...high dose steroids reduced the amount of patient-reported pain within the first 1-2 days after both hip and knee arthroplasty. there is a large body of evidence to guide decision making in constructing pathways of care, there are equally large gaps in knowledge which suggest avenues for future work. Many ERAS interventions are resource-intensive, so understanding which patients benefit from which components is of primary importance. The literature suggests that education programs could be most effective for anxious or socially isolated patients,13 although it remains to be seen if standardizing the content and method of delivery would have a positive effect for all patients. Likewise, the optimal analgesic regimen has yet to be determined, despite an abundance of choice: epidural, peripheral nerve block or catheter, local infiltration analgesia, and oral/intravenous multimodal agents all show analgesic efficacy and are opioidsparing after TJA. Ultimately, these decisions might have to be made according to institutional practice and capability. The risk-to-benefit balance of preoperative carbohydrate loading has yet to be established in TJA and the role of goal-directed fluid therapy is unclear – and may turn out to be of lesser importance compared to colorectal surgery. The concept of auditing compliance and outcomes, and using institution-specific data to refine pathway components, is currently lacking in TJA clinical pathway care. Additionally, some have argued for a shift of clinical and research efforts from current construction of TJA ERAS pathways, to more broad peri-operative strategies to improve post-discharge function, rehabilitation potential, and global recovery, areas that may prove equally as important to patient outcomes.14 Recent arthroplasty research has focused on improving global recovery through avoiding common postASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org Mallinckrodt, the “M” brand mark and the Mallinckrodt Pharmaceuticals logo are trademarks of a Mallinckrodt company. © 2015 Mallinckrodt. June 2015 operative complications such as anemia and pain. In two separate studies, consecutive patients were enrolled in a multidisciplinary hemoglobin management program that involved pre-operative anemia work-up and management. Both studies were able to show reduced post-operative transfusion rates when compared with a historical cohort.15,16 In order to minimize post-operative pain and nausea, two randomized, placebo-controlled trials were conducted to assess the role of high-dose steroids administered during hip and knee arthroplasty. Although each study enrolled fewer than 100 patients, high dose steroids reduced the amount of patient-reported pain within the first 1-2 days after both hip and knee arthroplasty.17,18 Because of the safety and efficacy of clinical pathways in TJA, we are increasingly offering surgery to patients who probably would have been denied surgery in the past. It has become routine to perform joint replacement for the elderly, morbidly obese, high ASA Physical Status, and/or chronic opioid dependent patient. Demand for same-day or same-admission bilateral TJA is also increasing. These changing patterns require increasingly creative strategies to understand and implement best practice. It may be the right time to standardize language in order to facilitate research and practice. “Clinical pathway”, “ERAS”, “Perioperative Surgical Home” and “Fast Track” are used interchangeably in SEEING COMPLEXITY IN A NEW LIGHT. For nearly 150 years, Mallinckrodt has made complex scientific problems manageable, developing valuable diagnostic tools and treatments for patients who need them. We view challenges as opportunities. See how at Mallinckrodt.com 7
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