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Sun J, Huang L, Yang Y, Liao H. Risk assessment and clinical prediction model of planned transfer to the ICU after hip arthroplasty in elderly individuals. BMC Surg 2023; 23:305. [PMID: 37805523 PMCID: PMC10559453 DOI: 10.1186/s12893-023-02204-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/23/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND With the development of hip arthroplasty technology and rapid rehabilitation theory, the number of hip arthroplasties in elderly individuals is gradually increasing, and their satisfaction with surgery is also gradually improving. However, for elderly individuals, many basic diseases, poor nutritional status, the probability of surgery, anaesthesia and postoperative complications cannot be ignored. How to reduce the incidence of postoperative complications, optimize medical examination for elderly patients, and reasonably allocate medical resources. This study focuses on the construction of a clinical prediction model for planned transfer to the ICU after hip arthroplasty in elderly individuals. METHODS We retrospectively analysed 325 elderly patients who underwent hip arthroplasty. The general data and preoperative laboratory test results of the patients were collected. Univariate and multivariate logistic regression analyses were performed to screen independent influencing factors. The backwards LR method was used to establish the prediction model. Then, we assessed and verified the degree of discrimination, calibration and clinical usefulness of the model. Finally, the prediction model was rendered in the form of a nomogram. RESULTS Age, blood glucose, direct bilirubin, glutamic-pyruvic transaminase, serum albumin, prothrombin time and haemoglobin were independent influencing factors of planned transfer to the ICU after hip arthroplasty. The area under the curve (AUC) of discrimination and the 500 bootstrap internal validation AUC of this prediction model was 0.793. The calibration curve fluctuated around the ideal curve and had no obvious deviation from the ideal curve. When the prediction probability was 12%-80%, the clinical decision curve was above two extreme lines. The discrimination, calibration and clinical applicability of this prediction model were good. The clinical prediction model was compared with the seven factors in the model for discrimination and clinical use. The discrimination and clinical practicability of this prediction model were superior to those of the internal factors. CONCLUSION The prediction model has good clinical prediction ability and clinical practicability. The model is presented in the form of a linear graph, which provides an effective reference for the individual risk assessment of patients.
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Affiliation(s)
| | - Lue Huang
- Meizhou People's Hospital, Meizhou, China
| | - Yali Yang
- Meizhou People's Hospital, Meizhou, China
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2
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Long H, Zeng C, Xiong Y, Shi Y, Wang H, Lei G. Neuraxial versus general anesthesia for perioperative outcomes and resource utilization following knee arthroplasty: experience from a large national database. Arch Orthop Trauma Surg 2023; 143:2153-2163. [PMID: 35695925 DOI: 10.1007/s00402-022-04483-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 05/15/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Attentions have been paid to the optimal anesthesia for knee arthroplasty (KA). We sought to investigate whether neuraxial anesthesia (NA) is superior to general anesthesia (GA) in terms of perioperative outcomes and resource utilization following KA. METHODS Patients undergoing primary KA registered in the Hospital Quality Monitoring System (HQMS) in China during 2013-2019 were identified. By utilizing a time-stratified propensity score matching, every patient receiving NA was matched by propensity score to a patient receiving GA. Then, we conducted Poisson, logistic, and linear regression to compare NA with GA in terms of perioperative outcomes and resource utilization. RESULTS Of 109,132 included participants, 75,945 (69.59%) underwent KA with GA and 33,187 (30.41%) with NA. After propensity score matching (26,425 participants per group), NA was associated with lower incidence of blood transfusion (OR: 0.82, 95% CI 0.77-0.87; p < 0.0001), 30-day readmission (OR: 0.76, 95% CI 0.68-0.84; p < 0.0001), and 90-day readmission (OR: 0.83, 95% CI 0.77-0.90; p < 0.0001). No statistically significant difference in in-hospital mortality, incidence of pulmonary embolism, deep vein thrombosis, and surgical site infection was found. In addition, NA was associated with a 1% decrease in length of stay (95% CI 0-2%; p = 0.0070) and a 3% lower total hospital charge (95% CI 2-4%; p < 0.0001) when compared with GA. CONCLUSION Compared with GA, NA was associated with decreased incidence of blood transfusion, readmission, reduced length of stay, and total hospital charge following KA, suggesting the favorable role of NA for perioperative outcomes and resource utilization in KA.
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Affiliation(s)
- Huizhong Long
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
- Hunan Engineering Research Center for Osteoarthritis, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yunchuan Xiong
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Ying Shi
- China Standard Medical Information Research Center, Shenzhen, China
| | - Haibo Wang
- China Standard Medical Information Research Center, Shenzhen, China
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China.
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China.
- Hunan Engineering Research Center for Osteoarthritis, Changsha, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
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3
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Knio ZO, Clancy PW, Zuo Z. Effect of spinal versus general anesthesia on thirty-day outcomes following total hip arthroplasty: A matched-pair cohort analysis. J Clin Anesth 2023; 87:111083. [PMID: 36848778 DOI: 10.1016/j.jclinane.2023.111083] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE It has not yet been established whether total hip arthroplasty complications are associated with anesthetic technique (spinal versus general). This study assessed the effect of spinal versus general anesthesia on health care resource utilization and secondary endpoints following total hip arthroplasty. DESIGN Propensity-matched cohort analysis. SETTING American College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2021. PATIENTS Patients undergoing elective total hip arthroplasty (n = 223,060). INTERVENTIONS None. MEASUREMENTS The a priori study duration was 2015 to 2018 (n = 109,830). The primary endpoint was 30-day unplanned resource utilization, namely readmission and reoperation. Secondary endpoints included 30-day wound complications, systemic complications, bleeding events, and mortality. The impact of anesthetic technique was investigated with univariate analyses, multivariable analyses, and survival analyses. MAIN RESULTS The 1:1 propensity-matched cohort included 96,880 total patients (48,440 in each anesthesia group) from 2015 to 2018. On univariate analysis, spinal anesthesia was associated with a lower incidence of unplanned resource utilization (3.1% [1486/48440] vs 3.7% [1770/48440]; odds ratio [OR], 0.83 [95% CI, 0.78 to 0.90]; P < .001), systemic complications (1.1% [520/48440] vs 1.5% [723/48440]; OR, 0.72 [95% CI, 0.64 to 0.80]; P < .001), and bleeding events requiring transfusion (2.3% [1120/48440] vs 4.9% [2390/48440]; OR, 0.46 [95% CI, 0.42 to 0.49]; P < .001). On multivariable analysis, spinal anesthesia remained an independent predictor of unplanned resource utilization (adjusted odds ratio [AOR], 0.84 [95% CI, 0.78 to 0.90]; c = 0.646), systemic complications (AOR, 0.72 [95% CI, 0.64 to 0.81]; c = 0.676), and bleeding events (AOR, 0.46 [95% CI, 0.42 to 0.49]; c = 0.686). Hospital length of stay was also shorter in the spinal anesthesia cohort (2.15 vs 2.24 days; mean difference, -0.09 [95% CI, -0.12 to -0.07]; P < .001). Similar findings were observed in the cohort from 2019 to 2021. CONCLUSIONS Total hip arthroplasty patients receiving spinal anesthesia experience favorable outcomes compared to propensity-matched general anesthesia patients.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - Paul W Clancy
- School of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America.
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4
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Zhong H, Garvin S, Poeran J, Liu J, Kirksey M, Wilson LA, DeMeo D, Yang E, Hong G, Jules-Elysee KM, Nejim J, Memtsoudis SG. The Use of Critical Care Services After Orthopedic Surgery at a High-Volume Orthopedic Medical Center: A Retrospective Study. HSS J 2022; 18:344-350. [PMID: 35846258 PMCID: PMC9247588 DOI: 10.1177/15563316211055166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/25/2021] [Indexed: 02/07/2023]
Abstract
Background: With an aging population, orthopedics has become one of the largest and fastest growing surgical fields. However, data on the use of critical care services (CCS) in patients undergoing orthopedic procedures remain sparse. Purpose: We sought to elucidate the prevalence and characteristics of patients requiring CCS and intermediate levels of care after orthopedic surgeries at a high-volume orthopedic medical center. Methods: We retrospectively reviewed inpatient electronic medical record data (2016-2020) at a high-volume orthopedic hospital. Patients who required CCS and intermediate levels of care, including step-down unit (SDU) and telemetry services, were identified. We described characteristics related to patients, procedures, and outcomes, including type of advanced services required and surgery type. Results: Of the 50,387 patients who underwent orthopedic inpatient surgery, 1.6% required CCS and 21.6% were admitted to an SDU. Additionally, 482 (1.0%) patients required postoperative mechanical ventilation and 3602 (7.1%) patients required continuous positive airway pressure therapy. Spine surgery patients were the most likely to require any form of advanced care (45.7%). Conclusions: This retrospective review found that approximately one-fourth of orthopedic surgery patients were admitted to units that provided critical and intermediate levels of care. These results may prove useful to hospitals in estimating needs and allocating resources for advanced and critical care services after orthopedic surgery.
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Affiliation(s)
- Haoyan Zhong
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Sean Garvin
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery
Science, Department of Population Health Science and Policy/Orthopedics, Icahn
School of Medicine at Mount Sinai, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA
| | - Meghan Kirksey
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA
| | - Lauren A. Wilson
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Danya DeMeo
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Elaine Yang
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA
| | - Kethy M. Jules-Elysee
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA
| | - Jemiel Nejim
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA
| | - Stavros G. Memtsoudis
- Department of Anesthesiology, Critical
Care & Pain Management, Hospital for Special Surgery, New York, NY, USA,Department of Anesthesiology, Weill
Cornell Medicine, New York, NY, USA,Department of Anesthesiology,
Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University,
Salzburg, Austria,Department of Health Policy and
Research, Weill Cornell Medicine College, New York, NY, USA,Stavros G. Memtsoudis, MD, PhD, MBA, FCCP,
Department of Anesthesiology, Critical Care & Pain Management, Hospital for
Special Surgery, New York, NY 10021, USA.
