MEHBOOB HUSSAIN MALIK1， Wang Tao2*
1.Qinghai University 2.Affiliated Hospital of Qinghai University
*Corresponding Author Email: wangtao740525@163.com
Abstract:
The core principle of ERAS (Enhanced Recovery After Surgery) is to decrease trauma and tension by using the lowest invasive surgical practices, thereby decreasing postoperative problems, saving costs, shortening length of stay (LOS) and encourage faster recovery. ERAS has achieved satisfactory results in other surgical discipline after use in gastrointestinal surgery. In recent years, advancement in orthopedic surgical procedures has brought forth mind-blowing clinical results in enhancing postoperative recovery. However these advances and productiveness of ERAS on arthroplasty has not been uniformly identified or accepted by orthopedic surgeons. Orthopedic surgery, in particular routine knee and hip replacement, is one of the areas in which the ERAS principle has been adopted. It has been associated with reduced length of hospital stay, readmission rate, and improved functional outcomes. Studies are needed to inform a dialogue among surgeons to evaluate the use of ERAS.In this review article , we have summarized the core concept of ERAS in peri-operative care among patients undergoing elective Hip arthroplasty.A literature search was carried out for articles that included the terms "improved recovery" and "orthopedic surgery". In this article, we summarized the clinical applications of ERAS and highlighted the key elements that characterize the enhanced recovery program.
Keywords: Enhanced recovery after surgery, nutrition, orthopedic surgery, postoperative care, preoperative care ， hip arthroplasty ,
Introduction:
Enhanced recovery after surgery (ERAS)© was first coined by Danish surgeon Henrik Kehlet in 1997.[ Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Survey of Anesthesiology. 1998 Aug 1;42(4):233.] The idea behind ERAS was reduction of postoperative physical and psychological stress, thereby decreasing recovery time and overall financial burden.Bardram et al reported that effective pain relief facilitated early mobilization in the patients undergoing colonic surgery and that hospital stay was reduced to two days without any reported nausea, vomiting, or ileus.[ Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet. 1995;345:763–4.]Over the last 10–20 years the rate of joint replacement surgeries has increased dramatically with the aging population. Approximately 4 million Americans who have had a knee replacement are currently living with a total knee replacement and the cost of these types of surgery is projected to rise.[ Kremers HM, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ. Prevalence of total hip and knee replacement in the United States. The Journal of bone and joint surgery. American volume. 2015 Sep 2;97(17):1386.]The burden of cost lies in postoperative care, including physical and occupational therapy, nutrition, and social services, which directly influence cost accrued.To address this burden, ERAS programs have been implemented at institutions and are designed to improve patient outcomes while at the same time, limiting cost and decreasing readmission rates after surgery.The concept of ERAS and it’s increased safety and efficacy in orthopedic surgery is continually being investigated. Studies have been conducted and suggested a decrease in the length of hospital stay(LOS) after total hip/knee arthroplasty from 4–12 to 1–3 days with no significant increase in readmission for any reason.[ Zhu S, Qian W, Jiang C, et al Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis Postgraduate Medical Journal 2017;93:736-742.]
The evidence appears clear that ERAS protocols improve hospital stay and patient outcomes, however, these processes can be streamlined to facilitate implementation.This article will focus on the various characteristics of an ERAS protocol designed specifically for orthopedic surgery and will discuss: Preoperative assessment, fasting, bowel preparation, anesthetics pre-op, and intra-op, prophylactic thrombosis prevention, postoperative nausea and vomiting, nutrition, and fluid management.
Enhanced Recovery after Surgery in Elective Hip/Knee Arthroplasty
PreOperative Phase:
1-Preoperative Education:
As with any surgery, preoperative evaluation and optimization are critical prior to an elective procedure. Even thought of surgery can lead to anxiety and fear for many patients. Preoperative training promotes patient confidence, greater patient satisfaction, and early recovery and discharge.[5 Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Critical care medicine. 2004 Apr 1;32(4):S76-86.] A preoperative education programme should establish achievable goals for postoperative oral intake, analgesia, physical therapy, mobilization and rehabilitation.
Connor et al conducted a small study among patients undergoing primary hip or knee arthroplasty, relating preoperative education and anxiety scores . Watching a series of presurgery educational videos on YouTube was associated with significant improvement
in generalized anxiety scores, particularly in patients with high preoperative anxiety.[ O'Connor MI, Brennan K, Kazmerchak S, Pratt J. YouTube videos to create a “virtual hospital experience” for hip and knee replacement patients to decrease preoperative anxiety: a randomized trial. Interactive journal of medical research. 2016;5(2):e10.]
