Enhanced Recovery After Surgery (ERAS) Protocols

Preoperative Phase (Days to Weeks Before Surgery)

Goal: Optimize patient condition and set expectations

Patient Education Details

Key topics to cover:

• What to expect on day of surgery
• Pain management expectations (realistic goals: VAS 3-4, not 0)
• Mobilization timeline (walking day 0)
• Expected length of stay (24-48 hours for TKA/THA)
• Discharge criteria
• Red flags for complications
• Follow-up plan

Methods:

• Written information booklets
• Video education
• Group education classes
• One-on-one counseling

Prehabilitation Programs

Components:

• Exercise: Strengthen quadriceps, hip abductors, core
• Aerobic fitness: Walking, cycling to improve cardiovascular reserve
• Education: As above
• Nutrition: Protein supplementation if needed

Duration: Typically 4-6 weeks preoperatively

Evidence: Meta-analyses show modest improvements in functional outcomes, particularly in frail/elderly patients. Effect size greater in patients with poor baseline function.

This completes the preoperative phase overview.

Intraoperative Phase

Goal: Minimize surgical stress response and physiologic derangement

Multimodal Analgesia - The Cornerstone

Standard multimodal regimen for TKA/THA:

1. Baseline analgesia:

• Paracetamol: 1g PO/IV pre-incision, then 1g QID (around-the-clock)
• NSAIDs: Celecoxib 200mg PO pre-incision, then 200mg BD (or parecoxib 40mg IV BD if nil by mouth)

2. Local techniques:

• Local infiltration analgesia (LIA): Surgeon infiltrates joint capsule, soft tissues with local anesthetic (e.g., ropivacaine 200mg + ketorolac 30mg + epinephrine)
• Peripheral nerve blocks: Adductor canal block for TKA (spares quadriceps strength vs femoral nerve block)

3. Adjuncts:

• Gabapentinoids: Gabapentin 300-600mg or pregabalin 75-150mg pre-incision (single dose, reduces neuropathic pain)
• Dexamethasone: 8mg IV (anti-inflammatory, anti-emetic, analgesic)

4. Opioids (rescue only):

• Minimize use: Only for breakthrough pain
• Short-acting preferred: Oxycodone immediate-release PRN (avoid long-acting/extended-release)

Tranexamic Acid (TXA)

Dosing regimens:

• IV: 1g pre-incision, repeat 1g 3 hours later OR 2g single dose
• Topical: 2-3g in 100mL saline, inject into joint before closure, clamp drain 2 hours
• Combined: IV + topical may have additive benefit

Evidence: Cochrane review shows TXA reduces blood loss by 30-50% and transfusion rate by 40-50% in TKA/THA. No increased VTE risk.

Contraindications: Active thromboembolic disease, seizure history (relative)

Goal-Directed Fluid Therapy (GDFT)

Principle: Maintain euvolemia - avoid both hypovolemia (organ hypoperfusion) and hypervolemia (tissue edema, delayed recovery)

Methods:

• Clinical assessment: Heart rate, blood pressure, urine output
• Advanced monitoring: Pulse pressure variation (PPV), stroke volume variation (SVV) if arterial line available
• Esophageal Doppler: Cardiac output monitoring (rarely used in routine arthroplasty)

Targets:

• Mean arterial pressure over 65 mmHg
• Urine output over 0.5 mL/kg/h
• Lactate under 2 mmol/L

Fluid choice: Balanced crystalloids (Hartmann's, Plasma-Lyte) preferred over 0.9% saline (reduces hyperchloremic acidosis)

This completes the intraoperative elements description.

