Impact of opioid use disorders on outcomes and readmission following cardiac operations

A National Analysis of Alcohol Withdrawal Syndrome in Patients with Operative Trauma

Background

Alcohol withdrawal syndrome (AWS) presents with a complex spectrum of clinical manifestations that complicate postoperative management. In trauma setting, subjective screening for AWS remains challenging due to the criticality of injury in these patients. We thus identified several patient characteristics and perioperative outcomes associated AWS development.

Methods

The 2016-2020 National Inpatient Sample was queried to identify all non-elective adult (≥18 years) hospitalizations for blunt or penetrating trauma undergoing operative management with a diagnosis of AWS. Patients with traumatic brain injury or with a hospital duration of stay <2 days were excluded. Outcomes of interest included in-hospital mortality, perioperative complications, hospitalization costs, length of stay (LOS) and non-home discharge.

Results

Of an estimated 2,965,079 operative trauma hospitalizations included for analysis, 36,415 (1.23 %) developed AWS following admission. The AWS cohort demonstrated increased odds of mortality (Adjusted Odds Ratio [AOR] 1.46, 95 % Confidence Interval [95 % CI] 1.23-1.73), along with infectious (AOR 1.73, 95 % CI 1.58-1.88), cardiac (AOR 1.24, 95 % CI 1.06-1.46), and respiratory (AOR 1.96, 95 % CI 1.81-2.11) complications. AWS was associated with prolonged LOS, (β: 3.3 days, 95 % CI: 3.0 to 3.5), greater cost (β: +$8900, 95 % CI $7900-9800) and incremental odds of nonhome discharge (AOR 1.43, 95 % CI 1.34-1.53). Furthermore, male sex, Medicaid insurance status, head injury and thoracic operation were linked with greater odds of development of AWS.

Conclusion

In the present study, AWS development was associated with increased odds of in-hospital mortality, perioperative complications, and resource burden. The identification of patient and operative characteristics linked with AWS may improve screening protocols in trauma care.

Trends and clinical outcomes of abdominal compartment syndrome among intensive care hospitalizations

BACKGROUND

Abdominal compartment syndrome has been shown to be a highly morbid condition among patients admitted to the intensive care unit. The present study sought to characterize trends as well as clinical and financial outcomes of patients with abdominal compartment syndrome.

METHODS

The 2010 to 2020 National Inpatient Sample was used to identify adults (≥18 years) admitted to the intensive care unit. Standard mean differences were obtained to demonstrate effect size with >0.1 denoting significance. Hospitals were divided into tertiles based on annual institutional intensive care unit admissions. Multivariable regression models were used to evaluate the association of abdominal compartment syndrome on outcomes. The primary endpoint was in-hospital mortality, while complications, costs, and length of stay were secondarily considered.

RESULTS

Of 11,804,585 patients, 19,644 (0.17%) developed abdominal compartment syndrome. Over the study period, the incidence of abdominal compartment syndrome (2010-0.19%, 2020-0.20%, P < .001) remained similar. Those with abdominal compartment syndrome were more commonly admitted for gastrointestinal (22.8% vs 8.4%) and cardiovascular (22.6% vs 14.9%) etiologies and were more frequently managed at urban teaching hospitals (77.7% vs 65.1%) as well as high-volume intensive care units (85.2% vs 79.1%) (all standard mean differences >0.1). After adjustment, abdominal compartment syndrome was associated with higher odds of mortality (adjusted odds ratio: 3.84, 95% confidence interval: 3.57-4.13, reference: non-abdominal compartment syndrome). Incremental length of stay (β: +5.0 days, 95% confidence interval: 4.2-5.8) and costs (β: $49.3K, 95% confidence interval: 45.3-53.4) were significantly higher in abdominal compartment syndrome compared to non-abdominal compartment syndrome.

CONCLUSION

Abdominal compartment syndrome, while an uncommon occurrence among intensive care unit patients, remains highly morbid with significant resource burden. Further work exploring factors to mitigate its clinical and financial burden is needed.

