Free flap

baseline Review the pathway, the fasting clock, pain plan, and who to call.

baseline Start prehabilitation when there are at least 2–4 weeks before surgery: walking, breathing, and protein.

baseline Ask the patient to stop smoking now. Four weeks is better than the day before.

baseline Hemoglobin is below the pathway threshold. Work it up and give IV iron if time allows.

baseline One carbohydrate drink, about 400 mL, finished by the stop-drinks time. ASA 2023 supports this in healthy adults.

baseline Clear liquids until 2 hours before anesthesia. The patient sheet uses the earlier of that time and 2 hours before arrival.

baseline Stop solids 6 hours before surgery. Stop fried or fatty meals 8 hours before.

baseline Do not give a long-acting sedative or benzodiazepine premedication.

baseline Agree the airway, tracheostomy timing, and who watches the airway overnight.

baseline Scheduled acetaminophen unless the liver plan says otherwise.

baseline Give a scheduled NSAID or COX-2 unless a safety rule holds it. Do not tell every patient to stop NSAIDs for 7 days.

baseline Single-dose dexamethasone for analgesia and nausea, unless a rule modifies it.

baseline Use the procedure-specific block.

Multimodal analgesia. Avoid a block that hides flap perfusion.

baseline Prophylaxis follows the Apfel score and the Fourth Consensus Guidelines.

Apfel 1 (Postoperative opioids expected). Give 1–2 agents.

path_flap_fluids Keep fluids tight so the flap is not edematous. Avoid both hypovolemia and a large positive balance.

baseline Active warming. Keep core temperature at or above 36°C.

baseline Treat hyperglycemia. Non-diabetic patients need a check only when clinically indicated.

safe_cancer_vte Cancer surgery: extend pharmacologic VTE prophylaxis to 28 days when bleeding risk allows.

baseline Start oral intake as soon as the patient is awake, unless a surgical rule restricts it.

baseline Mobilize the day of surgery or on postoperative day 1.

baseline Remove the urinary catheter on postoperative day 1 unless the operation requires it to stay.

baseline Do not place a drain by routine.

baseline Do not leave a nasogastric tube in by routine.

baseline Scheduled flap checks. Do not hide the flap under a warming blanket or a tight dressing.

baseline Tracheostomy care and pulmonary toilet start the day of surgery.