Primary hip and knee arthoplasty, post-operative ERAS bundle (Guidelines)

Background

The use of an enhanced recovery after surgery (ERAS) guideline in the peri-operative care of patients undergoing total hip and knee arthroplasty has been shown to reduce hospital length of stay and surgical complication. Implementation of a prescribing order-set on the Hepma will reduce variation in post-operative prescribing practice.

Inclusion

• All patients undergoing primary hip or knee replacements

Exclusion

•  Revision hip or knee surgery

The following is for opioid naïve patients and should be used as a baseline for non-opioid naïve patients

• Pre-operative modified release opioids should be continued at the same dose in the peri-operative period.
• Opioid reduction should be considered post-operatively under the care of the primary care team and/or hospital pain team as appropriate
  • Breakthrough strong opioids should be the same drug and dose as that used pre-operatively, OR oxycodone instant release (IR) at an appropriate dose (approximately one sixth of daily opioid dose, but no higher than 10mg until clinical effect observed).
  • Modified-release opioids should NOT be initiated in the immediate post-operative period.

• NSAIDs are effective analgesics following arthroplasty surgery, however the use of aspirin 150mg daily for surgical thromoboprophylaxis increases the risks associated with their use.
  • Use should be considered on a case by case basis, bearing in mind gastric, renal and cardiovascular side effects and risk. See NSAID guideline (see resources). 
  • If appropriate, either continue NSAID used pre-operatively, OR ibuprofen 400mg orally, three times a day, WITH lansoprazole 30mg orally, once daily for a maximum of five days.

Other essential components of the ERAS bundle include pre-operative analgesia, surgical and anaesthetic intra-operative analgesia, surgical venous thromboprophylaxis and non-pharmacological post-operative therapy including early mobilisation, cryotherapy and psychology. These are outside the scope of this guidance.