ERAS Total Joint

ENHANCED RECOVERY AFTER SURGERY (ERAS)

PRIMARY TOTAL KNEE ARTHROPLASTY AND TOTAL HIP ARTHROPLASTY

Revised: June 14, 2022

Goals:  Use a multidisciplinary plan of care to reduce surgical stress, enhance recovery and improve outcomes.  The use of evidence-based enhanced recovery after surgery (ERAS) protocols for hip and knee arthroplasty surgery to improve outcomes. ERAS components include education, nutrition, detection and correction of anemia, active pre-warming, preemptive oral analgesia, intraoperative anesthesia techniques, postoperative analgesia and early postoperative mobilization.  Multiple randomized controlled studies have demonstrated the benefits, safety, and cost-effectiveness of these protocols.

NMCP Total Joint Management Guidelines

Pre-operative Preparation:

·         Pre-operative Education:  Patients will be encouraged to attend a class held once every month that includes presentations by the Total Joint Team addressing anesthesia, physical therapy, occupational therapy, nutrition and discharge planning aspects of surgery.

·         In pre-admission testing all medications will be reviewed.  Patients will be asked to stop the following medications:

·         ACE inhibitors (i.e. Lisinopril) or angiotensin receptor blockers stopped 24 hours prior to surgery.

·         Diuretics should not be taken on the day of surgery unless given for heart failure.

·         Modifications to oral hypoglycemic and insulin regimens will be specified.

·         Assess postoperative nausea and vomiting (PONV) risk.  For patients at high risk, suggest totally intravenous anesthetic (TIVA) anesthetic or use of an adjunct propofol infusion.

·         All patients will have orders from the Total Joint Team for Profend nasal decolonization swabbing, IV antibiotics, sequential compression devices, and pre-op multimodal analgesia (Pregabalin 75mg (>70yo hold) , Mobic 15mg or Celebrex 200mg, acetaminophen 1000mg, Emend 40mg, Rapaflow 8mg (males >50yo) for administration in pre-operative holding area.  A paper Rx to pick up Ensure Pre-Surgery Clear Nutrition Drink at Nutrition Management next to the Galley to be taken at 0500 on DOS.

·         Patients will have an order in Essentris identifying them as “ERAS Total Joint Protocol.”  An orthopedic ERAS checklist template will be initiated upon admission in Essentris.   This will be a multidisciplinary flow sheet for the patient’s stay.

·         Patients must have ERAS entered under comments when scheduling in S3.  Same spot where “block” or “blood” is seen on S3.  Clinic scheduling must be aware so that “ERAS” appears on S3.

Pre-operative Hold Area:

·         Liberal pre-op fasting with solids up to 8 hours and approved clears up to 2 hours. No tobacco or nicotine 6 hours prior. Encourage preoperative clear fluids by mouth (preferably carbohydrate containing fluids) up to 2 hours before surgery.  The following are acceptable clear liquids: Water, apple juice, Pedialyte, Gatorade or other sports drinks, Sprite or 7-up, black coffee (NO CREAMER), tea.

·         An intravenous line will be started.  No bolus will be given (KVO).

·         Review consent.

·         Verify correct patient, correct procedure and correct side.

·         Answer any remaining patient questions.

·         Profend nasal decolonization swabbing will be completed by nursing staff.

·         Pre-op multimodal analgesia: oral Pregabalin 75 mg (>70yo hold), oral Mobic 15 mg or Celebrex 200 mg, oral acetaminophen 1,000 mg, oral Emend 40mg, oral Rapaflow 8mg (males >50yo) to be administered in pre-op holding area by the pre-operative nurse upon arrival.  Mobic and Celebrex will be held for renal impairment (Cr >1.4) or allergy. Acetaminophen will be held if allergy, hepatic impairment, chronic ETOH use. Any medication holds will be pre-determined by the surgery team and ordered in Essentris appropriately.

·         Skin: clip hair at operative site prn.

·         SCD applied to non-operative extremity. No TEDs.

·         Surgeon: Surgical site marking.

·         Regional adductor block completed for total knee replacements. Ropivacaine 0.2% with a maximum dosing of 15 mL.

Intra-operative:

·         Expected length of average operation: 2-3 hours.

·         Any deviations from flowsheet should be discussed at pre-operative TeamStepps.