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5
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Sun J, Yang Y, Feng G, Liang C, Ling W, Liao H. Analysis of related factors of scheduled ICU before primary hip arthroplasty. BMC Anesthesiol 2022; 22:221. [PMID: 35831810 PMCID: PMC9277812 DOI: 10.1186/s12871-022-01737-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methods for improving the safety of medical treatments for patients, reducing the occurrence of postoperative complications and optimizing medical resources for primary hip replacement are needed. Previous literature has mostly analysed the risk factors and constructed and models to predict a transfer to the ICU after surgery, and no reports on preoperative ICU reservations have been found. This study evaluated the risk factors for preoperative ICU reservation and considered the necessity of preoperative ICU reservations to optimize preoperative communication, enable a seamless transfer between the operating room and ICU, reduce postoperative complications and shorten hospital stays. METHODS We extracted the data of 1488 patients who underwent hip replacement from the hospital case database from November 2017 to May 2021 and used the case-control test to divide the patients into the case group (scheduled ICU admission, 134 cases) and the control group (Not scheduled ICU admission, 213 cases). The general conditions of the patients before surgery, including sex, age, Charlson comorbidity index, laboratory test results, and anaesthesia methods, were collected and used as independent variables. The t test, rank sum test, and X2 test were used to analyse and identify significant factors with a P < 0.05. Then, these factors were entered into binary logistic regression analysis, and a ROC curve was used to test the efficacy of the regression model. RESULTS In the data we collected, 134 patients were planned to be transferred to the ICU, and 213 patients were not transferred to the ICU. The two groups of data were analyzed by logistic regression. We defined the risk factors for preoperative ICU appointment in patients with primary hip arthroplasty, including age. (odds ratio (OR) 1.066, 95% (confidence interval) CI (1.039, 1.093), P < 0.001), general anesthesia ( (OR) 1.821, 95%CI (1.165, 2.845), P = 0.008), preoperative C-reactive protein ((OR) 1.016, 95%CI (1.010, 1.022), P < 0.05), preoperative alanine aminotransferase ((OR) 1.042, 95%CI ((1.016, 1.070)), P = 0.002). These were promoting factors for preoperative ICU appointment,and preoperative albumin ((OR) 0.0839, 95%CI (0.792, 0.889)), P < 0.05) was a protective factor for ICU appointment. CONCLUSION For patients requiring primary hip replacement. Age, general anesthesia, preoperative C-reactive protein, preoperative alanine aminotransferase and preoperative albumin are the key points of our preoperative assessment. Paying attention to the changes of these indicators will help surgeons assess the patient's condition and contact the ICU in advance.These data can be fully understood by the patients' families, reduce the unnecessary use of medical resources, and optimize perioperative management.
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Affiliation(s)
- Jianguang Sun
- Joint Surgery of Meizhou People' S Hospital, Meizhou, 514000, Guangdong Province, China
| | - Yali Yang
- Joint Surgery of Meizhou People' S Hospital, Meizhou, 514000, Guangdong Province, China
| | - Guilan Feng
- Joint Surgery of Meizhou People' S Hospital, Meizhou, 514000, Guangdong Province, China
| | - Chuanxing Liang
- Joint Surgery of Meizhou People' S Hospital, Meizhou, 514000, Guangdong Province, China
| | - Weiming Ling
- Joint Surgery of Meizhou People' S Hospital, Meizhou, 514000, Guangdong Province, China
| | - Hongxin Liao
- Joint Surgery of Meizhou People' S Hospital, Meizhou, 514000, Guangdong Province, China.
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6
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Sandhu K, Goyal D, Kahal KS, Khichy H. Assessment of Short-Term Outcomes of Total Knee Arthroplasty Performed With and Without a Tourniquet. Cureus 2022; 14:e25324. [PMID: 35755493 PMCID: PMC9231576 DOI: 10.7759/cureus.25324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Tourniquet use has been advocated for better visualization of the surgical field as it exsanguinates most of the blood from the limbs to the central compartment. On the contrary, its use may increase postoperative pain and recovery of quadriceps function, thereby increasing the length of stay (LOS). The study aims to assess short-term outcomes of total knee arthroplasty (TKA) performed with and without a tourniquet. Methodology: Eighty-six patients scheduled for TKA either with or without a tourniquet were selected and divided into two groups using simple random sampling. Knee replacements were performed with a tourniquet in group I and without a tourniquet in group II. In all cases, blood loss was estimated. A visual analog scale (VAS) was used for the assessment of postoperative pain. In the study, range of motion (ROM) and quadriceps lag were also assessed on postoperative day 2 and discharge. Results: There were 23 (26.7%) males and 20 (23.2%) females in group I and 28 (32.5%) males and 15 (17.4%) females in group II (p = 0.07). On comparing mean age and body mass index (BMI), statistically insignificant results were obtained. In group I and group II, a statistically significant difference was obtained in the estimation of mean total blood loss as 780.4 ± 152.49 and 1146.2 ± 193.14 ml, respectively (p = 0.02). Neither on postoperative day 2 nor at the time of discharge, no significant results were obtained in observing the ROM at the knee joint and quadriceps lag. Conclusion: It was found that tourniquet use is associated with lower blood loss and similar postoperative pain, ROM, quadriceps lag, and LOS.
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7
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Wei C, Muthiah A, Gu A, Quan T, Nguyen KT, Fassihi SC, Chen AZ, Amdur RL, Nunley RM, Liu J, Sculco PK, Berger JS. Association of Anesthesia Type with Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty. J Knee Surg 2022; 35:345-354. [PMID: 32663884 DOI: 10.1055/s-0040-1713776] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Revision total knee arthroplasty (TKA) is an increasingly common procedure and is effective in treating knee osteoarthritis, but it has higher complication rates than primary TKA. Anesthetic choice poses perioperative risk that has been extensively studied in primary TKA, showing favorable results for regional anesthesia compared with general anesthesia. The impact of anesthetic choice in revision TKAs is not well studied. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2014 and 2017 were divided into three anesthesia cohorts: (1) general anesthesia, (2) regional anesthesia, and (3) combined general-regional anesthesia. Univariate and multivariate analyses were used to analyze patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post hoc analysis. In total, 8,820 patients were identified. Of whom, 3,192 patients underwent general anesthesia, 3,474 patients underwent regional anesthesia, and 2,154 patients underwent combined anesthesia. After multivariate analyses, regional anesthesia was associated with decreased odds for any complication (p = 0.008), perioperative blood transfusion (p < 0.001), and extended length of stay (p < 0.001) compared with general anesthesia. In addition, regional anesthesia was associated with decreased odds for perioperative blood transfusion (p < 0.001) and extended length of stay (p = 0.006) compared with combined anesthesia. However, following multivariate analysis, regional anesthesia was not associated with decreased odds of wound, pulmonary, renal, urinary tract, thromboembolic, and cardiac complications, and was not associated with return to operating room, extended length of stay, minor and major complications, and mortality. Retrospective analysis of a large surgical database suggests that patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia. Prospective and controlled trials should be conducted to verify these findings.
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Affiliation(s)
- Chapman Wei
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Arun Muthiah
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Alex Gu
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York City, New York
| | - Theodore Quan
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Kenneth T Nguyen
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York
| | - Safa C Fassihi
- Department of Orthopedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Aaron Z Chen
- Weill Cornell Medical College, New York City, New York
| | - Richard L Amdur
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University at St Louis School of Medicine, St. Louis, Missouri
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York City, New York
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York City, New York
| | - Jeffrey S Berger
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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8
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Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Go G, Hargett MJ, Lee BH, Wendel P, Brouillette M, Kim SJ, Baaklini L, Wetmore DS, Hong G, Goto R, Jivanelli B, Athanassoglou V, Argyra E, Barrington MJ, Borgeat A, De Andres J, El-Boghdadly K, Elkassabany NM, Gautier P, Gerner P, Gonzalez Della Valle A, Goytizolo E, Guo Z, Hogg R, Kehlet H, Kessler P, Kopp S, Lavand'homme P, Macfarlane A, MacLean C, Mantilla C, McIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Peng P, Pichler L, Poeran J, Poultsides L, Schwenk ES, Sites BD, Stundner O, Sun EC, Viscusi E, Votta-Velis EG, Wu CL, YaDeau J, Sharrock NE. Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature. Reg Anesth Pain Med 2021; 46:971-985. [PMID: 34433647 DOI: 10.1136/rapm-2021-102750] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Janis Bekeris
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Dace Bekere
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - George Go
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Mary J Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bradley H Lee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Pamela Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Mark Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Sang Jo Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Lila Baaklini
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Douglas S Wetmore
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Rie Goto
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bridget Jivanelli
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Vassilis Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eriphili Argyra
- Faculty of Medicine, Aretaieion University Hospital, Athens, Greece
| | - Michael John Barrington
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Alain Borgeat
- Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Jose De Andres
- Anesthesia, Critical Care and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain.,Anesthesia Unit, Surgical Specialties Department, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Nabil M Elkassabany
- Anesthesiology and Critical Care, University Of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philippe Gautier
- Department of Anesthesiology and Resuscitation, Clinique Sainte-Anne Saint-Remi, Brussels, Belgium
| | - Peter Gerner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Alejandro Gonzalez Della Valle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Zhenggang Guo
- Department of Anesthesiology, Peking Universtiy Shougang Hospital, Beijing, China
| | - Rosemary Hogg
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Henrik Kehlet
- Department of Clinical Medicine, Rigshosp, Copenhagen, Denmark
| | - Paul Kessler
- Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Sandra Kopp
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Alan Macfarlane
- School of Medicine, Dentistry & Nursing, Glasgow Royal Infirmary and Stobhill Ambulatory Hospital, Glasgow, UK
| | - Catherine MacLean
- Center for the Advancement of Value in Musculoskeletal Care, Hospital for Special Surgery, New York, New York, USA.,Center for the Advancement of Value in Musculoskeletal Care, Weill Cornell Medical College, New York, New York, USA
| | - Carlos Mantilla
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dan McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexander McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Joseph M Neal
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA.,Benaroya Research Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Parks
- Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Javad Parvizi
- Orthopedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Philip Peng
- Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lukas Pichler
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jashvant Poeran
- Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lazaros Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, New York, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian D Sites
- Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
| | - Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria.,Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Eugene Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Effrossyni Gina Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Jacques YaDeau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Nigel E Sharrock
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
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9
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Ritz ML, Rosenfeld DM, Spangehl M, Misra L, Khurmi N, Butterfield RJ, Buras MR, Gorlin AW. Evaluation of the use of spinal anesthesia administered prior to proceeding to the operating room in patients undergoing total joint arthroplasty. ACTA ACUST UNITED AC 2021. [DOI: 10.1016/j.pcorm.2020.100154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Min L, Chen C, Yan Y, Jiang S, Linyi Y, Xiaoxuan B, Liwei Z, Dongmei C. Comparison of Combined Lumbosacral Plexus and T12 Paravertebral Nerve Blocks With General Anesthesia in Older Adults Undergoing Primary Total Hip Arthroplasty: A Retrospective, Propensity Score-Matched Cohort Study. Geriatr Orthop Surg Rehabil 2020; 11:2151459320976531. [PMID: 33282449 PMCID: PMC7691895 DOI: 10.1177/2151459320976531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/31/2020] [Accepted: 11/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Total Hip Arthroplasty(THA) is a surgical treatment for hip disease. A large
amount of evidence has been reported on comparing outcomes of
neuraxial(spinal or epidural) anesthesia and general anesthesia. However, it
is unclear whether nerve blocks(NB) as main anesthesia technique compared
with general anesthesia(GA) for THA could reduce perioperative
complications. We conducted a retrospective evaluation of NB and GA, using a
propensity score-matched analysis(PSMA). Methods: A total of 902 patients older than 60 years old with hip disease undergoing
primary THA received combined lumbosacral plexus and T12
paravertebral nerve blocks (n = 143) or GA (n = 759) at our institution from
2012 to 2018.Binary logistic regression was used for comparison of the
primary outcomes(the incidence of delirium) and the secondary outcomes(the
percentage of postoperative hemoglobin(>10g/dl), transfusion(>2
units), major cardiac events(MACE), postoperative pulmonary complications
(PPC) and 30-day mortality) in the matched cohorts.Statistical analysis was
performed using SPSS v 23.0. Results: Both cohorts were balanced in all included parameters after PSMA. The
incidence of delirium was lower (OR 0.233,95% CI 0.064-0.845, p = 0.030) in
NB group in matched cohorts. In the unmatched and matched cohorts, the
percentage of Hb(>10g/dl) was higher in GA group but the incidence of
transfusion(>2 units) was higher in NB group. No difference was found in
the incidence of 30-day mortality in the unmatched and matched cohorts. In
the unmatched cohorts, the incidence of PPC was higher and LOS was longer in
NB cohort, but no difference was observed in the matched cohorts. Conclusion: In patients older than 60 years old receiving primary THA, NB could be
associated with a lower incidence of delirium.
