Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

Abstract

Keywords:total knee arthroplasty opioid hypotension modifiable risk factors length of stay anemia a b s t r a c t Background: We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events. Methods: Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days. Results: The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63). Conclusion: This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.

The necessity of routine postoperative laboratory tests after total hip arthroplasty for hip fracture in a semi-urgent clinical setting

“…Although hypocalcemia frequently occurs after THA (54.93%), clinical symptoms associated with hypocalcemia are extremely rare [57]. Routinely, no intervention would be applied for hypocalcemia, but there is a limited understanding of hypocalcemia in patients after THA, thus warranting additional studies [58].…”

Preoperative Opioid Use Is a Risk Factor for Revision Surgery, Complications, and Increased Resource Utilization After Arthroscopic Rotator Cuff Repair

“…8,9,40,41,44 Concerning total joint arthroplasty, numerous publications have cited preoperative and perioperative opioid use as risk factors for deleterious outcomes after surgery, noting increased health care utilization and increased rates of prosthetic joint infection and revision surgery. 4,6,7,20,56,59 Similar studies have also identified preoperative opioid use as a negative predictor of patient-reported outcome measure scores, with lower preoperative baseline scores and lower overall change in function after arthroplasty. 12,31,32,33,50 A similar relationship has been found in patients undergoing RCR.…”

“…The MarketScan outpatient services database was queried for data from 2009 to 2018 for patients undergoing arthroscopic RCR using Current Procedural Terminology (CPT) code 29827 (arthroscopy, shoulder, surgical, with RCR). Patients were excluded based on a number of criteria including (1) 6-month noncontinuous preoperative enrollment (ie, patients who were not continuously enrolled in the database for the 6-month period preceding surgery), (2) 3-month noncontinuous postoperative enrollment, (3) no enrollment in the pharmaceutical claims database, (4) open RCR, (5) any concomitant shoulder arthroplasty or humerus/glenoid fracture fixation, (6) those with preoperative cancer diagnoses who may have required opioid medications for chronic cancer pain, and (7) those aged \18 years. Additionally, a second cohort was created with patients who had 3 years of postoperative continuous enrollment and CPT laterality code modifiers for the tracking of longer term revision rates in addition to the criteria above.…”

The burden of perioperative hypertension/hypotension: A systematic review

“…Other studies such as that of Roshanov et al . [ 56 ] reported hypotensive events in postoperative days 0 and 1 was also found to be associated with increased length of hospital stay (OR 1.305, p = 0.0239) [ 14 , 21 ]; and sepsis/systemic inflammatory response syndrome [ 23 ]. Other outcomes that were investigated were: surgical site infection, that was found to be not statistically significant in relation to MAP <55 mmHg and SBP <80 mmHg, but odds of 1.08 were found in association with minimum postoperative MAP, per 5 mmHg decrease by Yilmaz et al .…”