Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
Background : Enhanced recovery following surgery can be achieved through the introduction of evidence -based perioperative maneuvers .
This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery  and to provide evidence -based recommendations for an enhanced perioperative protocol .
Effect of paravertebral nerve blocks on narcotic use after mastectomy with reconstruction.
INTRODUCTION Pain control outcomes using local anesthetic delivery systems vs usual narcotics at our institution revealed that use of local anesthetic delivery systems decreased narcotic use greater than 40 % in patients with no reconstruction but had very little effect in patients receiving reconstruction . As part of our quality improvement program , the anesthesiology department trained and began offering paravertebral blocks ( PVBs ) to patients having reconstruction . We review ed pain control outcomes to underst and how the use of paravertebral nerve blocks affected narcotic use in reconstructed patients . METHODS Retrospective review of prospect ively collected data on patients undergoing mastectomy with or without reconstruction in the 6-month period after introduction of PVB analgesia .  Patients received preoperative single-shot paravertebral nerve blocks at T2 to T3 and T5 to T6 with bupivacaine .5 % and epinephrine 1:200,000 ( 7.5 mL per injection ) . Patients who had a bilateral mastectomy with reconstruction received bilateral paravertebral nerve blocks at the same locations . Narcotic doses were converted to morphine equivalents ( MSEs ) to allow comparison . RESULTS There were 102 patients with mastectomy during that period and 91 were evaluable . Fifty-one had no reconstruction with an average MSE use of 37.9 . There were 40 with reconstruction , 33 had PVB with average MSE of 42.6 , and 7 patients had reconstruction with no PVB with average MSE of 71.1 . There were no major complications . CONCLUSIONS Institution of the PVB for patients undergoing mastectomy with reconstruction lowered average MSE use . We will continue to offer paravertebral blocks in this cohort of patients
Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
Background : Enhanced recovery following surgery can be achieved through the introduction of evidence -based perioperative maneuvers .
This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery  and to provide evidence -based recommendations for an enhanced perioperative protocol .