Day of surgery — modern fasting, the carbohydrate drink, and pre-incision preparation

The day-of protocol, hour by hour

1. 1

   8 hours before — last full meal

   Stop eating heavy or fatty meals 8 hours before surgery. This includes red meat, fried food, and dairy-heavy meals.

2. 2

   6 hours before — last light snack

   A light snack such as dry toast, fruit, or a small portion of plain rice is allowed up to 6 hours before. After this, no solid food.

3. 3

   2 hours before — clear fluids stop, carb drink given

   Water, black tea, black coffee, plain apple juice are allowed until 2 hours before surgery. At the 2-hour mark, you take the maltodextrin-based carbohydrate drink we provide. This activates insulin so your body enters surgery in a fed metabolic state.

4. 4

   1 hour before — pre-op medication bundle, antibiotic, thromboprophylaxis

   A single pre-op oral medication bundle is given: paracetamol 1000mg, ibuprofen 400mg, and aprepitant 40mg (a long-acting NK1-receptor blocker for nausea prevention). This pre-loads the multimodal analgesia and PONV protocols before the first incision is made. Intravenous antibiotics are given within 1 hour of skin incision (cefazolin 2g, plus metronidazole if bowel surgery). Heparin or low-molecular-weight heparin is injected to prevent deep vein thrombosis. Sequential compression devices are placed on the legs.

5. 5

   In the operating room — final preparations

   Active warming device and warmed IV fluids to maintain core body temperature above 36.5°C. Chlorhexidine-alcohol skin preparation. Epidural placement before incision for major open abdominal/thoracic surgery. Short-acting volatile anaesthetic agents (sevoflurane or desflurane) are preferred to long-acting agents because they wear off quickly, so the patient wakes up clear-headed and can begin mobilisation the same day.

The carbohydrate drink — what it is and why it works

The pre-operative carbohydrate drink is a maltodextrin-based clear liquid containing 100g of complex carbohydrate plus electrolytes. It is consumed as 800ml the evening before surgery and 400ml two hours before. Despite being a clear fluid, it must pass the stomach quickly and elicit a strong insulin response. Generic sports drinks fail both criteria.

Why bowel preparation is no longer routine

Hyperosmotic bowel preparation (PEG, oral phosphate, picolax) was traditionally given the night before colorectal surgery. The fluids attract water into the bowel and rinse fecal content. The same osmotic effect dehydrates the patient. Combined with overnight fasting, the patient arrives in the operating room significantly volume-depleted, hypotensive under anesthesia, and treated with excess IV fluids that cause their own complications.

Selective bowel preparation is now the standard. When used (for some left-sided colon surgeries), oral antibiotics are added to reduce surgical site infection. The decision is operation-specific, not routine.

Post-operative nausea and vomiting (PONV) — the multimodal antiemetic protocol

Post-operative nausea and vomiting affect roughly one in three surgical patients without specific prophylaxis. The cost is not just discomfort: vomiting raises intra-abdominal pressure, threatens fresh anastomoses, delays oral intake, lengthens hospital stay, and is one of the patient-reported outcomes most associated with dissatisfaction with surgical care. The chapter on perioperative pathways in the Sabiston Textbook (Ljungqvist, de Boer, Nelson) frames PONV prevention as a non-negotiable ERAS element, not a rescue therapy.

Dr. Khaled Ghalwash use a multimodal antiemetic protocol that targets three different receptor pathways at once. The principle is the same as multimodal analgesia: drugs from different classes synergise so each can be given at a low dose with fewer side effects and stronger overall effect.

1. 1

   Aprepitant 40mg PO — given pre-op

   A long-acting NK1-receptor antagonist, taken with the pre-op medication bundle 1 hour before surgery. It covers the 24-hour post-op window when delayed nausea is most likely.

2. 2

   Dexamethasone 4-8mg IV — given at induction

   A single intra-operative steroid dose given by the anaesthetist at induction. It is one of the best-studied antiemetics in surgery and also reduces post-op pain modestly. The dose is adjusted for diabetic patients.

3. 3

   Ondansetron 4mg IV — given at end of surgery

   A 5-HT3 receptor blocker given by the anaesthetist as the operation finishes. Effective for the first 4-6 hours after surgery. Continued as 4mg orally every 6 hours as needed for 24-48 hours.

4. 4

   Rescue agents — droperidol or prochlorperazine

   For patients who break through the triple-blocker, a fourth drug from yet another class is available. Most patients on the protocol never need rescue.

Fluid therapy — euvolemia, Lactated Ringer's, and goal-directed fluid therapy

Intra-operative fluid management used to be guesswork: liberal fluids "just in case." We now know that both extremes — too little and too much — cause complications. The modern target is euvolemia: enough fluid to maintain perfusion of vital organs, no more.

Three evidence-based shifts run on every operation in this practice:

• Lactated Ringer's, not normal saline. Normal saline (0.9% sodium chloride) given in volume produces hyperchloraemic acidosis, which impairs renal perfusion and slows gut function recovery. Lactated Ringer's is balanced and physiological.
• Restrictive over liberal — but not too restrictive. The Brandstrup et al. trial in colorectal surgery showed liberal fluids increased complications. Subsequent trials confirmed that very-restrictive regimes also harm. The target is a precisely matched volume to maintain perfusion.
• Goal-Directed Fluid Therapy (GDFT) for high-risk cases. In major surgery (long-duration, high-blood-loss expected, frail patient, cardiac comorbidity), the anaesthetist uses real-time hemodynamic monitoring — stroke volume, pulse-pressure variation, or oesophageal Doppler — to titrate small fluid boluses to a measured cardiac response, rather than to a clock-based schedule. This reduces complications by approximately 20% in high-risk surgery (NICE MTG3, 2011).

Extended thromboprophylaxis — 28 days after cancer abdominal surgery

Patients undergoing major abdominal or pelvic surgery for cancer are at substantially elevated risk of venous thromboembolism (DVT and pulmonary embolism) for weeks after discharge, not just during the hospital stay. The modern guideline — backed by the ENOXACAN II trial and confirmed in subsequent meta-analyses — is to extend low-molecular-weight heparin prophylaxis for 28 days post-discharge in this population, reducing post-op VTE by approximately 50%.

Dr. Khaled Ghalwash prescribe self-administered subcutaneous enoxaparin (or equivalent LMWH) for 28 days after discharge for every patient operated for an abdominal or pelvic malignancy. The injection is once daily, the patient is taught the technique by ward nursing on day 1 post-op, and the prescription is reviewed at the 30-day follow-up. For non-cancer cases, prophylaxis duration is shorter and matched to mobility recovery. For specific high-risk non-cancer groups (e.g., severe obesity, prior VTE, hereditary thrombophilia), an extended course is also given.

Why the 1-hour antibiotic window matters

Intravenous antibiotic given more than 1 hour before incision has cleared the bloodstream by the time tissue is cut. Given less than 30 minutes before, levels in tissue have not yet peaked. The window of 30 to 60 minutes before incision delivers peak antibiotic concentration in tissue at the moment bacteria are introduced. This single timing change reduces surgical site infection by 50% in randomized trials.

Frequently asked questions