Postoperative Phase

Goal: Accelerate return to normal function and achieve discharge criteria

Early Mobilization Protocol

Timeline for TKA/THA:

• Day 0 (surgery day): Sit out of bed 2 hours post-op, walk 4 hours post-op (with PT assistance)
• Day 1: Walk independently with aids, stairs practice, aim for 30m+ walking distance
• Day 2: Achieve discharge criteria, safe for home discharge

Barriers to early mobilization:

• Inadequate analgesia (most common)
• Excessive sedation from opioids
• Orthostatic hypotension (from hypovolemia or excessive fluids)
• Patient fear/anxiety
• Lack of physiotherapy resources

Solutions:

• Optimize multimodal analgesia
• Minimize opioid use
• GDFT to maintain euvolemia
• Preoperative patient education
• Dedicated ERAS physiotherapy team

DVT Prophylaxis

Options (based on Australian guidelines, eTG):

• LMWH: Enoxaparin 40mg SC daily (start 6-12h post-op, continue 10-14 days for TKA, 28-35 days for THA)
• DOACs: Rivaroxaban 10mg PO daily or apixaban 2.5mg BD (start 6-12h post-op, same duration)
• Aspirin: 100mg daily (alternative in low-risk patients, some protocols)

Mechanical prophylaxis:

• Intermittent pneumatic compression (IPC) devices until fully mobile
• Thromboembolic stockings (TED stockings)

Australian context: PBS subsidizes LMWH and DOACs for arthroplasty. TGA guidelines recommend extended prophylaxis for THA (28-35 days). Refer to eTG for local protocols.

Early Oral Nutrition

Protocol:

• Resume clear fluids immediately post-op (recovery room)
• Progress to normal diet evening of surgery (if no nausea)
• No routine nasogastric tubes (delays oral intake, increases discomfort)

Nutritional goals:

• Protein intake 1.2-1.5 g/kg/day to support wound healing
• Maintain caloric intake to prevent catabolism
• Correct any deficiencies (vitamin D, calcium for bone health)

Postoperative Nausea and Vomiting (PONV) Prevention

Risk factors for PONV:

• Female sex
• Non-smoker
• History of PONV/motion sickness
• Postoperative opioid use

Multimodal PONV protocol:

• Dexamethasone 8mg IV (given intraop)
• Ondansetron 4mg IV at end of surgery
• Minimal opioids (multimodal analgesia strategy)
• Adequate hydration (GDFT)
• Rescue: Metoclopramide 10mg IV or promethazine 25mg IV/IM

This completes the postoperative phase interventions.

ERAS for Total Knee and Hip Arthroplasty

Most mature ERAS protocols in orthopaedics, with Level I evidence supporting multiple elements.

Specific Considerations for TKA

Pain management challenges:

• TKA typically more painful than THA in first 24-48 hours
• Multimodal analgesia essential:
  • LIA (ropivacaine + ketorolac)
  • Adductor canal block (ACB) - preserves quadriceps strength vs femoral block
  • Paracetamol + COX-2 inhibitor around-the-clock
  • Opioids for breakthrough only

Mobilization targets:

• Straight leg raise by 4 hours post-op
• Walk with walker by 6 hours post-op
• Stairs by day 1
• Discharge day 1-2 if criteria met

Discharge criteria:

• Walking 30m+ with walker
• Stairs (if home has stairs)
• Pain controlled on oral analgesia (VAS under 4)
• No complications (wound, neurovascular)
• Home support adequate

Specific Considerations for THA

Advantages for ERAS:

• Generally less painful than TKA
• Faster return to mobilization
• Lower DVT risk than TKA

Hip precautions debate:

• Traditional approach: Hip precautions (avoid flexion beyond 90�, adduction past midline, internal rotation) for 6-12 weeks
• ERAS approach: No routine precautions if stable implant and adequate soft tissue repair
• Evidence: Randomized trials show no difference in dislocation rate with vs without precautions in primary THA with modern techniques

Mobilization targets:

• Stand and walk by 4 hours post-op
• Independent mobilization with aids by evening of surgery
• Discharge day 1 if criteria met

Evidence for ERAS in TKA/THA

Meta-analyses and systematic reviews:

• LOS reduction: Mean 1.5-2.5 days shorter (typical LOS 1-2 days vs 3-4 days traditional)
• Complication reduction: 30-40% reduction in medical complications, 20-30% in surgical complications
• Readmission: No increase (some studies show reduction)
• Cost savings: AUD 2,000-5,000 per patient (from reduced LOS and complications)

Australian data (AOANJRR):

• ERAS protocols increasingly adopted by high-volume centers
• No adverse effect on revision rates or patient-reported outcomes
• Association with reduced LOS (registry does not capture LOS, but hospital data shows trend)

This completes the TKA/THA ERAS application.

