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 4Â 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 2Â h before induction of anesthesia, and solid food was allowed 6Â 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 |