-surgery&#41; is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Early mobilisation &#40;within 24<span class="elsevierStyleHsp" style=""></span>h post-surgery&#41; is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preoperative and postoperative chest physiotherapy is recommended&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients and their carers should receive individualised&#44; understandable&#44; comprehensive information at discharge from hospital&#46; A planned discharge and comprehensive information on care in the home reduces mean hospital stay and the re-admission rate&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Recommendations included in the Spanish Ministry of Health&#44; Social Policy and Equality enhanced recovery abdominal surgery pathway&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a></p>"
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            1 => array:3 [
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            2 => array:3 [
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                            1 => "L&#46; Gianotti"
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            3 => array:3 [
              "identificador" => "bib0020"
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                      "autores" => array:1 [
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                          "etal" => false
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                            0 => "M&#46;P&#46;W&#46; Grocott"
                            1 => "D&#46;S&#46; Martin"
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            4 => array:3 [
              "identificador" => "bib0025"
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                            1 => "D&#46; Hjort Jakobsen"
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                  ]
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            5 => array:3 [
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                          "etal" => false
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                            0 => "A&#46;D&#46;G&#46; Anderson"
                            1 => "C&#46;E&#46; McNaught"
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                  ]
                  "host" => array:1 [
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            6 => array:3 [
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              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Preoperative stress and anxiety in day-care patients and inpatients undergoing fast-track surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46;A&#46; Wetsch"
                            1 => "I&#46; Pircher"
                            2 => "W&#46; Lederer"
                            3 => "J&#46;F&#46; Kinzl"
                            4 => "C&#46; Traweger"
                            5 => "P&#46; Heinz-Erian"
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                  ]
                  "host" => array:1 [
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        "texto" => "<p id="par0285" class="elsevierStylePara elsevierViewall">The authors would like to the members of the Asociaci&#243;n Espa&#241;ola de Cirujanos &#40;AEC&#41;&#44; the Sociedad Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n &#40;SEDAR&#41;&#44; the Sociedad Espa&#241;ola de Ginecolog&#237;a y Obstetricia &#40;SEGO&#41;&#44; the Asociaci&#243;n Espa&#241;ola de Urolog&#237;a &#40;AEU&#41;&#44; the Asociaci&#243;n Espa&#241;ola de Enfermer&#237;a Quir&#250;rgica &#40;AEEQ&#41;&#44; the Sociedad Espa&#241;ola de Enfermer&#237;a y Cirug&#237;a &#40;SEECIR&#41;&#44; the Asociaci&#243;n Espa&#241;ola de Coloproctolog&#237;a &#40;AECP&#41;&#44; the Sociedad Espa&#241;ola de Nutrici&#243;n Parenteral y Enteral &#40;SENPE&#41; and the Grupo Espa&#241;ol de Rehabilitaci&#243;n Multimodal &#40;GERM&#47;ERAS-Spain&#41; who participated in developing the Enhanced Recovery Abdominal Surgery Clinical Pathway&#46;</p>"
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