Effectiveness of Comanagement Model: Geriatric Medicine and Vascular Surgery

ObjectivesOlder surgical patients frequently develop postoperative complications due to their frailty and multiple comorbidities. Geriatric medicine consultation helps to optimize risk factors and improve outcomes in patients with hip fracture. This study aimed to evaluate patient outcomes before and after comanagement model implementation between geriatric medicine (Geriatric Surgical Service) and vascular surgery services.DesignThis was a case-control study involving emergency vascular surgical patients who were comanaged by vascular surgery, geriatric medicine, and geriatric nursing services.Settings and ParticipantsThis study was conducted in a tertiary hospital in Singapore from 2015 to 2018 with acute vascular surgical patients aged older than 65 years.MethodsA retrospective cohort of 135 patients from 2013 to 2014 (control group) who fulfilled the criteria for the comanagement model was compared with a prospective cohort of 348 patients who were comanaged by a geriatric surgical service from 2015 to 2018, and a further subgroup analysis of patients between 2015 and 2016 (n = 150) (early intervention group) and between 2017 and 2018 (n = 198) (late intervention group) was performed.ResultsComanaged patients had a significantly shorter length of hospital stay (11.6 vs 20.8 days, P = .001), reduced nosocomial infections (3% vs 12% for urinary tract infection, P = .003) and decreased 30-day readmission rates (22% vs 34%, P = .011). A trend of a decreased incidence of fluid overload was noted in patients comanaged with the geriatric surgical service (3% vs 7%, P = .073). Subgroup analysis showed progressive reductions in the length of stay (15.4 vs 11.6 days, P = .001), 30-day readmission rate (35% vs 22%, P = .01), and nosocomial urinary tract infection (8% vs 3%, P = .003) between the early intervention group and the late intervention group. Although they were not statistically significant, reductions were also observed in the delirium rate (13% vs 11%) and other postoperative medical complications in the early intervention group and the late intervention group.Conclusion and ImplicationsDespite having increasing comorbidities, older vascular surgical inpatients had a significantly shorter length of stay, reduced nosocomial infections, and decreased 30-day readmission rates through a comanagement model with vascular surgery and geriatric medicine services. Improvements in outcomes were observed over time as the model of care evolved. Geriatric medicine intervention in the perioperative period improves the outcomes of older acute vascular surgical patients.     

Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty

BackgroundVancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections.MethodsWe reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups.ResultsWe reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012).ConclusionLate infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.     

Understanding the Main Predictors of Length of Stay After Total Hip Arthroplasty: Patient-Related or Procedure-Related Risk Factors?

BackgroundRemoving total hip arthroplasty (THA) from the Centers for Medicare & Medicaid Services (CMS) inpatient-only list allows Medicare to cover outpatient THA, driving hospitals to recommend outpatient surgery for appropriate patients and raising safety concerns over which patients’ admissions should remain inpatient. Thus, we aimed to determine the influence of patient-related and procedure-related risk factors as predictors of >1-day Length of Stay (LOS) after THA.MethodsA prospective cohort of 5281 patients underwent primary THA from 2016 to 2019. Risk factors were categorized as patient-related or procedure-related. Multivariable cumulative link models identified significant predictors for 1-day, 2-day, and ≥3-day LOS. Discriminating 1-day LOS from >1-day LOS, we compared performance between two regression models.ResultsA>1-day LOS was significantly associated with age, female gender, higher body mass index, higher Charlson Comorbidity Index, Medicare status, and higher Hip disability and Osteoarthritis Outcome Physical Function Shortform(HOOS-PS) and lower Veterans RAND12 Mental Component (VR-12 MCS) scores via the initial regression model that contained patient factors only. A second regression model included procedure-related risk factors and indicated that procedure-related risk factors explain LOS more effectively than patient-related risk factors alone, as Akaike information criterion (AIC) increased by approximately 1100 units upon removal from the model.ConclusionAlthough patient-related risk factors alone provide predictive value for LOS following THA, procedure-related risk factors remain the main drivers of predicting LOS. These findings encourage examination of which specific procedural risk factors should be targeted to optimize LOS when choosing between inpatient and outpatient THA, especially within a Medicare population.     

Impact of Perioperative Pain Control on Knee Range of Motion and Development of Arthrofibrosis Following Primary Total Knee Arthroplasty

BackgroundInadequate pain control following total knee arthroplasty (TKA) has been postulated to negatively impact knee range of motion (ROM). We sought to determine the association between perioperative pain levels and knee ROM at 3-month follow-up or need for manipulation under anesthesia (MUA).MethodsWe retrospectively reviewed 2243 primary TKAs performed from 2002 to 2019 at a single academic center using an institutional total joint registry. Mean age was 68, mean body mass index was 32.8, and 59% were female. Knee ROM was measured preoperatively and 3 months postoperatively. Change in knee ROM, rates of soft tissue contracture, and MUA were assessed in relation to in-hospital 10-point pain visual analog scale (VAS) measurements.ResultsOverall, 44% had improved ROM at 3-month follow-up, 29% had no change in ROM, and 27% had worsened ROM. There was no significant difference in mean VAS scores of patients with improved, unchanged, or worsened ROM postoperatively (3.0 vs 2.8 vs 3.0; P = .068). There was no significant difference in mean VAS scores of patients who developed a soft tissue contracture or required MUA vs those who did not develop these complications (2.7 vs 2.9; P = .24). Similarly, no significant relationship with these outcomes was identified when maximum and discharge VAS scores were analyzed.ConclusionComparable ROM and rates of MUA based on in-hospital pain levels were observed in this large series of primary TKA patients. While significant early pain may limit participation in ROM exercises initially, this does not appear to have a marked impact on ROM-related complications for most patients.Level of EvidenceIII, Therapeutic.     