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Affiliation(s)
- Li Min
- Department of Anesthesiology, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
| | - Chen Chen
- Department of Anesthesiology, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
| | - Yuan Yan
- Department of Anesthesiology, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
| | - Shen Jiang
- Department of Anesthesiology, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
| | - Yang Linyi
- Department of Anesthesiology, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
| | - Bu Xiaoxuan
- Department of Anesthesiology, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
| | - Zhang Liwei
- Department of Infection Control Management, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
| | - Cao Dongmei
- Hospital Medical Records Statistics Office, The Changzhou First People's Hospital, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, People's Republic of China
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11
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Cheng E, Lewin A, Churches T, Harris IA, Naylor J. Cost of investigations during the acute hospital stay following total hip or knee arthroplasty, by complication status. BMC Health Serv Res 2020; 20:1036. [PMID: 33183328 PMCID: PMC7659097 DOI: 10.1186/s12913-020-05892-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022] Open
Abstract
Background Total hip and total knee arthroplasties are among the most common types of surgery performed in Australia today and are effective treatments for severe osteoarthritis. However, the increasing financial burden on the health system owing to the increasing rates of surgery has led to a growing interest in improving the cost-effectiveness and safety of arthroplasty care. This study was designed to quantify the association between post-operative complications, a major cost driver, and the cost of investigations following total hip or knee arthroplasty. Methods This is a prospective cohort study of consecutive patients undergoing primary total hip or knee arthroplasty at an Australian public hospital. We measured the number and cost of imaging and pathology tests performed during the acute hospital stay and used linear regression to quantify the association between complication status and investigation costs. Results Five hundred patients were included in the analysis. On average, those with complications received more tests, and more expensive tests. The mean combined cost of imaging and pathology tests in patients with no complications was AU$ 187 (SD: 12.0). In comparison, patients with minor complications had a mean additional cost of AU$ 270 (SD: 31.0), and those with major complications had a mean additional cost of AU$ 493 (SD: 54.2) (p < 0.001). Conclusions In patients undergoing hip or knee arthroplasty, investigation costs are substantially greater in the presence of either minor or major complications. With growing volumes of total hip and total knee arthroplasties, a potential focus of future research could include optimising investigation practices for patients with and without complications.
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Affiliation(s)
- Emma Cheng
- South Western Sydney Clinical School, South West Sydney Clinical School UNSW, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.
| | - Adriane Lewin
- South Western Sydney Clinical School, South West Sydney Clinical School UNSW, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW, 2170, Australia.,Whitlam Orthopaedic Research Centre, Level 2, 1 Campbell St, Liverpool, NSW, 2170, Australia
| | - Tim Churches
- South Western Sydney Clinical School, South West Sydney Clinical School UNSW, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW, 2170, Australia.,Whitlam Orthopaedic Research Centre, Level 2, 1 Campbell St, Liverpool, NSW, 2170, Australia
| | - Ian A Harris
- South Western Sydney Clinical School, South West Sydney Clinical School UNSW, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW, 2170, Australia.,Whitlam Orthopaedic Research Centre, Level 2, 1 Campbell St, Liverpool, NSW, 2170, Australia
| | - Justine Naylor
- South Western Sydney Clinical School, South West Sydney Clinical School UNSW, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,Ingham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW, 2170, Australia.,Whitlam Orthopaedic Research Centre, Level 2, 1 Campbell St, Liverpool, NSW, 2170, Australia
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12
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Wang P, Yang Z, Shan S, Cao Z, Wang Z. Analgesic effect of perioperative ketamine for total hip arthroplasties and total knee arthroplasties: A PRISMA-compliant meta-analysis. Medicine (Baltimore) 2020; 99:e22809. [PMID: 33080757 PMCID: PMC7571980 DOI: 10.1097/md.0000000000022809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Total hip arthroplasties (THA) and total knee arthroplasties (TKA) are always associated with a frequent incidence of postoperative pain. Effective pain management after surgery is quite essential for surgeons and patients. The purpose of the present meta-analysis is to evaluate the analgesic effect of perioperative ketamine after THA and TKA. METHODS Seven online databases, Embase, Cochrane Library, Pubmed, Web of Science, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), and Wanfang Data were searched for the related randomized controlled trials (RCT) by August 15, 2019. The qualities of the included studies were assessed based on the Cochrane Handbook for Systematic Reviews of Interventions 5.0. The visual analog scale (VAS), morphine equivalent consumption, and the side effects were used to evaluate the postoperative analgesic effect of ketamine by meta-analysis, which was performed by Review Manager version 5.3 software. RESULTS The VAS scores at 6 hours, 12 hours, 24 hours, and 48 hours after surgery were statistically lower in the ketamine group. The morphine equivalent consumptions in 24 hours and 48 hours after surgery were also significantly lower in the ketamine group. For the side effects, no statistical differences in odds ratio (OR) of sedation, dizziness, hallucination, sweating, pruritus, urinary retention, constipation, version trouble, nightmares, and delirium were observed between the ketamine group and the control group. But postoperative nausea and vomiting (PONV) showed lower OR in the ketamine group. CONCLUSION The present meta-analysis demonstrated perioperative ketamine could be used as a safe and effective analgesic agent for THA and TKA.
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Affiliation(s)
| | - Zhong Yang
- Department of Orthopedics, The Fifth Central Hospital of Tianjian, Tianjin
| | | | - Zhipeng Cao
- School of Forensic Medicine, China Medical University, Shenyang, Liaoning Province
| | - Zhilin Wang
- Department of Anesthesiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, PR China
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13
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Ramos JGR, Zhang R, Maher B, Hardidge A, Weinberg L, Robbins R, Peyton PJ, Bellomo R, Jones D. Characteristics and outcomes of rapid response team activations for hypotension in orthopaedic patients. Intern Med J 2020; 50:61-69. [PMID: 31111607 DOI: 10.1111/imj.14374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/11/2019] [Accepted: 05/13/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid response teams (RRT) review patients on hospital wards with hypotension. AIM To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors and areas for future quality improvement. METHODS Timing of RRT activations, presumed causes of hypotension and associated treatments were assessed. RESULTS Among 963 RRT activations in 605 patients over 3 years, the first calls of 226 of 605 patients were due to hypotension, and 213 (94.2%) of 226 had sufficient data for analysis. The median age was 79 (interquartile range 66-87) years; 58 (27.2%) were male, and comorbidities were common. Most (68%) surgery was emergent, and 75.1% received intraoperative vasopressors for hypotension. Most activations occurred within 24 h of surgery, and hypovolaemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0-26.5) h. in cases where fluid boluses were given, compared with 33 (15.5-61.5) h. where they were not (P < 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In-hospital death was associated with older age, functional dependence, arrhythmia and presumed infection. CONCLUSIONS Hypotension-related RRT calls in orthopaedic patients are common. Future interventional studies might focus on perioperative fluid therapy and vaso-active medications, as well as withholding of anti-hypertensive medications preoperatively.
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Affiliation(s)
- João G R Ramos
- Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil.,UNIME Medical School, Lauro de Freitas, Brazil
| | - Richard Zhang
- Department of Orthopaedic Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Brendan Maher
- Department of Orthopaedic Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Andrew Hardidge
- Department of Orthopaedic Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia, Perioperative and Pain Medicine Unit, University of Melbourne, Melbourne, Victoria, Australia
| | - Ray Robbins
- Business Intelligence Unit, Austin Health, Melbourne, Victoria, Australia
| | - Phillip J Peyton
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia.,Department of Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Data Analytics and Evaluation (DARE) Centre, Austin Health, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Daryl Jones
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, Austin Health, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
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14
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Onwochei DN, Fabes J, Walker D, Kumar G, Moonesinghe SR. Critical care after major surgery: a systematic review of risk factors for unplanned admission. Anaesthesia 2020; 75 Suppl 1:e62-e74. [DOI: 10.1111/anae.14793] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 12/17/2022]
Affiliation(s)
- D. N. Onwochei
- Department of Anaesthesia Guy's & St. Thomas’ NHS Foundation Trust London UK
| | - J. Fabes
- Department of AnaesthesiaRoyal Free NHS Foundation Trust LondonUK
| | - D. Walker
- Centre for Anaesthesia and Peri‐operative Medicine UCL Division of Surgery and Interventional Science University College London London UK
| | - G. Kumar
- Centre for Anaesthesia and Peri‐operative Medicine UCL Division of Surgery and Interventional Science University College London London UK
| | - S. R. Moonesinghe
- Centre for Anaesthesia and Peri‐operative Medicine UCL Division of Surgery and Interventional Science University College London London UK
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15
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Stambough JB, Bloom GB, Edwards PK, Mehaffey GR, Barnes CL, Mears SC. Rapid Recovery After Total Joint Arthroplasty Using General Anesthesia. J Arthroplasty 2019; 34:1889-1896. [PMID: 31202638 DOI: 10.1016/j.arth.2019.04.066] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Multiple papers have purported the superiority of spinal anesthesia used in total joint arthroplasty (TJA). However, there is a paucity of data available for modern general anesthesia (GA) regimens used at high-volume joint replacement centers. METHODS We retrospectively reviewed a series of 1527 consecutive primary TJAs (644 total hip arthroplasties and 883 total knee arthroplasties) performed over a 3-year span at a single institution that uses a contemporary GA protocol and report on the length of stay, early recovery rates, perioperative complications, and readmissions. RESULTS From the elective TJAs performed using a modern GA protocol, 96.3% (n = 1471) of patients discharged on postoperative day 1, and 97.2% (n = 1482) of subjects were able to participate with physical therapy on the day of surgery. Only 6 patients (0.4%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 2.4% (n = 36), while the reoperation rate was 1.3% (n = 20). DISCUSSION Neuraxial anesthesia for TJA is commonly preferred in high-volume institutions utilizing contemporary enhanced recovery pathways. Our data support the notion that the utilization of modern GA techniques that limit narcotics and certain inhalants can be successfully used in short-stay primary total joint arthroplasty. LEVEL OF EVIDENCE IV- Case series.