On the contrary, there is little evidence to support the use of structured preoperative education to reduce postoperative complications, improve pain, or shorten the length of hospital stay.
Many orthopedic centers provide a preoperative education class where a multidisciplinary team including nurses, physical and occupational therapists, and care coordinators explain the care pathway, and address patient's physical, social, and psychological needs prior to their surgery.
2-Preoperative assessment and organ dysfunction optimization:
Pre-existing conditions such as coronary artery disease, hypertension, chronic obstructive pulmonary disease, diabetes and organ dysfunction are strong determining factors of postoperative complications and duration of hospital stay.[ Cui HW, Turney BW, Griffiths J. The preoperative assessment and optimization of patients undergoing major urological surgery. Current urology reports. 2017 Jul 1;18(7):54.]It is crucial to meet with patients several weeks before their scheduled surgery. It allows the preoperative team to optimize any organ dysfunction, address issues that may cause any potential risk, and to optimize preoperative anemia. It also gives the opportunity to initiate alcohol and smoking cessation programs if indicated.
3-Preoperative fasting and nutrition:
The concept of fasting from midnight prior to anesthesia for elective surgeries has been challenged with ERAS programs and is now considered obsolete.Instead, clear fluid has been permitted up to 2 hours prior to induction of anesthesia and solid food has been permitted up to 6 hours prior to induction of anesthesia. Growing evidence suggests there is no patient safety benefit associated with prolonged fasting. Instead ,fasting for longer periods can induce a catabolic state, which can increase the stress response to surgery resulting in insulin resistance and hyperglycemia, thereby prolonging the recovery period. Malnutrition is associated with wound infection, delayed healing, sepsis, and increased risk of mortality. Additionally, ERAS recommends a carbohydrate load via a clear carbohydrate reach drink 2–3 hours before surgery. The idea is to present the patient to surgery in a metabolically fed state leading to less postoperative protein loss and preservation of muscle mass.
There is limited data available that specifically addresses the role of metabolic and postoperative joint restoration. Aronsson et Al randomized 29 patients randomized in a double-blind placebo-controlled pilot study to a carbohydrate-rich drink or to placebo pre-operatively.[ Aronsson A, Al-Ani NA, Brismar K, Hedström M. A carbohydrate-rich drink shortly before surgery affected IGF-I bioavailability after a total hip replacement. A double-blind placebo controlled study on 29 patients. Aging clinical and experimental research. 2009 Apr 1;21(2):97-101.] The primary result was a metabolic state determined by
concentrations of insulin-like growth factor-1. Compared to placebo, patients who received a carbohydrate drink had significantly higher insulin-like growth factor-1 5 days and 2 months after surgery, which was interpreted as evidence of anabolic status. The higher insulin-like growth factor-1 did not lead to long-term changes in body composition.
Others argue that it is not the carbohydrate content in the drink that provides the protective effect, but the volume state of the patient during induction of anesthesia.
To test this, 66 patients were randomized to starve, water or a carbohydrate drink before total hip replacement under spinal anesthesia. There was no difference between the three
groups for any markers of catabolism (insulin resistance, glucose clearance or cortisol concentration) or hemodynamic status. However, patients in the on an empty stomach group received 10% more intraoperative intravenous colloids.
Available data were obtained from small studies of patients with hip arthroplasty. The methods used to assess the anabolic / catabolic condition are controversial and not without controversy.
The risk against the benefits of liberal fasting and carbohydrate loading before elective colorectal surgery suggests that similar concepts could be safely and effectively applied to the selected joint
replacement.
4-Prophylaxis against Venous Thromboembolism :
The most commonly used venous thromboembolism (VTE) prophylaxis in the hospital are unfractionated and low molecular weight heparin. Various surgical societies have developed their recommendations for VTE prophylaxis. The two competing recommendations are from the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS) . The AAOS holds to the view that pulmonary embolism (PE) and DVT are regarded separately, and prevention should be more focused on PE. Complicating this decision is the use of neuraxial catheters in epidurals. The American Society of Regional Anesthesia and Pain Medicine recommends against the use of VTE prophylaxis 12 hours prior to insertion or removal of a catheter. These recommendations from the various societies must be considered with any ERAS protocol.[ Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, Blondeel P, Hamming J, Dayan J, Ljungqvist O. Consensus review of optimal perioperative care in breast reconstruction: enhanced recovery after surgery (ERAS) society recommendations. Plastic and reconstructive surgery. 2017 May 1;139(5):1056e-71e.]