·         Anesthesia:  Spinal vs epidural vs general. Neuraxial preferred.  Most cases will be able to be done under single injection spinal anesthesia. Bupivacaine 0.5% 10-12mg or Mepivacaine 1.5% 50-60mg. NO EPINEPHRINE OR NARCOTICS IN SPINAL.

·         Antibiotics within 30 minutes prior to made incision. Recommended agent is cefazolin.  Alternative agents are vancomycin and clindamycin.  Cefazolin 1 gm IV for less than 80 kg, Cefazolin 2 mg IV for 80 kg to 119.9 kg, Cefazolin 3 mg IV for 120 kg+.  If true PCN allergy, Vancomycin IV. Will be ordered by surgery team. Any deviation from Cefazolin, needs to be discussed with surgeon.

·         Administer Tranexamic acid (TXA) 1 gm IV prior to incision and 1 gm IV on way to PACU.  Hold for TXA allergy, history of seizure disorder, or active thrombosis.

·         Administer 10 mg IV Dexamethasone.

·         PONV prophylaxis options: 5-HT3 receptor antagonist (ondansetron 4 mg IV), Dexamethasone 10 mg IV), Consider TIVA or Propofol infusion in high risk PONV patients.

·         Normoglycemia: Monitor finger stick blood glucose hourly in diabetics. Begin insulin administration if blood glucose > 200 mg/dl. Target 140-200 mg/dl.  Low dose insulin sliding scale (201-250 = 2 Units; 251-300 = 4 Units; 301-350 = 6 Units; 351-400 = 8 Units).

·         Positioning:  THA posterior and lateral approach position in lateral decubitus, THA anterior approach supine on Hana table or regular OR bed (surgeon preference). TKA supine position.

·         Surgeon preference regarding axillary roll for lateral decubitus position.

·         Protect bony prominences using egg crate or jelly padding.  Gel pads over pegs for lateral decubitus position.

·         Apply bovie pad and chest strap. Place Bair hugger over chest and arms.

·         Chloraprep operative site x 2 sticks.

·         Inject “Total Joint Cocktail” prior to wound closure: Ropivacaine 0.5% (200 mg) 40 mL + toradol 30 mg/mL (1 mL) + epinephrine 1:1000 (.6 mL) + saline 8.4 mL = 50 mL total volume.  No toradol if Cr >1.4 or CKD3.

·         Wound closure and dressing. Dressings include, Prineo and Mepilex Ag

·         TKA and THA patients: Apply ace wrap from foot to proximal leg.

·         Apply ice (ice machine) to operative site over surgical dressing and SCD to operative leg.

Post-operative:

Anesthesia:

·         Pain control should be ordered utilizing the “ANES PACU Adult” order set and see “ERAS-TJ PACU Med Instructions.”

·         Pain should be managed with ICE Man cooling device and Fentanyl for breakthrough pain.

·         No ketamine, Demerol, Phenergan, Benadryl, morphine, dilaudid, Ativan, valium, versed.

·         Zofran should be the primary agent for PONV.

·         Discuss dilaudid or Phenergan with Surgeon prior to ordering as second-line adjuncts.

PACU:

·         Radiographs.

·         Fluid management as needed.

·         Normothermia will be maintained with a temperature of 36°C on arrival to the PACU. Use a Bair hugger.

Ward:

·         Advance diet as tolerated.  KVO IV fluids once PO intake has normalized.

·         Antibiotic prophylaxis: Dosing to be completed by 24 hours post-op.

·         Foley catheter removal if present on POD #1 at 0400.

·         Early mobilization:  OOB to chair, physical therapy, occupational therapy, ambulation.  Patients should ambulate on DOS.

·         Incentive spirometer 10 times/hour while awake.

·         Ice machine and elevation when at rest.

·         Precautions:  TKA patients must keep knee straight when in bed.  No pillow under knee.  THA patients must avoid extremes of motion.  Bowel regimen: Surfak 1 cap po QD, Miralax 1 capful QD prn.  Milk of Magnesia 30-60 mL po QD prn.  Bisacodyl 10 mg QD suppository prn constipation not relieved by Milk of Magnesia.

·         PONV: Zofran 4 mg IV Q4h prn.

·         VTE prophylaxis:  SCDs and TEDS.  Aspirin 81 mg vs Eliquis start AM of POD #1.

