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Christensen TH, Gemayel AC, Bieganowski T, Lawrence K, Rozell JC, Macaulay WB, Schwarzkopf R. Opioid Use during Hospitalization following Total Knee Arthroplasty: Trends in Consumption from 2016 to 2021. J Arthroplasty 2023; 38:S26-S31. [PMID: 37019314 DOI: 10.1016/j.arth.2023.03.074] [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: 11/29/2022] [Revised: 03/24/2023] [Accepted: 03/24/2023] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION In response to physician and patient concerns, many institutions have adopted protocols aimed at reducing postoperative opioid consumption after total knee arthroplasty (TKA). Thus, this study sought to examine how consumption of opioids has changed following TKA in the past six years. METHODS We conducted a retrospective review of all 10,072 patients who received primary TKA at our institution from January 2016 to April 2021. We collected baseline demographic data including patient age, sex, race, body mass index (BMI), American Society of Anesthesiologist (ASA) classification, as well as dosage and type of opioid medication prescribed on each postoperative day while the patient was hospitalized following TKA. This data was converted to milligram morphine equivalents (MME) per day hospitalized to compare rates of opioid use over time. RESULTS Our analysis found the greatest daily opioid use was in 2016 (43.2±68.6 MME/day) and the least was in 2021 (15.0±29.2 MME/day). Linear regression analyses found a significant linear downward trend in postoperative opioid consumption over time, with a decrease of 5.55 MME per day per year (Adjusted R-squared: 0.982, P<0.001). The highest visual analog scale (VAS) score was 4.45 in 2016 and the lowest was 3.79 in 2021 (P<0.001). CONCLUSION Opioid reducing protocols have been implemented for patients recovering from primary TKA in an effort to decrease reliance on opioids for postoperative pain control. The results of this study demonstrate that such protocols have been successful in reducing overall opioid use during hospitalization following TKA.
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Affiliation(s)
| | - Anthony C Gemayel
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Thomas Bieganowski
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Kyle Lawrence
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - William B Macaulay
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York.
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Wirth K, Bähler C, Boes S, Näpflin M, Huber CA, Blozik E. Opioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare setting. BMJ Open 2023; 13:e067542. [PMID: 36889828 PMCID: PMC10008278 DOI: 10.1136/bmjopen-2022-067542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
OBJECTIVES The optimal use of opioids after knee replacement (KR) remains to be determined, given the growing evidence that opioids are no more effective than other analgesics and that their adverse effects can impair quality of life. Therefore, the objective is to examine opioid prescriptions after KR. DESIGN In this retrospective study, we used descriptive statistics and estimated the association of prognostic factors using generalised negative binomial models. SETTING The study is based on anonymised claims data of patients with mandatory health insurance at Helsana, a leading Swiss health insurance. PARTICIPANTS Overall, 9122 patients undergoing KR between 2015 and 2018 were identified. PRIMARY AND SECONDARY OUTCOME MEASURES Based on reimbursed bills, we calculated the dosage (morphine equivalent dose, MED) and the episode length (acute: <90 days; subacute: ≥90 to <120 days or <10 claims; chronic: ≥90 days and ≥10 claims or ≥120 days). The incidence rate ratios (IRRs) for postoperative opioids were calculated. RESULTS Of all patients, 3445 (37.8%) received opioids in the postoperative year. A large majority had acute episodes (3067, 89.0%), 2211 (65.0%) had peak MED levels above 100 mg/day and most patients received opioids in the first 10 postoperative weeks (2881, 31.6%). Increasing age (66-75 and >75 vs 18-65) was associated with decreased IRR (0.776 (95% CI 0.7 to 0.859); 0.723 (95% CI 0.649 to 0.805)), whereas preoperative non-opioid analgesics and opioids were associated with higher IRR (1.271 (95% CI 1.155 to 1.399); 3.977 (95% CI 4.409 to 3.591)). CONCLUSION The high opioid demand is unexpected given that current recommendations advise using opioids only when other pain therapies are ineffective. To ensure medication safety, it is important to consider alternative treatment options and ensure that benefits outweigh potential risks.