Intraoperative Phase:
The goal in the intraoperative phase is to reduce the physical stress of the surgery. Stress-free anesthesia and surgery to attenuate the trauma-induced physiological responses leading to a reduction of morbidity and mortality have been proposed. Reducing the physical stress of the surgery can be achieved with:
1-Minimally invasive surgical techniques:
Neuraxial anesthesia has always been preferred and considered superior to general anesthesia in ERAS protocols. It provides a sympathetic blockade, inhibits stress hormone release, and attenuates postoperative insulin release. When compared with general anesthesia, spinal anesthesia has been associated with shortened length of hospital stay, reduction in pulmonary complications, kidney injury, blood transfusion, and 30-day mortality.[ Alvarez A, Goudra BG, Singh PM. Enhanced recovery after bariatric surgery. Current opinion in anaesthesiology. 2017 Feb 1;30(1):133-9.] Local infiltration analgesia (LIA) is administered by surgeons intraoperatively, in and around the joint. Ropivacaine is most commonly used as local anesthetic, mixed with epinephrine and/or steroids. McCarthy et al in a systemic review concluded that LIA is more useful when used in total knee arthroplasty. It provides postoperative pain relief 6–12 hours after total knee arthroplasty. However, when used in total hip arthroplasty, it has no analgesic effect.[ McCarthy D, Iohom G. Local infiltration analgesia for postoperative pain control following total hip arthroplasty: a systematic review. Anesthesiology research and practice. 2012;2012.]
2-Maintaining normothermia:
Normothermia has been considered part of the anesthetic management in ERAS programs for joint arthroplasty. Maintaining perioperative normothermia and preventing intraoperative heat loss have been associated with reduced infections, coagulopathy, blood transfusion rate, and cardiovascular complications.Preoperative operating room warming did not prevent intraoperative hypothermia in total joint replacement surgery.[ Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: A review of the evidence. Br J Anaesth. 2016;117:iii62–72]
3-Optimal intraoperative fluid balance:
Goal-directed fluid management is an important component of ERAS protocols for all types of surgeries, comprising preoperative , intraoperative and postoperative fluid management. Strict fluid management may be more important in larger surgeries that may have more blood loss associated with the procedures, as opposed to elective total joint replacements. Patients in an ERAS protocol generally have less fluid deficits since they avoid prolonged fasting and bowel preparation in surgery. Regardless, goal-directed fluid replacement therapy can result in less postoperative infection, organ dysfunction, and transfusion requirements[ Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2015 Feb 1;62(2):158-68.]
Intravenous fluids should be discontinued as soon as the patient can take in enough fluids by mouth.
Hence ERAS obviate the use of preoperative fluid replacing it with Carbohydrate rich fluid a 2 hours before procedure , which further reduce intraoperative fluid equiremnt owing to hydrated status of patient and further encourage discontinuation of fluid in postoperative phase as soon as patient resume oral intake.
4-Preoperative Anesthetics:
Regional anesthesia is the optimal ERAS technique for hip and knee joint replacement. Studies have shown that providing analgesia using nerve block leads to improved physiological performance in specific organ systems.[ Desborough JP. The stress response to trauma and surgery. British journal of anaesthesia. 2000 Jul 1;85(1):109-17.]
Neuroaxial anesthesia is sufficient for surgery, provides sympathetic blockage, inhibits the secretion of stress hormone and weakens the postoperative insulin secretion.[ Halter JB, Pflug AE. Effects of anesthesia and surgical stress on insulin secretion in man. Metabolism. 1980 Nov 1;29(11):1124-7.]
The most recent meta-analysis of 29 studies, including 10,488 patients, showed that neuroaxial anesthesia reduces the duration of stay by almost half a day compared to general anesthesia..[ Johnson RL, Kopp SL, Burkle CM, Duncan CM, Jacob AK, Erwin PJ, Murad MH, Mantilla CB. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. BJA: British Journal of Anaesthesia. 2016 Jan 19;116(2):163-76.]