·         Multimodal analgesia:

·         Baseline coverage: NSAID - Toradol 15 mg IV q6h x 5 doses post-op.  Caution if renal impairment.  Oral Mobic 15 mg QD or Celebrex 200 mg QD to start after 5 Toradol doses completed. (Caution if renal impairment and hold for Cr >1.4)

·         First Line: Oral acetaminophen scheduled dosing 1,000 mg q8h.

·         Second Line: Tramadol 50 mg po q6h prn >5/10 pain not relieved by acetaminophen.

·         Third Line: Oxycodone (Roxicodone) IR 5 mg po q4h prn 5-8/10 pain not relieved by acetaminophen or Tramadol.  Oxycodone (Roxicodone) IR 10 mg po q4h prn 9-10/10 pain not relieved by acetaminophen or Tramadol.

·         Fourth Line: Morphine 2-4 mg IV (2 mg IV for 5-8/10 pain, 4 mg IV for 9-10/10 pain) q4h prn pain not relieved by acetaminophen, Tramadol and Roxicodone or Dilaudid .5-1 mg IV (.5 mg IV for 5-8/10 pain, 1 mg IV for 9-10/10 pain) q4h prn pain not relieved by acetaminophen, Tramadol and Roxicodone.

Dexamethasone 10 mg IV x 1 dose on POD #1. Hg A1c > 6.9 hold POD#1 dose and will be placed on SSI while inpatient. (Goal 140-200 blood glucose level)

Discharge planning including home PT, OT, home health, durable medical equipment:  Rolling walker, 3:1 commode.

·         Labs: CBC and BMP x 1 day, then as clinically indicated.  Daily INR if on Coumadin.

·         All patients will be encouraged to mobilize on DOS with Ward Staff assistance and walker use.

·         Physical therapy will evaluate the patient on DOS for same day discharge patients and POD#1 for all overnight stay patients. Surgical team will ensure these are the first case of the day and will contact the physical therapy team to inform them of the need for DOS evaluation in PACU or on Ward.

Patient care is based on individual circumstances and no policy or procedure can detail or describe each circumstance.  Thus, this policy is not a statement of the standard of care, and should not be interpreted as such.  It is meant to be a guideline only and should never be a substitute for the exercise of judgement.

Evidence:

The following goals were considered while developing this pathway:

·         Preanesthesia education can significantly relieve anxiety and emotional stress before hip and knee arthroplasty. ¹  

·         Preoperative education contributes to higher patient confidence, greater patient satisfaction, early recovery and discharge. ²

·         Preoperative fasting and carbohydrate loading:

·         Several systematic reviews found no evidence to support a safety benefit of prolonged fasting.^3,4 Enhanced recovery after surgery consensus guidelines now permit intake of clear fluids until 2 h before induction of anesthesia and a 6 h fast for solid foods.⁵ The safety of a 2 h-clear/6 h-solids fast is also upheld in obese and morbidly obese cohorts,⁶ and in patients with uncomplicated diabetes mellitus.⁷ A more conservative fast is recommended for diabetic patients with gastroparesis.⁸

·         There is insufficient data to make a decision for or against preoperative carbohydrate supplementation for joint arthroplasty.

·         Postoperative nausea and vomiting (PONV):

·         Patients at moderate risk of PONV (i.e. two risk factors) should receive prophylaxis with dexamethasone at induction or a serotonin receptor antagonist at the end of surgery. ⁹ High-risk individuals (three or more factors) should receive both dexamethasone at the beginning of surgery and a serotonin receptor antagonist at the end of surgery.  Forgoing dexamethasone prophylaxis in a diabetic patient should be decided on an individual basis, after balancing the individual risk of PONV with hyperglycemia. ¹⁰

·         Pain management:  Multimodal, opioid-sparing techniques as the basis for postoperative pain control.⁵ Multimodal pain management is effective in optimizing pain relief while minimizing complications and side effects. ⁶⁰  Safe and effective analgesia is a prerequisite to encourage postoperative mobilization.¹¹

·         Perioperative pregabalin administration reduces the incidence of chronic neuropathic pain after TKA, with less opioid consumption and better range of motion during the first 30 days of rehabilitation. ⁶¹  

·         Local infiltration of anesthesia (LIA):  Local infiltration analgesia provides 6–12h of pain relief after knee arthroplasty.¹²

·         Non-steroidal anti-inflammatory (NSAID).

