anesthesiologists contribute to successful outpatient joint replacement pro-
grams, beginning with working hard to set up patients for smooth recover-
ies.
1. Pre-op preparation
There's a lot of buzz surrounding the Enhanced Recovery After Surgery
(ERAS) movement as it pertains to total joints, and rightly so. Joint
replacements are perfectly suited for the bundled payment model in which
insurers pay a single global fee to surgeon groups and surgical facilities to
deliver an entire episode of care, beginning when cases are scheduled and
ending 90 days after surgery. The basic concept of ERAS dovetails nicely
with what it takes to manage patients during that period: a holistic, multi-
disciplinary approach from the preoperative phase straight through to
recovery is paramount to a positive surgical outcome.
In the pre-op phase, anesthesiologists identify candidates for surgery and
optimize comorbid conditions, including:
• Anemia. Hemoglobin levels lower than 13 g/dL are associated with
an increased need for blood transfusions and can lead to a number of
post-op complications that can delay ambulation and physical therapy.
Anemia is easily treated pre-operatively with iron supplements and/or
erythropoietin.
• Glycemic control. Elevated A1C is linked to a higher rate of surgical-
related infection. In general, patients should have an A1C of < 8 mg/dL
before surgery.
• NPO status. Some providers and patients think pre-op fasting means
drinking or eating nothing after midnight the night before surgery. That
shouldn't be the case. The American Society of Anesthesiologists recom-
mends that patients should be allowed to drink water up to 2 hours before
procedures. That's why I tell patients to drink 2 glasses of water before
bed, and 2 glasses before they leave in the morning for surgery. This sim-
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