Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Table 1 GRADE system for rating strength of recommendations and rating quality of evidence (Guyatt et al[15], 2008)

Recommendation strength	Definition
Strong	Desirable effects of intervention clearly outweigh the undesirable effects, or clearly do not
Weak	When trade-offs are less certain—either because of low-quality evidence or because evidence suggests desirable and undesirable effects are closely balanced
Evidence level	Definition
High quality	Further research unlikely to change confidence in estimate of effect
Moderate quality	Further research likely to have important impact on confidence in estimate of effect and may change the estimate
Low quality	Further research very likely to have important impact on confidence in estimate of effect and likely to change the estimate
Very low quality	Any estimate of effect is very uncertain

Table 2 Summary of recommended interventions for the perioperative care of knee replacement

		Recommendation	Recommendation grade	Level of evidence
Preoperative	Preoperative information, education and counselling	Preoperative patient education recommended	Strong	Low
Preadmission patient optimization	Smoking	Smoking cessation for 4 wk or more recommended before surgery	Strong	High
	Alcohol	Alcohol cessation recommended before surgery	Strong	Low
	Anemia	Anemia should be identified, investigated, and corrected prior to surgery	Strong	High
	Preoperative physiotherapy	Not recommended as an essential intervention	Strong	Moderate (for not recommending)
Perioperative	Preoperative fasting	Intake of clear fluids until 2 h before the induction of anesthesia, and a 6-h fast for solid food is recommended	Strong	Moderate
	Preoperative carbohydrate treatment	Not currently recommended as an essential routine Intervention	Strong	Moderate (for not recommending)
	Pre-anesthetic medication	routine administration of sedatives to reduce anxiety preoperatively is not recommended	Strong	Low
Standardized anesthetic protocol	General versus central neuraxial anesthesia	Both may be used as part of multimodal anesthetic regimes	Strong	Moderate (for both)
	Spinal (intrathecal) opioids	Not recommended for routine use	Strong	Moderate
	Epidurals	Not recommended for routine use	Strong	High (analgesic efficacy), moderate (negative safety and side-effect profile)
	Use of local anesthetics for nerve blocks and infiltration analgesia	LIA recommended for knee replacement Nerve blocks are therefore not recommended as an essential ERAS component	Strong	High (LIA in knee replacement)
Postoperative	Nausea and vomiting	screening for and multimodal PONV prophylaxis and treatment	Strong	Moderate
	Prevention of perioperative blood loss-tranexamic acid	Recommended to reduce perioperative blood loss	Strong	High
Multimodal analgesia	Paracetamol	Recommended for routine use	Strong	Moderate
	Non-steroidal anti-inflammatory drugs (NSAIDs)	Routine use of NSAIDS recommended for patients without contraindications	Strong	High
	Gabapentinoids	Not recommended currently	Strong	Moderate (for not recommending)
	Supplemental opioid analgesia	ERAS programs seek to minimize the use of opioids. However, opioids such as oxycodone may be used when required as part of a multimodal approach	Strong	High
Perioperative factors	Maintaining normothermia	Normal body temperature should be maintained peri- and postoperatively through pre-warming and the active warming of patients intraoperatively	Strong	High
	Antimicrobial prophylaxis	Systemic antimicrobial prophylaxis recommended in accordance with local policy and availability	Strong	Moderate
	Antithrombotic prophylaxis treatment	Patients should be mobilized as soon as possible post-surgery and receive antithrombotic prophylaxis treatment in accordance with local policy	Strong	Moderate
Perioperative surgical factors	Surgical technique	No recommendation on surgical technique	Strong	High
	Use of tourniquet	Routine use not recommended	Strong	Moderate
	Surgical Drain	Routine use not recommended	Strong	Moderate
	Fluid management	Intravenous fluids – judicious use	Strong	Moderate
		Postoperative intravenous fluids – discouraged in favor of early oral intake
	Urinary catheter	Routine use – not recommended	Strong	Moderate
		When used – should be removed as soon as the patient is able to void, ideally within 24 h of surgery
		Recommended catheterization threshold – 800 mL
	Nutritional care	Early return to normal diet recommended	Strong	Low
	Early mobilization	Patients should be mobilized as early as they are able to in order in order to facilitate early achievement of discharge criteria	Strong	Strong
	Criteria-based discharge	Objective discharge criteria should be used to facilitate patient discharge directly to their home	Strong	Low
Continuous improvement and audit		Routine internal and/or external audit of process measures, clinical outcomes, cost effectiveness, patient satisfaction/experience, and changes to the pathway is recommended	Strong	Low