Table 1 The consented pharmacotherapeutic options within each ERAS element for orthopedic joint surgery

Antihypertensive drugs

 Stop reserpine at least 5 days before the surgery

Continue with previous

antihypertensive regimen, reserpine be substituted with other antihyperten-

sives (calcium channel

blockers, angiotensin-

converting enzyme inhibitors, et al.)

 Avoid acute withdrawal of a beta blocker

 Withhold angiotensin converting enzyme inhibitors and angiotensin receptor blockers on the morning of surgery. For heart failure or poorly controlled

hypertension, continue to avoid further exacerbation of these

conditions

Antidiabetic drugs

 Not achieving goals: switch sulfonylurea to insulin glargine, insulin detemir or for other basic insulin; insulin lysine before meals

Continue with insulin therapy if necessary, for a stable glycemic control

 Consider adding metformin according to the blood glucose level

Preoperative analgesia

 Pain assessment

Pain assessment

 Adding NSAIDs, selective

cyclooxygenase-2 inhibitors

preferred if numeric rating

scales for pain > 3

Parecoxib or flurbiprofen(i.v) for 3 days, then continue with celecoxib (P.O.)if necessary

 Adding pregabalin or duloxetine (venlafaxine) for neuropathic pain

Adding pregabalin or duloxetine (venlafaxine) for neuropathic pain

 Adding tramadol (P.O) or acetaminophen if necessary

Adding tramadol (P.O) or acetaminophen if necessary

 Screening for mistakenly combination of two NSAIDs, tramadol (PCIA) and tramadol (P.O.), tramadol and duloxetine (venlafaxine)

Screening for mistakenly combination of two NSAIDs, tramadol (PCIA) and tramadol (P.O.), tramadol and duloxetine(venlafaxine)

 Parecoxib 40 mg (iv) before induction

Corticosteroids (patients who are now using or have history of using corticosteroids

 Evaluation of HPA axis suppression

 Continue with current corticosteroids therapy

Continue with current cor-

ticosteroids therapy

 For suppressed the HPA axis: hydrocortisone infusion 100 mg before anesthetic induction,50 mg q8h for 24 h after

sugery → 25 mg q8h, 24 h → 50 mg qd, 24 h → 

discontinue

For suppressed HPA axis: hydrocortisone infusion 50 mg q8h for 24 h after sugery → 25 mg q8h, 24 h → 50 mg qd,24 h → discontinue (evaluation of symptoms like nausea /vomiting/ tachycardia/ hyponatremia / hypotension)

Medication affecting hemostasis

 Discontinue aspirin or clopidogrel at least 5 days before the surgery, switching to low molecular weight heparin (LMWH) if necessary

Resumption of original antithrombotic therapy 24 h after surgery, typically the evening of the day of surgery or the evening of the day after surgery, as long as adequate hemostasis has been achieved

 Discontinue rivaroxaban, dabiga-tran, apixaban for 3 days

 before the surgery, switching toLMWH if necessary

 Discontinue warfarin after admission, bridging to LMWH

 Discontinue LMWH 12 or 24 h before the surgery

Medicine for sleep disorder

 Patients with new developed

insomnia: screening and

evaluating of medication that may disturb sleep (theophylline,

steroids et al.) adjust timing of administration to avoid

disturbance at night

The same strategy as before surgery

 Patients with new insomnia (Nonpharmacologic strategies not effective) initiation of non-benzodiazepines: zolpidem/ zopiclone

 For patients with anxiety or reduced total sleep time: benzodi-azepines (estazolam, apozolam). Long-acting benzodiazepines

(clonazepam) should be

avoided in older adults

Antipsychotics for delirium

 Assessment of delirium especially for senior patients with Alzheimer disease

The same strategy as before surgery

 Assessment of pain

 Initiation of small dose quetiapine, olanzapine if delirium presented

 Low-dose haloperidol (0.5 to 1 mg) be used as needed to

control moderate to severe agitation (avoided in patients with parkinsonism)

Prophylactic antibiotics

 Cefuroxime or cefazolin infusion 30 min before incision

Antibiotic prevention order should be discontinued within 24 h after surgery

 Vancomycin infusion 1–2 h before incision

 Clindamycin infusion 30 min before incision if patients are allergic to Cephalosporins

Antibiotic treatment for PJI

 Microbial cultivation (synovial fluid or blood) before initiation of antimicrobial therapy

Before transferring to other hospital: verification of medication supply in accordance with the present regimen

 Empiric therapy: vancomycin combined with levofloxacin/ a third- or fourth-generation cephalosporin/ piperacillin- tazobactam

 Definitive therapy should be based on the culture results and the effect of antibiotics used

 For patients with S. aureus PJI and residual hardware following surgery (eg, patients who undergo debridement with retention or patients who undergo one-stage exchange), using rifampin in combination with at least one other anti-staphylococcal agent

 Vancomycin level monitoring and dosage/interval adjustment to reach the trough level of 15–20 mg L⁻¹