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Affiliation(s)
- Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - G Barnes Bloom
- University of Arkansas for Medical Sciences, College of Medicine, Little Rock, AR
| | - Paul K Edwards
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Gregory R Mehaffey
- Department of Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR
| | - C Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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16
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Saku SA, Linko R, Madanat R. Outcomes of Triggering the Emergency Response Team at a High-Volume Arthroplasty Center. Scand J Surg 2019; 109:336-342. [PMID: 31216933 DOI: 10.1177/1457496919857263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Emergency Response Teams have been employed by hospitals to evaluate and manage patients whose condition is rapidly deteriorating. In this study, we aimed to assess the outcomes of triggering the Emergency Response Teams at a high-volume arthroplasty center, determine which factors trigger the Emergency Response Teams, and investigate the main reasons for an unplanned intensive care unit admission following Emergency Response Team intervention. MATERIAL AND METHODS We gathered data by evaluating all Emergency Response Team forms filled out during a 4-year period (2014-2017), and by assessing the medical records. The collected data included age, gender, time of and reason for the Emergency Response Teams call, and interventions performed during the Emergency Response Teams intervention. The results are reported as percentages, mean ± standard deviation, or median (interquartile range), where appropriate. All patients were monitored for 30 days to identify possible intensive care unit admissions, surgeries, and death. RESULTS The mean patient age was 72 (46-92) years and 40 patients (62%) were female. The Emergency Response Teams was triggered a total of 65 times (61 patients). The most common Emergency Response Team call criteria were low oxygen saturation, loss or reduction of consciousness, and hypotension. Following the Emergency Response Team call, 36 patients (55%) could be treated in the ward, and 29 patients (45%) were transferred to the intensive care unit. The emergency that triggered the Emergency Response Teams was most commonly caused by drug-related side effects (12%), pneumonia (8%), pulmonary embolism (8%), and sepsis (6%). Seven patients (11%) died during the first 30 days after the Emergency Response Teams call. CONCLUSION Although all 65 patients met the Emergency Response Teams call criteria, potentially having severe emergencies, half of the patients could be treated in the arthroplasty ward. Emergency Response Team intervention appears useful in addressing concerns that can potentially lead to unplanned intensive care unit admission, and the Emergency Response Teams trigger threshold seems appropriate as only 3% of the Emergency Response Teams calls required no intervention.
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Affiliation(s)
- S A Saku
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - R Linko
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - R Madanat
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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17
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Rantasalo MT, Palanne R, Juutilainen K, Kairaluoma P, Linko R, Reponen E, Helkamaa T, Vakkuri A, Olkkola KT, Madanat R, Skants NKA. Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol. BMJ Open 2018; 8:e025546. [PMID: 30580277 PMCID: PMC6307602 DOI: 10.1136/bmjopen-2018-025546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Total knee arthroplasty is a highly effective treatment for end-stage knee osteoarthritis, and it is usually performed under spinal or general anaesthesia with or without a surgical tourniquet. Some debate about the preferred mode of anaesthesia regarding patient outcomes remains. The aim of this study, which compares general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty, is to determine the optimal type of anaesthesia regimen and assess the effect of a tourniquet on the patient's recovery following total knee arthroplasty. METHODS AND ANALYSIS This study is a randomised, controlled, parallel-group, four-arm study comparing spinal and general anaesthesia with and without a tourniquet in 400 patients undergoing fast-track total knee arthroplasty, with a 12-month follow-up. The primary outcome is cumulative intravenous oxycodone consumption by patient-controlled analgesia during the first 24 postoperative hours. Secondary outcomes include postoperative nausea and vomiting, the length of hospital stay, the duration of the surgery, blood loss, demand for surgical unit resources, complications, readmissions, postoperative knee function, range of motion, health-related quality of life, prolonged pain and mortality. ETHICS AND DISSEMINATION This study's protocol is in accordance with the declaration of Helsinki. The results of this study will be disseminated in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03364088; Pre-results.
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Affiliation(s)
- Mikko Tuomas Rantasalo
- Peijas Hospital, Department of Orthopaedics and Traumatology, Arthroplasty Centre, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Riku Palanne
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Katarina Juutilainen
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Pekka Kairaluoma
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Rita Linko
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Elina Reponen
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Teemu Helkamaa
- Peijas Hospital, Department of Orthopaedics and Traumatology, Arthroplasty Centre, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Anne Vakkuri
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rami Madanat
- Peijas Hospital, Department of Orthopaedics and Traumatology, Arthroplasty Centre, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
| | - Noora Kati Annukka Skants
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Vantaa, Finland
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Abstract
The demand for total knee arthroplasty (TKA) is rising worldwide. Controversy persists in the literature regarding the benefits of general versus neuraxial anesthesia and which anesthetic is associated with the best outcomes. Likewise, the abundance of analgesic options for post-TKA pain have led to debate regarding the safest, most effective regimens. In this paper, we evaluated a selection of recent publications regarding anesthetic and analgesic choices for TKA. High-quality studies and meta-analyses linking anesthetic agents and analgesic modalities to clinically important outcomes were chosen wherever possible. We included a range of clinical and population-based research, incorporating established and emerging techniques. Although not uniform, clinical and population-based data favor neuraxial anesthesia, and suggest less morbidity compared to general anesthesia. There is good evidence to support an opioid-minimizing, multimodal approach to post-TKA analgesia, featuring peripheral nerve blocks and/or peri-articular injection. The recently described IPACK (interspace between the popliteal artery and posterior capsule of the knee) block may address posterior knee pain after TKA. Ultrasound-guided regional analgesia techniques are cost and clinically effective. Liposomal bupivacaine represents an expanding topic of research in TKA-analgesia, but currently, data do not support routine use. Evidence to guide the creation of pathways of care for TKA abounds, but must be tailored to local practice to maximize chances of success. Recent data supports the use of neuraxial anesthesia and regional analgesia techniques for TKA. Recommendations for clinical practice and future research to improve the state of the art are provided.
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Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA -
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
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Greimel F, Maderbacher G, Baier C, Keshmiri A, Schwarz T, Zeman F, Meissner W, Grifka J, Benditz A. Multicenter cohort-study of 15326 cases analyzing patient satisfaction and perioperative pain management: general, regional and combination anesthesia in knee arthroplasty. Sci Rep 2018; 8:3723. [PMID: 29487361 PMCID: PMC5829078 DOI: 10.1038/s41598-018-22146-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/19/2018] [Indexed: 12/21/2022] Open
Abstract
Numbers of knee replacement surgeries have been rising over the past years. After having ameliorated operation techniques and material, pain management and anesthetic methods have come into focus. All 15326 patients included had undergone primary knee arthroplasty within this multicenter cohort-study, conducted in 46 orthopedic departments. Parameters were evaluated on first postoperative day. Primary outcome values were pain levels (activity, minimum and maximum pain, and pain management satisfaction). Pain medication necessity was analyzed. Parameters were compared between the types of anesthesia used: general, regional and combination anesthesia. Pain scores and pain management satisfaction were significantly better in the groups of either spinal or peripheral anesthesia combined with general anesthesia (p < 0.001, respectively). Patients who received the combination of general and spinal anesthesia were associated with the lowest need for opioids (p < 0.001). The use of a combined general and spinal anesthesia as well as using a combination of general and peripheral anesthesia in knee arthroplasty was associated with a highly significant advantage to other anesthetic techniques regarding perioperative pain management in daily clinical practice, but maybe below clinical relevance. Furthermore they were associated with positive tendency considering side effects and subjective well-being parameters.
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Affiliation(s)
- Felix Greimel
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany.
| | - Guenther Maderbacher
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - Clemens Baier
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - Armin Keshmiri
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - Timo Schwarz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center of Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Joachim Grifka
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - Achim Benditz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
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Rosas S, Sabeh K, Kurowicki J, Buller L, Law TY, Roche M, Conway S, Hernandez VH. National use of total hip arthroplasty among patients with a history of breast, lung, prostate, colon or bladder cancer-an analysis of the Medicare population. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S34. [PMID: 29299481 DOI: 10.21037/atm.2017.11.18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Total hip arthroplasty (THA) is a common and growing procedure in the United States. Concomitantly, there has been a rise in patients diagnosed with certain types of malignancies including solid organ ones. Unfortunately there is limited data available in the literature that describes the use of THA in patients who concomitantly have one of these forms of cancer. Because of the limited data available in the literature regarding this topic, the purpose of this study was to analyze the trends in use of THA among patients with the five most common malignancies in the United States, which include breast, lung, prostate, colon and bladder cancer according to the National Cancer Institute (NCI). Methods We conducted a retrospective review of the entire Medicare patient population to analyze the use of THA in patients with a diagnosis of solid organ malignancy including breast, lung, prostate, colon and bladder cancer. Results Our analysis of over 14 million patients, demonstrate that THA is not as commonly performed procedure in patients with such diagnoses with a 0.26% prevalence. The mean incidence of THA was 0.29%, 0.17%, 0.31%, 0.33% and 0.36% for patients with breast, lung, prostate, colon and bladder cancer respectively. Conclusions THA in cancer patients are not frequently performed but the use of this technique has increased significantly in patients with lung, prostate and bladder cancer.
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Affiliation(s)
- Samuel Rosas
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Karim Sabeh
- Department of Orthopedic Surgery and Rehabilitation, University of Miami, Miami, FL, USA
| | - Jennifer Kurowicki
- Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, FL, USA.,Department of Orthopaedic Surgery, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA
| | - Leonard Buller
- Department of Orthopedic Surgery and Rehabilitation, University of Miami, Miami, FL, USA
| | - Tsun Yee Law
- Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Martin Roche
- Department of Orthopedic Surgery, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Sheila Conway
- Department of Orthopedic Surgery and Rehabilitation, University of Miami, Miami, FL, USA
| | - Victor H Hernandez
- Department of Orthopedic Surgery and Rehabilitation, University of Miami, Miami, FL, USA
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21
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Greimel F, Maderbacher G, Zeman F, Grifka J, Meissner W, Benditz A. No Clinical Difference Comparing General, Regional, and Combination Anesthesia in Hip Arthroplasty: A Multicenter Cohort-Study Regarding Perioperative Pain Management and Patient Satisfaction. J Arthroplasty 2017. [PMID: 28641966 DOI: 10.1016/j.arth.2017.05.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Steadily increasing numbers of hip arthroplasties are reported in the past years. Different types of anesthetic methods for surgery itself as well as pain management programs have been established. It is one of the main goals to reduce postoperative pain levels and guarantee better and faster mobilization in the postoperative period. The present study aims to compare the use of general and regional spinal anesthesia and their combination regarding perioperative pain management and patient satisfaction. METHODS All patients included in the present study had undergone primary hip arthroplasty. Parameters were analyzed on the first postoperative day within the scope of the "Quality Improvement in Postoperative Pain Management" project, which is conducted nationwide in 49 orthopedic departments at the time of data evaluation. RESULTS From 2009-2015, 18,118 patients underwent primary hip arthroplasty and have been evaluated. Demographic and general patient data were homogenous. The need for opioids was significantly higher in patients where general and combination anesthesia was applied (P < .001, respectively). Pain scores and pain management satisfaction were significantly better in regional and combination anesthesia (P < .001, respectively). CONCLUSION We were able to show a highly significant advantage in the use of regional or the combination of regional and general anesthesia in comparison with general anesthesia alone in hip arthroplasty regarding patients' satisfaction and the requirement of opioid pain medication, although maybe below clinical relevance.
