Obstructive Sleep Apnea: A Risk Factor for Surgical Site Infection following Colectomy

The Use of Continuous Positive Airway Ventilation for Patients With Obstructive Sleep Apnea is Associated With Early Medical and Surgery-related Complications Following Total Hip Arthroplasty: A National Database Study

Background

The objective of this study was to determine the effect size of the use of continuous positive airway pressure (CPAP), as a surrogate in cases of active and more severe diseases, on early medical and surgery-related complications following total hip arthroplasty (THA) within an obstructive sleep apnea (OSA) patient population.

Methods

Patients with OSA who underwent primary THA between 2010 and 2019 were identified using a large national insurance database. Ninety-day incidence of various medical and surgery-related complications and hospital utilization were evaluated for OSA patients who had used CPAP prior to THA and those who did not. Propensity score matching was used to control for patient demographic factors and comorbidities as covariates.

Results

Propensity score matching resulted in 7351 OSA patients who had used CPAP within 6 months of primary THA and 7351 OSA patients who had not. Patients who had used CPAP were at increased 90-day risk of medical complications, as well as 1-year risk of periprosthetic fracture (OR 1.5429; P = .0356), osteolysis (OR 2.4488; P = .0237), aseptic loosening (OR 2.4057; P < .001), and dislocation (OR 1.283; P = .016).

Conclusions

Our findings suggest that OSA patients on CPAP are at increased risk of several 90-day medical complications, 1-year surgical complications, and health-care utilization compared to OSA patients not recently using CPAP.

Level of Evidence

III, Retrospective review.

The association between obstructive sleep apnoea and wound healing: a systematic review

Purpose

Obstructive sleep apnoea (OSA) is a common, significantly underdiagnosed sleep-related breathing disorder, characterised by upper airway collapse and resultant intermittent hypoxia. Oxygen plays an important role in collagen synthesis and as a result in wound healing. An association between OSA and wound healing has not been clearly delineated. A systematic review was performed to understand this association.

Methods

Randomised controlled trials, cohort, cross-sectional and case–control studies evaluating the relationship between OSA or OSA-related symptoms and wound healing in adult populations were searched in the systematic review using electronic databases PubMed, EMBASE and Ovid MEDLINE.

Main results

A total of 11 cohort studies and 1 case–control study with a total of 58,198,463 subjects were included. Most studies suggest that patients diagnosed with OSA or who are at high risk of having OSA are more likely to suffer from wound complications. Patients with OSA have been found to be at higher risk for post-operative wound infection and wound dehiscence. Contradictory results were obtained on time to heal, with one study concluding that individuals with OSA were more likely to heal earlier when compared to patients without OSA. Quality of evidence, however, was deemed very low due to high risk of bias.

Conclusions

This systematic review did identify an association between OSA and wound healing. However, due to the very low-quality evidence, further research is warranted to better characterise this association and investigate whether or not treating OSA can indeed affect wound healing.

Cardiac Surgery Outcomes: A Case for Increased Screening and Treatment of Obstructive Sleep Apnea

BACKGROUND

Due to the limited published information on complications that obstructive sleep apnea (OSA) patients experience during and after cardiac surgery, we are investigating OSA as a risk factor for post-operative outcomes.

METHODS

This project utilized the Northern New England Cardiovascular Disease Study Group's data collected between 2011 and 2017 based on the Society of Thoracic Surgeons Adult Cardiac Surgery Database Data Collections form. A retrospective analysis of 1,555 patients with OSA and 10,450 patients without OSA, across 5 medical centers undergoing isolated CABG, isolated valve, combined CABG valve surgery was conducted. We used 1:1 nearest neighbor propensity score matching with no replacement to balance characteristics among patients with and without OSA.

RESULTS

There was a statistically significant increased risk of post-operative pneumonia, increased length of total and post-operative stay, and time to initial extubation. Two outcomes trended towards significance: intra- and post-operative IABP use. Outcomes that failed to show statistical significance included: surgical site infection, atrial fibrillation cerebrovascular accident, permanent pacemaker placement, and blood products given. A chart review conducted on a subset of the study cohort revealed that more than 40% of OSA patients did not receive CPAP or BiPAP therapy post-operatively during their hospitalization.

