Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Table 1 Summary of enhanced recovery after surgery pathways for oncology patients who will undergo hip or knee reconstruction surgery

Preoperative approach
Informed consent	Patient should be informed and consented about all the care practices he/she will receive, the expected results from his/her care, the active role he/she will have in the program and to meet all the members of the interdisciplinary team
Health history and determination of the patient's vital function	To determine patient’s vital function and to identify any health conditions that can be improved prior to surgery. Patient of high risk are identified by calculating individual risk based history, symptoms, health status using specific questionnaires
Counseling	Targeted preoperative counseling. It is recommended to quit smoking 2-4 wk and drinking alcohol 4 wk prior to surgery
Preoperative fasting	ERAS protocols recommend 2 h of fasting from clear fluids and 6 h of solids prior to induction of anesthesia
Preoperative anemia management	Preoperative anemia should be evaluated and treated before surgery
Intraoperative phase
Anesthesia protocol	Standard Anesthetic Protocol and neuraxial techniques as a part of a multimodal approach
	GA with TIVA using continuous drip infusion of Propofol and Remifentanil is recommended by ERAS pathways
Neuraxial anesthesia	The gold-standard of ERAS programs is the use of epidural or spinal anesthesia, but especially for hip or knee replacement surgery is not recommended as a routine alone
RA/analgesia	A multimodal approach to pain management with RA and MA is supported by ERAS protocols. Should not be considered as an alternative technique to GA, but as a complement to an integrated strategy
Intraoperative analgesia	The use of NSAIDs or COX-2 inhibitors is recommended for the treatment of pain, in combination with paracetamol, in order to significantly reduce the use of opioid drugs in the context of a MA
Optimal intraoperative fluid management	Optimal fluid balance is necessary to avoid over or under hydration. Intraoperative isotonic crystalline fluids are administered to maintain the homeostasis and the electrolyte balance at a rate of 3-5 mL/kg/h
Prevention and treatment of perioperative nausea and vomiting	It is recommended to administer IV ondansetron 4 mg before induction to anesthesia and metoclopramide 30 min before awakening. Especially for high-risk patients, a combination of 2-3 antiemetics is recommended (ondansetron, dexamethasone, droperidol)
	Chewing gum postoperatively appears to help mobilize the gastrointestinal system
Normothermia	Normal body temperature is achieved by the use of electric hot air devices (for the patient's body) and fluid warmer devices for the IV fluids or blood agents to 37-40 ℃
	The temperature of the operating room should not be under 21 ℃
Prophylactic anticoagulant treatment	Rapid mobilization, elastic anticoagulant socks and low molecular weight heparin anticoagulant therapy for 28 d in hip surgery and 14 d in knee surgery, are recommended
Antimicrobial prophylaxis	The most suitable antibiotic for prophylactic antimicrobial treatment is 1st or 2nd generation cephalosporin (cefazolin or cefuroxime) intravenously 30-60 min before the skin incision, as a single-dose, depending on the patient's weight (weight-adjusted dose)
Surgical management	The ERAS Society makes no recommendations for surgical technique
	However, it recommends avoiding the use of tourniquets and drains as a routine in all operations
Postoperative phase
Postoperative analgesia	Effective postoperative pain management includes a combination of analgesic drugs with central and peripheral action
	Postoperative analgesia is determined and depends on the intraoperative analgesia plan and follows the same method used
	The use of paracetamol 1 gr in combination with lornoxicam or celecoxib/parecoxib is recommended
	Oral analgesia as soon as patients begins to eat
Postoperative fasting	Clear fluids or jelly 4-6 h post-surgery. Return to normal diet as soon as possible
Prevent falls after surgery	Many factors can contribute to the fall after TKA and THA, such as reoperation, elderly, female gender and comorbidities, which highlights the importance of establishing a multidisciplinary fall prevention program at every orthopedic ward
Physiotherapy approach	Physiotherapy, Kinessiotherapy, Strengthening
	Physiotherapy rehabilitation of the patient undergoing TKA or THA should begin much earlier than the day of surgery, as counseling
	After the physical evaluation, interventions are made to reduce BMI and increase muscle strength by increasing physical exercise and activity
	The procedure can be started up to 4 wk before scheduled surgery, with regular sessions aimed at early mobilization
	Respiratory physiotherapy with 3-flow spirometer

ERAS: Enhanced recovery after surgery; TIVA: Total intravenous anesthesia; BMI: Body mass index; GA: General anesthesia; MA: Multimodal analgesia; NSAIDs: Nonsteroidal anti-inflammatory drugs; COX-2: Cyclooxygenase-2; TKA: Total knee arthroplasty; THA: Total hip arthroplasty; RA: Regional anesthesia.