Enhanced recovery program for hip and knee replacement reduces death rate

Figures & data

Table 1. Protocol followed during the different periods

Traditional	“Enhanced recovery” protocol
Generic patient and staff education.	Patient and staff education specifically detailing “enhanced recovery” principles.
General anaesthesia, spinal, or epidural according to the preference of the anesthetist and consent of the patient.	Pre-admission medication: – Gabapentin (300 mg) on the night before surgery (to continue twice daily for 5 days). – Dexamethasone—10 mg orally on the night before surgery and 4 mg intravenously at induction.
Perioperative urinary catheterization—standard intravenous fluid until next day	Perioperative urinary catheterization—as per clinical indication.
Mobilization next day.	Low-dose spinal anesthesia: – 2–3 mL of 0.25% Bupivacaine (plain) or 2 mL of 0.5% Bupivacaine (heavy). – No intrathecal opioids.
Patient-controlled opioid analgesia intravenously	Propofol intravenous infusion (0–2.5 µg/mL) ± Ketamine (0.5 mg/kg, slow intravenous bolus).
Discharge when standardized criteria were met.	Paracetamol (1 g intravenously) ± Parecoxib (40 mg intravenously). Judicious intraoperative fluid and vasopressor administration. Tranexamic acid (15 mg/kg—slow intravenous bolus at induction; withheld in cases of thromboembolic event in the last 6 months). Intra- and postoperative infiltration of local anesthetic (100 mL levobupivacaine 1.25 mg/mL). Aim for same-day mobilization. Discharge when standardized criteria met.

Table 2. Comparison of mortality rates between the 2 groups

	Traditional	Enhanced	p-value
	(n = 3,000)	(n = 1,500)	Chi-squared test
Death (30-day)	15 (0.5%)	1 (0.1%)	0.02
Death (90-day)	25 (0.8%)	3 (0.2%)	0.01

Table 3. Comparison of the demographics between the 2 groups

	Traditional	Enhanced	p-value
	(n = 3,000)	(n = 1,500)	Chi-squared test
Age (years)	69	68
THR	1,368	630
TKR	1,632	870
Gender (M:F)	1,482:1,518	711:789	0.2
Comorbidities
Hypertension	921 (31%)	673 (45%)	< 0.001
AF	143 (5%)	84 (6%)	0.2
IHD	211 (7%)	113 (8%)	0.5
IDDM	20 (1%)	18 (1%)	0.07
NIDDM	205 (7%)	150 (10%)	< 0.001
COPD	85 (3%)	67 (4%)	0.004
Alzheimer	6 (0.2%)	5 (0.3%)	0.4

AF: atrial fibrillation; IHD: ischemic heart disease; IDDM: insulin-dependent diabetes mellitus; NIDDM: non-insulin-dependent diabetis mellitus; COPD: chronic obstructive pulmonary disease.

Table 4. Comparison of complications between the 2 groups

	Traditional	Enhanced	p-value
	(n = 3,000)	(n = 1,500)	Chi-squared test
RTT (30-day)	74 (2.5%)	27 (1.8%)	0.2
Stroke (30-day)	14 (0.5%)	3 (0.2%)	0.2
GI bleeding (30-day)	18 (0.6%)	4 (0.3%)	0.1
MI (30-day)	25 (0.8%)	7 (0.5%)	0.2
ARF (30-day) ^a	1 (0.03%)	2 (0.13%)	0.2
DVT (60-day)	23 (0.8%)	9 (0.6%)	0.5
PE (60-day)	36 (1.2%)	17 (1.1%)	0.9
Re-admission	140 (4.7%)	72 (4.8%)	0.8

RTT: return to theater, GI: gastrointestinal, MI: myocardial infarction,

ARF: acute renal failure, DVT: deep venous thrombosis, PE: pulmonary embolism

^a Requiring admission to high dependency unit.

Figure 1. Box plot to compare the length of stay between the tradiional (Trad) and the enhanced recovery (ER) groups.

Figure 2. Trend of various complications through the study period. Grouping of patients is explained in the footnote to Figure 1.