Association of opioid use disorder with outcomes of hospitalizations for acute myocardial infarction in the United States

OBJECTIVE

While Opioid Use Disorder (OUD) has been linked to inferior clinical outcomes, studies examining the clinical outcomes and readmission of OUD patients experiencing Acute Myocardial Infarction (AMI) remain lacking. The authors analyze the clinical and financial outcomes of OUD in a contemporary cohort of AMI hospitalizations.

METHODS

All non-elective adult (≥ 18 years) hospitalizations for AMI were tabulated from the 2016‒2019 Nationwide Readmissions Database using relevant International Classification of Disease codes. Patients were grouped into OUD and non-OUD cohorts. Bivariate and regression analyses were performed to identify the independent association of OUD with outcomes after non-elective admission for AMI, as well as subsequent readmission.

RESULTS

Of an estimated 3,318,257 hospitalizations for AMI meeting study criteria, 36,057 (1.1%) had a concomitant diagnosis of OUD. While OUD was not significantly associated with mortality, OUD patients experienced superior cardiovascular outcomes compared to non-OUD. However, OUD was linked to increased odds of non-cardiovascular complications, length of stay, costs, non-home discharge, and 30-day non-elective readmission.

CONCLUSIONS

Patients with OUD presented with AMI at a significantly younger age than non-OUD. While OUD appears to have a cardioprotective effect, it is associated with several markers of increased resource use, including readmission. The present findings underscore the need for a multifaceted approach to increasing social services and treatment for OUD at index hospitalization.

Opioid Agents and Cardiac Arrhythmia: A Literature Review

Opioids are compounds that cause similar effects to morphine by binding to its receptors. Opioids can be synthetic, semi-synthetic, or natural and can easily bind to the receptors of opioids in order to depict their effects, which may vary depending upon the exposure of the drug and its dose. However, several side effects of opioids can also be observed, with the most crucial being their impact on the heart's electrical activity. This review majorly focuses on opioids' impact on the prolongation of the QT curve and their arrhythmogenic susceptibility. Articles published up to the year 2022 in various databases were identified and searched with the use of keywords. Search terms included "cardiac arrhythmias," "QT interval," "opioids," "opioid dependence," and "torsade de pointes (TdP)". These terms highlight the impact of each opioid agent on the activity of the heart on an electrocardiogram. The results of the available data depict that opioids, such as methadone, pose higher risks, even when taken in smaller amounts, and have the capability for QT interval prolongation and TdP development. A variety of opioids, i.e., oxycodone and tramadol, are considered as intermediary risk drugs and can build long QT intervals and TdP in large doses. Several other opioids are considered low-risk drugs, including buprenorphine and morphine, which lead to no production of TdP and QT interval prolongation in daily routine doses. Evidence indicates a high risk of sinus bradycardia, atrial fibrillation, cardiac block, and supra-ventricular arrhythmias in opium consumers. This literature review will play a key role in determining the association between the use of opioids and cardiac arrhythmias. It will further highlight the practical implications of opioids for the management of cardiac issues based on their dose, frequency, and intensity. Moreover, it will also depict the adverse effects of opioids along with their dose-specific relationship. Opioids display disparate cardiac arrhythmogenicity, and methadone contains a greater ability to induce long QT intervals and hazardous arrhythmias at conventional doses. In order to reduce arrhythmogenic risk, opioids taken in large amounts should be monitored with a regular electrocardiogram in high-risk consumers, i.e., patients on opioid maintenance.

Effect of Preoperative Chronic Opioid Use on Mortality and Morbidity in Vascular Surgical Patients

Introduction

Opioid derivates are an essential part of everyday clinical pain management practice. They have excellent analgesic, sedative, and sympatholytic effects and are widely used in various conditions. Beyond advantageous aspects, there are numerous problems with the chronic use of these agents. Dependency and life-threatening complications are the biggest problems with both illegal and prescribed opioid derivates. In our current study, effects of chronic opioid use were observed on mortality and life quality in the case of vascular surgery.