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Affiliation(s)
- Kevin Wirth
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Caroline Bähler
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Stefan Boes
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Markus Näpflin
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Carola A Huber
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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Lei Y, Huang Z, Huang Q, Pei F, Huang W. Dose optimization of intravenous dexamethasone for total knee arthroplasty: when two is not better than one. Arch Orthop Trauma Surg 2022; 142:665-672. [PMID: 33743063 DOI: 10.1007/s00402-021-03859-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The optimal dose regimen of dexamethasone in total knee arthroplasty (TKA) has not been determined. This study was performed to evaluate the impact of a single preoperative high-dose dexamethasone compared with two perioperative low-dose dexamethasone in TKA. MATERIALS AND METHODS We prospectively studied three regimens on dexamethasone: no dexamethasone (A), a single preoperative dose of 20-mg dexamethasone (B), and two perioperative doses of 10-mg dexamethasone (C). The primary outcome was postoperative pain level. The incidence of postoperative nausea and vomiting (PONV), use of analgesic and antiemetic rescue, interleukin-6 (IL-6) and C-reactive protein (CRP) levels, range of motion (ROM), and complications were also compared. RESULTS The dynamic pain scores and CRP and IL-6 levels were significantly lower for Group B compared to Groups A and C on postoperative days 1 and 2 (POD 1 and 2). Such differences were also detected between Groups C and A. Besides, the pain scores at rest were significantly lower in Groups B and C than in Group A on POD 1 and 2. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, and improved ROM than in Group A. No complications occurred in any group. CONCLUSION Dexamethasone in TKA provides short-term advantages in analgesic, antiemetic and anti-inflammatory effects. Besides, regarding the effects of pain and inflammatory control on POD 1 and 2, a single preoperative high dose of 20-mg dexamethasone was more effective than two perioperative low doses of 10-mg dexamethasone. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Yiting Lei
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China
| | - Zeyu Huang
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China
| | - Qiang Huang
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China
| | - Fuxing Pei
- Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People's Republic of China.
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Examining current patterns of opioid prescribing and use after bariatric surgery. Surg Endosc 2021; 36:2564-2569. [PMID: 33978853 DOI: 10.1007/s00464-021-08544-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Evidence-based guidelines on the appropriate amount of opioid medications to prescribe following bariatric surgery are lacking. We sought to determine our current opioid-prescribing practices, patient utilization, and satisfaction with pain control following elective bariatric surgery. METHODS A retrospective chart review and phone survey were conducted on patients who underwent laparoscopic or robotic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from April 2018 to March 2019 at a single academic medical center. Opioid medications were converted to morphine milligram equivalents provided (MMEs). RESULTS In total, 192 patients met inclusion criteria. The median amount of opioid medication prescribed on discharge was 300 oral MMEs, although there was a significant difference between the MMEs prescribed to patients with and without chronic opioid therapy (median 300 MMEs opioid naïve vs. 375 MMEs chronic opioid therapy, p = 0.01). Significantly fewer SG patients required a refill of their opioid medication compared to RYGB (8.3% vs. 23.9%, p = 0.003). Of the 192 patients, 87 (45.3%) completed the phone survey. Fifty-six patients (64%) reported that they took half or less of the initially prescribed opioids. Of the patients with leftover medication, 36% reported that they did not dispose of the medication. Overall understanding of pain control options after surgery was significantly lower in patients who felt they were prescribed "too little" opioids (p = 0.01), patients requiring refills (p = 0.02), and patients who were not satisfied with their pain control (p = 0.02). CONCLUSION There is a gap between the amount of opioid medication prescribed and taken by patients following bariatric surgery in our practice. Patients who were least satisfied with their pain control reported knowledge gaps about pain control options that were more significant than patients who were more satisfied. Future initiatives should focus on the reduction of opioids prescribed to bariatric surgery patients post-operatively and on opioid education for patients.
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Li D, Wang Q, Zhao X, Luo Y, Kang P. Comparison of Intravenous and Topical Dexamethasone for Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Study of Effects on Dexamethasone Administration Route and Enhanced Recovery. J Arthroplasty 2021; 36:1599-1606. [PMID: 33293172 DOI: 10.1016/j.arth.2020.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/26/2020] [Accepted: 11/10/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The optimal route for dexamethasone (DEX) administration regimen for patients undergoing primary TKA has not been investigated. This study aims to determine whether intravenous and topical DEX provide different clinical effects in patients with TKA. METHODS In this double-blinded, placebo-controlled trial, 90 patients undergoing primary TKA were randomized to intravenous DEX group (n = 45) or topical DEX group (n = 45, DEX applied in anesthetic cocktail for periarticular injection). The primary outcome was postoperative VAS pain score and morphine consumption. Secondary outcomes were included knee swelling, knee flexion, and extension angle, Knee Society Score (KSS), and postoperative hospital stays. Tertiary outcomes assessed the blood-related metrics, including inflammatory biomarkers and fibrinolysis parameters. Finally, nausea and vomiting and other adverse events were compared. RESULTS The topical administration of DEX provide lower pain score at 2h, 8h, 12h at rest (P < .05) and 12h, 24h with activity (P < .05), and less knee swelling in the first postoperative day (P < .05), while intravenous DEX was more effective in decreasing blood inflammatory biomarkers, including C-reactive protein (CRP) at postoperative 24h (P < .05) and interleukin-6 (IL-6) at postoperative 24h, 48h (P < .05), and reducing postoperative nausea (P < .05) for patients receiving TKA. However, there was no significant difference in knee flexion and extension angle, KSS, postoperative hospital stays, and complications occurrence (P > .05) between intravenous and topical DEX after TKA. CONCLUSION Topical administration of DEX provided better clinical outcomes on postoperative pain management and knee swelling early after TKA, while intravenous DEX was more effective in decreasing blood inflammatory biomarkers and preventing postoperative nausea.
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Affiliation(s)
- Donghai Li
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qiuru Wang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xin Zhao
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yue Luo
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Shing EZ, Leas D, Michalek C, Wally MK, Hamid N. Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery. BMC Musculoskelet Disord 2021; 22:104. [PMID: 33485328 PMCID: PMC7824925 DOI: 10.1186/s12891-021-03972-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics. METHODS We developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status. DISCUSSION We describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis. TRIAL REGISTRATION The protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783 ) on November 25, 2019, retrospectively registered.
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Affiliation(s)
- Elaine Z Shing
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, P.O. Box 32861, Charlotte, NC, 28232, USA.
| | - Daniel Leas
- Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA
| | | | - Meghan K Wally
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, P.O. Box 32861, Charlotte, NC, 28232, USA
| | - Nady Hamid
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA
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Crawford DA, Adams JB, Berend KR, Lombardi AV. Low complication rates in outpatient total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:1458-1464. [PMID: 31104079 DOI: 10.1007/s00167-019-05538-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/07/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE The primary purpose of this study is to report the incidence of complications associated with outpatient total knee arthroplasty (TKA). Secondarily, 2-year minimum outcomes are reported. METHODS Between 2013 and 2016, 928 patients underwent 1143 outpatient TKAs with the Vanguard Complete Knee System (Zimmer Biomet, Warsaw, IN). Patients were selected for outpatient surgery if they were medically optimized without a failing organ system and had sufficient support at home. Overnight stays, medical complications and early perioperative complications were assessed in this entire cohort. Two-year minimum follow-up was available on 793 patients (978 knees). Patient records were analyzed for outcome measures and revisions. RESULTS In 124 procedures, the patient stayed overnight for 23-h observation. Thirty-seven (3.2%) were for convenience reasons and 87 (7.6%) for medical observation. Heart disease and chronic obstructive pulmonary disease were associated with increased risk of overnight stay. Excluding manipulations, reoperation within 90 days occurred in eight (0.7%) knees. Patients with 2-year minimum follow-up had significant improvements in ROM, Knee Society Clinical, Functional and Pain scores (p < 0.005). Nine (0.8%) patients required revision. Manipulations were performed on 118 (10.3%) patients. The overall deep infection rate was 0.17% (2/1143). CONCLUSIONS Outpatient TKA is safe for a large proportion of patients. Certain medical co-morbidities increase the risk of overnight stay. Patients had significant improvement in ROM and outcome scores with low revision rate. LEVEL OF EVIDENCE III.
