Effectiveness of enhanced recovery after surgery in the perioperative management of patients with bone surgery in China

Table 1 Enhanced recovery after major bone tumor surgery

Phase	Item	ERAS pathway	Conventional care
Preoperative	Patient and family	Detailed communication of the basic knowledge of the tumor, the purpose and method of surgery, rehabilitation process, postoperative further treatment. Requested informed consent for study participation	Routine consultation. Requested informed consent for study participation
	Patient evaluation	Preoperative KPS, pain VAS score, anxiety and depression HADS score, nutritional status NRS 2002 score, VTE Caprini Risk Assessment Scale	Preoperative KPS, pain VAS score, anxiety and depression HADS score, nutritional status NRS 2002 score, VTE Caprini Risk Assessment Scale
	Nutritional intervention	Nutritional consultation for patients with BMI < 18.5 or > 24, serum albumin level < 3.5 g/dL	Nutritional consultation as needed
	Antithromboticprophylaxis	Active/passive limb movement, plantar vein pump, intermittent air pressure device, color Doppler ultrasound screening of lower extremity vein	Active/passive limb movement, plantar vein pump, intermittent air pressure device
	Preventive analgesia	Use of opioids to reduce central and peripheral sensitivity to pain and relieve preoperative anxiety	No
	Blood management	HB raised to above 100 g/L	No
	Diet management	Liquid food 2 h before anesthesia and solid food 6 h before anesthesia for patients without aspiration risk	Fasting time for 6-8 h
Intraoperative	General anesthesia	Combined IV-inhalation anesthesia, induced with propofol sufentanil and rocuronium, and maintained with propofol, fentanyl, and sevoflurane	Combined IV-inhalation anesthesia, induced with propofol sufentanil and rocuronium, and maintained with propofol, fentanyl, and sevoflurane
	Local incisionanesthesia	Local infiltration anesthesia or intraspinal anesthesia according to patient condition	No
	Control bleeding	Selective interventional embolization and balloon occlusion of abdominal aorta; Intraoperative control of hypotension and antifibrinolytic drugs administration	Selective interventional embolization and balloon occlusion of abdominal aorta
	Pain management	Adductor block under the guidance of ultrasound during anesthesia. Drug injection into the periarticular area. Prescriptions included ropivacaine, morphine, ketorolac tromethamine, betamethasone, and norepinephrine	Opioids
	Infusion restriction	Limited infusion, rational use of colloid and crystal gel combined with intraoperative infusion	No
	ICU and extubation	Avoid admission to ICU extubate at end of surgery	Routine admission to ICU delayed extubation in ICU
Postoperative	Diet	Oral free fluids: 6 h after surgery light diet, 8 h after surgery as tolerated by the patient; semi-liquid/solid diet, 12-24 h after surgery; ordinary diet, 24-48 h after surgery	Oral liquid diet
	Infusion restriction	Daily infusion volume less than 1500 mL	No restrictions
	Pain management	Combined with selective COX-2 inhibitors, opioids, sedatives, hypnotics, and anxiolytics	Combined with selective COX-2 inhibitors
	Blood management	Elastic bandage applied to the incision of limb surgery, icing, and limb elevation	No
	Urinary catheterremoval	Early removal of urinary catheter within 24 h after surgery whenever possible	Routine removal of urinary catheter on POD 1-2
	PONV	Prevention with dexamethasone or serotonin receptor	No
	Early mobilization	In-bed mobilization, 6 h after surgery early ambulation, POD1	Routine mobilization and ambulation
Discharge	Patient assessment	Preoperative KPS, pain VAS score, anxiety and depression HADS score,	Preoperative KPS, pain VAS score, anxiety and depression HADS score Nursing satisfaction
	Other assessments	Complications, LOS	Complications, LOS
Follow-up	Patient evaluation 30d after discharge	Satisfaction, VAS, daily standing walking time	Satisfaction, VAS, daily standing walking time

BMI: Body mass index; ERAS: Enhanced recovery after surgery; KPS: Karnofsky Performance Status; VAS: Visual analog scale; HADS: Hospital Anxiety and Depression Scale; NRS 2002: Nutritional Risk Screening 2002; VTE: Venous thromboembolism; PONV: Postoperative nausea and vomiting; ICU: Intensive care unit; POD: Postoperative day; LOS: Length of stay.

