Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content ++ A well-functioning enhanced recovery program (ERP) uses evidence-based practices to decrease variation in clinical management, minimize organ dysfunction, and accelerate convalescence; it requires adjustments in multiple aspects of care, including surgical and anesthetic techniques, nursing care, physiotherapy, and nutrition support. Persistent postsurgical pain—chronic pain that continues beyond the typical healing period of 1-2 months following surgery, or well past the normal period for postoperative follow-up—is increasingly acknowledged as a common and significant problem following surgery. The magnitude of the surgical stress response is related to the intensity of the surgical stimulus, can be amplified by other factors, including hypothermia and psychological stress, and can be moderated by perioperative interventions, including deeper planes of general anesthesia, neural blockade, and reduction in the degree of surgical invasiveness. Neuraxial blockade of nociceptive stimuli by epidural and spinal local anesthetics has been shown to blunt the metabolic and neuroendocrine stress response to surgery. In major open abdominal and thoracic procedures, thoracic epidural blockade with local anesthetic provides excellent analgesia, facilitates mobilization and physical therapy, and decreases the incidence and severity of ileus. By sparing opioid use and minimizing the incidence of systemic opioid-related side effects, epidural analgesia facilitates earlier mobilization and earlier resumption of oral nutrition, expediting exercise activity and attenuating loss of body mass. Continuous peripheral nerve blocks with local anesthetics block afferent nociceptive pathways and are an excellent way to reduce the incidence of opioid-related side effects and facilitate recovery. Lidocaine (intravenous bolus of 100 mg or 1.5-2 mg/kg, followed by continuous intravenous infusion of 1.5-3 mg/kg/h or 2-3 mg/min) has analgesic, antihyperalgesic, and antiinflammatory properties. Multimodal analgesia combines different classes of medications, having different (multimodal) pharmacological mechanisms of action and additive or synergistic effects, to control multiple perioperative pathophysiological factors that lead to postoperative pain and its sequelae. The addition of nonsteroidal antiinflammatory drugs (NSAIDs) to systemic opioids diminishes postoperative pain intensity, reduces the opioid requirement by approximately 30%, and decreases opioid-related side effects such as postoperative nausea and vomiting and sedation. However, NSAIDs may increase the risk of gastrointestinal and postoperative bleeding, decrease kidney function, and impair wound healing. Opioid administration by patient-controlled analgesia provides better pain control, greater patient satisfaction, and fewer opioid side effects when compared with on-request parenteral opioid administration. Single-shot and continuous peripheral nerve blockade is frequently utilized for fast-track ambulatory and inpatient orthopedic surgery, and can accelerate recovery from surgery and improve analgesia and patient satisfaction. Postoperative ileus delays enteral feeding, causes patient discomfort, and is one of the most common causes of prolonged postoperative hospital stay. Nasogastric tubes should be discouraged whenever possible or used for only a very short period of time, even in gastric and hepatic surgery. Multimodal analgesia and nonopioid analgesia techniques shorten the duration of postoperative ileus. Because either excessive, or excessively restricted, perioperative fluid therapy may increase the ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth