ERAS Protocols Are Pathways to Success

Pain Management

By: Alan Kaye

Published: 12/10/2020

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Enhanced recovery protocols improve patient experiences, clinical outcomes and your facility's bottom line.


The concept of enhanced recovery after surgery (ERAS) has been around for more than 20 years, introduced in colorectal and abdominal cases as fast-tracked "accelerated surgery" that tried to reduce surgical stress and organ dysfunction in order to speed up postoperative recovery times. While the patient-centered, evidence-based interventions have been adopted to some degree in orthopedic arenas, particularly with hip and knee arthroplasties, widespread adoption of ERAS principles in the overall total joints space has been limited.

That needs to change — and soon. When used in all phases of the perioperative continuum of care, ERAS protocols result in faster discharges, accelerated recoveries, fewer readmissions and happier patients. Post-op pain is controlled with fewer narcotics, meaning patients are at less risk of addiction from surgery-induced opioid use. The model's clinical efficiencies make for more profitable facilities as well. Here are the key elements to a successful multimodal and coordinated ERAS-based clinical care pathway.

  • Pre-op practices. Patients should meet with the surgical and anesthesia teams several weeks in advance of their procedures to discuss expectations for realistic and timely recoveries. Your facility should also conduct pre-op education sessions with patients to explain the details and purpose of their surgeries, and to address commonly asked questions. Some patients have considerable anxiety and stress before undergoing joint replacement surgery, particularly if they have a history of depression or no family support. Work with them to set achievable goals with respect to when they'll be mobile again, and always make sure to tell them they will be experiencing a certain level of post-op discomfort no matter what form of pain-control regimen they receive. Ortho centers with pre-op teams that include physical therapists, occupational therapists, care coordinators and nurses have a high level of success in meeting patients' pre-surgery needs.

QUICK RECOVERIES Ultrasound-guided regional blocks have revolutionized post-op pain management and help patients ambulate soon after surgery.   |  Pamela Bevelhymer

Scheduling pre-op meetings several weeks in advance of procedures allows the medical team to screen patients for organ dysfunction and conditions such as heart disease or diabetes that could put them at high risk of postoperative complications. The advance sessions also allow time for patients to begin alcohol and nicotine cessation if necessary. Pre-op nutrition should be addressed as well. Our ERAS protocols include recommendations for patients to load up on carbohydrates with a specially formulated drink two or three hours before their procedures.

The opioid crisis that killed almost 72,000 people in the United States last year has triggered a multimodal pain management approach during the entire surgical episode of care. NSAIDs, acetaminophen, preoperative bupivacaine and gabapentin can all be effective non-opioid analgesics before surgeries. Midazolam, a sedative, is part of the standard pre-op cocktail as well. Taking measures to prevent thrombosis should also be part of any orthopedic ERAS protocol.

  • In the OR. Using minimally invasive surgical and anesthesia techniques is the best way to reduce the physical stress on the body that takes place during procedures. Neuraxial anesthesia, for example, causes less of a stress hormone release than general anesthesia. Spinal anesthesia in general results in fewer complications than general anesthesia. There are newer modes of general anesthesia, such as total intravenous anesthesia, that could result in improved outcomes. Local infiltration analgesia used by surgeons intraoperatively in and around the joint provides six to 12 hours of pain relief after total knee arthroplasties, but has no analgesic effect with total hip arthroplasties.
PROACTIVE APPROACH Educating patients about pre-op nutrition and how much post-op pain to expect are as important as giving pre-operative analgesics and antibiotics.   |  Baptist Health South Florida

Active patient warming has proven to be the best way to adhere to the ERAS protocol for maintaining normothermia. Heat loss in patients during surgery causes an increased stress response, and can cause infections and cardiovascular complications.

Optimal intraoperative fluid balance should be maintained. Anemic patients should be treated preoperatively with iron supplements or erythropoietin. Hypotensive anesthesia techniques can be used to minimize blood loss. Tranexamic acid given orally, intravenously or topically in the joint space can reduce the need for transfusions.

  • In recovery and beyond. Enhancing postoperative comfort is a key element of orthopedic ERAS, but can be challenging because of the pain involved after the procedures. Acetaminophen, NSAIDs, gabapentin and ketamine have all been used for this purpose, but essentially reduce discomfort while falling short of eliminating pain. Fortunately, ultrasound-guided continuous nerve blocks have revolutionized post-op pain relief. They're precise and provide targeted analgesia for up to three or four days.

Preventing postoperative nausea and vomiting (PONV) is best achieved by completely avoiding general anesthesia and opioids. Patients with increased risk factors for PONV should receive dexamethasone at the induction or the end of the procedure, a serotonin receptor antagonist at the procedure's end — or both.

Early mobilization and rehabilitation are key elements of a successful ERAS protocol.

Too much bed rest after a total joints procedure causes a higher likelihood of thromboembolism, pulmonary complications, insulin resistance and delayed wound healing. Physical therapy should begin within six hours of a procedure as permitted by the patient's condition. Multimodal non-opioid pain management allows patients to start moving quickly after surgery.

Meet regularly
ON THE MOVE Preparing patients for the recovery phase of their care will help them ambulate sooner after surgery, an essential factor in readying them for same-day discharge.   |  Boston Out-Patient Surgical Suites

Ongoing communication with all stakeholders involved in the episode of care is crucial. Your facility's administration should be involved in the meetings because they control purchasing. Surgeons, nurses and anesthesia providers need seats at the table as well. I suggest meeting monthly in order to agree on the details of ERAS protocols and how they work in relation to each other. At first many of the providers will ask how they would benefit from the ERAS model, and it's at these meetings where they learn that patient care improves if every provider is actively involved.

These sessions are where leadership begins to understand that, if everyone does their part in an overall ERAS strategy, patient satisfaction scores will skyrocket as they arrive at home in little to no pain. These scores are critically important for your facility's grades and reputation. Surgeons will be delighted to have protocols in place that provide patients with less post-op pain in a world in which you no longer prescribe 180 oxycodone tablets. Stakeholders will begin to understand that shorter stays and quicker recovery times increase profits.

Continuing to meet is an effective way to fine-tune ERAS protocols and to ensure you maintain buy-in from all the parties as patient care continues to evolve. For example, a new kind of nerve block might take a few extra minutes of OR time to perform. You might need to hire an anesthesiologist who's an expert at regional anesthesia and invest in a new $100,000 ultrasound machine. All these elements of a seemingly straightforward decision need to be discussed. Good administrators will lead the conversation and listen to feedback. Bad ones who don't continue to evolve their ERAS protocols will end up running facilities that fall behind the curve of optimal patient care. OSM

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