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Affiliation(s)
- David A Crawford
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA.
| | - Joanne B Adams
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA
| | - Keith R Berend
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA.,Mount Carmel Health System, 7333 Smith's Mill Road, New Albany, OH, 43054, USA
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., 7277 Smith's Mill Road, Suite 200, New Albany, OH, 43054, USA.,Mount Carmel Health System, 7333 Smith's Mill Road, New Albany, OH, 43054, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, 376W 10th Ave, Suite 725, Columbus, OH, 43210, USA
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Sheth U, Mehta M, Huyke F, Terry MA, Tjong VK. Opioid Use After Common Sports Medicine Procedures: A Systematic Review. Sports Health 2020; 12:225-233. [PMID: 32271136 PMCID: PMC7222661 DOI: 10.1177/1941738120913293] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
CONTEXT The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. OBJECTIVE To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. DATA SOURCES A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. STUDY SELECTION Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. RESULTS A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. CONCLUSION Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.
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Affiliation(s)
- Ujash Sheth
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Mitesh Mehta
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Fernando Huyke
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Michael A. Terry
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Vehniah K. Tjong
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
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The Effect of Dexamethasone on Postoperative Blood Glucose in Patients With Type 2 Diabetes Mellitus Undergoing Total Joint Arthroplasty. J Arthroplasty 2020; 35:671-674. [PMID: 31761675 DOI: 10.1016/j.arth.2019.10.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Perioperative glucocorticoids are routinely administered to patients undergoing total joint arthroplasty (TJA) to decrease postoperative pain and nausea. However, there is concern regarding the effects of glucocorticoids on perioperative glucose control in diabetes. The goal of this study is to determine if administration of preoperative dexamethasone to diabetic patients is significantly associated with hyperglycemia and increased insulin requirements in the immediate postoperative period after TJA and to identify risk factors for postoperative hyperglycemia immediately after TJA. METHODS A retrospective review of type 2 diabetic patients undergoing TJA from 2010 to 2015 (n = 285) was undertaken to evaluate the effect of dexamethasone on postoperative glucose control. Preoperative baseline characteristics were compared between patients who did and did not receive 8 mg of intravenous dexamethasone preoperatively. Postoperative glucose and insulin requirements were evaluated with respect to dexamethasone dosing. Statistical analysis was performed using logistic regression models. RESULTS Dexamethasone administration did not correlate with the maximum postoperative blood glucose (P = .78). There was a significantly higher initial postoperative blood glucose after intravenous dexamethasone administration (P < .01). Dexamethasone administration was associated with increased aspart insulin requirements on postoperative day 0 (P = .04). However, preoperative hemoglobin A1c was most strongly associated with postoperative glucose control. CONCLUSION Preoperative dexamethasone administration to diabetic patients was associated with an initial increase in blood glucose and increased insulin requirement on postoperative day 0. Yet the observed effect on glucose control in diabetic patients may not outweigh the known clinical benefits of perioperative glucocorticoids.
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Anastasio AT, Farley KX, Boden SD, Bradbury TL, Premkumar A, Gottschalk MB. Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use. J Arthroplasty 2020; 35:82-88. [PMID: 31500913 PMCID: PMC7194191 DOI: 10.1016/j.arth.2019.07.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Albert T. Anastasio
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kevin X. Farley
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Scott D. Boden
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Thomas L. Bradbury
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael B. Gottschalk
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA,Reprint requests: Michael B. Gottschalk, MD, Department of Orthopaedic Surgery, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30307
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