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Affiliation(s)
- Felix Greimel
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Guenther Maderbacher
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center of Regensburg, Regensburg, Germany
| | - Joachim Grifka
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Achim Benditz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
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22
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Piolanti N, Del Chiaro A, Matassi F, Graceffa A, Nistri L, Marcucci M. Clinical and instrumental evaluation of two different regimens of tranexamic acid in total hip arthroplasty: a single-centre, prospective, randomized study with 80 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:233-237. [PMID: 28887640 DOI: 10.1007/s00590-017-2038-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The use of tranexamic acid (TXA) in total hip arthroplasty (THA) can significantly reduce blood losses with many clinical and economical advantages. However, no consensus has been reached regarding the optimal regimen for TXA administration. The aim of this study is to analyse and compare the haemostatic effect of two different intravenous (IV) regimens of TXA. MATERIALS AND METHODS We planned a single-centre, prospective, randomized study including 80 patients who underwent primary unilateral minimally invasive THA because of a hip osteoarthritic degeneration. We divided patients into two groups: the G10 group received two IV doses of 10 mg/kg of TXA, and the G20 group received two doses of 20 mg/kg. RESULTS No significant differences in mean minimum levels of Hb and HcT stratified by days after surgery were uncovered between the two groups despite the use of two different dosages of TXA. Also the mean blood volume loss was statistically similar between two groups. No differences were also observed regarding the occurrence of adverse effects. CONCLUSIONS In two IV bolus regimens of TXA administration, the use of a dose of 10 or 20 mg/kg provides statistically similar results in blood loss sparing. Therefore, the use of two 10 mg/kg doses could be considered more advisable in order to reduce the potential thromboembolic risks related to this drug.
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Affiliation(s)
- Nicola Piolanti
- 1st Orthopaedic Department, University of Pisa, Via Paradisa 2, 56100, Pisa, Italy.
| | - Andrea Del Chiaro
- 1st Orthopaedic Department, University of Pisa, Via Paradisa 2, 56100, Pisa, Italy.
| | - Fabrizio Matassi
- Department of Surgical Science and Translational Medicine, University of Florence, Largo P. Palagi 1, 50139, Florence, Italy
| | - Angelo Graceffa
- Azienda Sanitaria Provinciale di Enna, Via Armando Diaz 7/9, 94100, Enna, Italy
| | - Lorenzo Nistri
- CESAT, Piazza Spartaco Lavagnini 1, 50054, Fucecchio, Italy
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Lagerkranser M. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors. Scand J Pain 2017; 15:118-129. [DOI: 10.1016/j.sjpain.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Background
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.
Methods
MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.
Results
Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.
Conclusions and implications
The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.
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Affiliation(s)
- Michael Lagerkranser
- Section for Anaesthesiology and Intensive Care Medicine , Department of Physiology and Pharmacology , Karolinska Institutet , 171 77 Stockholm Stockholm , Sweden
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24
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Association of obstructive sleep apnea with adverse pregnancy-related outcomes in military hospitals. Eur J Obstet Gynecol Reprod Biol 2017; 210:166-172. [DOI: 10.1016/j.ejogrb.2016.12.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 12/01/2016] [Accepted: 12/12/2016] [Indexed: 11/23/2022]
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26
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Shin JI, Keswani A, Lovy AJ, Moucha CS. Simplified Frailty Index as a Predictor of Adverse Outcomes in Total Hip and Knee Arthroplasty. J Arthroplasty 2016; 31:2389-2394. [PMID: 27240960 DOI: 10.1016/j.arth.2016.04.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 04/04/2016] [Accepted: 04/15/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The modified frailty index (mFI) has been shown to predict adverse outcomes in multiple nonorthopedic surgical specialties. This study aimed to assess whether mFI is a predictor of adverse events in patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS Patients who underwent THA and TKA from 2005-2012 were identified in the National Surgical Quality Improvement Program database. mFI was calculated for each patient using 15 variables found in National Surgical Quality Improvement Program. Bivariate and multivariate analyses of postoperative adverse events, including Clavien-Dindo grade IV complications, were performed. RESULTS A total of 14,583 THA and 25,223 TKA patients were included for analysis. The mean (standard deviation, range) mFIs were 0.083 (0.080, 0-0.55) for THA and 0.097 (0.080, 0-0.64) for TKA cohorts. On bivariate analyses, incidence of Clavien-Dindo grade IV complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), hospital-acquired conditions (surgical site infection, venous thromboembolism, and urinary tract infection), any complications, and mortality increased significantly with increase in mFI (P < .0001 for all). Adjusting for demographics, age ≥ 75, body mass index ≥40, American Society of Anesthesiologists class ≥4, and nonclean wound status, mFI ≥0.45 was shown to be the strongest independent predictor of Clavien-Dindo grade IV complications for both THA and TKA cohorts with odds ratios of 5.140 and 4.183, respectively. CONCLUSION mFI ≥0.45 is an independent predictor of Clavien-Dindo grade IV complications in TKA/THA patients with greater odds ratios than age >75, body mass index ≥40, American Society of Anesthesiologists class ≥4. mFI should be considered for risk stratifying joint arthroplasty patients preoperatively and perhaps determining immediate postoperative destination.
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Affiliation(s)
- John I Shin
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aakash Keswani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew J Lovy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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27
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Abstract
Abstract
Background
This propensity score–matched cohort study evaluates the effect of anesthetic technique on a 30-day mortality after total hip or knee arthroplasty.
Methods
All patients who had hip or knee arthroplasty between January 1, 2003, and December 31, 2014, were evaluated. The principal exposure was spinal versus general anesthesia. The primary outcome was 30-day mortality. Secondary outcomes were (1) perioperative myocardial infarction; (2) a composite of major adverse cardiac events that includes cardiac arrest, myocardial infarction, or newly diagnosed arrhythmia; (3) pulmonary embolism; (4) major blood loss; (5) hospital length of stay; and (6) operating room procedure time. A propensity score–matched-pair analysis was performed using a nonparsimonious logistic regression model of regional anesthetic use.
Results
We identified 10,868 patients, of whom 8,553 had spinal anesthesia and 2,315 had general anesthesia. Ninety-two percent (n = 2,135) of the patients who had general anesthesia were matched to similar patients who did not have general anesthesia. In the matched cohort, the 30-day mortality rate was 0.19% (n = 4) in the spinal anesthesia group and 0.8% (n = 17) in the general anesthesia group (risk ratio, 0.42; 95% CI, 0.21 to 0.83; P = 0.0045). Spinal anesthesia was also associated with a shorter hospital length of stay (5.7 vs. 6.6 days; P < 0.001).
Conclusions
The results of this observational, propensity score–matched cohort study suggest a strong association between spinal anesthesia and lower 30-day mortality, as well as a shorter hospital length of stay, after elective joint replacement surgery.
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28
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Wong PBY, McVicar J, Nelligan K, Bleackley JC, McCartney CJL. Factors influencing the choice of anesthetic technique for primary hip and knee arthroplasty. Pain Manag 2016; 6:297-311. [DOI: 10.2217/pmt.16.6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite evidence in the literature, continuing wide variation exists in anesthetic technique for primary joint arthroplasties. Recent evidence suggests that neuraxial anesthesia has advantages over general anesthesia in terms of mortality, major morbidity and healthcare utilization. Yet, despite the proposed benefits, utilization of these two techniques varies greatly across geographical locations, with general anesthesia being most common for total hip arthroplasty (THA) and total knee arthroplasty (TKA) in parts of the world. We uncover some factors that promote or hinder the use of neuraxial anesthesia in THA and TKA. Healthcare professionals should be familiarized with the evidence for neuraxial anesthesia, and unbiased educational material should be developed for patients regarding anesthetic options for THA and TKA in order to promote best practice.
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Affiliation(s)
- Patrick BY Wong
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Jason McVicar
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Kathleen Nelligan
- Schulich School of Medicine & Dentistry, Western University, ON, N6G 2M1, Canada
| | - Joanne C Bleackley
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Colin JL McCartney
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
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Huang GP, Jia XF, Xiang Z, Ji Y, Wu GY, Tang Y, Li J, Zhang J. Tranexamic Acid Reduces Hidden Blood Loss in Patients Undergoing Total Knee Arthroplasty: A Comparative Study and Meta-Analysis. Med Sci Monit 2016; 22:797-802. [PMID: 26961597 PMCID: PMC4790217 DOI: 10.12659/msm.895571] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/12/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND To explore the efficacy of tranexamic acid (TXA) on reducing hidden blood loss (HBL) in total knee arthroplasty (TKA) by conducting a comparative study and meta-analysis. MATERIAL/METHODS A total of 108 patients underwent TKA was equally distributed to experimental and control groups. The only difference between two groups was the administrations of 15 mg of TXA mixed in 100 mL normal saline for experimental group and 100 mL of normal saline for control group. The volumes of blood loss, red blood loss (RBL) were recorded, calculated and analyzed. Stata 12.0 software was applied for data analysis. RESULTS The intraoperative and postoperative blood loss volume in experimental group were remarkably reduced compared with those in control group (intraoperative: 105.1±12.1 mL vs. 185.5±20.3 mL, P<0.001; postoperative: 220.7±16.8 mL vs. 290.5±22.4 mL, P<0.001). Accordingly, the control group had significantly higher transfusion rate than experimental group (3.7% vs.25.9%, P=0.001). Our results also found that both the measured and hidden RBL were obviously reduced in experimental group compared with control group (measured RBL: 96.9±11.8 mL vs. 135.2±13.5 mL, P<0.001; hidden RBL: 170.8±37.2 mL vs. 364.2±41.5 mL, P<0.001). Furthermore, meta-analysis confirmed that TXA can notably decrease HBL (SMD=2.68, 95%CI=1.55~3.80, P<0.001). CONCLUSIONS TXA can significantly reduce the intraoperative and postoperative blood loss and HBL, therefore decreasing the transfusion need in TKA.
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Affiliation(s)
- Guang-Ping Huang
- Department of Orthopedics, West China Medical Center, Sichuan University, Chengdu, Sichuan, P.R. China
- Department of Orthopedics, Jianyang People’s Hospital, Jianyang, Sichuan, P.R. China
| | - Xu-Feng Jia
- Department of Orthopedics, Jianyang People’s Hospital, Jianyang, Sichuan, P.R. China
| | - Zhou Xiang
- Department of Orthopedics, West China Medical Center, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Yong Ji
- Department of Orthopedics, Jianyang People’s Hospital, Jianyang, Sichuan, P.R. China
| | - Guo-Yong Wu
- Department of Orthopedics, Jianyang People’s Hospital, Jianyang, Sichuan, P.R. China
| | - Yi Tang
- Department of Orthopedics, Jianyang People’s Hospital, Jianyang, Sichuan, P.R. China
| | - Jian Li
- Department of Orthopedics, West China Medical Center, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Jun Zhang
- Department of Orthopedics, West China Medical Center, Sichuan University, Chengdu, Sichuan, P.R. China
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Abstract
Abstract
Background
Differences in health care represent a major health policy issue. Despite increasing evidence on the mediating role of anesthesia type used for surgery on perioperative outcome, there is a lack of data on potential care differences in this field. The authors aimed to determine whether anesthesia practice (use of neuraxial anesthesia [NA] or peripheral nerve block [PNB]) differs by patient and hospital factors.
Methods
The authors extracted data on n = 1,062,152 hip and knee arthroplasty procedures from the Premier Perspective database (2006 to 2013). Multilevel multivariable logistic regression models measured associations (odds ratios [ORs] and 95% CIs) between patient/hospital factors and NA or PNB use.
