Recommendations | Perioperative care in adults | Guidance | NICE (2024)

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Information and support for people having surgery

Providing a point of contact

1.1.1

When booking surgery, give people a point of contact within the perioperative care team who can be approached for information and support before and after their surgery.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on information and support for people having surgery.

Full details of the evidence and the committee's discussion are in evidence reviewA: information and support needs.

Communicating and giving information

1.1.2

Follow the recommendations in the NICE guidelines on patient experience in adult NHS services and shared decision making, particularly relating to:

  • involvement of family members and carers

  • communication

  • information

  • shared decision making.

1.1.3

For people with a learning disability, follow the recommendations on communicating and making information accessible in the NICE guideline on care and support of people growing older with learning disabilities.

1.2 Enhanced recovery programmes

1.2.1

Offer an enhanced recovery programme to people having elective major or complex surgery.

1.2.2

Use an enhanced recovery programme that includes preoperative, intraoperative and postoperative components.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on enhanced recovery programmes.

Full details of the evidence and the committee's discussion are in evidence reviewB: enhanced recovery programmes.

1.3 Preoperative care

Assessing the risks of surgery

1.3.1

Use a validated risk stratification tool to supplement clinical assessment when planning surgery, including dental surgery. Discuss the person's risks and surgical options with them to allow for informed shared decision making.

1.3.2

Discuss lifestyle modifications with people having surgery, for example stopping smoking and reducing alcohol consumption. Follow the relevant NICE guidance on lifestyle and wellbeing.

Preoperative optimisation clinics for older people

1.3.3

Be aware that there was not enough clear evidence to show whether the benefits of preoperative optimisation clinics for older people outweigh the costs. Therefore, the committee made a recommendation for research.

Managing iron-deficiency anaemia

Iron supplementation
1.3.4

For people with iron-deficiency anaemia having surgery, follow the recommendations on intravenous and oral iron in the NICE guideline on blood transfusion.

Oral iron regimens
1.3.5

Consider an alternate-day oral iron regimen for people who have side effects from taking oral iron every day.

When to start oral iron supplementation
1.3.6

Be aware that there was no evidence comparing different starting times for iron supplementation, so the committee made a recommendation for research.

Reducing the risk of venous thromboembolism

1.3.8

Follow the recommendations on assessing and reducing the risk of venous thromboembolism for people having surgery in the NICE guideline on venous thromboembolism in over16s.

Anticoagulation for people taking a vitaminK antagonist who need bridging therapy

1.3.9

Be aware that there was no evidence comparing low molecular weight heparin with unfractionated heparin used as perioperative anticoagulant bridging therapy for people taking a vitaminK antagonist. The committee therefore made a recommendation for research.

Nutritional assessment

1.3.10

Offer preoperative nutritional screening to people having intermediate surgery or major or complex surgery.

1.3.11

Follow the recommendations in the NICE guideline on nutrition support for adults on:

  • screening for malnutrition

  • indications for nutrition support

  • what to give.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preoperative care.

Full details of the evidence and the committee's discussion are in:

  • evidence review C: preoperative risk stratification tools

  • evidence review D: preoperative optimisation clinics for older adults

  • evidence review E: preoperative management of anaemia

  • evidence review F: management of anticoagulant medication

  • evidence review G: nutritional screening in preoperative assessment.

1.4 Intraoperative care

Managing fluids

Oral fluids
1.4.1

Tell people having surgery, including dental surgery, that:

  • they may drink clear fluids until 2hours before their operation

  • drinking clear fluids before the operation can help reduce headaches, nausea and vomiting afterwards

  • clear fluids are water, fruit juice without pulp, coffee or tea without milk and ice lollies.

1.4.2

Consider carbohydrate drinks before surgery for people having abdominal major or complex surgery.

Intravenous fluids
1.4.3

Consider using intravenous crystalloid for intraoperative fluid maintenance.

1.4.4

Follow the recommendations in the NICE guideline on intravenous fluid therapy in adults in hospital on resuscitation and routine maintenance.

Cardiac output monitoring

1.4.5

Consider cardiac output monitoring for people having major or complex surgery or high-risk surgery.

Blood glucose control

1.4.6

For people with type1 diabetes, follow the recommendations on care of adults with type1 diabetes in hospital in the NICE guideline on type1 diabetes in adults.

1.4.7

Do not use glucose-lowering medicines to achieve tight blood glucose control (4to6mmol/litre) for people having surgery who have type2 diabetes or do not have diabetes.

Surgical safety checklists

1.4.9

Consider adding steps to the WHO surgical safety checklist to eliminate preventable events reported locally or nationally, such as those in NHS Improvement's national patient safety alerts and surgical 'never events'. Follow the WHO surgical safety checklist implementation manual when adding steps to the checklist.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on intraoperative care.