ERAS for Spine Surgery

Adopted later than arthroplasty, but growing evidence base. ERAS Society published spine surgery guidelines in 2019.

ERAS Elements Specific to Spine

Preoperative:

• Patient selection: ERAS most effective for elective 1-2 level fusions and decompressions
• Prehabilitation: Core strengthening, smoking cessation critical (fusion rates)
• Minimize fasting: Carbohydrate loading as per standard ERAS

Intraoperative:

• Minimally invasive techniques: Tubular retractors, endoscopic approaches reduce muscle trauma
• Multimodal analgesia:
  • IV paracetamol + ketorolac intraop
  • Local anesthetic infiltration of wound and paraspinal muscles
  • Consider intrathecal morphine (controversial, can delay discharge)
• TXA: 1-2g IV reduces blood loss in fusion surgery
• GDFT: Critical for prone positioning cases

Postoperative:

• Early mobilization: Mobilize evening of surgery for microdiscectomy, day 1 for fusion
• Bracing: Minimize use - modern instrumentation usually stable without brace
• Avoid drains: Meta-analyses show no benefit for routine drainage in spine surgery
• DVT prophylaxis: LMWH + mechanical (higher risk than arthroplasty due to prone positioning)

Evidence for Spine ERAS

Systematic reviews:

• LOS reduction: 1-2 days for elective spine surgery
• Opioid use: 30-40% reduction with multimodal analgesia
• Complications: Modest reduction (10-20%) - less dramatic than arthroplasty
• Patient satisfaction: Improved

Caveats:

• Evidence strongest for elective 1-2 level procedures
• Complex deformity surgery has less robust ERAS evidence
• Neurologic complications not reduced (no harm from ERAS)

This concludes the spine surgery ERAS overview.

ERAS for Hip Fracture Surgery

Unique considerations: Elderly, frail population with multiple comorbidities. ERAS principles adapted to fragility fracture context.

Hip Fracture ERAS Elements

Preoperative (first 24h):

• Early surgery: Target under 36 hours from admission (NICE guidelines, Australian eTG)
• Multidisciplinary team: Orthogeriatrician involvement from admission
• Medical optimization: Treat dehydration, correct electrolytes, optimize cardiac status
• Analgesia: Nerve block (fascia iliaca block) reduces pain, facilitates assessment
• Avoid fasting: Clear fluids until 2h before surgery

Intraoperative:

• Regional anesthesia: Spinal preferred over general (reduced delirium, faster recovery)
• Multimodal analgesia: LIA, paracetamol, avoid excessive opioids
• TXA: Reduces transfusion need
• GDFT: Many elderly patients hypovolemic on admission

Postoperative:

• Mobilize day 1: Walk with PT assistance, even if partial weight-bearing
• Delirium prevention: Avoid sedatives, minimize opioids, reorient patient
• DVT prophylaxis: LMWH or DOACs for 28-35 days
• Bone protection: Vitamin D, calcium, consider bisphosphonates (fracture liaison service)
• Multidisciplinary rounds: Daily review by orthopedics + geriatrics + PT + OT + social work

Evidence for Hip Fracture ERAS

Registry and trial evidence:

• National registries (e.g. UK NHFD) associate surgery within 36 h and orthogeriatric co-management with lower mortality and length of stay (observational)
• The HIP ATTACK RCT (Lancet 2020) showed ultra-early surgery (median 6 h vs 24 h) did NOT significantly reduce 90-day mortality or major complications - so the guideline target (within 36-48 h) is about avoiding harmful delay, not racing to theatre
• Early mobilisation (day 1) and orthogeriatric input remain associated with fewer complications

Australian data:

• ANZHFR (Australian and New Zealand Hip Fracture Registry) shows similar trends
• Early surgery within 36-48 hours is standard of care
• eTG guidelines recommend multidisciplinary hip fracture units

This completes the hip fracture ERAS section.