Results
Of all patients, 22.2% (n = 236,083) received NA and 17.9% (n = 189,732) received PNB. Lower adjusted odds for receiving NA were seen for black patients (OR, 0.88; 95% CI, 0.86 to 0.91) and those on Medicaid (OR, 0.78; 95% CI, 0.74 to 0.82) or without insurance (OR, 0.89; 95% CI, 0.81 to 0.98). Furthermore, teaching hospitals (compared with nonteaching hospitals) had lower adjusted odds for NA utilization (OR, 0.35; 95% CI, 0.14 to 0.89). Although generally similar patterns were seen for PNB utilization, the main difference was that particularly Hispanic patients were less likely to receive PNB compared with white patients (OR, 0.60; 95% CI, 0.56 to 0.65). Sensitivity analyses generally validated our results.
Conclusions
Significant differences exist in the provision of regional anesthetic care with factors such as race and insurance type being important determinants of anesthetic practice. Further and in-depth research is needed to fully assess the background of these differences.
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31
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Johnson RL, Kopp SL, Burkle CM, Duncan CM, Jacob AK, Erwin PJ, Murad MH, Mantilla CB. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth 2016; 116:163-176. [PMID: 26787787 DOI: 10.1093/bja/aev455] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2025] Open
Abstract
BACKGROUND This systematic review evaluated the evidence comparing patient-important outcomes in spinal or epidural vs general anaesthesia for total hip and total knee arthroplasty. METHODS MEDLINE, Ovid EMBASE, EBSCO CINAHL, Thomson Reuters Web of Science, and the Cochrane Central Register of Controlled Trials from inception until March 2015 were searched. Eligible randomized controlled trials or prospective comparative studies investigating mortality, major morbidity, and patient-experience outcomes directly comparing neuraxial (spinal or epidural) with general anaesthesia for total hip arthroplasty, total knee arthroplasty, or both were included. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. Meta-analysis was conducted using the random-effects model. RESULTS We included 29 studies involving 10 488 patients. Compared with general anaesthesia, neuraxial anaesthesia significantly reduced length of stay (weighted mean difference -0.40 days; 95% confidence interval -0.76 to -0.03; P=0.03; I2 73%; 12 studies). No statistically significant differences were found between neuraxial and general anaesthesia for mortality, surgical duration, surgical site or chest infections, nerve palsies, postoperative nausea and vomiting, or thromboembolic disease when antithrombotic prophylaxis was used. Subgroup analyses failed to find statistically significant interactions (P>0.05) based on risk of bias, type of surgery, or type of neuraxial anaesthesia. CONCLUSION Neuraxial anaesthesia for total hip or total knee arthroplasty, or both appears equally effective without increased morbidity when compared with general anaesthesia. There is limited quantitative evidence to suggest that neuraxial anaesthesia is associated with improved perioperative outcomes. Future investigations should compare intermediate and long-term outcome differences to better inform anaesthesiologists, surgeons, and patients on importance of anaesthetic selection.
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Affiliation(s)
- R L Johnson
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
| | - S L Kopp
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
| | - C M Burkle
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
| | - C M Duncan
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
| | - A K Jacob
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
| | - P J Erwin
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
| | - M H Murad
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
| | - C B Mantilla
- College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
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McCormick F, Nwachukwu BU, Kiriakopoulos EBS, Schairer WW, Provencher MT, Levy J. In-hospital mortality risk for total shoulder arthroplasty: A comprehensive review of the medicare database from 2005 to 2011. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2015; 9:110-3. [PMID: 26622126 PMCID: PMC4639999 DOI: 10.4103/0973-6042.167938] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: The in-hospital mortality rate after total shoulder arthroplasty (TSA) is unknown. The purpose of this study is to quantify the in-patient mortality rates and associated demographic risk factors for patients undergoing a TSA from 2005 to 2011 using a comprehensive Medicare registry database. Materials and Methods: We conducted a retrospective review of the Medicare database within the PearlDiver database. The PearlDiver database is a publicly available Health Insurance Portability and Accountability Act-compliant national database that captures 100% of the Medicare hospital data for TSA between 2005 and 2011. Using International Classification of Diseases, Ninth Revision codes for TSA we identified a dataset of patients undergoing TSA as well as a subset of those for whom there was a death discharge (i.e., in-patient death). Risk for this outcome was further quantified by age, gender and year. Linear regression was performed to identify risk factors for the primary outcome. Results: A total of 101,323 patients underwent 125,813 TSAs between 2005 and 2011. There were 113 in-patient mortalities during this period. Thus the incidence of death was 0.09%. Increasing age was a significant risk factor for mortality (P = 0.03). Gender and year of procedure were not significant risk factors for mortality. Conclusion: The incidence of in-patient mortality for Medicare patients undergoing TSA between 2005 and 2011 was <1 in 1000 surgeries. Increased age is a significant predictor of mortality. Level 4: Retrospective analysis
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Affiliation(s)
- Frank McCormick
- Holy Cross Orthopedic Institute, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Benedict U Nwachukwu
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - William W Schairer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Jonathan Levy
- Holy Cross Orthopedic Institute, Holy Cross Hospital, Fort Lauderdale, FL, USA
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Karam JA, Huang RC, Abraham JA, Parvizi J. Total joint arthroplasty in cancer patients. J Arthroplasty 2015; 30:758-61. [PMID: 25583683 DOI: 10.1016/j.arth.2014.12.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 12/16/2014] [Indexed: 02/01/2023] Open
Abstract
Increasing numbers of total joint arthroplasty (TJA) patients have a history, or an active diagnosis, of cancer. We aimed to evaluate the risk of early postoperative complications in these patients. In our series, a history of malignancy was associated with an elevated risk of ischemic cardiac events and postoperative deep vein thrombosis (DVT), while active malignancy was associated with increased respiratory and renal complications, hematoma/seroma formation and early postoperative mortality. Both groups presented increased rates of overall in-hospital complications. Patients with bone metastasis to the hip demonstrated increased DVT and 90-day mortality rates. Cancer patients have increased morbidity and mortality after TJA and should undergo comprehensive medical optimization and adapted thromboprophylaxis.
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Affiliation(s)
- Joseph A Karam
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ronald C Huang
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John A Abraham
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Chen WH, Hung KC, Tan PH, Shi HY. Neuraxial anesthesia improves long-term survival after total joint replacement: a retrospective nationwide population-based study in Taiwan. Can J Anaesth 2015; 62:369-76. [PMID: 25608641 DOI: 10.1007/s12630-015-0316-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 01/13/2015] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION This study explored the effects of general (GA) and neuraxial (NA) anesthesia on the outcomes of primary total joint replacement (TJR) in terms of postoperative mortality, length of stay (LOS), and hospital treatment costs. METHODS From 1997 to 2010, this nationwide population-based study retrospectively evaluated 7,977 patients in Taiwan who underwent primary total hip or knee replacement. We generated two propensity-score-matched subgroups, each containing an equal number of patients who underwent TJR with either GA or NA. RESULTS Of the 7,977 patients, 2,990 (37.5%) underwent GA and 4,987 (62.5%) underwent NA. Propensity-score matching was used to create comparable GA and NA groups adjusted for age, sex, comorbidities, surgery type, hospital volume, and surgeon volume. Survival over the first three years following surgery was similar. The proportion of patients alive up to 14 years postoperatively for those undergoing NA was 58.2% (95% confidence interval [CI] 50.4 to 66.0), and for those undergoing GA it was 57.3% (95% CI 51.4 to 63.2). Neuraxial anesthesia was associated with lower median [interquartile range; IQR] hospital treatment cost ($4,079 [3,805-4,444] vs $4,113 [3,812-4,568]; P < 0.001) and shorter median [IQR] LOS (8 [7-10] days vs 8 [6-10] days, respectively; P = 0.024). CONCLUSIONS Our results support the use of NA for primary TJR. The improvements in hospital costs persist even when anesthesia costs are removed. The mechanism underlying the association between NA and long-term survival is unknown.
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MESH Headings
- Aged
- Anesthesia, Conduction/economics
- Anesthesia, Conduction/methods
- Anesthesia, General/economics
- Anesthesia, General/methods
- Arthroplasty, Replacement, Hip/economics
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Knee/economics
- Arthroplasty, Replacement, Knee/methods
- Female
- Follow-Up Studies
- Hospital Costs
- Humans
- Length of Stay/statistics & numerical data
- Male
- Middle Aged
- Postoperative Complications/epidemiology
- Postoperative Complications/mortality
- Propensity Score
- Retrospective Studies
- Survival Rate
- Taiwan
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Affiliation(s)
- Wei-Hung Chen
- Department of Anesthesiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan
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Stundner O, Ortmaier R, Memtsoudis SG. Which outcomes related to regional anesthesia are most important for orthopedic surgery patients? Anesthesiol Clin 2014; 32:809-821. [PMID: 25453663 DOI: 10.1016/j.anclin.2014.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
An increasing body of evidence supports the benefits of regional anesthesia in orthopedic surgery. Compared with systemic anesthetic and analgesic approaches, these benefits include more focused and sustained pain control, less systemic side effects, improved patient comfort, earlier mobilization and hospital discharge, lower rates of advanced service requirements, and lower perioperative morbidity and mortality. However, there is discussion about the various outcomes as judged by patients and heath care practitioners. This article recapitulates the literature and presents an overview of endpoints.
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Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Rainhold Ortmaier
- Department of Trauma Surgery and Sports Traumatology, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA.
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Aksoy M, Dostbil A, Ince I, Ahiskalioglu A, Alici HA, Aydin A, Kilinc OO. Continuous spinal anaesthesia versus ultrasound-guided combined psoas compartment-sciatic nerve block for hip replacement surgery in elderly high-risk patients: a prospective randomised study. BMC Anesthesiol 2014; 14:99. [PMID: 25414593 PMCID: PMC4237736 DOI: 10.1186/1471-2253-14-99] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 10/27/2014] [Indexed: 11/23/2022] Open
Abstract
Background Our aim is to compare the hemodynamic effects of combined psoas compartment-sciatic nerve block (PCSNB) with continuous spinal anaesthesia (CSA) in elderly high-risk patients undergoing hip replacement surgery. Methods Seventy patients over the age of 60 with ASA III or IV physical status were randomly allocated to two groups: In the PCSNB group, ultrasound-guided psoas compartment block was performed with modified Winnie technique using 30 mL of 0.25% bupivacaine with 1:200.000 epinephrine (5 μgr/mL) and iliac crest block was performed using the same local anaesthetic solution (5 mL). All patients in the PCSNB group needed continuing infusion of propofol (2 mg/kg/h) during operation. In the CSA group, CSA was performed in the L3-L4 interspaced with the patient in lateral decubitus position using 2.5 mg of isobaric bupivacaine 0.5%. When sensory block was not reached to the level of T12 within 10 minutes in the CSA group, additional 2.5 mg of isobaric bupivacaine 0.5% was administered through the catheter at 5-min intervals by limiting the total dose of 15 mg until a T12 level of the sensory block was achieved. Results The PCSNB group had significantly higher mean arterial blood pressure values at the beginning of surgery and at 5th, 10th and 20th minutes of surgery compared to the CSA group (P =0.038, P =0.029, P =0.012, P =0.009 respectively). There were no significant differences between groups in terms of heart rate and peripheral oxygen saturation values during surgery and the postoperative period (P >0.05). Arterial hypotension required ephedrine was observed in 13 patients in the CSA and 4 patients in the PCSNB group (P =0.012). Conclusions CSA and PCSNB produce satisfactory quality of anaesthesia in elderly high-risk patients with fewer hemodynamic changes in PCSNB cases compared with CSA cases. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12614000658617, Registered 24 June 2014.
