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 review A: information and support needs.

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 review B: 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.

Medicines adherence

1.3.7 Follow the recommendations in the NICE guideline on medicines adherence to encourage adherence to oral iron regimens.

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 over 16s.

Anticoagulation for people taking a vitamin K 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 vitamin K 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.

1.4 Intraoperative care

Managing fluids

Oral fluids

1.4.1 Tell people having surgery, including dental surgery, that:

  • they may drink clear fluids until 2 hours 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.

Cardiac output monitoring

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

Blood glucose control

1.4.7 Do not use glucose-lowering medicines to achieve tight blood glucose control (4 to 6 mmol/litre) for people having surgery who have type 2 diabetes or do not have diabetes.

Surgical safety checklists

1.4.8 Ensure that the World Health Organization (WHO) surgical safety checklist is completed for each surgical procedure, including dental procedures.

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.

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 review M: 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 recommendation 1.6.1.

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 (0.25 mg/kg to 1 mg/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:

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 than 5%.

Immediate postoperative pain

Pain during the first 24 hours 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.

  • National Institute for Health and Care Excellence (NICE)