Back to TAM (Treatments and Medicines) NHS Highland home NHS Highland

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



  • Highland HSCP
  • Secondary Care.



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.


  • All patients undergoing primary hip or knee replacements


  •  Revision hip or knee surgery

Post operative analgesia

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

Drug  Dose  Route  Times 
Paracetamol  1g  oral  08.00, 12.00 18.00, 22.00 
Dihydrocodeine  30mg  oral  08.00, 12.00 18.00, 22.00
Dihydrocodeine  30mg  oral  4 hourly as required for mild to moderate pain. Max 240mg daily in total, including regular.
Oxcodone IR 5mg  oral  2 hourly as required for severe pain.  Dose may need to be adjusted as clinically indicated.  Unlikely to be outside 2.5 to 10mg range.  
Laxido  1 sachet  oral  08.00, 18.00 while on regular opioids 
Ondansetron  4mg  IV  6 hourly as required for PONV.  Max three times a day. 
Prochlorperazine  3mg  buccal  As required for PONV. Max twice daily.  
  • 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.


Last reviewed: 19/06/2023

Next review date: 30/06/2026

Author(s): Orthopaedic ERAS group, NHS Highland.

Version: 1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Jayne Halcrow, Consultant Anaesthetist .

Document Id: TAM576