Search

Background: The coronavirus-2019 (COVID-19) pandemic highlighted the unfortunate reality that many hospitals have insufficient intensive care unit (ICU) capacity to meet massive, unanticipated increases in demand. To drastically increase ICU capacity, NewYork-Presbyterian/Weill Cornell Medical Center modified its existing operating rooms and post-anaesthesia care units during the initial expansion phase to accommodate the surge of critically ill patients. Methods: This retrospective chart review examined patient care in non-standard Expansion ICUs as compared to standard ICUs. We compared clinical data between the two settings to determine whether the expeditious development and deployment of critical care resources during an evolving medical crisis could provide appropriate care. Results: Sixty-six patients were admitted to Expansion ICUs from March 1st to April 30th, 2020 and 343 were admitted to standard ICUs. Most patients were male (70%), White (30%), 45–64 years old (35%), non-smokers (73%), had hypertension (58%), and were hospitalized for a median of 40 days. For patients that died, there was no difference in treatment management, but the Expansion cohort had a higher median ICU length of stay (q = 0.037) and ventilatory length (q = 0.015). The cohorts had similar rates of discharge to home, but the Expansion ICU cohort had higher rates of discharge to a rehabilitation facility and overall lower mortality. Conclusions: We found no significantly worse outcomes for the Expansion ICU cohort compared to the standard ICU cohort at our institution during the COVID-19 pandemic, which demonstrates the feasibility of providing safe and effective care for patients in an Expansion ICU. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: There is a concern for higher rates of wound complications and a potentially increased periprosthetic joint infection (PJI) risk after total hip arthroplasty (THA) with the direct anterior approach (DAA) compared to the posterolateral approach (PLA). Our purpose was to compare PJI risk after THA with the DAA or the PLA and to identify risk factors for PJI after primary THA. Methods: Clinical characteristics of patients treated in our institution with primary DAA or PLA THA between 1/2010 and 12/2015 were retrospectively reviewed. The respective deep PJI rates were calculated. A logistic regression model was constructed to determine a potential difference in the PJI risk between the 2 groups, and risk factors for hip PJI in all patients. Results: During the period studied, there were 1,182 DAA THAs and 18,853 PLA THAs. The PJI rate was 0.25% for the DAA group and 0.31% for the PLA group (p = 1.0). The DAA was not associated with a significantly increased risk for PJI compared to the PLA. Compared to younger patients, older patients had lower PJI risk; patient discharge to home was also associated with lower PJI risk compared to other discharge disposition; longer length of stay was associated with higher PJI risk compared to shorter length of stay. Conclusion: The DAA is equally safe compared the PLA with respect to PJI risk. Younger age, discharge to facilities other than home and increased length of stay increase the risk for deep PJI after primary THA. [ABSTRACT FROM AUTHOR]

Background: While increased surgical-provider volume has been associated with improved outcomes, research regarding volume-outcome relationships within high-volume institutions and the role of anaesthesiologists is limited. Further, the effect of anaesthesia-care-team composition remains understudied. This analysis aimed to identify the impact of anaesthesiologist and surgeon volume on adverse events after total joint arthroplasties.Methods: We retrospectively identified 40 437 patients who underwent total joint arthroplasties at a high-volume institution from 2005 to 2014. The main effects of interest were anaesthesiologist and surgeon volume and experience along with anaesthesia-care-team composition. Multivariable logistic regression models were used to evaluate three outcomes: any complication, cardiopulmonary complication, and length of stay (>5 days). Odds ratios (ORs) and 99.75% confidence intervals (CIs) were reported.Results: Across all three models, anaesthesiologist volume and experience, and anaesthesia-care-team composition were not significant predictors. Surgeon annual case volume >50 was associated with significantly reduced odds of any complication (annual case volume: 50-149; OR: 0.80; CI: 0.66-0.98) and prolonged length of stay (OR: 0.69; CI: 0.60-0.80). Surgeon experience >20 yr was associated with significantly reduced odds of prolonged length of stay (OR: 0.85; CI: 0.75-0.95).Conclusions: Anaesthesiologist volume and experience, and anaesthesia-care-team composition did not impact the odds of an adverse outcome, although a higher surgeon volume was associated with decreased odds of complications and prolonged length of stay. Further study is necessary to determine if these findings can be extrapolated to less specialised, lower volume surgical settings. [ABSTRACT FROM AUTHOR]

