Anaes · Orthopaedic anaesthesia
Arthroplasty anaesthesia, ERAS, and blood conservation
Also known as arthroplasty eras blood conservation
Arthroplasty ERAS combines optimised comorbidities, preferred neuraxial or regional plus light GA, TXA for blood conservation (typical 1 g IV or 10–15 mg/kg with local protocols), multimodal opioid-sparing analgesia, early mobilisation, and VTE prophylaxis timed safely with neura
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Red flags
- Cemented hip arthroplasty in frail elderly risks BCIS — optimise, communicate, and consider uncemented when appropriate.
- TXA reduces bleeding but needs documented risk-benefit discussion in active thromboembolic disease.
- Neuraxial plus anticoagulation requires ASRA-compatible timing.
- Failure of multimodal analgesia delays mobilisation and defeats ERAS goals.
Meet the patient
An 82-year-old woman with osteoarthritis presents for a cemented total hip arthroplasty. Her haemoglobin is 102 g/L, she takes apixaban for atrial fibrillation (held per protocol), she has mild COPD, and her exercise tolerance is one flight. The surgeon wants her walking by 16:00. Your job is to deliver an anaesthetic that gets her standing without losing her to BCIS, bleeding, or a dense motor block that keeps her in bed.[1]
The question that owns this case: can you thread the needle — enough analgesia to walk, enough haemostasis to avoid transfusion, safe neuraxial-to-anticoagulant timing, and a cement plan that does not stop her heart? ERAS is the framework that makes all four align.[1]
References8ShowHide
- [1]Sukeik M, Alshryda S, Haddad FS, Mason JM Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement J Bone Joint Surg Br, 2011.PMID 21196541
- [2]Alshryda S, Sukeik M, Sarda P, et al. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement Bone Joint J, 2014.PMID 25086114
- [3]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [4]Donaldson AJ, Thomson HE, Harper NJ, Kenny NW Bone cement implantation syndrome Br J Anaesth, 2009.PMID 19059919
- [5]Horlocker TT, Vandermeuelen E, Kopp SL, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) Reg Anesth Pain Med, 2018.PMID 29561531
- [6]Gao F, Ma J, Sun W, et al. Adductor Canal Block Versus Femoral Nerve Block for Analgesia After Total Knee Arthroplasty: A Systematic Review and Meta-analysis Clin J Pain, 2017.PMID 27322397
- [7]Piette N, Beck F, Carella M, et al. Oral as compared to intravenous tranexamic acid to limit peri-operative blood loss associated with primary total hip arthroplasty: A randomised noninferiority trial Eur J Anaesthesiol, 2024.PMID 38214552
- [8]Moskal JT, Capps SG Meta-analysis of Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty Orthopedics, 2016.PMID 27248332