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 .
Processes of Care in Autogenous Breast Reconstruction with Pedicled TRAM Flaps: Expediting Postoperative Discharge in an Ambulatory Setting
Background : A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included ( 1 ) preadmission patient education , ( 2 ) perioperative multimodal pain management , ( 3 ) intraoperative nerve blocks , and ( 4 ) postdischarge telephone advice . This study evaluated the success of this care plan in the first 18 months after its implementation . Methods : A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction ( November of 2009 to May of 2011 ) was performed . The primary outcome was time to discharge ; secondary outcomes included complications , readmission , and self-report pain at discharge . Predictors of discharge time were analyzed using stepwise multivariable regression modeling . Results : Ninety-one women ( mean age , 50.0 ± 8.5 years ) underwent pedicled TRAM flap reconstruction ( 76 percent unilateral and 81 percent delayed ) , with 77 percent receiving the intended multimodal analgesia protocol . Mean time to discharge was 38.7 ± 27.6 hours . Overall , 40 percent of patients were discharged within 24 hours , but successful early discharge increased significantly over the study period . Key predictors of shorter time to discharge were use of multimodal analgesia , lower American Society of Anesthesiologists class , and surgery more than 6 months after implementation of the care plan . Conclusions : The authors ’ initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction , with adherence to the authors ’ care plan improving steadily over the study period . Multimodal pain management proved a key modifiable factor in facilitating early discharge . A prospect i ve study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , IV
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 .