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Affiliation(s)
- Mehmet Aksoy
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Aysenur Dostbil
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Ilker Ince
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Ali Ahiskalioglu
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Hacı Ahmet Alici
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Ali Aydin
- Department of Orthopedics and Traumatology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Osman Ozgur Kilinc
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
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Hemodynamic effects of angiotensin inhibitors in elderly hypertensives undergoing total knee arthroplasty under regional anesthesia. ACTA ACUST UNITED AC 2014; 8:644-51. [DOI: 10.1016/j.jash.2014.05.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/06/2014] [Accepted: 05/07/2014] [Indexed: 11/17/2022]
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Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, Boettner F, Memtsoudis SG. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 2014; 349:g4829. [PMID: 25116268 PMCID: PMC4130961 DOI: 10.1136/bmj.g4829] [Citation(s) in RCA: 329] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the effectiveness and safety of perioperative tranexamic acid use in patients undergoing total hip or knee arthroplasty in the United States. DESIGN Retrospective cohort study; multilevel multivariable logistic regression models measured the association between tranexamic acid use in the perioperative period and outcomes. SETTING 510 US hospitals from the claims based Premier Perspective database for 2006-12. PARTICIPANTS 872,416 patients who had total hip or knee arthroplasty. INTERVENTION Perioperative intravenous tranexamic acid use by dose categories (none, ≤ 1000 mg, 2000 mg, and ≥ 3000 mg). MAIN OUTCOME MEASURES Allogeneic or autologous transfusion, thromboembolic complications (pulmonary embolism, deep venous thrombosis), acute renal failure, and combined complications (thromboembolic complications, acute renal failure, cerebrovascular events, myocardial infarction, in-hospital mortality). RESULTS While comparable regarding average age and comorbidity index, patients receiving tranexamic acid (versus those who did not) showed lower rates of allogeneic or autologous transfusion (7.7% v 20.1%), thromboembolic complications (0.6% v 0.8%), acute renal failure (1.2% v 1.6%), and combined complications (1.9% v 2.6%); all P<0.01. In the multilevel models, tranexamic acid dose categories (versus no tranexamic acid use) were associated with significantly (P<0.001) decreased odds for allogeneic or autologous blood transfusions (odds ratio 0.31 to 0.38 by dose category) and no significantly increased risk for complications: thromboembolic complications (odds ratio 0.85 to 1.02), acute renal failure (0.70 to 1.11), and combined complications (0.75 to 0.98). CONCLUSIONS Tranexamic acid was effective in reducing the need for blood transfusions while not increasing the risk of complications, including thromboembolic events and renal failure. Thus our data provide incremental evidence of the potential effectiveness and safety of tranexamic acid in patients requiring orthopedic surgery.
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Affiliation(s)
- Jashvant Poeran
- Institute of Healthcare Delivery Science, Mount Sinai Hospital System / Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rehana Rasul
- Institute of Healthcare Delivery Science, Mount Sinai Hospital System / Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suzuko Suzuki
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - Thomas Danninger
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - Madhu Mazumdar
- Institute of Healthcare Delivery Science, Mount Sinai Hospital System / Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mathias Opperer
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
| | - Friedrich Boettner
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
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Opperer M, Danninger T, Stundner O, Memtsoudis SG. Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review. World J Orthop 2014; 5:336-343. [PMID: 25035837 PMCID: PMC4095027 DOI: 10.5312/wjo.v5.i3.336] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/24/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Over the last decades the demand for hip surgery, be it elective or in a traumatic setting, has greatly increased and is projected to expand even further. Concurrent with demographic changes the affected population is burdened by an increase in average comorbidity and serious complications. It has been suggested that the choice of anesthesia not only affects the surgery setting but also the perioperative outcome as a whole. Therefore different approaches and anesthetic techniques have been developed to offer individual anesthetic and analgesic care to hip surgery patients. Recent studies on comparative effectiveness utilizing population based data have given us a novel insight on anesthetic practice and outcome, showing favorable results in the usage of regional vs general anesthesia. In this review we aim to give an overview of anesthetic techniques in use for hip surgery and their impact on perioperative outcome. While there still remains a scarcity of data investigating perioperative outcomes and anesthesia, most studies concur on a positive outcome in overall mortality, thromboembolic events, blood loss and transfusion requirements when comparing regional to general anesthesia. Much of the currently available evidence suggests that a comprehensive medical approach with emphasis on regional anesthesia can prove beneficial to patients and the health care system.
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Stundner O, Rasul R, Chiu YL, Sun X, Mazumdar M, Brummett CM, Ortmaier R, Memtsoudis SG. Peripheral nerve blocks in shoulder arthroplasty: how do they influence complications and length of stay? Clin Orthop Relat Res 2014; 472:1482-8. [PMID: 24166076 PMCID: PMC3971209 DOI: 10.1007/s11999-013-3356-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery. QUESTIONS/PURPOSES Using a large national cohort, we asked: (1) How frequently are upper-extremity peripheral nerve blocks added to general anesthesia in patients undergoing total shoulder arthroplasty? (2) Are there differences in the incidence of and adjusted risk for major perioperative complications and mortality between patients receiving general anesthesia with and without nerve blocks? And (3) does resource utilization (blood product transfusion, intensive care unit admission, length of stay) differ between groups? METHODS We searched a nationwide discharge database for patients undergoing total shoulder arthroplasty under general anesthesia with or without addition of a nerve block. Groups were compared with regard to demographics, comorbidities, major perioperative complications, and length of stay. Multivariable logistic regressions were performed to measure complications and resource use. A negative binomial regression was fitted to measure length of stay. RESULTS We identified 17,157 patients who underwent total shoulder arthroplasty between 2007 and 2011. Of those, approximately 21% received an upper-extremity peripheral nerve block in addition to general anesthesia. Patients receiving combined regional-general anesthesia had similar mean age (68.6 years [95% CI: 68.2-68.9 years] versus 69.1 years [95% CI: 68.9-69.3 years], p < 0.0043), a slightly lower mean Deyo (comorbidity) index (0.87 versus 0.93, p = 0.0052), and similar prevalence of individual comorbidities, compared to those patients receiving general anesthesia only. Addition of regional anesthesia was not associated with different odds ratios for complications, transfusion, and intensive care unit admission. Incident rates for length of stay were also similar between groups (incident rate ratio = 0.99; 95% CI: 0.97-1.02; p = 0.467) CONCLUSIONS: Addition of regional to general anesthesia was not associated with an increased complication profile or increased use of resources. In combination with improved pain control as known from previous research, regional anesthesia may represent a viable management option for shoulder arthroplasty. However, further research is necessary to better clarify the risk of neurologic complications. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Rehana Rasul
- Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY USA
| | - Ya-Lin Chiu
- Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY USA
| | - Xuming Sun
- Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY USA
| | - Madhu Mazumdar
- Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY USA
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI USA
| | - Reinhold Ortmaier
- Department of Trauma Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Stavros G. Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY USA
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Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology 2014; 120:551-63. [PMID: 24534855 DOI: 10.1097/aln.0000000000000120] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Much controversy remains on the role of anesthesia technique and peripheral nerve blocks (PNBs) in inpatient falls (IFs) after orthopedic procedures. The aim of the study is to characterize cases of IFs, identify risk factors, and study the role of PNB and anesthesia technique in IF risk in total knee arthroplasty patients. METHODS The authors selected total knee arthroplasty patients from the national Premier Perspective database (Premier Inc., Charlotte, NC; 2006-2010; n = 191,570, >400 acute care hospitals). The primary outcome was IF. Patient- and healthcare system-related characteristics, anesthesia technique, and presence of PNB were determined for IF and non-IF patients. Independent risk factors for IFs were determined by using conventional and multilevel logistic regression. RESULTS Overall, IF incidence was 1.6% (n = 3,042). Distribution of anesthesia technique was 10.9% neuraxial, 12.9% combined neuraxial/general, and 76.2% general anesthesia. PNB was used in 12.1%. Patients suffering IFs were older (average age, 68.9 vs. 66.3 yr), had higher comorbidity burden (average Deyo index, 0.77 vs. 0.66), and had more major complications, including 30-day mortality (0.8 vs. 0.1%; all P < 0.001). Use of neuraxial anesthesia (IF incidence, 1.3%; n = 280) had lower adjusted odds of IF compared with adjusted odds of IF with the use of general anesthesia alone (IF incidence, 1.6%; n = 2,393): odds ratio, 0.70 (95% CI, 0.56-0.87). PNB was not significantly associated with IF (odds ratio, 0.85 [CI, 0.71-1.03]). CONCLUSIONS This study identifies several risk factors for IF in total knee arthroplasty patients. Contrary to common concerns, no association was found between PNB and IF. Further studies should determine the role of anesthesia practices in the context of fall-prevention programs.
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Stundner O, Chiu YL, Sun X, Ramachandran SK, Gerner P, Vougioukas V, Mazumdar M, Memtsoudis SG. Sleep apnoea adversely affects the outcome in patients who undergo posterior lumbar fusion: a population-based study. Bone Joint J 2014; 96-B:242-8. [PMID: 24493191 DOI: 10.1302/0301-620x.96b2.31842] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite the increasing prevalence of sleep apnoea, little information is available regarding its impact on the peri-operative outcome of patients undergoing posterior lumbar fusion. Using a national database, patients who underwent lumbar fusion between 2006 and 2010 were identified, sub-grouped by diagnosis of sleep apnoea and compared. The impact of sleep apnoea on various outcome measures was assessed by regression analysis. The records of 84,655 patients undergoing posterior lumbar fusion were identified and 7.28% (n = 6163) also had a diagnostic code for sleep apnoea. Compared with patients without sleep apnoea, these patients were older, more frequently female, had a higher comorbidity burden and higher rates of peri-operative complications, post-operative mechanical ventilation, blood product transfusion and intensive care. Patients with sleep apnoea also had longer and more costly periods of hospitalisation. In the regression analysis, sleep apnoea emerged as an independent risk factor for the development of peri-operative complications (odds ratio (OR) 1.50, confidence interval (CI) 1.38;1.62), blood product transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation (OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10, CI 1.03;1.18). Patients with sleep apnoea who undergo posterior lumbar fusion pose significant challenges to clinicians.