Purpose: Information regarding the impact of provider characteristics on perioperative outcomes in the spine surgery setting is limited. Existing studies primarily consider the impact of surgical provider volume. This analysis sought to identify the impact of anesthesiologist and surgeon volume and experience as well as anesthesia care team composition on adverse outcomes following anterior cervical discectomy and fusions (ACDF) and posterior lumbar fusions (PLF).Methods: We identified 5900 patients who underwent ACDF or PLF procedures at a high-volume orthopedic institution from 2005 to 2014. Provider characteristics of interest were anesthesiologist and surgeon volume and experience along with anesthesia care team composition. Multivariable logistic regression models were used to evaluate the outcomes of any complication, cardiopulmonary complication, and prolonged length of stay (> 7 days). Intraclass correlation coefficients were calculated to determine how much variation in outcomes could be explained by provider characteristics.Results: There were no significant relationships between provider characteristics and perioperative outcomes among ACDF patients. Within the PLF cohort, surgeon annual case volume > 25 was associated with decreased odds of prolonged length of stay, while anesthesia resident involvement was associated with increased odds of prolonged length of stay. Surgeon characteristics explained the greatest proportion of variation in outcomes while anesthesiologist characteristics explained the least.Conclusions: Anesthesia provider volume and experience did not significantly impact the odds of adverse outcome for ACDF and PLF patients. Higher surgeon volume was exclusively associated with decreased odds of prolonged length of stay following PLF. Further study is necessary to determine if these relationships persist in a less-specialized setting. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Same-day Bilateral Total Knee Arthroplasty (BTKA) safety is still controversial. The aim of this study was to examine the association of blood transfusion type (pure autologous, pure allogeneic, and combined) with complication and prolonged length of stay (PLOS) following same-day BTKA. 649 consecutive patients were retrospectively identified over a two-year period. Pure allogeneic transfusions were associated with increased odds of minor complication when compared to patients who had pure autologous transfusions. No association was found between blood transfusion type and major complication or PLOS. Our results suggest that blood transfusion type may be influential in minor complication after BTKA. [ABSTRACT FROM AUTHOR]

Background: Data on the utilization of critical care services (CCSs) among patients who underwent spine fusion are rare. Given the increasing popularity of this procedure, information regarding demographics and risk factors for the use of these advanced services is needed in order to appropriately allocate resources, educate clinical staff, and identify targets for future research. Methods: We analyzed hospital discharge data of patients who underwent lumbar spine fusion in approximately 400 US hospitals between 2006 and 2010. Patient, procedure, and health care system-related demographics for those requiring CCS were compared to those who did not. Outcomes such as mortality, complications, disposition status, and hospital charges were compared among groups and risk factors for the utilization of CCS identified. Results: A total of 95 434 entries of patients who underwent posterior lumbar spine fusion surgery between 2006 and 2010 were identified. Approximately 10% of the patients required CCS. On average, patients requiring CCS were older and had a higher comorbidity burden, developed more complications, had longer hospital stays and higher costs, and were less likely to be discharged home compared to non-CCS patients. Risk factors with increased odds for requiring CCS included advanced age, increasing comorbidity burden, increasing surgical invasiveness, and presence of postoperative complications, especially pulmonary. Conclusions: Approximately, 10% of the patients undergoing lumbar spine surgery require CCS. Utilizing the present data, critical care physicians and administrators can identify patients at risk, educate clinical staff, identify targets for intervention, and allocate resources to meet the needs of this particular patient population. [ABSTRACT FROM AUTHOR]

This Viewpoint characterizes the evidence base underlying existing interventions to reduce complications and improve patient outcomes after surgery, and emphasizes the need for science to guide extension and development of new interventions in the face of pressures to use length-of-stay (LOS) as the primary measure of enhanced recovery and to use interventions shown effective for one population and setting to others. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study.Objective: We sought to determine if there was an association between enhanced recovery after surgery (ERAS) implementation level and complication risk, length of stay, and cost of hospitalization.Summary Of Background Data: ERAS protocols aim to minimize the stress response of surgery by promoting early mobilization, oral intake, as well as improvement of analgesia. Implementation of ERAS protocols in spine surgeries has been limited to mostly single-institution studies, and no population-based data exist on the impact of the level of implementation of various ERAS components on outcomes.Methods: In this study we identified 265,576 posterior lumbar fusion surgeries from 2006 to 2016. The main effect was the application of eight ERAS-related practices: (1) multimodal analgesia, (2) tranexamic acid, (3) antiemetics, (4) steroids, (5) early physical therapy, (6) avoidance of urinary catheters, (7) avoidance of patient-controlled analgesia, (8) avoidance of wound drains. Patients were classified by levels of ERAS implementation: "High," "Medium," and "Low" ERAS implementation if they received more than five, three to five, or less than three ERAS components, respectively. Mixed-effects models measured associations between ERAS implementation categories and complications, length and cost of hospitalization; odds ratios (OR, or average ratios for continuous outcomes), and 99.4% confidence intervals (CI) were reported.Results: Overall, 13.3%, 62.8%, and 24.4% of cases were categorized as "High," "Medium," and "Low" ERAS implementation, respectively. After adjusting for study variables, "Medium" and "High" (compared with "Low") ERAS implementation levels were significantly associated with incrementally improved outcomes regarding "any complication" (OR 0.84 CI 0.80-0.88 and OR 0.77 CI 0.71-0.84), cardiopulmonary complications (OR 0.75 CI 0.68-0.73 and OR 0.69 CI 0.59-0.80), length of stay (average ratio 0. 94 CI 0.93-0.94 and average ratio 0.91 CI 0.90-0.91), and hospitalization cost (average ratio 0.99 CI 0.98-0.99 and average ratio OR 0.95 0.95-0.96).Conclusion: In a cohort undergoing posterior lumbar spine fusion the level of utilization of ERAS protocol components was independently associated with incrementally improved complication odds as well as reduced length of stay and a small decrease in overall hospitalization cost.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects. Retrospective study of population-based database. The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery. None. The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes. In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p <.001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p <.001) when compared with patients who received oral APAP. In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients. • IVAPAP use on the day of surgery failed to reduce opioid related adverse effects when compared with oral APAP. • IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use when compared with oral APAP. • These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients. [ABSTRACT FROM AUTHOR]