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Sayegh MJ, Garbarino LJ, Gold PA, Anis HK, Chen Z, Sodhi N, Danoff JR, Mont MA. Does Time Spent in the Post-Anesthesia Care Unit Affect Hospital Lengths of Stay following Primary Total Knee Arthroplasty? J Knee Surg 2024; 37:43-48. [PMID: 36588281 DOI: 10.1055/s-0042-1759791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Given the current healthcare economic environment, substantial efforts have been made to help streamline the in-hospital care for total knee arthroplasty (TKA) patients. While potential cost-reducing factors have been identified in the literature, analyses specifically considering post-anesthesia care unit (PACU) lengths of stay (LOS) are lacking. Therefore, the purpose of this study was to identify factors associated with (1) longer PACU LOS as well as (2) longer Hospital LOS. Prospectively collected TKA data from seven participating hospitals within a large health system were evaluated for patient demographics, body mass indices, Charlson Comorbidity Indices (CCI), surgeon volumes/training, admission types, anesthesia types, PACU LOS, and overall hospital LOS. Complete data was available for 1,690 patients (1,082 females, mean age: 67 years). Univariate and multivariate analytical models were constructed to identify which factors were predictive of longer PACU and overall hospital LOS. Same-day admissions, higher volume surgeons (≥ 100 cases per year), fellowship-trained arthroplasty surgeons, and longer operative times were associated with longer PACU LOS (p < 0.05). Multivariate analyses found age more than or equal to 65 years (β= 0.124) and CCI more than or equal to 3 (β= 0.088) to be associated with longer hospital LOS (p < 0.001). Operative times, PACU LOS, and procedure times (operative time plus PACU LOS) were not associated with longer hospital LOS (p > 0.05). These data identify associative factors for PACU LOS, as well as the influence of time spent in the PACU on overall hospital LOS. Interestingly, this analysis revealed that patients of arthroplasty fellowship-trained and higher-volume surgeons had longer PACU LOS; however, this could be explained by the observation that these particular surgeons tend to perform more complex deformity cases. Also of importance, increased PACU LOS, meaning the patient spent more time in a high-monitored setting immediately after surgery, did not necessarily confer a longer overall hospital LOS. Based on these data, it may be more beneficial to identify alternate sources than time spent in the operating room or PACU to potentially help reduce overall hospital LOS. LEVEL OF EVIDENCE: II, prospective cohort.
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Affiliation(s)
- Michael J Sayegh
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Luke J Garbarino
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Peter A Gold
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nipun Sodhi
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Jonathan R Danoff
- Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
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Jensen CB, Gromov K, Foss NB, Kehlet H, Pleckaitiene L, Varnum C, Troelsen A. Spinal anaesthesia versus general anaesthesia (SAGA) on recovery after hip and knee arthroplasty: A study protocol for three randomized, single-blinded, multi-centre, clinical trials. Acta Anaesthesiol Scand 2024; 68:137-143. [PMID: 37743099 DOI: 10.1111/aas.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
Mobilisation difficulties, due to muscle weakness, and urinary retention are common reasons for prolonged admission following hip and knee arthroplasty procedures. Whether spinal anaesthesia is detrimental to early mobilisation is controversial. Previous studies have reported differences in post-operative recovery between spinal anaesthesia and general anaesthesia; however, up-to-date comparisons in fast-track setups are needed. Our randomized, single-blinded, multi-centre, clinical trials aim to compare the post-operative recovery after total hip (THA), total knee (TKA), and unicompartmental knee arthroplasties (UKA) respectively when using either spinal anaesthesia (SA) or general anaesthesia (GA) in a fast-track setup. Included patients (74 THA, 74 TKA, and 74 UKA patients) are randomized (1:1) to receive either SA (2 mL 0.5% Bupivacaine) or GA (Induction: Propofol 1.0-2.0 mg/kg iv with Remifentanil 3-5 mcg/kg iv. Infusion: Propofol 3-5 mg/kg/h and Remifentanil 0.5 mcg/kg/min iv). Patients undergo standard primary unilateral hip and knee arthroplasty procedures in an optimized fast-track setup with intraoperative local infiltrative analgesia in TKA and UKA, post-operative multimodal opioid sparing analgesia, immediate mobilisation with full weightbearing, no drains and in-hospital only thromboprophylaxis. Data will be collected on the day of surgery and until patients are discharged. The primary outcome is the ability to be safely mobilised during a 5-m walking test within 6 h of surgery. Secondary outcomes include fulfilment of discharge criteria, post-operative pain, dizziness, and nausea as well as patient reported recovery and opioid related side effects. Data will also be gathered on all hospital contacts within 30-days of surgery. This study will offer insights into advantages and disadvantages of anaesthetic methods used in fast-track arthroplasty surgery.
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Affiliation(s)
- Christian Bredgaard Jensen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lina Pleckaitiene
- Department of Anaesthesiology, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Clinical Orthopaedic Surgery Hvidovre (CORH), Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Vejlgaard M, Maibom SL, Joensen UN, Kehlet H, Bundgaard-Nielsen M, Aasvang EK, Røder A. Haemodynamic and respiratory perioperative outcomes for open versus robot-assisted radical cystectomy: A double-blinded, randomised trial. Acta Anaesthesiol Scand 2023; 67:293-301. [PMID: 36560861 DOI: 10.1111/aas.14187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/16/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The clinical impact of prolonged steep Trendelenburg position and CO2 pneumoperitoneum during robot-assisted radical cystectomy (RC) on intraoperative conditions and immediate postoperative recovery remains to be assessed. The current study investigates intraoperative and immediate postoperative outcomes for open RC (ORC) versus robot-assisted RC with intracorporal urinary diversion (iRARC) in a blinded randomised trial. We hypothesised that ORC would result in a faster haemodynamic and respiratory post-anaesthesia care unit (PACU) recovery compared to iRARC. METHODS This study is a predefined sub-analysis of a single-centre, double-blinded, randomised feasibility study. Fifty bladder cancer patients were randomly assigned to ORC (n = 25) or iRARC (n = 25). Patients, PACU staff, and ward personnel were blinded to the surgical technique. Both randomisation arms followed the same anaesthesiologic procedure, fluid treatment plan, and PACU care. The primary outcome was immediate postoperative recovery using a standardised PACU Discharge Criteria (PACU-DC) score. Secondary outcomes included respiration- and arterial O2 saturation scores as well as perioperative interventions and recordings. RESULTS All patients underwent the allocated treatment. The total PACU-DC score was highest 6 h postoperatively with no difference in the total score between randomisation arms (p = 0.80). Both the ORC and iRARC groups maintained a mean respiration- and arterial O2 saturation score below 1 (out of 3) throughout PACU stay. The iRARC patients had significantly, but clinically acceptable, higher maximum airway pressure and arterial blood pressure, as well as lower minimum pH levels. The ORC group received significantly more opioids after extubation but marginally less analgesics in the PACU, compared to the iRARC group. CONCLUSIONS A prolonged Trendelenburg position and CO2 pneumoperitoneum was well-tolerated during iRARC, and immediate postoperative recovery was similar for ORC and iRARC patients.
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Affiliation(s)
- Maja Vejlgaard
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Sophia L Maibom
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ulla N Joensen
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Morten Bundgaard-Nielsen
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Andreas Røder
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Maibom SL, Joensen UN, Aasvang EK, Rohrsted M, Thind PO, Bagi P, Kistorp T, Poulsen AM, Salling LN, Kehlet H, Brasso K, Røder MA. Robot-assisted laparoscopic radical cystectomy with intracorporeal ileal conduit diversion versus open radical cystectomy with ileal conduit for bladder cancer in an ERAS setup (BORARC): protocol for a single-centre, double-blinded, randomised feasibility study. Pilot Feasibility Stud 2023; 9:7. [PMID: 36639814 PMCID: PMC9838067 DOI: 10.1186/s40814-022-01229-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Radical cystectomy (RC) with urinary diversion is the recommended treatment for selected cases of non-metastatic high-risk non-muscle-invasive and muscle-invasive bladder cancer. It remains unknown whether robot-assisted laparoscopic cystectomy (RARC) offers any advantage in terms of safety compared to open cystectomy (ORC) in an Enhanced Recovery After Surgery (ERAS) setup. Blinded randomised controlled trials (RCTs) between RARC versus ORC have never been conducted in cystectomy patients. We will investigate the feasibility of conducting a double-blinded RCT comparing ORC with RARC with intra-corporal ileal conduit (iRARC) in an ERAS setup. METHODS This is a single-centre, double-blinded, randomised (1:1) clinical feasibility study for patients with non-metastatic high-risk non-muscle-invasive or muscle-invasive bladder cancer scheduled for cystectomy. All participants are recruited from Rigshospitalet, Denmark. The planned sample size is 50 participants to investigate whether blinding of the surgical technique is feasible. Participants and postoperative caring physicians and nurses are blinded using a pre-study designed abdominal dressing and blinding of the patient's electronic health record. Study endpoints are assessed 90 days postoperatively. The primary aim is to study the frequency and pattern of unplanned unblinding after surgery and the number of participants who cannot guess the surgical technique at the day of discharge. Eleven secondary endpoints are assessed: length of stay, days alive and out of hospital, in-hospital complication rate, 30-day complication rate, 90-day complication rate, readmission rate, quality of life, blood loss, pain, rate of moderate/severe post-anaesthesia care unit (PACU) complications, and delirium. Participants are managed in an ERAS setup in both arms of the trial. DISCUSSION We report on the design and objectives of a novel experimental feasibility study investigating whether blinding of the surgical technique in cystectomy patients is possible. This information is essential for the design of future blinded trials comparing ORC to RARC. There is a continued need to compare RARC and ORC in terms of both efficacy, safety, and oncological outcomes. Estimated end of study is March 2021. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03977831. Registered on the 6th of June 2019.
