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Background: Postoperative orthostatic intolerance (OI) can be a major obstacle to early ambulation and its determinants are poorly understood. We aimed to study postoperative changes in vascular tone and their potential association with OI in various orthopedic surgical settings.Methods: In this prospective cohort study, 350 patients undergoing total joint arthroplasty under neuraxial anesthesia or spine surgery under general anesthesia were enrolled. We determined the augmentation index (AI) as a measure of vascular tone and studied symptoms of OI using a validated questionnaire at various postoperative time points.Results: The AI was significantly reduced postoperatively (at spinal resolution in patients with neuraxial anesthesia or two hours postoperatively in general anesthesia) compared with baseline values in all procedures and did not subsequently return to baseline throughout the postoperative period in the majority of patients [252/335 (75.2%); P < 0.001]. The majority [260/342 (76.0%); P < 0.001] of patients had postoperative symptoms of OI. Nevertheless, no association was found between postoperative change in AI from baseline and postoperative symptoms of OI.Conclusions: A significantly prolonged decrease in AI and symptoms of OI are common after orthopedic surgery. Nevertheless, an association between the two measures was not observed. While compensatory mechanisms may limit the influence of an AI decrease on symptoms of OI, more research is needed to understand the contributing factors and aid in the identification of patients at risk of OI. [ABSTRACT FROM AUTHOR]

Background: Effective blood management strategies are a major determinant of successful outcomes after one-stage bilateral total knee arthroplasty (BTKA). Proper patient selection with preoperative optimization and intra- and postoperative interventions can reduce transfusion risk and associated morbidity in these patients.Questions/Purposes: The purpose of this study was to evaluate intraoperative blood management modalities based on three keystone questions: (1) What is the role of the anesthesiologist?, (2) Which are the surgeon-dependent strategies?, and (3) Is there any place for pharmacologic interventions?Methods: We searched the established electronic literature database MEDLINE. After critical appraisal, 94 studies were deemed eligible from which to draw documented evidence.Results: A number of blood-conserving methods are currently implemented in patients undergoing one-stage BTKA. Among them, regional anesthesia, tourniquet use, and tourniquet deflation after wound closure, femoral canal sparing or femoral canal plugging, avoidance of drains, and tranexamic acid use were the intraoperative strategies with documented efficacy in blood conservation.Conclusion: Combined proper intraoperative anesthesiologic, surgical, and pharmacologic interventions reduce blood loss and need for transfusion in BTKA patients. However, contemporary relevant literature is lacking evidence-based guidelines. [ABSTRACT FROM AUTHOR]

Purpose: Obstructive sleep apnea (OSA) has been linked to higher rates of perioperative complications. Practice guidelines recommend minimizing opioids in this cohort to reduce complications. However, a paucity of evidence exists relating different levels of opioid prescription to perioperative complications. Our aim was to investigate if different levels of opioid prescription are related to perioperative complication risk in patients with OSA.Methods: A total of 107,610 OSA patients undergoing total knee or hip arthroplasty between 2006 and 2013 were identified in a nationwide database and divided into subgroups according to the amount of opioids prescribed. We then compared those subgroups for odds of perioperative complications using multilevel multivariable logistic regression models.Results: OSA patients with higher levels of opioid prescription had increased odds for gastrointestinal complications (OR 1.90, 95% CI 1.47-2.46), prolonged length of stay (OR 1.64, 95% CI 1.57-1.72), and increased cost of care (OR 1.48, 95% CI 1.40-1.57). However, we found lower odds for pulmonary complications (OR 0.85, 95% CI 0.74-0.96) for the high-prescription group.Conclusions: Higher levels of opioid prescription were associated with higher odds for gastrointestinal complications and adverse effects on cost and length of stay but lower odds for pulmonary complications in OSA patients undergoing joint arthroplasties. The latter finding is unlikely causal but may represent more preventive measures and early interventions among those patients. Attempts to reduce opioid prescription should be undertaken to improve quality and safety of care in this challenging cohort in the perioperative setting. [ABSTRACT FROM AUTHOR]

Purpose: To determine the incidence and to identify potential risk factors for in-hospital and late infections, as well as for deep periprosthetic joint infection (PJI) following TKA.Methods: We identified 17,959 patients treated with primary TKA between 2000 and 2009. We recorded patient demographics, comorbidities and in-hospital complications. The rates of in-hospital, late, and deep PJIs were determined. Different logistic regression models were built to identify risk factors for each of the above types of infection.Results: The rates for in-hospital, post-discharge, and deep PJI were 0.65%, 0.41%, and 0.26%, respectively. Younger age, allogeneic blood transfusion, liver disease, and unilateral or staged bilateral TKA were risk factors for in-hospital infection. Renal and pulmonary disease, urinary tract infection, wound dehiscence, and prior in-hospital infection were risk factors for post-discharge infection. Male gender, history of in-hospital infection, prolonged length of stay, and pulmonary disease were identified as risk factors for deep PJI.Conclusion: Despite low infection rates after primary TKA, there are patients at higher risk that would benefit by addressing modifiable risk factors for both in-hospital or post-discharge infections, including deep PJIs. [ABSTRACT FROM AUTHOR]

Discharge against medical advice ( DAMA) is associated with greater risk of hospital readmission and higher morbidity, mortality, and costs, but with a rapidly increasing elderly inpatient population, there is a lack of national data on DAMA in this subgroup. The National Inpatient Sample (2003-2013 for trends, 2013 for multivariable analysis, n = 29,290,852) was used to describe trends in DAMA in elderly inpatients, to study diagnosis codes associated with admission, and to assess factors associated with DAMA using multivariable logistic regression. Odds ratios ( ORs) and 95% confidence intervals ( CIs) are reported for risk factors of interest. Although DAMA rates in individuals aged 65 and older were one fourth of those found in individuals aged 18 to 64, an increasing trend was found in both groups. From 2003 to 2013, rates increased in individuals aged 18 to 64 (from 1.44% to 1.78%) and in those aged 65 and older (from 0.37% to 0.42% (both P < .001). In both age groups, individuals admitted for mental illness had the highest risk of DAMA. Factors associated with higher adjusted odds of DAMA were generally similar between age groups, although risk of DAMA was higher in elderly adults than in those aged 18 to 64 for blacks ( OR 1.65, 95% CI 1.49-1.82 vs OR 1.16, 95% CI 1.12-1.20), Hispanics ( OR 1.58, 95% CI 1.41-1.77 vs OR 0.83, 95% CI 0.79-0.87), and those in the lowest income quartile ( OR 1.57, 95% CI 1.43-1.72 vs OR 1.12, 95% CI 1.08-1.17), suggesting that race/ethnicity and poverty are more pronounced as risk factors for DAMA in elderly inpatients. [ABSTRACT FROM AUTHOR]