ERAS for Hip & Knee (THA & TKA) Arthroplasty – A Need To Look Beyond LOS By Henrik Kehlet, Prof. MD, PhD E RAS programs in total joint arthroplasty have been introduced worldwide in many centers with documented success and reduced length of stay (LOS) and morbidity. However, despite the achieved success, several challenges lie ahead. First of all “what is the optimal LOS?”, since there is a lack of documentation on the economic and safety aspects of same-day discharge vs next day in a general THA and TKA population vs the proportion of selected suitable patients. Although overall morbidity is reduced by ERAS, further studies on the relative importance of conventional risk factors needs to be clarified, since recent data question the relevance from standard risk assessment within traditional care. Still, a major problem is the need to improve pain management after discharge in relation to patient activity and optimal rehabilitation. In this context, further 4 The optimal technique of rehabilitation needs evaluation... studies are required to preoperatively predict high-pain responders in subpopulations such as pain catastrophizers, preoperative opioid users and other pain “sensitized” patients. Also, more data are required on the otherwise documented risk of postoperative delirium especially with opioid-based pain management, but where a fully implemented opioidsparing ERAS program may almost eliminate this problem. Although it is well-established that preoperative anemia should be diagnosed and treated, more focus on postdischarge anemia should be made, since it may impair rehabilitation and increase risk of organ dysfunction, but so far with sparse available data. Further data are required on thromboembolic complications and need for prophylaxis, since early mobilization with ERAS may reduce the risk. Importantly, readmissions and discharge destination must be clarified due to a huge discrepancy between individual institutions and countries and where readmission to “own institution” is insufficient because some patients may be readmitted to other institutions. Also, discharge destination, which has major economic implications, needs further evaluation, since discharge to a “nursing care facility” or “rehabilitation” institution is variable, and in some ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org feature
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