Multi-institutional retrospective studies link the use of general anaesthesia with an 8.5-fold elevated risk of moderate to severe postoperative pain and a 2.5-fold elevated risk of sustained postoperative pain in knee arthroplasty.. [ Liu SS, Buvanendran A, Rathmell JP, Sawhney M, Bae JJ, Moric M, Perros S, Pope AJ, Poultsides L, Della Valle CJ, Shin NS. Predictors for moderate to severe acute postoperative pain after total hip and knee replacement. International orthopaedics. 2012 Nov 1;36(11):2261-7.]
Postoperative Phase:
Enhancing postoperative comfort by reducing pain and post operative nausea and vomiting and optimizing postoperative care are the key elements of post operative phase .Early mobilization and rehabilitation are the integral part of ERAS in orthopaedic care.
1-Multimodal opioid-sparing analgesic techniques:
Multimodal analgesia is the combination of analgesic techniques and various analgesic drugs from different pharmacological classes. Epidural analgesia, continuous or patient-controlled, peripheral nerve blocks, single injection or continuous, acetaminophen, NSAIDs, gabapentin, and ketamine, have all been used for this purpose. An important component of an ERAS protocol is to provide an effective postoperative pain relief. However, postjoint arthroplasty pain can be challenging. The aim of postoperative pain management should be directed toward reducing the discomfort more than eliminating the pain. Reducing the pain as much as possible must be weighed against the medications, side effects, and the delay in mobilization due to any regional technique or nerve block.[ Halawi MJ, Grant SA, Bolognesi MP. Multimodal analgesia for total joint arthroplasty. Orthopedics. 2015;38:e616–25]
2-Prevention of postoperative nausea and vomiting:
The typical risk factors for postoperative nausea and vomiting (PONV) are female sex, nonsmoker, history of PONV, motion sickness, and the need for postoperative opioids.[ Apfel CC, Kranke P, Eberhart LH, Roos A, Roewer N. Comparison of predictive models for postoperative nausea and vomiting. British journal of anaesthesia. 2002 Feb 1;88(2):234-40.] The best way to prevent PONV is to avoid using general anesthesia and opioids altogether. Total intravenous anesthesia with minimization of volatile anesthetics while maximizing regional and neuraxial techniques will likely decrease postoperative nausea and vomiting. Patients with two risk factors should receive dexamethasone at induction or the end of the procedure or a serotonin receptor antagonist at the end of the procedure. Those with three or more risk factors should receive both.
3-Early mobilization and rehabilitation:
Prolonged bed rest postoperatively is associated with increased risk of thromboembolism , pulmonary complications and delayed wound healing. Early mobilization and physical therapy are key elements of successful ERAS protocol. A detailed assessment preoperatively to identify the patient's expectations and the goals of rehabilitation is important. Physical therapy is recommended on day 0 and as early as 2–6 hours postoperatively as permitted by patient stability. Adequate analgesia with the multimodal approach is vital to enable successful and less distressing early ambulation.
Adverse physiological effects of prolonged bed rest include increased resistance to insulin, myopathy, decreased pulmonary function, impaired tissue oxygenation and increased risk.
Recent meta-analysis shows a significant reduction in the duration of stay (by 1.8 days), when patients move within 24 hours after surgery..[ Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clinical rehabilitation. 2015 Sep;29(9):844-54.] Early mobilisation after arthroplasty of the knee joint is also associated with improved functional recovery93 and reduced TGV frequency.[ Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. The Journal of bone and joint surgery. British volume. 2007 Mar;89(3):316-22.] [ Chandrasekaran S, Ariaretnam SK, Tsung J, Dickison D. Early mobilization after total knee replacement reduces the incidence of deep venous thrombosis. ANZ journal of surgery. 2009 Jul;79(7-8):526-9.]
Conclusion:
Notable progress has been made in the application of ERAS in orthopaedic surgery. Decades of research have made it possible to improve patient safety, improve results, shorten inpatient stay and achieve savings. However, significant work remains to be done to fill a gap that has already been covered by many specialties such as colorectal surgery and urology. Additional evidence is needed to confirm that the adoption of ERAS protocols is beneficial for patients with hip and knee replacement. Future research should focus on understanding which components contribute to improved recovery and through which mechanism and adoption should be a priority for collaborative endoprosthetics providers..
References: