View as “PDF version”
We did our first presentation on ERAS (Enhanced Recovery After Surgery) 10 years ago. It has also been known by multiple different names (Enhanced Recovery After Surgery or ERAS, Enhanced Recovery or ERP, Fast Track, Accelerated Recovery, etc.). ERAS made its name in colorectal surgery but now has been adopted for a wide variety of surgical procedures. ERAS has been a success in both financial and human terms. It reduces complications or surgery, shortens hospital length of stay considerably, and is very cost-effective.
But widespread adoption of ERAS has been relatively slow, perhaps because many of its components were foreign to many “old time” surgeons. Perhaps we were early champions of ERAS because one of its major elements dates back to seminal research done by one of our former colleagues at the Erie County Medical Center and University of Buffalo, Dr. John Borders. Dr. Borders’ research showed the detrimental effects of letting the gut go to sleep in trauma patients. One of the key elements of ERAS is “don’t put the gut to sleep”.
The basic philosophical elements of ERAS are:
Components of ERAS:
A review of ERAS (Ljungqvist 2017) described work of the international ERAS® Society. The review described the evidence-based care changes in ERAS programs: change from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization, and serving of drinks and food the day of the operation. It touts that ERAS protocols have resulted in shorter length of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. Altman et al. (Altman 2019) note that implementation of an ERAS protocol can lead to savings of $2200-$2500 per patient treated.
In 2017 the American College of Surgeons (ACS), in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality launched the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR), funded and guided by AHRQ (ACS 2017, ACS 2020).
The AHRQ Safety Program for ISCR will support hospitals in implementing perioperative evidence-based pathways to meaningfully improve clinical outcomes, reduce hospital length-of-stay, and improve the patient experience. This program aims to enroll at least 750 hospitals throughout the five-year contract. Participating hospitals will have access to US leaders in enhanced recovery, including representatives of surgery, anesthesiology, and nursing, prototype enhanced recovery pathways developed for procedures in colorectal, orthopedic, gynecology, and emergency general surgery, based on up-to-date evidence review, literature to support pathways, tools and educational materials to facilitate implementation, quality improvement support from a nurse consultant, and coaching calls to support hospital work.
And, this month, Williams and colleagues published a study on the Canadian experience with ERAS in a special issue of the Canadian journal Healthcare Quarterly (Williams 2020). The Canadian Patient Safety Institute (CPSI) launched the Enhanced Recovery Canada™ (ERC) program in early 2017.
The ERC began as “a volunteer group of passionate physicians, nurses, patients and allied healthcare providers who agreed to work together to spread ERAS across the country” after recognizing its slow adoption in Canada. It convened stakeholders from multiple disciplines and multiple organizations.
A core group developed the resources and knowledge tools to support teams with ERAS implementation and identified metrics for evaluation of the program. They developed clinical pathways, first focusing on ERAS in colorectal surgery but with the intent to spread to other surgeries in the future. The ERC clinical pathways focus on nutrition, mobilization, hydration, pain and symptom control and other surgical best practices (such as prevention of surgical site infections).
What are the features of ERAS programs and protocols?
Two excellent articles describe the development and implementation of ERAS protocols. Wu et al. (Wu 2017) described the development and implementation of a colorectal ERAS pathway at Johns Hopkins Hospital. Altman and colleagues (Altman 2019) also describe both the elements of ERAS and how to go about implementing ERAS in Canadian hospitals.
There are slight differences between the Hopkins and the Canadian individual elements in the ERAS protocols, but they are mostly in agreement. Both, of course, also incorporate those evidence-based elements that apply to all surgery, regardless of whether ERAS is being used or not.
Both the patient’s primary care physician and the multidisciplinary team are important in educating the patient about the surgery and the recovery period and preparing him/her for the surgery. Patients are encouraged to quit smoking at least 4 weeks prior to surgery for elective cases. PCP’s can be very valuable in both counseling the patients and prescribing smoking cessation aids. Patients are also counseled about alcohol cessation, where appropriate. They are also instructed about when and which medications should be discontinued prior to surgery. Nutritional counseling is also important.
Most important in the pre-operative period relates to diet/oral intake. The time-honored adage “NPO after midnight” no longer applies. Many ERAS protocols do recommend stopping solid foods 6 hours before surgery and clear fluids 2 hours before surgery. But a carbohydrate load 2 hours prior to surgery is a mainstay of ERAS protocols.
The issue of a bowel prep depends upon what type of surgery is being performed. Pre-op, patients are usually given a combination of non-opioid analgesics (usually acetaminophen and/or NSAID’s, if appropriate) and antiemetics. (Some have also used gabapentin but we’d be cautious about that given our discussion in our January 2020 What's New in the Patient Safety World column “FDA Warning on Gabapentinoids”.) Also, for those surgeries where maintenance of normothermia is important, a warming blanket or equivalent is provided.
Just prior to surgery, prophylactic antibiotics are given (as recommended for the particular type of surgery) and DVT prophylaxis may be indicated in some cases (beware when epidural catheters used).
The original ERAS protocols, which were developed for colorectal surgery, emphasized use of epidural anesthesia/analgesia in order to minimize the use of opioids. Whether an epidural is used depends today upon the type of surgery being performed. During surgery, in addition to the anesthesia used, non-opioid analgesics and antiemetics are usually also given.
One of the basic theories leading to ERAS has been avoidance of fluid overload. Hence, most ERAS protocols have focused on maintenance of euvolemia. We recall seeing many colorectal surgery patients with significant edema and symptoms of fluid overload, including pulmonary congestion, several days following surgery. That is one of the reasons ERAS protocols have focused on fluid management. Restricting fluids to achieve zero balance is a key component of enhanced recovery after surgery (ERAS) pathways. But that concept has been challenged by researchers who noted the evidence for fluid restriction is scant and theoretically might predispose patients to complications of hypotension and reduced organ perfusion, leading to organ dysfunction. So those researchers undertook the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial (Myles 2018). They found that, in patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury.
So, issues surrounding fluid status remain somewhat controversial. It is probably wise to avoid fluid restriction that might promote hypotension or inadequate tissue perfusion, yet also avoid providing so much fluid that the post-op sequelae described above don’t occur.
One core concept of ERAS has been to avoid tubes (NG tubes, Foley catheters, etc.) and drains. Nasogastric intubation is not routinely recommended for bowel surgery as it is known to be associated with increased risk of postoperative pneumonia and has not been associated with a reduction in wound dehiscence or anastomotic leak. And the historic use of peritoneal drains (e.g., Jackson–Pratt drain) has also become less common.
Early feeding and early mobilization are the hallmarks of ERAS protocols. We emphasized above avoiding putting the gut to sleep. So early feeding is a key component of all ERAS protocols. Many begin clear liquids right after surgery and advance diet as tolerated. Use of antiemetics and avoidance of opioids are important in promoting early feeding.
Pain management depends upon whether the oral route is available. If a patient is not yet taking things orally, epidural analgesia is important. The Hopkins protocol used patient-controlled epidural bupivacaine. Once the patient is able to take things orally, multimodal analgesia, minimizing use of opioids, is the heart of the ERAS protocol. The Hopkins protocol uses acetaminophen, ibuprofen and gabapentin (again, see our caution on gabapentin in our January 2020 What's New in the Patient Safety World column “FDA Warning on Gabapentinoids”). Use of a Lidoderm patch may also be helpful. For breakthrough pain, they first use tramadol and only go to more potent opioids if that fails.
Get that Foley out! We have done so many columns on CAUTI’s that we hate to elaborate on this again. But there may be challenges in this population. Continued use of epidural analgesia may prevent early urinary catheter removal. And, in those cases where fluid overload remains problematic, some advocate continued use of a urinary catheter for accurate I&O measurement. But if the patient is alert the catheter can usually be removed. If there are questions about urinary retention, use of bladder ultrasound has been very useful.
Note that early catheter removal also facilitates promotion of early mobilization, the other key component of post-op ERAS. The Altman article notes that many protocols include actively mobilizing the patient within 24 hours of surgery, and that most suggest mobilizing for a minimum of 2 hours on the day of surgery, followed by 6 hours on all subsequent hospital days. And it is important to note that early mobilization can take place in an ICU setting as well as on a med/surg floor,
So how do you go about implementing ERAS?
Altman and colleagues (Altman 2019) offered the following key points in starting an ERASA program:
They emphasize that your multidisciplinary team should include family physicians and will interact with patients before admission and after discharge.
These are the same steps we went through 10 years ago as we promoted ERAS. We began with meetings with surgeons, anesthesiologists, OR nurses, OR manager, floor and ICU nurses, and administrators. Our first task was to show the theory of ERAS, elaborate on the evidence base for ERAS, and point out the advantages to patients, healthcare professionals, and the hospital.
The Altman article also notes some of the challenges in implementing ERAS protocols. One is having adequate staffing to promote that early mobilization, noting that may require increased support from nursing, health care aids and physiotherapy. It also notes that sometimes resistance to early removal of urinary catheters may come from night staff, though we have always found nursing staff to actually be forceful advocates for catheter removal. It also points out the issue of DVT prophylaxis in patients with epidural catheters.
In our experience, the biggest barrier to ERAS implementation is resistance to change in general. “We’ve always done it this way” is the bane of any change management program. Another barrier is the lack of availability of anesthesia support for epidural analgesia, a problem more often seen in small and rural hospitals. And, of course, there is the dichotomy between complete elimination of pain vs. the adverse effects on bowl function of opioids.
You may have to convince your CFO to fund the extra help needed for early mobilization. But once he/she sees the likely fiscal benefits of an ERAS program, he/she should have no qualms about complying with that request.
Having clinical champions is the key. That includes not only surgical champions but also anesthesiologist and nursing staff that are strong advocates. Having a representative multidisciplinary team involved in all aspects of planning and implementation is important. Above all, communication is essential at all levels. Getting the support of frontline staff is key in any change management project.
Grant et al. (Grant 2019) emphasized the role anesthesiologists play in ERAS programs. They looked at compliance with 9 specific process measures directly influenced by the anesthesiologist or acute pain service. They found that process measure compliance was associated with a stepwise reduction in LOS (length of stay). Patients who received >4 process measures (high compliance) had a significantly shorter LOS (incident rate ratio IRR 0.77) compared to low compliance (0–2 process measures) counterparts. Parameters independently associated with reduced LOS were: utilization of multimodal nausea and vomiting prophylaxis (IRR 0.78), scheduled postoperative nonsteroidal pain medication use (IRR 0.76), and strict adherence to a postoperative opioid administration protocol for breakthrough pain (IRR 0.58).
We also recommend you start ERAS for one type of surgery first. Once you have demonstrated the benefits of ERAS, you’ll probably find others beginning to clamor for ERAS in their respective areas. Historically, ERAS made its name in colorectal surgery, so most hospitals try it there first. But you need to determine which procedures are done in your facility and consider which types of surgery are ready for the switch to ERAS.
Stone and colleagues in a systematic review (Stone 2018) found that, despite many studies looking at safety or efficacy or cost-effectiveness of ERAS, there was a paucity of studies on success factors or barriers in implementation of ERAS programs. They basically found that the facilitators were those you need for any quality improvement program:
Also, not unexpectedly, the biggest barrier identified was resistance from frontline clinicians.
So, what are the benefits of ERAS?
ERAS has resulted in significant reduction in hospital costs, largely due to reductions in hospital length of stay (LOS). But the improvements in patient outcomes have also been substantial, with reductions in complications and reduced mortality rates.
The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support enhanced recovery protocol (ERP) implementation (Berian 2018). 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program (NSQIP) achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions, compared to control hospitals. Mean LOS decreased by 1.7 days in the pilot hospitals, compared with 0.4 days in controls. Serious morbidity or mortality decreased for pilot participants (14.1% before implementation vs. 10.5% after implementation), with no difference in controls.
Jung and colleagues at the University of Cincinnati College of Medicine published results that followed implementation of enhanced recovery pathways (Jung 2018). Implementation of an ERP for patients undergoing elective colorectal resection substantially reduced length of stay, total hospital cost, and direct pharmacy cost without increasing complications or readmission rates. Enhanced recovery pathway after colorectal resection has both clinical and financial benefits. After implementation, median length of stay decreased from 5.0 to 3.0 days. ERP patients required significantly less narcotics during their index hospitalization and tolerated a regular diet 1 day sooner. Despite a higher daily pharmacy cost, the total direct pharmacy cost for the hospitalization was reduced in ERP patients ($1,534 vs $1,859) and total direct cost was also lower in ERP patients ($9,791 vs $11,508). There were no differences in 30-day complications (8.1% vs 8.9%) or hospital readmission (11.9% vs 11.0%).
Liu and colleagues (Liu 2017) evaluated an ERAS program at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. There were 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. Postoperative complications were reduced for both patients undergoing colorectal resection and for patients with hip fracture (odds ratios 0.68 and 0.67, respectively). Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality. Among patients with hip fracture, implementation was associated with increased rates of discharge to home.
POWER, a multi-center study of over 2000 colorectal surgeries in Spain (Ripollés-Melchor 2019) achieved some striking results. The rate of moderate or severe complications was lower in patients in the ERAS group (25.2% vs 30.3%; odds ratio 0.77). Moreover, patients with the highest rates of adherence to the ERAS protocols had fewer moderate to severe complications (OR, 0.34), overall complications (OR 0.33), and mortality (OR 0.27) compared with those who had the lowest adherence rates.
Another major benefit is that almost all ERAS programs have also reported significant reductions in opioid usage. Penn Medicine found that ERAS in patients undergoing spine or peripheral nerve surgery saw substantial reductions in opioid use (Penn Medicine 2019). In fact, use of intravenous opioid medications via patient-controlled analgesia (PCA) was nearly eliminated in the ERAS group (0.5 percent) compared to over half of spinal surgical patients in the control group. And, after one month, 38% of patients in the ERAS group were using opioids compared to 53% of patients in the historical control group. ERAS, of course, includes multi-modal pain management protocols, with judicious use of opioids only as needed.
How do you evaluate whether your ERAS program is successful?
Every quality improvement project needs objective measures to be able to demonstrate that improvement resulted from the project. Here are some parameters of measurement to consider:
Calculating the financial benefits is more complex. Most calculate those using formulas pertinent to the LOS savings. But we always caution that reducing LOS translates to cost savings only if you can reduce staffing (either by using flex staffing or by being able to close a unit). So be wary of simply multiplying your reduced hospital days by some magic number. Today’s sophisticated hospital cost-accounting systems provide a better picture.
What types of surgery have used ERAS?
While ERAS had its origin in colorectal surgery, enhanced recovery components are being implemented in an increasing number of surgeries. A recent systematic review of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures (Visioni 2018) concluded that ERAS protocols decreased length of stay and cost without increasing complications or readmission rates. Liu et al. (Liu 2017) demonstrated their ERAS program resulted in significant absolute and relative decreases in hospital length of stay and postoperative complication rates patients undergoing emergency hip fracture repair. The Wu article (Wu 2017) discussed expansion of the Johns Hopkins ERAS pathways to liver resection, radical cystectomy, gynecologic oncology and pediatric surgery, with plans to develop ERAS pathways for thoracic surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), pancreatoduodenectomy, and breast surgery.
ERAS protocols have also now been used in spine surgery (Helwick 2018, Penn Medicine 2019), peripheral nerve surgery (Penn Medicine 2019), pancreaticoduodenectomy (Mander 2018a), elective C-sections (Mander 2018b), complex hip and pectus excavatum surgeries in children (Vlessides 2018b), craniotomy (Porter 2018), esophagectomy (Mander 2019), breast flap reconstruction (Vlessides 2017), and even in the interventional radiology suite (Vlessides 2018a). Guidelines for perioperative care in cardiac surgery have now also incorporated ERAS concepts and protocols (Engelman 2019).
Hospitals that have implemented ERAS across service lines have also seen quality improvements and reductions in LOS and costs for most surgeries (Smith 2019). New Hanover Regional Medical Center in North Carolina implemented ERAS across six service lines—colorectal, gynecology, hepatopancreatobiliary (HPB), urology, cardiac and spinal fusion. Hospital LOS decreased for all service lines except urology. LOS for colorectal surgery fell from 5.5 to 3.6 days, gynecology from 3.9 to 1.4 days, and spinal fusion from 2.38 to 1.6 days. LOS in cardiac surgery also decreased from 4.67 to 3.05 days but this did not reach statistical significance. Overall, this resulted in 1,846 hospital days saved in 2018 and hospital cost savings of more than $4.7 million in 2018 alone. The cost savings was due to both decreased LOS and less time spent in ICU and step-down care units, At the same time, the 30-day readmission rate either fell (for colorectal, gynecology, urology and HPB) or remained about the same compared with pre-ERAS procedures, and complications were either fewer (for colorectal, gynecology, urology and spinal fusion) or about the same as they had been for the pre-ERAS procedures.
A Geisinger Health System program highlighted the importance of the switch from traditional pre-op fasting to use of a carbohydrate drink given 2 hours prior to surgery as part of its ProvenRecovery program, a typical ERAS program that also focuses on early mobilization and appropriate pain management (Porter 2018). Benefits due at least in part to the program include a length of stay reduction for the average neurosurgery patient of 39% (from 4.3 to 2.62 days) and for the average colon surgery patient 44% (from 4.5 days to 2.5 days). Those earlier discharges saved more than $4,500 per case for colorectal surgery patients. Geisinger has announced that it will make the pilot permanent and roll out the ProvenRecovery program systemwide across 42 surgical procedures affecting about 15,000 cases annually.
If you are not yet using ERAS, you probably should be! For those of you who have not yet implemented ERAS for any surgeries, we suggest you read the CMAJ article (Altman 2019) and the article about the Johns Hopkins ERAS program (Wu 2017). Other excellent resources may be found at the ERAS® Society, Enhanced Recovery Canada™, and the ACS AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR) (ACS 2020).
Update: Since our original column the result of the POWER2 study have been published (Ripollés-Melchor 2020). This study looked at the impact of ERAS on elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Spain. Fewer patients in the ERAS group had moderate to severe complications (4.6% vs 6.1%, OR, 0.74). Patients with the highest adherence to ERAS protocols had fewer overall postoperative complications (10.6% vs 13.0%; OR, 0.80), and moderate to severe postoperative complications (4.4% vs 6.9%, OR, 0.62), and shorter median length of hospital stay (4 vs 5 days, OR, 0.97). The study confirms that adherence to ERAS protocols is important in reducing postop complications in total joint arthroplasty.
Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery. A Review. JAMA Surg 2017; 152(3): 292-298
Altman AD, Helpman L, McGee J, et al. on behalf of the Society of Gynecologic Oncology of Canada’s Communities of Practice in ERAS and Venous Thromboembolism. Enhanced recovery after surgery: implementing a new standard of surgical care. CMAJ 2019; 191(17): E469-E475 April 29, 2019
ACS (American College of Surgeons). National Effort to Advance Best Practices in Surgical Patient Care Begins with Recommendations for Colorectal Operations. Press release August 8, 2017
ACS (American College of Surgeons) AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR). Accessed February 5, 2020
Williams C, Laflamme C, Penner B. Accelerating Post-Surgical Best Practices Using Enhanced Recovery After Surgery. Healthcare Quarterly 2020; 22(SP): 72-81
Enhanced Recovery Canada™
Wu CL, Benson AP, Hobson DB, Wick EC. Development and Implementation of a Colorectal ERAS Pathway. Anesthesiology News 2017; October 16, 2017
Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med 2018; Published online May 10, 2018
Grant MC, Pio Roda CM, Canner JK, et al. The Impact of Anesthesia-Influenced Process Measure Compliance on Length of Stay: Results From an Enhanced Recovery After Surgery for Colorectal Surgery Cohort. Anesthesia & Analgesia 2019; 128(1): 68-74, January 2019
Stone AB, Yuan CT, Rosen MA, et al. Barriers to and Facilitators of Implementing Enhanced Recovery Pathways Using an Implementation Framework. JAMA Surg 2018; 153(3): 270-279
Berian JR, Ban KA, Liu JB, et al. Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program. JAMA Surg 2018; 153(4): 358-365
Jung AD, Dhar VK, Hoehn RS, et al. Enhanced Recovery after Colorectal Surgery: Can We Afford Not to Use It? J Am Coll Surg 2018; 226(4): 586-593
Liu VX, Rosas E, Hwang J, et al. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surg 2017; 152(7): e171032. Epub 2017 Jul 19
Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R, et al. Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study. JAMA Surg 2019; 154(8): 725-736
Penn Medicine. Penn’s ‘Enhanced Recovery’ Protocol Reduces Opioid Use in Spinal Surgery Patients. First study to show benefit of a comprehensive ERAS pathway in spine and peripheral nerve surgery patients. Penn Medicine Press Release 2019; January 25, 2019
Visioni A, Shah R, Gabriel E, et al. Enhanced Recovery After Surgery for Noncolorectal Surgery? A Systematic Review and Meta-analysis of Major Abdominal Surgery. Annals of Surgery 2018; 267(1): 57-65
Helwick C. Reduced Opioids After Spinal Surgery With ERAS Protocol. Medscape Medical News 2018; May 08, 2018
Mander K. Pancreaticoduodenectomy Enhanced Recovery Program Reduces Opioid Use. Anesthesiology News 2018; May 10, 2018
Mander K. Implementing an Enhanced Recovery Program For Elective Cesareans Improves Care and Saves Money. Anesthesiology News 2018; May 21, 2018
Vlessides M. ERAS Protocol Succeeds in Breast Flap Reconstruction. Anesthesiology News 2017; August 30, 2017
Vlessides M. Pediatric Enhanced Recovery Pathways Reduced Pain, PONV, Length of Stay and Costs. Anesthesiology News 2018; July 16, 2018
Porter S. Beyond Pre-Surgery Fasting: Geisinger Boosts Nutrition to Speed Up Recovery. HealthLeaders 2018; November 26, 2018
Vlessides M. Enhanced Recovery Protocol Successful In Interventional Radiology Suite. Anesthesiology News 2018; November 19, 2018
Mander K. Multidisciplinary Enhanced Recovery Pathway Reduces LOS Post-Esophagectomy. Anesthesiology News 2019; January 22, 2019
Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg 2019; 154(8): 755-766
Smith MJ. Group Shares ERAS Experience Across 8 Surgical Services. Length of Stay, Complications Decrease for Most Surgical Lines. Anesthesiology News 2019; June 26, 2019
Ripollés-Melchor J, Abad-Motos A, Díez-Remesal Y, et al. Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2). JAMA Surg 2020; Published online February 12, 2020
Print “PDF version”