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.
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 disease on postoperative complications and resource utilization in the orthopedic population. With an increasing number of surgical patients suffering from SA, this information is of high importance to physicians, patients, policymakers and administrators alike. Methods We analyzed hospital discharge data of patients who underwent total hip or knee arthroplasty (THA, TKA) in approximately 400 United States hospitals between 2006 and 2010. Patient, procedure, and healthcare-system related demographics and outcomes such as mortality, complications, and resource utilization were compared amongst 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 THA and TKA. Of those, 8.4% had a diagnosis code for SA. In the multivariate analysis, the diagnosis of SA emerged as independent risk factor for major postoperative complications (OR 1.47 (95% 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 require ventilatory support, utilize more intensive care, step-down and telemetry services, consume more economic resources, and require increased lengths of hospitalization. Conclusions The presence of SA represents 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 in order to aid in the allocation of clinical and economic resources.
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.
Objective Antibiotic use, particularly type and duration, is a crucial modifiable risk factor for Clostridium difficile. Cardiac surgery is of particular interest because prophylactic antibiotics are recommended for 48 hours or less (vs ≤24 hours for noncardiac surgery), with increasing vancomycin use. We aimed to study associations between antibiotic prophylaxis (duration/vancomycin use) and C difficile among patients undergoing coronary artery bypass grafting. Methods We extracted data on coronary artery bypass grafting procedures from the national Premier Perspective claims database (2006–2013, n = 154,200, 233 hospitals). Multilevel multivariable logistic regressions measured associations between (1) duration (<2 days, “standard” vs ≥2 days, “extended”) and (2) type of antibiotic used (“cephalosporin,” “cephalosporin + vancomycin,” “vancomycin”) and C difficile as outcome. Results Overall C difficile prevalence was 0.21% (n = 329). Most patients (59.7%) received a cephalosporin only; in 33.1% vancomycin was added, whereas 7.2% received vancomycin only. Extended prophylaxis was used in 20.9%. In adjusted analyses, extended prophylaxis (vs standard) was associated with significantly increased C difficile risk (odds ratio, 1.43; confidence interval, 1.07–1.92), whereas no significant associations existed for vancomycin use as adjuvant or primary prophylactic compared with the use of cephalosporins (odds ratio, 1.21; confidence interval, 0.92–1.60, and odds ratio, 1.39; confidence interval, 0.94–2.05, respectively). Substantial inter-hospital variation exists in the percentage of extended antibiotic prophylaxis (interquartile range, 2.5–35.7), use of adjuvant vancomycin (interquartile range, 4.2–61.1), and vancomycin alone (interquartile range, 2.3–10.4). Conclusions Although extended use of antibiotic prophylaxis was associated with increased C difficile risk after coronary artery bypass grafting, vancomycin use was not. The observed hospital variation in antibiotic prophylaxis practices suggests great potential for efforts aimed at standardizing practices that subsequently could reduce C difficile risk.
Neuraxial anesthesia is associated with decreased odds for major complications and resource utilization after joint arthroplasty for all patient groups, irrespective of age and comorbidity burden.
Background. Various studies have raised concern of worse outcomes in patients receiving blood transfusions perioperatively compared to those who do not. In this study we attempted to determine the proportion of perioperative complications in the orthopedic population attributable to the use of a blood transfusion. Methods. Data from 400 hospitals in the United States were used to identify patients undergoing total hip or knee arthroplasty (THA and TKA) from 2006 to 2010. Patient and health care demographics, as well as comorbidities and perioperative outcomes were compared. Multivariable logistic regression models were fitted to determine associations between transfusion, age, and comorbidities and various perioperative outcomes. Population attributable fraction (PAF) was determined to measure the proportion of outcome attributable to transfusion and other risk factors. Results. Of 530,089 patients, 18.93% received a blood transfusion during their hospitalization. Patients requiring blood transfusion were significantly older and showed a higher comorbidity burden. In addition, these patients had significantly higher rates of major complications and a longer length of hospitalization. The logistic regression models showed that transfused patients were more likely to have adverse health outcomes than nontransfused patients. However, patients who were older or had preexisting diseases carried a higher risk than use of a transfusion for these outcomes. The need for a blood transfusion explained 9.51% (95% CI 9.12–9.90) of all major complications. Conclusions. Advanced age and high comorbidity may be responsible for a higher proportion of adverse outcomes in THA and TKA patients than blood transfusions.
ObjeCtive To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications. exPOsures Perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5%, or neither. Main OutCOMe MeasuresAcute renal failure and thromboembolic, cardiac, and pulmonary complications. resultsCompared with patients who received neither colloid, perioperative fluid resuscitation with hydroxyethyl starch 6% or albumin 5% was associated with an increased risk of acute renal failure (odds ratios 1.23 (95% confidence interval 1.13 to 1.34) and 1.56 (1.36 to 1.78), respectively) and most other complications. A recent decrease in hydroxyethyl starch 6% use was noted, whereas that of albumin 5% increased. COnClusiOnsSimilar to studies in critically ill patients, we showed that use of hydroxyethyl starch 6% was associated with an increased risk of acute renal failure and other complications in the elective perioperative orthopedic setting. This increased risk also applied to albumin 5%. These findings raise questions regarding the widespread use of these colloids in elective joint arthroplasty procedures.
Results suggest that participants with higher PTSD symptoms were more likely to grow from the impact of the storm, indicating resilience. Highly exposed participants were more likely to experience PTG. A decrease in PTG was found among those with both PTSD and depression symptoms. The development and implementation of interventions fostering PTG could be beneficial in clinical disaster response work. (PsycINFO Database Record
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