Risk of Postoperative Gastrointestinal Bleeding and Its Associated Factors: A Nationwide Population-Based Study in Korea

Gastrointestinal Bleeds Are a Rare Event After Total Hip and Knee Arthroplasty

BACKGROUND

The presence of a gastrointestinal (GI) bleed after elective total hip arthroplasty and total knee arthroplasty (THA and TKA, respectively) is concerning and a potential cause for hospital readmission. This condition can also be life-threatening if not identified and treated appropriately. Many surgeons use multimodal analgesia protocols to limit opioid use and also use venous thromboembolism prophylaxis. Aspirin and nonsteroidal anti-inflammatories, often a component of these protocols, reduce prostaglandin production necessary for gastric mucosal protection. The authors hypothesized that the incidence of a GI bleed after TKA and THA would be rare.

METHODS

This was a retrospective review of 8,207 patients 18 years or older who had THA or TKA at a single institution between 2015 and 2022. Patients who were evaluated for GI bleed within 90 days postoperatively were identified. Perioperative risks were analyzed based on demographics, procedures, and other risk factors.

RESULTS

The incidence of GI bleeding was 0.33%, in which 27 patients sustained a GI bleed in 8,206 THA and TKA cases. The average days from the time of surgery for GI bleed were 18.6 days. There was a difference in the occurrence of GI bleeds by age, with increasing age being positively associated with an increase in the odds of GI bleeds, odds ratio = 1.15 (95% CI [confidence interval]: 1.09 to 1.21), P < 0.01. No statistical difference was found based on other demographic data, procedure type, or site.

CONCLUSIONS

This institution's perioperative protocol, including the use of nonsteroidal anti-inflammatories and aspirin for TKA and THA, had a low incidence of GI bleeds in the perioperative setting at our community hospital over the course of 2015 to 2022.

Clinical Outcomes and Risk Factors of Heart Transplantation Patients Experiencing Gastrointestinal Bleeding

Gastrointestinal bleeding (GIB) after heart transplantation (HT) remains a significant clinical issue. This study aimed to explore the incidence, trends, outcomes, and clinical predictors of GIB in HT patients. Adult patients who underwent HT between 2015 and 2021 at Union Hospital were recruited and divided into two groups based on the presence or absence of postoperative GIB. The primary outcomes were evaluated at follow-up. Independent predictors of GIB after HT were identified using a logistic regression analysis. A nomogram prediction model was constructed according to these independent variables, and the accuracy of the model was assessed using the receiver operating characteristic (ROC) curve and the calibration curve. Among the 461 patients, 40 (8.7%) developed GIB post-HT. HT patients with postoperative GIB exhibited higher in-hospital, 30-day, 90-day, and 1-year mortality (all p < 0.05). A multivariate analysis was used to identify age, preoperative warfarin, postoperative continuous renal replacement therapy, and postoperative nasogastric tubes as independent risk factors for GIB following HT. A nomogram prediction model was applied using the four variables. The area under the curve (AUC) of this model was 0.852 (95% CI: 0.787-0.917, p < 0.001), and the calibration curve was close to the ideal diagonal line. GIB following HT is associated with a poor clinical prognosis. The constructed nomogram demonstrated a favorable predictive value for GIB.

Assessing the Knowledge, Attitude, and Practice of Orthopedicians for Pain Management by Multimodal Approach: A Prospective, Cross-Sectional, and Observational Survey

BACKGROUND

The routine use of multimodal analgesic modality results in lower pain scores with minimum side effects and opioid utilization.

MATERIALS AND METHODS

 A prospective, cross-sectional, observational study was conducted among orthopedicians practicing across India to assess the professional opinions on using analgesics to manage orthopedic pain effectively.

RESULTS

 A total of 530 orthopedicians participated in this survey. Over 50% of the participants responded that tramadol with or without paracetamol was the choice of therapy for acute pain. Nearly 50% of the participants mentioned that multimodal interventions can sometimes help to manage pain. A total of 55.6% of participants mentioned that using Non-steroidal anti-inflammatory drugs was the most common in their clinical practice, while 25.7% of participants mentioned that they used tramadol more commonly in their clinical practice. As per clinical efficacy ranking, the combination of tramadol plus paracetamol (44.3%) was ranked first among analgesic combinations, followed by aceclofenac plus paracetamol (40.0%). The severity of pain (62.6%) followed by age (60.6%) and duration of therapy (52.6%) were the most common factors that should be considered while prescribing tramadol plus paracetamol combination. Gastrointestinal and renal are reported as the most common safety concerns encountered with analgesics.

CONCLUSION

 The combination of tramadol and paracetamol was identified as the most preferred choice of analgesics for prolonged orthopedic pain management.

Endoscopic management of postoperative bleeding

Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.

Incidence of Acute Upper Gastrointestinal Bleeding and Related Risk Factors among Elderly Patients Undergoing Surgery for Major Limb Fractures: An Analytical Cohort Study

(1) Background: Upper gastrointestinal bleeding (UGIB), a major postoperative complication after surgical fixation of major limb fractures, can be fatal but is often neglected. This study determined the incidence rates of and related risk factors for perioperative UGIB among older patients with major upper limb fractures but without a history of peptic ulcer disease (PUD). (2) Methods: We collected the data of patients aged more than 65 years who underwent surgery for major limb fracture between 1 January 2001 and 31 December 2017, from Taiwan's National Health Insurance Research Database and excluded those with a history of UGIB and PUD before the date of surgery. The primary outcome was the incidence of UGIB requiring panendoscopy during hospitalization. A multiple logistic regression model was used to identify the independent predictors of UGIB, with adjustment for confounding factors. The final model included variables that were either statistically significant in univariate analyses or deemed clinically important. (3) Results: The incidence of UGIB was 2.8% among patients with major limb fractures. Male sex, older age, major lower limb fracture, and a history of chronic renal disease were significant risk factors for the increased incidence of perioperative UGIB. (4) Conclusions: Patients with major limb fractures who underwent surgery exhibited a higher rate of stress ulceration with UGIB, even when they had no history of PUD. Perioperative preventive protocols (e.g., protocols for the administration of proton-pump inhibitors) may be necessary for patients with these major risk factors.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.