Yoeri Bemelmans

Chapter 1 10 analgesia (PCA)), shorten LOS (e.g. introduction of discharge criteria) and improved patient satisfaction (e.g. involvement of a coach, patient centred care) [6,7]. A less stringent postoperative policy was then introduced, making it able for patients to be mobilised the first day after surgery. These optimisations tremendously changed the in-hospital treatment of arthroplasty patients in terms of postoperative outcomes (e.g. reduction of transfusion rate and thrombo-embolic events, and improvement of pain scores and patient reported outcomes measures (PROMs)) and reduced LOS [8]. The introduction of evidence-based pathways was thereby established as an indispensable factor in the treatment of hip and knee arthroplasty patients. Fast-track surgery and surgical stress response As a further development of the previously described pathways, fast-track surgery pathways were introduced in the 21 st century [9]. The fast-track philosophy is based on the reduction of the surgical stress response [10]. This response is characterized by activation and changes of several systems. After surgical tissue injury, the nervous system activates the stress response leading to an endocrine response, as well as induction of changes in the immunological and haematological systems with a systemic inflammatory response [11]. To manage and even reduce this response, optimised perioperative protocols are needed to guide the patient through the operative process with minimized effects of surgical stress. The surgical stress tops within the first days after surgery. Therefore, the first days (even first hours) after surgery are of crucial importance to prevent for (S)AEs. Several crucial optimisations are the basis of an optimised pathway and the reduction of surgical stress, starting preoperatively until the end of the rehabilitation. For example, with the introduction of a multimodal pain protocol, which included a time-based schedule of several non-opioid medications, the consumption and need for opioid medication could be significantly reduced [12]. One of these factors is the usage of local infiltration analgesia (LIA) in knee arthroplasty [13]. Furthermore, systemic glucocorticoids were introduced to prevent for PONV [14]. With a positive side effect on pain reduction, systemic glucocorticoid holds an important role in early discharge. Low-dose spinal anaesthesia or low dose opioid general anaesthesia provided the basics for patients to be mobilised early during the direct postoperative phase. Combined with LIA, patients are able to mobilise safe within several hours after surgery. Which allows to rapidly achieve discharge criteria (e.g. safe mobilisation, walking stairs with crutches if necessary, adequate aids at home) and decreases (S)AEs (e.g. thrombo-embolic events, joint stiffness).