Full details of the evidence and the committee's discussion are in:

  • evidence review H: preoperative fasting

  • evidence review I: intravenous fluid management strategy

  • evidence review J: non-invasive cardiac output monitoring

  • evidence review K: blood glucose control management

  • evidence review L: management systems to promote safety in operating theatres.

1.5 Postoperative care

1.5.1

Provide postoperative care in a specialist recovery area (a high-dependency unit, a post-anaesthesia care unit or an intensive care unit) for people with a high risk of complications or mortality.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on postoperative care.

Full details of the evidence and the committee's discussion are in evidence reviewM: postoperative recovery in specialist areas.

1.6 Managing pain

Planning pain management

1.6.1

Discuss the options for postoperative pain management with people before they have surgery, including dental surgery.

Take into account:

  • clinical features including comorbidities, age, frailty, renal and liver function, allergies, current medicines and cognitive function

  • whether the surgery is immediate, urgent, expedited or elective.

    Include in the discussion:

  • the likely impact of the procedure on the person's pain

  • the person's preferences and expectations

  • their pain history

  • the potential benefits and risks, including long-term risks, of different types of pain relief

  • plans for discharge.

Selecting analgesia

1.6.2

Offer a multimodal approach in which analgesics from different classes are combined to manage postoperative pain. Take into account the factors listed in recommendation1.6.1.

1.6.3

If controlled drugs are used, follow the recommendations on prescribing controlled drugs in the NICE guideline on controlled drugs.

1.6.4

Consider prescribing pre-emptive analgesia for use when local anaesthesia wears off.

Paracetamol
1.6.5

Offer oral paracetamol before and after surgery, including dental surgery, irrespective of pain severity.

1.6.6

Do not offer intravenous paracetamol unless the person cannot take oral medicine.

Non-steroidal anti-inflammatory drugs (NSAIDs)
1.6.7

Offer oral ibuprofen to manage immediate postoperative pain of all severities (including pain after dental surgery) unless the person has had surgery for hip fracture (see the recommendations on analgesia in the NICE guideline on hip fracture).

1.6.8

Do not offer an intravenous NSAID to manage immediate postoperative pain (including pain after dental surgery) unless the person cannot take oral medicine.

1.6.9

If offering an intravenous NSAID to manage immediate postoperative pain, choose a traditional NSAID rather than a COX‑2 (cyclo-oxygenase‑2) inhibitor.

Opioids
1.6.10

Offer an oral opioid only if immediate postoperative pain is expected to be moderate to severe. When giving an oral opioid:

  • give the opioid as soon as the person can eat and drink after surgery

  • adjust the dose to help the person achieve functional recovery (such as coughing and mobilising) as soon as possible.

1.6.11

For people who cannot take oral opioids, offer a choice of PCA (patient-controlled analgesia) or a continuous epidural to relieve pain after surgery. Take into account the benefits of a continuous epidural for people who:

  • are having major or complex open‑torso surgery or

  • are expected to have severe pain or

  • have cognitive impairment.

Intravenous ketamine
1.6.12

Consider a single dose (0.25mg/kg to 1mg/kg) of intravenous ketamine given either during or immediately after surgery to supplement other types of pain relief if:

  • the person's pain is expected to be moderate to severe and an intravenous opioid alone does not provide adequate pain relief or

  • the person has opioid sensitivity.

    In August 2020, this was an off‑label use of intravenous ketamine. See NICE's information on prescribing medicines.

Gabapentin
1.6.13

Be aware that, although there was evidence showing that the use of gabapentin to supplement other types of pain relief can be beneficial, the evidence about when to give gabapentin, and how much to give, was inconclusive. The committee therefore made a recommendation for research.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on managing pain.

Full details of the evidence and the committee's discussion are in:

  • evidence reviewA: information and support needs

  • evidence review N1: managing acute postoperative pain

  • evidence review N2: managing acute postoperative pain (appendices).

Terms used in this guideline

Cardiac output monitoring

Interventions to monitor parameters such as stroke volume, cardiac output or central venous pressure to evaluate volume status and guide decisions on fluid replacement therapy.

High-risk surgery

Surgery with a risk of mortality greater than5%.

Immediate postoperative pain

Pain during the first 24hours after surgery.

Intermediate surgery

Examples include primary repair of inguinal hernia, excising varicose veins in the leg, tonsillectomy or adenotonsillectomy, and knee arthroscopy.

Major or complex surgery

Examples include total abdominal hysterectomy, endoscopic resection of prostate, lumbar discectomy, thyroidectomy, total joint replacement, lung operations, colonic resection and radical neck dissection.

Recommendations | Perioperative care in adults | Guidance | NICE (2024)
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