1) This document outlines a fast-track protocol for patients undergoing surgery, which includes pre-operative fasting guidelines, thromboembolic prophylaxis, epidural anesthesia protocols, intra-operative temperature and fluid management, and post-operative analgesia, nutrition, and monitoring plans. 2) The protocol emphasizes epidural anesthesia with general anesthesia as needed, early removal of tubes, multi-modal post-operative analgesia including epidural and oral medications, early post-operative nutrition and fluids, and daily weight monitoring. 3) The goal is to provide adequate pain control and recovery support while allowing early mobilization through a structured multi-disciplinary care pathway.

1. FAST-TRACK (OPEN & SCOPIC)
Preop-assessment Fast-track talk, discussing epidural
anaesthesia
Pre-operative fasting Last meal: 6 h before operation
Last clear drink: 2 h before operation
and 2 units nutridrink Pre-op®
Pre-medication Evening before the operation:
lorazepam 1 mg
The day of operation:
no premedication
Thrombo-embolic Pre-op: Fraxiparine® 2850 E s.c.;
prophylaxis 20.00 h
Post-op: Fraxiparine® 2850 E s.c.;
20.00 h
Anesthesia protocol Epidural anesthesia T 9-10 ± 1
- Test dose: 3 ml bupivacaine 0.25%
- Top-up: bupivacaine 0.25 or 0.5%
with sufentanil /fentanyl
- No pre-surgical block testing
- Insufficient pain relief at PACU:
block testing by using 10 ml
lidocaine 2% and performing pin-
prick and temperature testing, in
case of failure new attempt.
Epidural in combination with general

2. anesthesia using propofol or volatile
anesthetics; fentanyl or sufentanil;a
muscle relaxant and if necessary
antagonized at the end of the procedure
(TOF-guided!)
Nasogastric tube To be removed before extubation
Urinary drainage Supra-pubic catheter
Intra-operative Infusion of warmed fluids and use of
temperature upper-body forced-air heating cover
management
Intra-operative fluid 1.Maintenance with Ringer’s lactate
a. 1e hr.: 20 ml/kg BW
management
b. 2e etc. hrs: 6 ml/kg BW
2.Blood-loss management:
a. Starting 500 ml Voluven®
b. Blood loss ≥ 500 ml: 2e 500 ml
Voluven®
c. Blood loss ≥ 1.000 ml: 3e 500 ml
Voluven®
d. Blood loss ≥ 1.500 ml: than PC
guided by Hb;
i. Patient < 70 yrs: Trigger Hb
= 5.0 mmol/l
ii. Patient ≥ 70 yrs: Trigger Hb
= 5.5 mmol/l
e. when the first Voluven® was
given ≥ 6 h. before, a 4th
Voluven® can be given,
otherwise per 2 E PC’s, 1 E
ESDEP will be infused.

3. No extra fluid loading
Vasopressors should be considered for the
intra-operative management of epidural-
related hypotension
-metaraminol
-phenylephrine
-norepineprine
PONV-prophylaxis - Odansetron 4 mg (first choice)
- Kytril 1mg (second choice)
- Droperidol 0.625 mg
- Haloperidol 1 mg
Post-operative analgesia Epidural analgesia:
PCEA bupivacaine 0.1% + fentanyl 2.0
mcg/ml + background infusion or
continuous infusion bupivacaine
0.125% + sufentanil 1 mcg/ml for 48
hrs.
Remove on day POD 2
In combination with Paracetamol 4 x 1
g
Add NSAID after removal of epidural
catheter
Post-operative fluids Day 0: first oral drinks; 2 h post-
surgery, infusion of RL 1.5 l/24 h
Day 1: infusion will be stopped, iv.
canula will be left behind. Oral intake 2
litres
Day 2: iv. canulla will be removed at
the time epidural catheter will be
removed.

4. Post-operative nutrition Day 2: normal diet
Bodyweight Patients must be weighted on a daily
basis