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Affiliation(s)
- Sophia Liff Maibom
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Eske Kvanner Aasvang
- grid.5254.60000 0001 0674 042XDepartment of Anaesthesiology, Centre for Cancer and Organ Diseases, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Malene Rohrsted
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Peter Ole Thind
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Per Bagi
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Kistorp
- grid.5254.60000 0001 0674 042XDepartment of Anaesthesiology, Centre for Cancer and Organ Diseases, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Lisbeth Nerstrøm Salling
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- grid.5254.60000 0001 0674 042XSection of Surgical Pathophysiology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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5
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Bullock WM, Gadsden J. Turning baby steps into big leaps: shifting paradigms in fast-track joint replacement surgery. Anaesthesia 2023; 78:14-16. [PMID: 36308017 DOI: 10.1111/anae.15903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 12/13/2022]
Affiliation(s)
- W M Bullock
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - J Gadsden
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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6
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Nielsen NI, Kehlet H, Gromov K, Troelsen A, Foss NB, Aasvang EK. Bypassing the post‐anaesthesia care unit after elective hip and knee arthroplasty: a prospective cohort safety study. Anaesthesia 2022; 78:36-44. [PMID: 36108163 PMCID: PMC10086992 DOI: 10.1111/anae.15852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 12/22/2022]
Abstract
Following knee and hip arthroplasty, transfer to a recovery area immediately following surgery and before going to ward might be unnecessary in low-risk patients. Avoiding the recovery area in this way could allow for more targeted use of resources for higher risk patients, which may improve operating theatre flow and productivity. A prospective single-centre cohort study on the safety of criteria for bypassing the post-anaesthesia care unit in elective hip and knee arthroplasty was designed. Criteria were: ASA physical status < 3; peri-operative bleeding < 500 ml; low postoperative discharge-score (modified Aldrete-score); and an uncomplicated surgical and neuraxial anaesthesia procedure. The primary outcome was the number of patients in need of secondary readmission to the post-anaesthesia care unit. Events within the first 24 postoperative hours were recorded, along with readmission and complication rates. A total of 696 patients were included, with 287 (41%) undergoing total hip arthroplasty, 274 (39%) undergoing total knee arthroplasty and 135 (19%) undergoing unicompartmental knee-arthroplasty. Of these, 207 (44%) bypassed the post-anaesthesia care unit. Patients all received multimodal analgesia without peripheral nerve blockade. Only one patient in the ward group required secondary readmission to the post-anaesthesia care unit. Within 24 h, 151 events were reported, with 41 (27%) in the ward group and 110 (73%) in the post-anaesthesia care unit group. Two events in each group occurred within 2 hours of surgery. No complications were attributed to bypassing the post-anaesthesia care unit. The use of simple pragmatic criteria for bypassing the post-anaesthesia care unit for patients undergoing knee and hip arthroplasty with spinal anaesthesia is possible and associated with significant reduction of post-anaesthesia care unit admission and without apparent safety issues. Confirmation is needed from other studies and external validity should be interpreted cautiously in centres with different peri-operative regimens, organisational and staffing structures.
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Affiliation(s)
- N. I. Nielsen
- Department of Anaesthesia Copenhagen University, Hvidovre Hospital Hvidovre Denmark
| | - H. Kehlet
- Section of Surgical Pathophysiology Rigshospitalet, University of Copenhagen Denmark
| | - K. Gromov
- Department of Orthopaedic Surgery Copenhagen University, Hvidovre Hospital Hvidovre Denmark
| | - A. Troelsen
- Department of Orthopaedic Surgery Copenhagen University, Hvidovre Hospital Hvidovre Denmark
| | - N. B. Foss
- Department of Anaesthesia Copenhagen University, Hvidovre Hospital Hvidovre Denmark
| | - E. K. Aasvang
- Department of Anaesthesia Rigshospitalet, University of Copenhagen Denmark
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7
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Steinthorsdottir KJ, Awada HN, Schultz NA, Larsen PN, Hillingsø JG, Jans Ø, Kehlet H, Aasvang EK. Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial. BJS Open 2021; 5:6364138. [PMID: 34480563 PMCID: PMC8418207 DOI: 10.1093/bjsopen/zrab063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery. METHODS This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity. RESULTS A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups. CONCLUSION A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017-002652-81 (https://eudract.ema.europa.eu/).
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Affiliation(s)
- K J Steinthorsdottir
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.,Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - H N Awada
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - N A Schultz
- Department of Gastrointestinal Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - P N Larsen
- Department of Gastrointestinal Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - J G Hillingsø
- Department of Gastrointestinal Surgery and Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Ø Jans
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - H Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - E K Aasvang
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
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Jensen CB, Troelsen A, Nielsen CS, Otte NKS, Husted H, Gromov K. Why are patients still in hospital after fast-track, unilateral unicompartmental knee arthroplasty. Acta Orthop 2020; 91:433-438. [PMID: 32285727 PMCID: PMC8023914 DOI: 10.1080/17453674.2020.1751952] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Previous studies have investigated risk factors related to prolonged length of stay following total knee arthroplasty (TKA), but little is known about specific factors resulting in continued hospitalization within the 1st postoperative days after unicompartmental knee arthroplasty (UKA). We investigated what specific factors prevent patients from being discharged on the day of surgery (DOS) and the first postoperative day (POD-1) following primary UKA in a fast-track setting.Patients and methods - We prospectively collected data on 100 consecutive and unselected medial UKA patients operated from December 2017 to May 2019. All patients were operated in a standardized fast-track setup with functional discharge criteria continuously evaluated from DOS and until discharge.Results - Median length of stay for the entire cohort was 1 day. 22% and 78% of all patients were discharged on DOS and POD-1, respectively. Lack of mobilization and pain separately delayed discharge in respectively 78% and 24% of patients on DOS. The main reasons for lack of mobilization were motor blockade (37%) and logistical factors (26%). For patients placed 1st or 2nd on the operating list, we estimate that the same-day discharge rate would increase to 55% and 40% respectively, assuming that pain and mobilization were successfully managed.Interpretation - One-fifth of unselected UKA patients operated in a standardized fast-track setup were discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24-48 hours. Strategies aimed at decreasing length of stay after UKA should strive to improve analgesia and postoperative mobilization.
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Affiliation(s)
- Christian Bredgaard Jensen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; ,Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Denmark,Correspondence:
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; ,Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Denmark
| | - Christian Skovgaard Nielsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; ,Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Denmark
| | - Niels Kristian Stahl Otte
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; ,Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Denmark
| | - Henrik Husted
- Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre; ,Clinical Orthopaedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Denmark
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9
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Förster JG, Pitkänen M. Biased data about the frequency of failed spinal anaesthesia. Acta Anaesthesiol Scand 2018; 62:1481. [PMID: 30058171 DOI: 10.1111/aas.13206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Aasvang EK, Kehlet H. Response to the letter by Dr. Förster and Pitkanen regarding our manuscript "Incidence and related factors for intraoperative failed spinal anaesthesia for lower limb arthroplasty". Acta Anaesthesiol Scand 2018; 62:1482. [PMID: 29963690 DOI: 10.1111/aas.13205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Rigshospitalet Copenhagen Denmark
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11
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Yeung K, Eiberg JP, Kehlet H, Aasvang EK. Acute complications in the post-anaesthesia care unit after infrainguinal surgery for lower limb ischaemia - a prospective observational cohort study. VASA 2018; 48:89-97. [PMID: 30355274 DOI: 10.1024/0301-1526/a000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arterial surgery for lower limb ischaemia is a frequently performed procedure in patients with severe cardio-pulmonary comorbidities, making them high-risk patients for acute postoperative complications with a need for prolonged stay in the post-anaesthesia care unit (PACU). However, detailed information on complications during the PACU stay is limited, hindering mechanism-based interventions for early enhanced recovery. Thus, we aimed to systematically describe acute complications and related risk factors in the immediate postoperative phase after infrainguinal arterial surgery. PATIENTS AND METHODS Patients transferred to the PACU after infrainguinal arterial surgery due to chronic or acute lower limb ischaemia were consecutively included in a six-month observational cohort study. Pre- and intraoperative data included comorbidities as well as surgical and anaesthetic technique. Data on complications and treatments in the PACU were collected every 15 minutes using a standardised assessment tool. The primary endpoint was occurrence of predefined moderate or severe complications occurring during PACU stay. RESULTS In total, 155 patients were included for analysis. Eighty (52 %) patients experienced episodes with oxygen desaturation (< 85 %) and moderate or severe pain occurred in 72 patients (47 %); however, circulatory complications (hypotension, tachycardia) were rare. Preoperative opioid use was a significant risk factor for moderate or severe pain in PACU (59 vs. 38 % chronic vs. opioid naïve patients (P = 0.01). CONCLUSIONS Complications in the PACU after infrainguinal arterial surgery relates to saturation and pain, suggesting that future efforts should focus on anaesthesia and analgesic techniques including opioid sparing regimes to enhance early postoperative recovery.