Methods

This prospective, observational study was conducted between 2014 and 2017. After obtaining informed consent, all participants were asked to fill a questionnaire containing different psychological tests. Perioperative data, chronic medical therapy, and anthropometric data were also collected. Opioid user and non-user patients’ psychological results were compared with non-parametrical tests. The effect of chronic opioid administration was investigated with logistic regression method with bootstrapping.

Results

Finally, the data of 164 patients were analyzed. 64.0% of participants were male, the mean age was 67.05 years, and the standard deviation was 9.48 years. The median follow-up time was 1312 days [interquartile range (IQR): 930-1582 days]. During the follow-up time, 42 patients died (25.6%). In the examined patient cohort, the frequency of opioid derivate use was 3.7% (only six patients). In the non-survived group, opioid use was significantly higher (1.6% vs. 9.5%, p=0.019). Significant differences were found in the aspect of cognitive performance measured by Mini-Mental State Examination (MMSE), opioid users have had lower points [25.5 (IQR: 24.5-26.0) vs. 28.0 (IQR: 27.0-29.0) p=0.008]. Opioid users have showed higher score on Beck Depression Inventory (BDI) [15.5 (IQR: 10.0-18.0) vs. 6.0 (IQR: 3.0-11.0), p=0.030). In a multivariate Cox regression model built up from registered preoperative medical treatment, opioids were found as a risk factor for all-cause mortality [adjusted hazard ratio (AHR): 4.31, 95% CI: 1.77-10.55, p=0.001].

Conclusion

Our current findings suggest that chronic, preoperative use of opioids could associate with increased mortality. Furthermore, both decrease in cognitive performance and increased depression symptoms were found in the opioid user cohorts which emphasize the importance of further risk stratification of these patients.

Impact of delayed intervention on clinical outcomes following traumatic hip fracture in the elderly: A national analysis

The present study sought to evaluate clinical outcomes of delayed intervention following hip fractures. Adults (≥60 years) who underwent operative intervention for hip fracture following traumatic fall were identified using the 2008-2018 National Inpatient Sample. Patients were classified as Delayed if repair was >48 h after admission and otherwise considered Early. Of an estimated 1,942,905 patients, 148,441 (7.6%) were Delayed. Delayed more commonly suffered neck fractures, underwent hip arthroplasty and were managed at low-volume hospitals. After adjustment, delayed operation was associated with greater likelihood of mortality (adjusted odds ratio (AOR): 1.28, 95% CI: 1.17-1.40), studied complications, hospitalization duration and costs.

The Impact of Expedited Discharge on 30-Day Readmission Following Lung Resection: A National Study

BACKGROUND

Expedited discharge (within 24 hours) following lung resection has received scrutiny due to concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions using a nationally-representative sample. In addition, we sought to determine inter-hospital practice variation.

METHODS

Adults undergoing elective lobar or sublobar resection were identified using the 2016-2018 Nationwide Readmissions Database, while those with postoperative duration of hospitalization >5 days or experienced any perioperative complication, were excluded. Patients were classified as Expedited if postoperative hospitalization was 0 or 1 day and otherwise as Routine. Inverse probability of treatment weighing was utilized to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions as well as associated mortality and costs.

RESULTS

Of an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared to Routine, Expedited were younger, less likely to have chronic obstructive pulmonary disease and undergo open procedures. Following adjustment, early discharge was associated with lower incremental costs (β coefficient: -$3.6K, 95%CI: -4.4 - -2.8) as well as similar readmissions (odds ratio: 0.89, 95%CI: 0.70 - 1.13) and related-mortality. Nearly half (48.1%) of all hospitals performed zero early discharges.

CONCLUSIONS

Expedited discharge following lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared to the norm. Select individuals should be strongly considered for expedited discharge following lung resection.