CONCLUSIONS

Our study aligns with the literature in concluding that OSA has deleterious effects on post-operative outcomes of cardiac surgery patients. Further research to better stratify OSA patients by severity are still needed. Additionally, heightened awareness of the need to screen, diagnose, and properly treat patients for OSA is needed.

Association of diagnosed obstructive sleep apnea with kidney transplant outcomes

Obstructive sleep apnea (OSA) is common but underdiagnosed among patients with kidney disease. This study examines whether the diagnosis of OSA in kidney transplant recipients (KTR) affected death, death-censored graft failure (DCGF), and acute rejection (AR). We analyzed the records of KTR who underwent transplant between 2000 and 2015. A total of 4014 kidney transplants were performed during the study period. Of these, 415 (10.3%) had a diagnosis of pretransplant OSA. Pretransplant OSA was associated with a higher risk of death in unadjusted analyses. After adjustment for potential confounders, pretransplant OSA was not associated with risk of death (HR = 1.04, 95% CI: 0.80-1.36). Similarly, pretransplant OSA was associated with a slightly higher incidence of DCGF or AR but neither associations were significant (HR: 1.23, 95% CI: 0.85-1.47 for DCGF; HR 1.10, 95% CI: 0.90-1.36 for AR). A total of 117 (3.3%) were diagnosed with de novo OSA after transplant. Similar to the pretransplant OSA, unadjusted HR for death was significantly higher in the de novo OSA group (HR: 1.48, 95% CI: 1.19-1.84); however, after adjustment, de novo OSA was not significantly associated with risk of death (HR: 1.15, 95% CI: 0.92-1.45). Similarly, DCGF and AR rates were not significantly associated with de novo OSA (HR: 1.10, 95% CI: 0.84-1.44 for DCGF; HR 1.10, 95% CI: 0.90-1.33 for AR). Our work did not detect significant associations between OSA and risk of death, graft failure, and rejection but the estimates might be underestimated due to underdiagnosis of OSA.

Sleep Apnea Increases Ninety-Day Complications and Cost Following Primary Total Joint Arthroplasty

BACKGROUND

Sleep apnea (SA) negatively affects bone mineralization, cognition, and immunity. There is paucity in the literature regarding the impact of SA on total joint arthroplasty (TJA). The purpose of this study is to compare complications in patients with and without SA undergoing either total knee (TKA) or total hip arthroplasty (THA).

METHODS

A retrospective review from 2005 to 2014 was conducted using the Medicare Standard Analytical Files. Patients with and without SA on the day of the primary TJA were queried using the International Classification of Diseases, ninth revision codes. Patients were matched by age, gender, Charlson Comorbidity Index), and body mass index. Patients were followed for 2 years after their surgery. Ninety-day medical complications, complications related to implant, readmission rates, length of stay, and 1-year mortality were quantified and compared. Logistic regression was used to calculate odds ratios (OR) with their respective 95% confidence interval and P values.

RESULTS

After the random matching process there were 529,240 patients (female = 271,656, male = 252,106, unknown = 5478) with (TKA = 189,968, THA = 74,652) and without (TKA = 189,968, THA = 74,652) SA who underwent primary TJA between 2005 and 2014. Patients with SA had greater odds of developing medical complications following TKA (OR 3.71) or THA (OR 2.48).

CONCLUSION

The study illustrates an increased risk of developing postoperative complications in patients with SA following primary TJA. Surgeons should educate patients on these adverse effects and encourage the use of continuous positive airway pressure which has been shown to mitigate many postoperative complications.

Spinal Cord Stimulation Infection Rate and Incremental Annual Expenditures: Results From a United States Payer Database

OBJECTIVES

Surgical site infections (SSIs) result in significant negative clinical and economic outcomes. The objective of this study is to estimate annual health expenditures associated with spinal cord stimulation (SCS)-related infections.

MATERIALS AND METHODS

Data from the Truven MarketScan® databases were used to identify patients with an SCS implant (2009-2014) and a continuous health plan enrollment for at least 12-months before and after implant (index date). Annual expenditures were estimated for patients with a device-related infection vs. those without infection since index date. A generalized linear model estimated annual expenditures attributable to device-related infection. Multivariable expenditure models were conducted separately for patients in initial and replacement groups, controlling for demographics, comorbidities, and clinical characteristics.

