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 .
British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) – Cassandra’s view
Not enough fluid and too much fluid are both bad . That is the one great irrefutable truth in fluid management in anaesthesia and in the critically ill . For almost every other question in fluid therapy there is ‘ current opinion ’ . The big questions are when , where , which and why but of greater moment than all of these is ‘ how much ’ . The current drift towards the use of smaller volumes of fluid in major surgery suggests that the right amount at the right time is probably the way to go , so volume and timing are seemingly linked . This ties in neatly with the rediscovery of the notion that early fluid resuscitation in the emergency room is better than late and dovetails with the concept that adequate resuscitation , or optimisation , improves outcome in high risk surgery . New gadgets that help to achieve this end abound since the pulmonary artery catheter fell from grace . The recent discovery of hyperchloraemic acidosis as a new iatrogenic disease entity has focused attention on the importance of the fundamental constituents of the fluids that are given [ 1 ] . The meta-analytical cloud that the Cochrane collaboration placed over albumin was dissipated by the SAFE study only to be replaced by a different evidential cloud drifting over the world of starches [ 2 ] . This has reawakened interest in the potentially malevolent nature of synthetic molecules . As the dynamics of the questions and current answers change , it is easy to become confused . The publication of the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients could therefore not be more timely [ 3 ] . The authors have asked a very large number of relevant questions , assessed a vast array of available information and measured it with an evidence -based score to produce recommendations bundled into guidelines . There are no less than 28 evidence -scored recommendations to assist in fluid management . This major work should be m and atory reading for anyone involved in fluid management for a range of reasons that will come clear . The recommendations , all 28 of them , each has an evidence level of between 1 and 5 , although some have several evidence levels for different parts of the same question . In brief ; level 1 is very good , 1a – a systematic review or 1b a r and omised control trial , while level 4 is a case series and level 5 is expert opinion without critical appraisal , so ‘ 1 – good and 5 – bad ’ . The first recommendation dismisses normal saline from routine use because it causes hyperchloraemic acidosis , and advocates balanced solutions . The evidence level is 1b and appears to be very good using no fewer than seven papers . On closer scrutiny some of these are small r and omised controlled trials which demonstrate mild acidosis [ 4–9 ] . Saline and hyperchloraemic acidosis are associated and by implication this is harmful , although any evidence for harm is circumstantial and inconsequential [ 10 ] . The recommendation , supportive of balanced solutions , is inappropriate given the limited evidence ( this author ’s opinion – level 5 ) . Sensible maybe , but evidence -based ? To be fair , many of the recommendations have been st and ard practice for years and , paradoxically , several of these are level 5 . The pre-operative recommendations may raise eyebrows . Most anaesthetists know that fluids can be given orally up to 2 h pre-operatively but how many actively encourage it despite the evidence level of 1a ? The implication is there should be a general and active move to 2-h fluid fasting . These guidelines are based on three references , two of which are themselves guidelines and one being a Cochrane review . The fact that fluids make patients feel better is supported by trials and rates an evidence level of 2a . Curiously , the guidelines contain useful tips on the current position of bowel preparation , grade d level 1a , while the predicted fluid and electrolyte disturbance which it causes only achieves level 5 . Mind you , using a parachute when jumping out of an aircraft presumably only gets a score of 4 [ 11 ] . It is curious that the Geigy Scientific tables for the electrolyte content of secretions rates level 5 while the Hartmann ’s vs saline question in the replacement of gastric losses rates level 2a , again largely because saline is associated with hyperchloraemic acidosis . No-one would argue that balanced crystalloid or a colloid can be used for the treatment of hypovolaemia but , of the 11 references quoted , nine involve starches , a curious selection from a very extensive literature , while balanced crystalloid is once again recommended because of the supposed risks of hyperchloraemic acidosis , if such risks exist . The recommendations move on to the diagnosis of hypovolaemia and the use of incremental 200-ml boluses of either crystalloid or colloid . This is level 1b evidence based on two small trials [ 12 , 13 ] . While one must question whether this constitutes substantial evidence , it does make sense . Orthopaedic and abdominal surgery are singled out to recommend stroke volume measurement to guide fluid management peri-operatively ( level 1b ) . In orthopaedic surgery this is based on two well known studies , each of which can be interpreted either to indicate that the intervention reduced hospital stay or that the control group could have been better managed . The former is more widely accepted . In non-elective surgery , in the same specialities , this management should continue for 8 h and , in these circumstances , low dose dopexamine , which performed well in a meta- analysis , is Anaesthesia , 2009 , 64 , pages 235–238
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 .