Guest Post: Enhanced Recovery After Orthopaedic Surgery
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Grigory Gershkovich, MD and Shahriar Rahman, MS.
Recovery after surgery is an outcome that matters to everyone. The concept of enhanced recovery after surgery (ERAS) was first introduced in 1997 in Denmark by general surgeon Henrik Kehlet. The key objective is to accelerate postoperative recovery, reduce the length of hospital stay, and improve patient experience and clinical outcomes.
There are four key elements to ERAS:
- Optimizing preoperative care – The patient, surgeon, anesthesiologist, and nurses form a single team. A preoperative plan and classes help patients manage expectations.
- Reducing the physical stress of surgery –This may include minimally invasive techniques, reduced surgical times, optimized anesthetic techniques (e.g., spinal anesthesia or blocks), and maintenance of normovolemia. Traditionally, patients have nothing by mouth for many hours prior to surgery. ERAS, however, allows patients to receive clear fluids by mouth up to two hours prior to the operation. This practice has proven to be of limited risk and may better optimize fluid balance perioperatively.
- Enhancing postoperative comfort – This entails effective multimodal analgesia and prophylaxis against nausea. Narcotics are minimized, especially in elderly patients. A well-structured and consistent plan is developed among the patient, physicians, nurses, social workers, family/ caretakers, and physical therapists. Orthopaedic-floor staff standardize protocols to provide consistent, structured care with well-defined roles.
- Optimizing postoperative care – Early mobilization, normal feeding and hydration, and unambiguous discharge and post-discharge instructions are the goals here. Many ERAS programs also employ a Bring Your Own Gum initiative. Evidence suggests that chewing gum diminishes postoperative gastrointestinal dysfunction by preserving efferent vagal nerve activity, even when the surgical procedure did not involve the gastrointestinal tract.
The ERAS protocol was used initially in colorectal patients. A 2014 ERAS pilot of colorectal patients at Boston’s Brigham and Women’s Hospital found lower rates of complications after surgery. Cardiac events dropped by as much as 90 percent; there were 66 percent fewer surgical site infections, and patients left the hospital two days earlier on average. The Brigham is expanding ERAS guidelines to at least three other departments, and a study by Dwyer et al. in 2012 found that ERAS benefits seem to be universal and confer an advantage regardless of the patient’s preoperative condition.
Elective total joint arthroplasty (TJA) is one area of orthopaedics that has adopted several principles of ERAS. Reilly et al. (2005) were able to show that ERAS is beneficial in the treatment of patients undergoing unicompartmental knee replacement. As ERAS adoption increases among the orthopaedic surgery specialty, it is reasonable that its implementation may extend to subspecialties beyond TJA, such as hip fractures and upper extremity surgery. Macfie et al. (2012) demonstrated ERAS benefits in patients with a fractured femoral neck.
The improvements to quality of care and efficiency that are gained by implementing ERAS programs are largely due to changes in the underlying organizational structure of hospitals. To make further progress in orthopaedic care, we have to not only introduce new interventions that are proven beneficial, but also (and perhaps more importantly) stop doing things that are not beneficial and may even cause harm to patients.
Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will be completing a hand fellowship at the University of Chicago in 2017-2018.
Shahriar Rahman, MS is a consultant orthopaedic surgeon at the Ministry of Health & Family Welfare in Bangladesh.