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Baker CM, Goh GS, Tarabichi S, Sherman MB, Khan IA, Parvizi J. Hyponatremia Is an Overlooked Sign of Trouble Following Total Joint Arthroplasty. J Bone Joint Surg Am 2023; 105:744-754. [PMID: 37000860 DOI: 10.2106/jbjs.22.00928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Hyponatremia is a common electrolyte abnormality in arthroplasty patients. This issue, underrecognized by surgeons, can impact the postoperative course of patients. There are, however, little data on the implications of sodium disturbances following total joint arthroplasty (TJA). The primary aims of this study were to (1) report the rate of hyponatremia following TJA, and (2) examine the impact of hyponatremia on the perioperative course of TJA patients. METHODS This was a retrospective analysis of 3,071 primary and revision TJAs performed between 2015 and 2017. Based on preoperative and postoperative sodium values (pre-post), patients were classified into 4 groups: normonatremic-normonatremic (Group 1), normonatremic-hyponatremic (Group 2), hyponatremic-normonatremic (Group 3), and hyponatremic-hyponatremic (Group 4). Primary end points were length of stay (LOS), postoperative discharge, in-hospital complications, and 90-day readmissions. RESULTS The distribution of cases was 84.6% Group 1, 9.4% Group 2, 2.1% Group 3, and 3.8% Group 4. Overall, 13.2% of patients had hyponatremia after TJA. Older age, hip arthroplasty, general anesthesia, higher Charlson Comorbidity Index, congestive heart failure, revision surgery, and history of stroke, liver disease, and chronic kidney disease were risk factors for postoperative hyponatremia. Patients with postoperative hyponatremia (Groups 2 and 4) had greater likelihoods of having a 90-day complication and non-home discharge and greater LOS. CONCLUSIONS Postoperative hyponatremia was a relatively common occurrence in patients undergoing TJA, and was associated with greater LOS, complications, and non-home discharge. Surgeons should identify patients at risk for developing sodium abnormalities in order to optimize these patients and avoid increased resource utilization. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Kinoshita Y, Tamai K, Oka M, Habibi H, Terai H, Hoshino M, Toyoda H, Suzuki A, Takahashi S, Nakamura H. Prevalence, risk factors, and potential symptoms of hyponatremia after spinal surgery in elderly patients. Sci Rep 2022; 12:18622. [PMID: 36329205 PMCID: PMC9633822 DOI: 10.1038/s41598-022-23583-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/02/2022] [Indexed: 11/06/2022] Open
Abstract
Old age and spinal surgery significantly increase the risk of postoperative hyponatremia. However, detailed analyses of postoperative hyponatremia after spinal surgery in elderly patients are lacking. Therefore, we retrospectively reviewed the records of 582 consecutive patients aged > 60 years who underwent spinal surgery to evaluate the frequency, risk factors, and symptoms of postoperative hyponatremia after spinal surgery in the elderly population. Postoperative hyponatremia was defined as a postoperative blood sodium level < 135 meq/L at postoperative day (POD)1, POD3, and/or after POD6. A total of 92 (15.8%) patients showed postoperative hyponatremia. On a multivariate analysis, a diagnosis of a spinal tumor/infection, decompression and fusion surgery, and lower preoperative sodium levels were significant independent factors of postoperative hyponatremia (p = 0.014, 0.009, and < 0.001, respectively). In total, 47/92 (51%) cases could have been symptomatic; vomiting was noted in 34 cases (37%), nausea in 19 cases (21%), headache in 14 cases (15%), and disturbances in consciousness, including delirium, in ten cases (21%); all incidences of these symptoms were significantly higher in elderly patients with postoperative hyponatremia than in the matched control group without postoperative hyponatremia (p < 0.05, respectively). Additionally, the length of stay was 2 days longer in patients than in the matched controls (p = 0.002).
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Affiliation(s)
- Yuki Kinoshita
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Koji Tamai
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Makoto Oka
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Hasibullah Habibi
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Hidetomi Terai
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Masatoshi Hoshino
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Hiromitsu Toyoda
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Akinobu Suzuki
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Shinji Takahashi
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
| | - Hiroaki Nakamura
- grid.258799.80000 0004 0372 2033Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, 1-5-7, Asahimachi, Abenoku, Osaka, Osaka 545-8585 Japan
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Kunze KN, Sculco PK, Zhong H, Memtsoudis SG, Ast MP, Sculco TP, Jules-Elysee KM. Development and Internal Validation of Machine Learning Algorithms for Predicting Hyponatremia After TJA. J Bone Joint Surg Am 2022; 104:265-270. [PMID: 34898530 DOI: 10.2106/jbjs.21.00718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The development of hyponatremia after total joint arthroplasty (TJA) may lead to several adverse events and is associated with prolonged inpatient length of stay as well as increased hospital costs. The purpose of this study was to develop and internally validate machine learning algorithms for predicting hyponatremia after TJA. METHODS A consecutive cohort of 30,703 TJA patients from an institutional registry at a large, tertiary academic hospital were included. A total of 19 potential predictor variables were collected. Hyponatremia was defined as a serum sodium concentration of <135 mEq/L. Five machine learning algorithms were developed using a training set and internally validated using an independent testing set. Algorithm performance was evaluated through discrimination, calibration, decision-curve analysis, and Brier score. RESULTS The charts of 30,703 patients undergoing TJA were reviewed. Of those patients, 5,480 (17.8%) developed hyponatremia postoperatively. A combination of 6 variables were demonstrated to optimize algorithm prediction: preoperative serum sodium concentration, age, intraoperative blood loss, procedure time, body mass index (BMI), and American Society of Anesthesiologists (ASA) score. Threshold values that were associated with greater hyponatremia risk were a preoperative serum sodium concentration of ≤138 mEq/L, an age of ≥73 years, an ASA score of >2, intraoperative blood loss of >407 mL, a BMI of ≤26 kg/m2, and a procedure time of >111 minutes. The stochastic gradient boosting (SGB) algorithm demonstrated the best performance (c-statistic: 0.75, calibration intercept: -0.02, calibration slope: 1.02, and Brier score: 0.12). This algorithm was turned into a tool that can provide real-time predictions (https://orthoapps.shinyapps.io/Hyponatremia_TJA/). CONCLUSIONS The SGB algorithm demonstrated the best performance for predicting hyponatremia after TJA. The most important factors for predicting hyponatremia were preoperative serum sodium concentration, age, intraoperative blood loss, procedure time, BMI, and ASA score. A real-time hyponatremia risk calculator was developed, but it is imperative to perform external validation of this model prior to using this calculator in clinical practice. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Haoyan Zhong
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY.,Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY.,Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY.,Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Michael P Ast
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Thomas P Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kethy M Jules-Elysee
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY.,Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY
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Hennrikus E, Ou G, Kinney B, Lehman E, Grunfeld R, Wieler J, Damluji A, Davis C, Mets B. Prevalence, Timing, Causes, and Outcomes of Hyponatremia in Hospitalized Orthopaedic Surgery Patients. J Bone Joint Surg Am 2015; 97:1824-32. [PMID: 26582612 DOI: 10.2106/jbjs.o.00103] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hyponatremia is common among orthopaedic patients and is associated with adverse clinical outcomes. We examined the prevalence, timing, causes, and outcomes of hyponatremia in adult hospitalized orthopaedic surgery patients. METHODS We evaluated the medical records of 1067 consecutive orthopaedic surgery patients admitted to a tertiary academic institution. The medical records were reviewed to investigate hyponatremia (serum sodium <135 mEq/L) that (1) had been present on hospital admission or (2) had developed postoperatively. The primary outcomes were the prevalence and timing of, and risk factors for, presentation with or development of hyponatremia. Secondary outcomes were hospital length of stay, total hospital cost, and discharge disposition. Multivariable logistic regression models were used to assess the variables associated with hyponatremia and the effects of hyponatremia on clinical outcomes. RESULTS Of the 1067 patients, seventy-one (7%) had preoperative hyponatremia and 319 (30%) developed hyponatremia postoperatively. Of the latter, 298 (93%) developed hyponatremia within forty-eight hours postoperatively. Compared with patients with normonatremia, those who presented with hyponatremia, on the average, were older (67.2 versus 60.5 years, p < 0.001), had longer hospital stays (4.6 versus 3.3 days, p < 0.001), incurred higher hospital costs ($19,200 versus $17,000, p = 0.006), and were more likely to be discharged to an extended-care facility (odds ratio [OR] = 2.87, p < 0.001). Developing hyponatremia postoperatively resulted, on average, in a longer hospital stay (3.7 versus 3.3 days, p = 0.002) and greater hospital cost ($18,800 versus $17,000, p < 0.001). Age (OR = 1.13 per decade, p = 0.012), spine surgery (OR = 2.76 versus knee, p < 0.001), hip surgery (OR = 1.76 versus knee, p < 0.001), and the amount of lactated Ringer solution used (OR = 1.16, p = 0.002) increased the risk of developing hyponatremia. CONCLUSIONS Hyponatremia in orthopaedic patients is associated with longer, costlier hospitalizations. The factors that significantly increased the risk of developing postoperative hyponatremia were an older age, spine fusion, hip arthroplasty, and the amount of lactated Ringer solution used.
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Affiliation(s)
- Eileen Hennrikus
- Departments of Internal Medicine (E.H.), Orthopedics and Rehabilitation (C.D.), and Anesthesiology (B.M.), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive, MC H034, Hershey, PA 17033. E-mail address for E. Hennrikus:
| | - George Ou
- Department of Internal Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Bradley Kinney
- Senior Medical Officer, Special Boat Team 22, Stennis Space Center, MS 39520
| | - Erik Lehman
- Department of Public Health Sciences, Penn State Hershey College of Medicine, 90 Hope Drive, Hershey, PA 17033
| | - Robert Grunfeld
- Department of Orthopedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY 14642
| | - Jane Wieler
- Rocky Vista University College of Osteopathic Medicine, 8401 South Chambers Road, Parker, CO 80134
| | - Abdulla Damluji
- Cardiovascular Division Internal Medicine, University of Miami Miller School of Medicine, 1600 NW 10th Avenue, Miami, FL 33136
| | - Charles Davis
- Departments of Internal Medicine (E.H.), Orthopedics and Rehabilitation (C.D.), and Anesthesiology (B.M.), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive, MC H034, Hershey, PA 17033. E-mail address for E. Hennrikus:
| | - Berend Mets
- Departments of Internal Medicine (E.H.), Orthopedics and Rehabilitation (C.D.), and Anesthesiology (B.M.), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive, MC H034, Hershey, PA 17033. E-mail address for E. Hennrikus:
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Barber J, McKeever TM, McDowell SE, Clayton JA, Ferner RE, Gordon RD, Stowasser M, O'Shaughnessy KM, Hall IP, Glover M. A systematic review and meta-analysis of thiazide-induced hyponatraemia: time to reconsider electrolyte monitoring regimens after thiazide initiation? Br J Clin Pharmacol 2015; 79:566-77. [PMID: 25139696 PMCID: PMC4386942 DOI: 10.1111/bcp.12499] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/13/2014] [Indexed: 12/13/2022] Open
Abstract
AIMS Hyponatraemia is one of the major adverse effects of thiazide and thiazide-like diuretics and the leading cause of drug-induced hyponatraemia requiring hospital admission. We sought to review and analyze all published cases of this important condition. METHODS Ovid Medline, Embase, Web of Science and PubMed electronic databases were searched to identify all relevant articles published before October 2013. A proportions meta-analysis was undertaken. RESULTS One hundred and two articles were identified of which 49 were single patient case reports. Meta-analysis showed that mean age was 75 (95% CI 73, 77) years, 79% were women (95% CI 74, 82) and mean body mass index was 25 (95% CI 20, 30) kg m(-2) . Presentation with thiazide-induced hyponatraemia occurred a mean of 19 (95% CI 8, 30) days after starting treatment, with mean trough serum sodium concentration of 116 (95% CI 113, 120) mm and serum potassium of 3.3 (95% CI 3.0, 3.5) mm. Mean urinary sodium concentration was 64 mm (95% CI 47, 81). The most frequently reported drugs were hydrochlorothiazide, indapamide and bendroflumethiazide. CONCLUSIONS Patients with thiazide-induced hyponatraemia were characterized by advanced age, female gender, inappropriate saliuresis and mild hypokalaemia. Low BMI was not found to be a significant risk factor, despite previous suggestions. The time from thiazide initiation to presentation with hyponatraemia suggests that the recommended practice of performing a single investigation of serum biochemistry 7-14 days after thiazide initiation may be insufficient or suboptimal. Further larger and more systematic studies of thiazide-induced hyponatraemia are required.
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Affiliation(s)
- Jennifer Barber
- Division of Therapeutics and Molecular Medicine, University of NottinghamNottingham, NG7 2UH, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, University of NottinghamNottingham, NG5 1PB, UK
| | - Sarah E McDowell
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirmingham, B18 7QH, UK
| | - Jennifer A Clayton
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS TrustNottingham, NG7 2UH, UK
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirmingham, B18 7QH, UK
| | - Richard D Gordon
- Endocrine Hypertension Research Centre, University of Queensland School of MedicineBrisbane, Australia
| | - Michael Stowasser
- Endocrine Hypertension Research Centre, University of Queensland School of MedicineBrisbane, Australia
| | - Kevin M O'Shaughnessy
- Clinical Pharmacology Unit, Department of Medicine, University of CambridgeCambridge, CB2 2QQ, UK
| | - Ian P Hall
- Division of Therapeutics and Molecular Medicine, University of NottinghamNottingham, NG7 2UH, UK
| | - Mark Glover
- Division of Therapeutics and Molecular Medicine, University of NottinghamNottingham, NG7 2UH, UK
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Jung ES, Kang WC, Jang YR, Kim S, Yang JW, Lee K, Ahn T. Acute severe symptomatic hyponatremia following coronary angiography. Korean Circ J 2011; 41:552-4. [PMID: 22022333 PMCID: PMC3193049 DOI: 10.4070/kcj.2011.41.9.552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 12/22/2010] [Accepted: 12/27/2010] [Indexed: 11/26/2022] Open
Abstract
Hyponatremia is a relatively common electrolyte disorder. Although severe acute hyponatremia following coronary angiography is rare, potentially lethal neurologic manifestations may result. We describe a patient with severe, symptomatic hyponatremia, an unusual complication of coronary angiography. Lack of familiarity with contrast media-related hyponatremia caused a delay in diagnosis and therapy in our case. The diagnosis of acute hyponatremia should be considered in any patient who develops behavioral or neurologic manifestations following coronary angiography. Prompt diagnosis and treatment is essential to avoid permanent neurologic damage or death.
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Affiliation(s)
- Eul Sik Jung
- Department of Cardiology, Gil Hospital, Gachon University of Medicine and Science, Incheon, Korea
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Gluck GS, Lachiewicz PF. Symptomatic hyponatremia in patients undergoing total hip and knee arthroplasty. A report of three cases. J Bone Joint Surg Am 2008; 90:634-6. [PMID: 18310715 DOI: 10.2106/jbjs.g.01403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- George S Gluck
- Department of Orthopaedics, University of North Carolina at Chapel Hill, 3151 Bioinformatics Building, CB 7055, Chapel Hill, NC 27599-7055, USA
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Abstract
We performed a retrospective review of hyponatraemia in patients with hip fractures, before and after surgery. All patients admitted with fractures of the neck of femur who had a surgical intervention to deal with the fracture were included. Results were determined using two definitions for hyponatraemia. The incidence of pre-operative and post-operative hyponatraemia were both 2.8% if hyponatraemia was defined as [Na] < 130 mmol/l. No cases of hyponatraemia were found pre-operatively when hyponatraemia was defined as [Na] < 125 mmol/l. Using this definition the post operative incidence of hyponatraemia was 0.93%. The incidence of hyponatraemia in this group of patients is small. However the potentially severe affects of hyponatraemia warrant close monitoring of these patients and the establishment of methods to prevent this problem from occurring.
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Affiliation(s)
- E McPherson
- Department of Orthopaedics, Hairmyres Hospital, Eaglesham Road, East Kilbride
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