Researchers at Hospital for Special Surgery (HSS) have found evidence supporting the use of Enhanced Recovery After Surgery (ERAS) protocols in orthopedic surgery. They are presenting their findings at the 2019 American Society of Anesthesiologists (ASA) Annual Meeting.

ERAS protocols aim to use evidenced-based techniques to improve clinical outcomes and reduce costs by lessening patients’ stress response before surgery and optimizing recuperation. Techniques can include reducing nausea, early mobilization, oral nutrition and improvement of analgesia.

Though ERAS protocols were initially developed more than 20 years ago for colorectal surgery, there is evidence of their positive effects for additional procedures. ERAS for spine and total joint replacement surgeries has not been well studied.

In an opinion piece published in the Journal of the American Medical Association in early 2019, Stavros Memtsoudis, MD, PhD, MBA, an anesthesiologist at HSS, cautioned against the use of ERAS protocols in specific surgeries without evidence to support them. He contended that doing so could cause lengthy protocols with as many as 20 components that are not supported by evidence, possible drug interactions, and potentially increased risks for patients or increased costs for hospitals in cases for which patient outcomes cannot be meaningfully improved. Dr. Memtsoudis concluded that ERAS protocols should be studied further to develop a basis of evidence supporting them for specific surgeries.

Since then, Dr. Memtsoudis and colleagues have conducted studies examining ERAS protocols for use in spine surgery¹ and in total joint replacement.²

ERAS in Spine Surgery

For their retrospective cohort study, the researchers identified 119,144 posterior lumbar fusion surgeries in the national Premier Healthcare Database of HSS patients from 2006 to 2016. The ERAS practices they examined were use of multimodal anesthesia, use of tranexamic acid, day zero antiemetic use, day zero steroid use, day zero or day one physical therapy, avoidance of Foley catheters, avoidance of patient-controlled analgesia and avoidance of wound drains. Cases were classified as high ERAS if greater than five practices were used, medium ERAS if three to five practices were used and low ERAS if less than three practices were used.

Overall, 10% of cases were high ERAS, 83% were medium ERAS and 7% were low ERAS. The researchers found that compared with low ERAS, medium and high ERAS cases were associated with significantly lower odds for any complication as well as for cardiopulmonary complications specifically. Length of stay was also improved in medium and high ERAS cases, but minimal differences were seen for average hospitalization cost.

ERAS in Total Joint Replacement

For this retrospective cohort study, researchers identified 1,539,713 patients from the Premier Healthcare Database having elective total hip or knee arthroplasty between 2006 and 2016. ERAS practices examined included use of regional anesthesia, use of multimodal anesthesia, use of tranexamic acid, day zero antiemetic use, day zero steroid use, day zero or one physical therapy, avoidance of Foley catheters, avoidance of patient-controlled analgesia and avoidance of wound drains. Cases were categorized as high ERAS if greater than six ERAS practices were used, medium ERAS if five to six practices were used or low ERAS if less than five ERAS practices were used.

The researchers found that 21% of cases were high ERAS, 58% were medium ERAS and 21% were low ERAS, with use of ERAS practices increasing over time for both hip and knee replacement surgeries. Similar to the results of the spine study, medium and high ERAS cases showed lower odds for any complication as well as for cardiopulmonary complication specifically, and improved the average length of stay incrementally as more ERAS components were used. Minimal effects were seen on the average hospitalization cost. A more profound impact from ERAS protocols was seen after 2013.

While these studies support use of ERAS protocols in orthopedic spine and total joint replacement surgeries, future studies should examine additional ERAS components.

“What these studies answer is that there is a benefit to having a certain amount of interventions within ERAS protocols,” Dr. Memtsoudis said. “In order to actually improve outcomes and recovery, you need to make sure that a minimum number of these aspects are being addressed. You can’t just do one part and ignore the other aspects. It seems that protocols that focus around making patients mobile and facilitating rehabilitation are the ones that are most effective.”

“However, we still need to determine if there is a ceiling effect,” he added. “Is there a point where it no longer adds benefit to add more of those aspects? Also, what medications are most useful and independently helpful when we look at multimodal pain management? Those are the issues that still need to be looked into.”

References

1. Megan Fiasconaro MS, Ellen M. Soffin MD PhD, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Janis Bekeris MD, Stavros G. Memtsoudis MD PhD MBA FCCP. “Exploring Enhanced Recovery Components in Spine Surgery: A Retrospective Study.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.

2. Megan Fiasconaro MS, Ellen M. Soffin MD PhD, Lauren A. Wilson MPH, Jashvant Poeran MD PhD, Jiabin Liu MD PhD, Janis Bekeris MD, Stavros G. Memtsoudis MD PhD MBA FCCP. “The Association Between Enhanced Recovery Components and Perioperative Outcomes in Total Joint Arthroplasty.” Presented at: 2019 American Society of Anesthesiologists® (ASA) Annual Meeting, October 19-23, 2019; Orlando, FL.