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Table 1 Summary of the ERAS components for orthopedic surgery

From: Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Period

Component

Contents

Preadmission

Preadmission counseling

Patients should be informed of the treatment they receive, what to expect, and their role in the recovery process during their hospital stay

Optimization of medical condition

Underlying disease: underlying disease should be identified through blood test, imaging tests, and history taking, and optimized with the help of a specialist

Smoking: it is recommended to stop smoking at least 4 weeks before total joint arthroplasty

Alcohol: alcohol cessation is recommended before total joint arthroplasty

Malnutrition and anemia: preoperative correction of malnutrition and anemia is recommended before total joint arthroplasty

Preoperative

Avoid prolonged fasting

Clear fluid was allowed 2 h before induction of anesthesia, and solid food was allowed 6 h before, but routine intake of carbohydrates before surgery is still not recommended

Multimodal analgesia

NSAID, paracetamol: decrease postoperative pain and reduce supplemental analgesic

(opioid) use following hip and knee replacement

Gabapentinoid: routine use is not recommended because of insufficient evidence

Antidepressant (duloxetine): significantly reduce opioid use and nausea

Opioid: current trend is to implement multimodal analgesia without opioid

Corticosteroid: can be used as a drug for preemptive analgesia with NSAID and pregabalin

PONV

Corticosteroids (dexamethasone), serotonin (5HT3) antagonists (ondansetron), and dopamine (D2) antagonists (droperidol) are commonly used to prevent PONV

Intraoperative

Anesthetic protocol

Anesthesia techniques (neuraxial versus general) more suitable for orthopedic surgery have not yet been clarified. Routine use of spinal opioids or epidural anesthesia is unreasonable

Prevent hypothermia

Normal body temperature should be maintained intraoperatively through prewarming and humidification of anesthetic gases, warming IV and irrigation fluids, and warming blankets

Fluid management

Fluid management should be adjusted to maintain the normal state of the body fluid compartment, facilitate the excretion of waste, and return to oral intake as early as possible after surgery

Urinary catheterization

should be removed as soon as possible, ideally within 24 h after completion of surgery. However, it should not be used routinely, and should be determined by patients’ condition

Antimicrobial prophylaxis

Antibiotics prophylaxis and dilute betadine lavage can prevent surgical site infection and periprosthetic joint infection, but preoperative hair removal is not recommended

Blood conservation

Tranexamic acid is effective in reducing blood loss and transfusion rate in orthopedic surgery

LIA ad local nerve block

LIA is effective for TKA and is more suitable for the ERAS protocol than a nerve block, which can inhibit early mobilization by blocking the motor nerve

Surgical factors

Surgical approach: there is no conclusive evidence that choice of surgical approach accelerates the achievement of discharge criteria

Tourniquet, drainage: routine use is not recommended in orthopedic surgery

ICE therapy: effective in relieving pain, reducing swelling, and improving ROM

Postoperative period

Early oral nutrition

An early return to normal diet as soon as patients feel able is recommended

Thromboembolism prophylaxis

Patients should be mobilized as soon as possible after surgery and should receive appropriate antithrombotic prophylactic treatment

Early mobilization

Patients should be mobilized as early as they are able because prolonged bed rest causes thromboembolism, pulmonary complications, and muscle atrophy

Discharge planning

Objective discharge criteria should be established so that patients can be discharged directly

to their home

  1. NSAID nonsteroidal anti-inflammatory drugs; PONV prevention of postoperative nausea and vomiting; IV intravenous; LIA local infiltration analgesia; TKA total knee arthroplasty; ERAS enhanced recovery after surgery; ROM range of motion