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Affiliation(s)
- O Stundner
- Paracelsus Medical University, Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
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Memtsoudis SG, Stundner O, Rasul R, Chiu YL, Sun X, Ramachandran SK, Kaw R, Fleischut P, Mazumdar M. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg 2014; 118:407-418. [PMID: 24445639 DOI: 10.1213/ane.0000000000000051] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite the concern that sleep apnea (SA) is associated with increased risk for postoperative complications, a paucity of information is available regarding the effect of this disorder on postoperative complications and resource utilization in the orthopedic population. With an increasing number of surgical patients suffering from SA, this information is important to physicians, patients, policymakers, and administrators alike. METHODS We analyzed hospital discharge data of patients who underwent total hip or knee arthroplasty in approximately 400 U.S. Hospitals between 2006 and 2010. Patient, procedure, and health care system-related demographics and outcomes such as mortality, complications, and resource utilization were compared among groups. Multivariable logistic regression models were fit to assess the association between SA and various outcomes. RESULTS We identified 530,089 entries for patients undergoing total hip and knee arthroplasty. Of those, 8.4% had a diagnosis code for SA. In the multivariate analysis, the diagnosis of SA emerged as an independent risk factor for major postoperative complications (OR 1.47; 95% confidence interval [CI], 1.39-1.55). Pulmonary complications were 1.86 (95% CI, 1.65-2.09) times more likely and cardiac complications 1.59 (95% CI, 1.48-1.71) times more likely to occur in patients with SA. In addition, SA patients were more likely to receive ventilatory support, use more intensive care, stepdown and telemetry services, consume more economic resources, and have longer lengths of hospitalization. CONCLUSIONS The presence of SA is a major clinical and economic challenge in the postoperative period. More research is needed to identify SA patients at risk for complications and develop evidence-based practices to aid in the allocation of clinical and economic resources.
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Affiliation(s)
- Stavros G Memtsoudis
- From the *Department of Anesthesiology, Hospital for Special Surgery, †Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, New York; ‡Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan; §Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio; and ‖Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York
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Sleep apnea and total joint arthroplasty under various types of anesthesia: a population-based study of perioperative outcomes. Reg Anesth Pain Med 2014; 38:274-81. [PMID: 23558371 DOI: 10.1097/aap.0b013e31828d0173] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES The presence of sleep apnea (SA) among surgical patients has been associated with significantly increased risk of perioperative complications. Although regional anesthesia has been suggested as a means to reduce complication rates among SA patients undergoing surgery, no data are available to support this association. We studied the association of the type of anesthesia and perioperative outcomes in patients with SA undergoing joint arthroplasty. METHODS Drawing on a large administrative database (Premier Inc), we analyzed data from approximately 400 hospitals in the United States. Patients with a diagnosis of SA who underwent primary hip or knee arthroplasty between 2006 and 2010 were identified. Perioperative outcomes were compared between patients receiving general, neuraxial, or combined neuraxial-general anesthesia. RESULTS We identified 40,316 entries for unique patients with a diagnosis for SA undergoing primary hip or knee arthroplasty. Of those, 30,024 (74%) had anesthesia-type information available. Approximately 11% of cases were performed under neuraxial, 15% under combined neuraxial and general, and 74% under general anesthesia. Patients undergoing their procedure under neuraxial anesthesia had significantly lower rates of major complications than did patients who received combined neuraxial and general or general anesthesia (16.0%, 17.2%, and 18.1%, respectively; P = 0.0177). Adjusted risk of major complications for those undergoing surgery under neuraxial or combined neuraxial-general anesthesia compared with general anesthesia was also lower (odds ratio, 0.83 [95% confidence interval, 0.74-0.93; P = 0.001] vs odds ratio, 0.90 [95% confidence interval, 0.82-0.99; P = 0.03]). CONCLUSIONS Barring contraindications, neuraxial anesthesia may convey benefits in the perioperative outcome of SA patients undergoing joint arthroplasty. Further research is needed to enhance an understanding of the mechanisms by which neuraxial anesthesia may exert comparatively beneficial effects.
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Wang L, Bauer M, Curry R, Larsson A, Sessler DI, Eisenach JC. Intrathecal ketorolac does not improve acute or chronic pain after hip arthroplasty: a randomized controlled trial. J Anesth 2014; 28:790-3. [PMID: 24535482 DOI: 10.1007/s00540-014-1798-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 01/23/2014] [Indexed: 01/27/2023]
Abstract
Hypersensitivity to mechanical stimuli following surgery has been reported in patients who subsequently develop chronic pain after surgery. In animals, peripheral injury increases prostaglandin production in the spinal cord, and spinal cyclooxygenase inhibitors reduce hypersensitivity after injury. We therefore tested the hypothesis that spinal ketorolac reduces hypersensitivity and acute and chronic pain after hip arthroplasty ( www.clinicaltrials.gov NCT 00621530). Sixty-two patients undergoing total hip arthroplasty with spinal anesthesia were randomized to receive 13.5 mg hyperbaric bupivacaine with spinal saline or 13.5 mg hyperbaric bupivacaine with 2 mg preservative-free ketorolac. The primary outcome was area of hypersensitivity surrounding the wound 48 h after surgery, but this only occurred in 4 patients, precluding assessment of this outcome. The groups did not differ in acute pain, acute opioid use, or pain incidence or severity at 2 and 6 months after surgery. There were no serious adverse events. Our results suggest that a single spinal dose of ketorolac does not substantially reduce acute surgical pain and is thus unlikely to reduce the risk of persistent incisional pain.
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Affiliation(s)
- Lu Wang
- The Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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Survey criteria for fibromyalgia independently predict increased postoperative opioid consumption after lower-extremity joint arthroplasty: a prospective, observational cohort study. Anesthesiology 2014; 119:1434-43. [PMID: 24343289 DOI: 10.1097/aln.0b013e3182a8eb1f] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Variance in pain after total knee and hip arthroplasty may be due to a number of procedural and peripheral factors but also, in some individuals, to aberrant central pain processing as is described in conditions like fibromyalgia. To test this hypothesis, the authors conducted a prospective, observational cohort study of patients undergoing lower-extremity joint arthroplasty. METHODS Five hundred nineteen patients were preoperatively phenotyped using validated self-reported pain questionnaires, psychological measures, and health information. In addition to being assessed for factors previously found to be associated with poor outcomes in arthroplasty, participants also completed the American College of Rheumatology survey criteria for fibromyalgia. Previous studies have suggested that rather than being "present" or "absent," features of fibromyalgia as measured by this instrument, occur over a wide continuum. Postoperative pain control was assessed by total postoperative opioid consumption. RESULTS Preoperatively, patients with higher fibromyalgia survey scores were younger, more likely to be female, taking more opioids, reported higher pain severity, and had a more negative psychological profile. In the multivariate analysis, the fibromyalgia survey score, younger age, preoperative opioid use, knee (vs. hip), pain severity at baseline, and the anesthetic technique were all predictive of increased postoperative opioid consumption. CONCLUSIONS The use of the survey criteria for fibromyalgia led to the finding of distinct phenotypic differences, and the measure was independently predictive of opioid consumption. This self-report measure may provide an additional simple means of predicting postoperative pain outcomes and analgesic requirements. Future studies are needed to determine whether tailored therapies can improve postoperative pain control in this population.
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Perry TE, Zha H, Zhou K, Frias P, Zeng D, Braunstein M. Supervised embedding of textual predictors with applications in clinical diagnostics for pediatric cardiology. J Am Med Inform Assoc 2014; 21:e136-42. [PMID: 24076750 PMCID: PMC3957389 DOI: 10.1136/amiajnl-2013-001792] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 07/14/2013] [Accepted: 08/13/2013] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Electronic health records possess critical predictive information for machine-learning-based diagnostic aids. However, many traditional machine learning methods fail to simultaneously integrate textual data into the prediction process because of its high dimensionality. In this paper, we present a supervised method using Laplacian Eigenmaps to enable existing machine learning methods to estimate both low-dimensional representations of textual data and accurate predictors based on these low-dimensional representations at the same time. MATERIALS AND METHODS We present a supervised Laplacian Eigenmap method to enhance predictive models by embedding textual predictors into a low-dimensional latent space, which preserves the local similarities among textual data in high-dimensional space. The proposed implementation performs alternating optimization using gradient descent. For the evaluation, we applied our method to over 2000 patient records from a large single-center pediatric cardiology practice to predict if patients were diagnosed with cardiac disease. In our experiments, we consider relatively short textual descriptions because of data availability. We compared our method with latent semantic indexing, latent Dirichlet allocation, and local Fisher discriminant analysis. The results were assessed using four metrics: the area under the receiver operating characteristic curve (AUC), Matthews correlation coefficient (MCC), specificity, and sensitivity. RESULTS AND DISCUSSION The results indicate that supervised Laplacian Eigenmaps was the highest performing method in our study, achieving 0.782 and 0.374 for AUC and MCC, respectively. Supervised Laplacian Eigenmaps showed an increase of 8.16% in AUC and 20.6% in MCC over the baseline that excluded textual data and a 2.69% and 5.35% increase in AUC and MCC, respectively, over unsupervised Laplacian Eigenmaps. CONCLUSIONS As a solution, we present a supervised Laplacian Eigenmap method to embed textual predictors into a low-dimensional Euclidean space. This method allows many existing machine learning predictors to effectively and efficiently capture the potential of textual predictors, especially those based on short texts.
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Affiliation(s)
- Thomas Ernest Perry
- School of Computational Science & Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Hongyuan Zha
- School of Computational Science & Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Ke Zhou
- School of Computational Science & Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Patricio Frias
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Dadan Zeng
- Software Engineering Institute, East China Normal University, Shanghai, China
| | - Mark Braunstein
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, Georgia, USA
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Kamath AF, McAuliffe CL, Gutsche JT, Kosseim LM, Hume EL, Baldwin KD, Kornfield Z, Israelite CL. Intensive care monitoring after total joint replacement. Bone Joint J 2014; 95-B:74-6. [PMID: 24187358 DOI: 10.1302/0301-620x.95b11.33093] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient safety is a critical issue in elective total joint replacement surgery. Identifying risk factors that might predict complications and intensive care unit (ICU) admission proves instrumental in reducing morbidity and mortality. The institution's experience with risk stratification and pre-operative ICU triage has resulted in a reduction in unplanned ICU admissions and post-operative complications after total hip replacement. The application of the prediction tools to total knee replacement has proven less robust so far. This work also reviews areas for future research in patient safety and cost containment.
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Affiliation(s)
- A F Kamath
- University of Pennsylvania, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
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McCartney CJL, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013; 111:331-3. [PMID: 23946357 DOI: 10.1093/bja/aet200] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kamath AF, Gutsche JT, Kornfield ZN, Baldwin KD, Kosseim LM, Israelite CL. Prospective study of unplanned admission to the intensive care unit after total hip arthroplasty. J Arthroplasty 2013; 28:1345-8. [PMID: 23507067 DOI: 10.1016/j.arth.2013.01.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 12/14/2012] [Accepted: 01/04/2013] [Indexed: 02/01/2023] Open
Abstract
The morbidity associated with elective total hip arthroplasty (THA) may result in intensive care unit (ICU) admission. A total of 175 consecutive THA patients were prospectively triaged to either an ICU bed or routine post-operative floor according to admission criteria based on a prior published study of 1259 THA patients. Primary end points were a reduction in unplanned ICU admission, as well as major complications. With our triage model, the rate of unplanned ICU admissions dropped from 7.1% to 2.2% (P=0.013). The as-treated odds of unplanned admission pre- versus post-intervention were 3.2 (1.2, 10.6). The complication rate fell from 12.5% to 2%, and the mortality index decreased from 4.77 to 1.62. Triage according to selected risk factors affects a reduction in unplanned ICU admissions and major complications after THA.
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Affiliation(s)
- Atul F Kamath
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First St SW, Gonda 14, Rm 130, Rochester, Minnesota 55905, USA
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