Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS^®) Society recommendations

Figures & data

Table 1. GRADE system for rating quality of evidence (Guyatt et al. 2008)

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. GRADE system for rating strength of recommendations (Guyatt et al. 2008)

Recommendation strength	Definition
Strong	When 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

Table 3. Summary of recommended interventions for the perioperative care of hip and knee replacement

Number Item	Recommendation	Evidence level	Recommendation grade	Number Item
1	Preoperative information,	Patients should routinely receive preoperative education education and counseling	Low	Strong
2	Preoperative optimization	4 weeks’ or more smoking cessation is recommended prior to surgery.	Smoking: High	Strong
		Alcohol cessation programs are recommended for alcohol abusers	Alcohol: Low	Strong
		Anemia should be actively identified, investigated, and corrected preoperatively	High
3	Preoperative fasting	Clear fluids should be allowed up to 2 h and solids up to 6 h hours prior to induction of anesthesia	Moderate	Strong
4	Standard anesthetic protocol	General anesthesia and neuraxial techniques may both be used as part of multimodal anesthetic regimes	General anesthesia: moderate neuraxial techniques: Moderate	Strong
5	Use of local anesthetics for infiltration analgesia and nerve blocks	Within a multimodal opioid-sparing analgesic regimen, the routine use of LIA is recommended for knee replacement but not for hip replacement	LIA in knee replacement: High	Strong
		Nerve block techniques have not shown clinical superiority over LIA
6	Postoperative nausea and vomiting	Patients should be screened for and given multimodal PONV prophylaxis and treatment	Moderate	Strong
7	Prevention of perioperative blood loss	Tranexamic acid is recommended to reduce perioperative blood loss and the requirement for postoperative allogenic blood transfusion	High	Strong
8	Perioperative oral analgesia	A multimodal opioid-sparing approach to analgesia should be adopted	Paracetamol: Moderate	Strong
		The routine use of paracetamol and NSAIDs is recommended for patients without contraindications	NSAIDS: High	Strong
9	Maintaining normothermia	Normal body temperature should be maintained peri- and postoperatively	High	Strong
10	Antimicrobial prophylaxis	Patients should receive systemic antimicrobial prophylaxis	Moderate	Strong
11	Antithrombotic prophylaxis treatment	Patients are at increased risk of VTE and should undergo pharmacologic and mechanical prophylaxis in line with local policy	Moderate	Strong
12	Perioperative surgical factors	There is no conclusive evidence that choice of surgical approach accelerates the achievement of discharge criteria	High	Strong
		Therefore no recommendation can be given
13	Perioperative fluid management	Fluid balance should be maintained to avoid over- and under-hydration	Moderate	Strong
14	Postoperative nutritional care	An early return to normal diet should be promoted	Low	Strong
15	Early mobilization	Patients should be mobilized as early as they are able in order to facilitate early achievement of discharge criteria	Moderate	Strong
16	Criteria-based discharge	Team-based functional discharge criteria should be used to facilitate patient discharge directly to their home	Low	Strong
17	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	Low	Strong

Guyatt G H, Oxman A D, Vist G E, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann H J, Group GW. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336(7650): 924–6.

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