RESULTS

The study included 6615 patients. Multivariable expenditure models revealed that patients with infection have higher annual expenditures than patients without infection. Estimated incremental annual healthcare expenditures for patients with an infection were $59,716 (95% CI: $48,965-$69,480) for initial implanted patients and $64,833 (95% CI: $37,377-$86,519) for replacement patients. Only 26% of patients who were explanted for infection underwent a reimplant.

CONCLUSIONS

These results show the substantial expenditure burden associated with an SCS-related infection. Management of SCS-related infection is important from both clinical and economic standpoints. The economic and clinical data presented here reinforce the need for additional research and strategies for healthcare providers to minimize SCS infections. Future economic research is needed to further define the specific economic cost drivers associated with the extensive expenditure burden.

Spinal Cord Stimulation Infection Rate and Risk Factors: Results From a United States Payer Database

Objective

Surgical site infections can cause negative clinical and economic outcomes. A recent international survey on Spinal Cord Stimulation (SCS) infection control practices demonstrated low compliance with evidence‐based guidelines. This study defines infection rate for SCS implants and identifies infection risk factors.

Materials and Methods

A retrospective analysis of the MarketScan® Databases identified patients with SCS implant (2009–2014) and continuous health plan enrollment for ≥12‐months (12 m) preimplant. For logistic regression analysis, patients were enrolled for 12 m postimplant. Kaplan–Meier and Cox Proportional Hazard survival analyses assessed time to infection, with infection rate reported at 12 m postimplant. Logistic regression characterized risk factors based on demographics, comorbidities, and clinical characteristics.

Results

In the logistic regression (n = 6615), 12 m device‐related infection rate was 3.11%. Infection risk factors included peripheral vascular disease (OR, 1.784; 95% CI: 1.011–3.149; p = 0.0457) and infection in 12 m before implant (OR, 1.518; 95% CI: 1.022–2.254; p = 0.0386). The odds of patients experiencing an infection decreased by 3.2% with each additional year of age (OR, 0.968; 95% CI: 0.952–0.984; p < 0.0001). Survival analysis (n = 13,214) identified prior infection (HR, 1.770; 95% CI: 1.342–2.336; p < 0.0001) as a risk factor. Infection was less likely in older patients (HR, 0.974; 95% CI: 0.962–0.986; p < 0.0001). Expected risk factors including obesity, diabetes, and smoking were not identified as risk factors in this analysis. There was no significant difference between infection rate for initial and replacement implants.

Conclusions

The 3.11% SCS‐related infection rate within 12 m of implant emphasizes the need for improved infection control practices. Research is needed to limit SCS infections in younger patients and those with infection history.

Obstructive Sleep Apnea Increases the Perioperative Risk of Cardiac Valve Replacement Surgery: A Prospective Single-Center Study

STUDY OBJECTIVES

Sleep apnea is common in patients referred for cardiac valve replacement (CVR). We aimed to determine the association of obstructive sleep apnea (OSA) and central sleep apnea (CSA) with perioperative events in CVR surgery in patients with rheumatic valvular heart disease (RVHD).

METHODS

Between April 2010 and April 2014, 290 patients with RVHD undergoing CVR were screened for sleep apnea 1 to 7 days before CVR. Baseline medications, cardiac function, sleep parameters, perioperative events, and related risk factors were evaluated.

RESULTS

OSA patients had longer duration of intensive care unit (ICU) stay and mechanical ventilation compared with no sleep-disordered breathing and CSA patients. Patients with CSA had a higher rate of pacemaker use and higher first dose of dobutamine in ICU. NYHA Class and the presence of OSA were independently associated with overall worsening of postoperative recovery (ICU stay ≥ 25 h). Age, NYHA class, and the presence of OSA were independently associated with postoperative respiratory insufficiency (mechanical ventilation ≥ 20 h). Preoperative atrial fibrillation, pulmonary hypertension, and OSA were independently associated with postoperative pacemaker use.

CONCLUSIONS

RVHD patients with OSA have an increased incidence of perioperative adverse events. OSA was independently associated with overall postoperative recovery, respiratory insufficiency, and higher rate of postoperative pacemaker use, while CSA was not associated with postoperative events.