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 .
Atrophy and impaired muscle protein synthesis during prolonged inactivity and stress.
CONTEXT We recently demonstrated that 28-d bed rest in healthy volunteers results in a moderate loss of lean leg mass and strength . OBJECTIVE The objective of this study was to quantify changes in muscle protein kinetics , body composition , and strength during a clinical bed rest model reflecting both physical inactivity and the hormonal stress response to injury or illness . DESIGN Muscle protein kinetics were calculated during a primed , continuous infusion ( 0.08 micromol/kg.min ) of 13C6-phenylalanine on d 1 and 28 of bed rest . SETTING The setting for this study was the General Clinical Research Center at the University of Texas Medical Branch . PARTICIPANTS Participants were healthy male volunteers ( n = 6 , 28 + /- 2 yr , 84 + /- 4 kg , 178 + /- 3 cm ) . INTERVENTION During bed rest , hydrocortisone sodium succinate was administered iv ( d 1 and 28 ) and orally ( d 2 - 27 ) to reproduce plasma cortisol concentrations consistent with trauma or illness ( approximately 22 microg/dl ) . MAIN OUTCOME MEASURES We hypothesized that inactivity and hypercortisolemia would reduce lean muscle mass , leg extension strength , and muscle protein synthesis .  RESULTS Volunteers experienced a 28.4 + /- 4.4 % loss of leg extension strength ( P = 0.012 ) and a 3-fold greater loss of lean leg mass ( 1.4 + /- 0.1 kg ) ( P = 0.004 ) compared with our previous bed rest-only model . Net protein catabolism was primarily due to a reduction in muscle protein synthesis [ fractional synthesis rate , 0.081 + /- 0.004 ( d 1 ) vs. 0.054 + /- 0.007%/h ( d 28 ) ; P = 0.023 ] . There was no change in muscle protein breakdown . CONCLUSION Prolonged inactivity and hypercortisolemia represents a persistent catabolic stimulus that exacerbates strength and lean muscle loss via a chronic reduction in muscle protein synthesis
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 .