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Affiliation(s)
- Karin Yeung
- 1 Department of Anaesthesiology and Surgery, Rigshospitalet, University of Copenhagen, Denmark.,2 Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark
| | - Jonas Peter Eiberg
- 2 Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,3 Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen Denmark
| | - Henrik Kehlet
- 4 Section for Surgical Pathophysiology, Rigshospitalet, University of Copgenhagen, Denmark
| | - Eske Kvanner Aasvang
- 1 Department of Anaesthesiology and Surgery, Rigshospitalet, University of Copenhagen, Denmark
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Aasvang EK, Laursen MB, Madsen J, Krøigaard M, Solgaard S, Kjaersgaard-Andersen P, Mandøe H, Hansen TB, Nielsen JU, Krarup N, Skøtt AE, Kehlet H. Incidence and related factors for intraoperative failed spinal anaesthesia for lower limb arthroplasty. Acta Anaesthesiol Scand 2018; 62:993-1000. [PMID: 29578248 DOI: 10.1111/aas.13118] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 02/06/2018] [Accepted: 02/19/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Spinal anaesthesia is the preferred choice for total hip- and knee arthroplasty (THA/TKA), due to the claimed superior outcome profile, relative simple technique and without the need for advanced airway support. However, choosing and informing about spinal anaesthesia should also include the risk for intraoperative failed spinal anaesthesia with associated pain, discomfort and suboptimal settings for airway management. Small-scale studies suggest incidences from 1 to 17%; however, no multi-institutional large data exists on failed spinal incidence and related factors during THA/TKA, hindering evidence-based information and potential anaesthesia stratification. METHODS In a sub-analysis, data from a prospective study on spinal anaesthesia for THA/TKA were examined for incidence of intraoperative conversion to general anaesthesia. Potential perioperative factors (age, gender, American Society of Anaesthesiologist (ASA) score, height, weight, BMI, procedure, bupivacaine dosage and duration of time from spinal administration until end of surgery) were analysed with logistic regression for relation to failed spinal anaesthesia. RESULTS In all, 1451 patients were included for analysis, whereof 57 (3.9%) had failed spinal anaesthesia. Spinal failure patients were significantly younger (61 vs. 67 years, P = 0.003), and operation time longer in the failed spinal group vs no-failure, respectively (133 vs. 89 min, P < 0.001). No significant differences were found with regard to bupivacaine volume, gender, ASA-score, height, weight, BMI or THA vs. TKA. CONCLUSION Failed spinal anaesthesia for THA and TKA is a relatively frequent occurrence and identification of risk patients is not feasible. These results should be considered when choosing anaesthesia and included in the information to patients.
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Affiliation(s)
- E. K. Aasvang
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Section for Surgical Pathophysiology; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - M. B. Laursen
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Aalborg University Hospital; Farsø Denmark
| | - J. Madsen
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Aalborg University Hospital; Farsø Denmark
| | - M. Krøigaard
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Copenhagen University Hospital Gentofte; Hellerup Denmark
| | - S. Solgaard
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Copenhagen University Hospital Gentofte; Hellerup Denmark
| | - P. Kjaersgaard-Andersen
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Vejle Hospital; Vejle Denmark
| | - H. Mandøe
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Vejle Hospital; Vejle Denmark
| | - T. B. Hansen
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Holstebro Regional Hospital; Holstebro Denmark
| | - J. U. Nielsen
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Holstebro Regional Hospital; Holstebro Denmark
| | - N. Krarup
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Viborg Regional Hospital; Viborg Denmark
| | - A. E. Skøtt
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Department of Orthopedic Surgery; Viborg Regional Hospital; Viborg Denmark
| | - H. Kehlet
- The Lundbeck foundation centre for fast-track hip and knee replacement; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Section for Surgical Pathophysiology; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
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To Move, or Not to Move: Accelerating PACU Flow After Spinal Anesthetics. Anesthesiology 2017. [DOI: 10.1097/aln.0000000000001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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