·         Peripheral nerve block (PNB):  Adductor canal catheters provide equivalent analgesia without quadriceps weakness.^13-16  Combination of epidural analgesia and a single-injection nerve block has been advocated as a way to improve analgesia for knee arthroplasty, with reduced pain scores with therapy and improved physical therapy outcomes.¹⁷  Adductor canal block combined with epidural analgesia provides analgesia similar to the combination of femoral nerve block plus epidural analgesia but without the quadriceps weakness that can limit rehabilitation and contribute to falls.¹⁸

·         Early mobilization:  Adverse physiological effects of prolonged bed rest include increased insulin resistance, myopathy, reduced pulmonary function, impaired tissue oxygenation, and increased risk of thromboembolism.¹⁹ A meta-analysis shows a significant reduction in length of stay (by 1.8 days) when patients ambulate within 24 h of surgery.²⁰ Early mobilization after knee arthroplasty is also associated with improved functional recovery²¹ and lower incidence of DVT.^22,23

·         Normothermia: Measures to avoid hypothermia and hypoxemia also decrease surgical stress and the resulting systemic complications.²⁴  Maintaining perioperative normothermia with forced-air heating has been firmly established to reduce infection,²⁵ cardiac complications,²⁶ coagulopathy, and transfusion requirements.²⁷ Aggressive warming reduced intraoperative blood loss during total hip arthroplasty²⁸ and was associated with reduced opioid need and greater satisfaction after total knee arthroplasty.²⁹ Active intraoperative warming before tourniquet deflation prevented subsequent hypothermia in elderly patients undergoing primary knee replacement under general anaesthesia.³⁰ Short-term postoperative cognitive impairment has been associated with warmer temperatures in elderly patients after knee replacement.³¹

·         Antimicrobial prophylaxis: Infection after joint arthroplasty is a serious complication that can be difficult to treat.³² Evidence from a large systematic review and meta-analysis indicated that systemic antibiotic prophylaxis before hip replacement significantly reduced the incidence of infection.³³  The Agency for Healthcare Research and Quality-recommended regimen for patients undergoing primary hip and knee arthroplasty is cefazolin.³⁴ Clindamycin and vancomycin should be reserved as alternative agents, if there is a cephalosporin allergy or surveillance data indicating causative organisms. Pre-operative intranasal betadine swabbing is recommended for all patients and specifically with documented S. aureus colonization.

·         Blood conservation: Transfusion and anemia are both associated with increased incidence of infection, increased length of stay, and higher mortality after joint arthroplasty.^35-37 Correction of preoperative anemia is particularly important in patients with multiple risk factors.³⁸ Options to increase preoperative hemoglobin include iron supplements³⁹ and erythropoietin.⁴⁰ Both are associated with a lower requirement for transfusion after hip and knee arthroplasty.  Blood salvage techniques minimize the effects of acute blood loss during both total hip^41-43 and total knee arthroplasty.^44-46 Pharmacological interventions—specifically, the antifibrinolytic tranexamic acid—have supplanted cell salvage techniques in recent years,⁴⁷ with multiple publications demonstrating both clinical and cost efficacy in hip,^48,49 knee,^50-52 and bilateral total knee arthroplasty.⁵³  Tranexamic acid reduces blood loss and the risk of transfusion irrespective of the route of administration (i.v.⁵⁴ or topical⁵⁵). The benefits afforded by tranexamic acid are achieved without significant increase in side-effects, including DVT, PE, stroke, myocardial infarction, or seizure.^50,52,56

·         Venous thromboembolism prevention: Low-dose aspirin is not inferior to high-dose aspirin for venous thromboembolism following total joint arthroplasty.⁵⁷  Current guidelines from the American College of Chest Physicians (ACCP) recommend routine use of anticoagulants to prevent clinical and radiographic DVT and PE after joint arthroplasty.⁵⁸ Additionally, all-cause mortality is higher in patients taking potent anticoagulants (LMWH or DOAC) than in patients receiving aspirin or warfarin, and clinically significant PE occurred despite the use of anticoagulants.⁵⁹ Eliquis has been shown to induce fewer wound related complications as compared to other Xa inhibitors.