Table 2 Patient baseline demographics and clinical characteristics

	Study group	Control group	t/χ2	P value
Sex (male/female)	34/19	38/16	0.47	0.49
Age1 (yr)	48.59 ± 5.21 (22-65)	46.54 ± 4.86 (21–62)	2.24	0.13
BMI (kg/m2)2	18.73 ± 3.92	19.21 ± 4.04	0.14	0.89
Preoperative VAS2	6.57 ± 1.08	6.61 ± 1.24	0.23	0.56
Fasting blood glucose2 (mmol/L)	6.42 ± 1.11	6.61 ± 1.67	2.89	0.07
Complication, n (%)
Diabetes	9 (16.98)	4 (7.41)	1.49	0.22
Hypertension	35 (66.04)	27 (50.0)	2.82	0.09
Chronic heart disease	6 (11.32)	6 (11.11)	0.12	0.97
Liver/gallbladder	4 (7.55)	3 (5.56)	0.01	0.98
Lung	7 (13.21)	9 (16.67)	0.02	0.86
KPS3	90 (60-100)	90 (70-100)	1.71	0.18
Anxiety3	6 (1-20)	7 (2-17)	0.42	0.34
Depression3	4 (1-18)	6 (2.18)	0.27	0.45
Surgical site
Spine	15	16	0.61	0.89
Pelvis	7	6
Upper limb joint	7	5
Lower limb joint	24	27

¹mean ± SD (range).

²mean ± SD.

³Median (P25-P75). BMI: Body mass index; VAS: Visual analog scale; KPS: Karnofsky Performance Status.

Table 3 Comparison of the main outcome measures between groups after bone tumor surgery

	Study group	Control group	t/χ2	P value
LOS1 (d)	7.72 ± 3.34	10.28 ± 4.27	23.47	0.00
Complications, n (%)
PONV	16 (30.19)	38 (70.37)	17.28	0.00
Incision infection	8 (15.09)	14 (25.93)	1.92	0.17
Urinary tract infection	5 (9.43)	7 (12.96)	0.34	0.56
Pulmonary infection	5 (9.43)	3 (5.96)	0.58	0.45
VTE	0	0
30-d readmission, n (%)	7 (13.21)	11 (20.37)	0.98	0.32
Death	0	0

¹mean ± SD. LOS: Length of stay; PONV: Postoperative nausea and vomiting; VTE: Venous thromboembolism.

Table 4 Comparison of the secondary outcome measures between two groups after bone tumor surgery

	Study group	Control group	t/χ2	P value
VAS of POD 11	4.79 ± 2.34	5.28 ± 3.27	13.47	0.00
VAS of POD 31	2.79 ± 1.53	3.98 ± 2.27	8.23	0.01
VAS 1 mo after discharge1	0.88 ± 0.12	1.23 ± 0.67	2.24	0.13
Drainage volume1 (mL)	124.36 ± 23.43	167.43 ± 30.87	12.23	0.00
Blood transfusion, n (%)	7 (13.21)	19 (35.19)	7.02	0.00
Standing walking time (h)1	3.25 ± 3.23	2.92 ± 4.17	3.13	0.07
Satisfaction, n			8.72	0.00
Satisfied	45	32
Dissatisfied	8	22

¹mean ± SD. Visual analog scale (VAS) and of postoperative day 1 (POD 1): VAS score on the first day after operation; VAS and of POD 3: VAS score on the third day after operation. VAS: Visual analog scale; POD: Postoperative day.