Impact of Eliminating Gabapentinoids From an Orthopedic Enhanced Recovery Protocol on Postoperative Hypotension After...

Gabapentinoids have been widely incorporated into enhanced recovery after surgery (ERAS) pathways for total joint arthroplasty despite limited evidence of benefit and increasing concern for adverse hemodynamic effects. In response to frequent postoperative hypotension observed on inpatient units, a multidisciplinary team initiated a quality improvement effort to remove routine gabapentinoids from an orthopedic ERAS pathway.

This initiative was conducted at a tertiary academic medical center as part of ongoing medication safety monitoring within an established ERAS program. Routine perioperative gabapentinoids were removed from the orthopedic ERAS pathway following multidisciplinary review, education, and correction of an electronic order set autoselection defect. Outcomes were monitored using routinely collected clinical data from adult patients undergoing primary or revision total hip or knee arthroplasty. The primary outcome was postoperative hypotension occurring from postoperative day 1 to discharge. Gabapentinoid exposure rates and patient and procedural characteristics were tracked to contextualize changes over time.

A total of 1246 total joint arthroplasty cases were included during the quality monitoring period. Following pathway modification, gabapentinoid exposure decreased from 532 of 589 (90.3%) to 102 of 543 (18.8%) (P < .0001). This change was accompanied by a descriptive decrease in postoperative hypotension from 59 of 589 (10.0%) to 36 of 543 (6.6%) with P values reported descriptively. Patient demographics, procedure types, and anesthesia distributions remained similar across monitoring periods, suggesting that observed changes were temporally associated with pathway modification rather than shifts in case mix.

Eliminating routine gabapentinoids from a total joint arthroplasty ERAS pathway was associated with lower observed rates of postoperative hypotension and substantially lower gabapentinoid exposure. This quality improvement initiative demonstrates how multidisciplinary review, electronic order set evaluation, and structured monitoring can support safer medication use and improve the reliability of perioperative care pathways.