Perioperative Mortality and Periprosthetic Fracture: A Single-Center Experience of 857 Uncemented Hemiarthroplasties for Displaced Femoral Neck Fractures

BackgroundUncemented hemiarthroplasty (UHA) for displaced femoral neck fracture (FNF) is favored by some surgeons because of the reduced rate of perioperative mortality and operative time. However higher rates of intraoperative and postoperative periprosthetic fractures (PPFs) have been reported. The aim of the study was to review day-0, day-1, day-2, day-30, and one-year mortality as well as intraoperative and postoperative PPF after UHA for displaced FNF and compare this with cemented hemiarthroplasties (CHAs) performed. Secondary objectives were to assess whether femoral stem geometry and alignment were associated with PPF in UHA.MethodsA retrospective observational study was conducted of patients treated with a hemiarthroplasty for a displaced FNF over an eleven-year period. Radiographic analysis was conducted of femoral geometry and stem alignment.ResultsOver the 11-year study period, 857 UHAs and 247 CHAs were performed. There were no on-table, day-0, day-1, or day-2 deaths in UHA. Intraoperative PPF occurred in 3.6% UHA and 2% CHA and postoperative PPF in 2.4% UHA and 4.8% CHA. Intraoperative PPF was not associated with increased mortality (P = .15), postoperative PPF, or all-cause revision in UHA. Valgus stem alignment was a risk factor for a postoperative PPF and additional surgery in UHA (P = .004).ConclusionUHA was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. It can be considered in patients with multiple medical comorbidities. Careful surgical planning and technique is important to optimize stem alignment particularly in Dorr C type femurs.     

从围手术期处理到围手术期病人之家：认识进展与展望

随着社会老龄化及环境、工作模式等外部因素的改变,外科治疗病种发生了巨大变化,需要外科治疗的复杂免疫疾病、肿瘤及器官移植等病种数量显著增加。为适应这一新形势,围手术期处理理念取得显著进步,学术界正在探索并建立以多学科团队为基础、多级医疗机构相互配合甚至整合全社会医疗资源共同参与的围手术期病人之家运行模式,实现以病人为中心、以优化外科疾病治疗全流程为目的的综合治疗体系,促进病人的术后康复。     

腹腔镜辅助腹横肌平面阻滞技术临床应用进展

腹横肌平面（TAP）阻滞技术在腹部手术中的应用经历了一个复杂的阶梯式的发展过程,由外科医生主导的腹腔镜辅助腹横肌平面阻滞（Lap-TAP）是近年来国际上一种新兴的围手术期镇痛方式,逐渐被临床推广应用。与超声引导下TAP阻滞技术相比,Lap-TAP可在腹腔镜直视侧腹壁下,由外科医师独立完成操作,无需麻醉科医师及超声设备,具有良好的围手术期镇痛效果,是一种更为安全、有效、简单、省时的镇痛方式,可推荐其作为超声引导下TAP阻滞的替代方法,广泛应用于各腹部微创外科领域的围手术期镇痛。     

围手术期外科之家在减重代谢外科的应用

围手术期外科之家（PSH）是对病人从术前准备到术后随访进行重新设计的临床新理念,强调从评估手术指征到围手术期并发症预防的长程管理模式。PSH涵盖了以往围手术期医学和加速康复理念。PSH理念更适合针对接受减重代谢手术的重度肥胖病人院前和围手术期管理以及长期随访,即在院前对于病人的伴发疾病进行干预,包括术前减重,心肺功能改善,血糖血压治疗等;住院以后针对病人的心理问题以及维生素缺乏、肝肾功能障碍、心肺功能进行评估,在术后施行加速康复措施,全程优化病人术式选择以及术后康复指导等。针对减重手术的特殊性,倡导终身随访,多学科团队干预,特别是内分泌科营养科以及心理医师进行术后的随访指导等。PSH理念可以为重度肥胖病人提供多学科全程围手术期管理,提高安全性。     

湖北省胃肠道肿瘤病人围手术期静脉血栓栓塞症多中心调查及分析

目的 调查分析湖北省胃肠道肿瘤病人围手术期静脉血栓栓塞症（VTE）防治现状。方法 回顾性分析2019-01-01至2019-12-31湖北省胃肠外科联盟成员医院收治的行手术治疗的胃肠道肿瘤病人VTE防治相关临床资料。 结果 收集62家医院调查问卷7751份,其中有效问卷共计7474份,有效率96.4%。所有病人中,术前736例（9.8%）接受恰当预防措施,7012例（93.8%）术前行D-二聚体检查,2301例（30.7%）术前行下肢静脉超声检查。术后451例（6.0%）病人接受恰当预防措施。术后6434例（86.1%）病人行D-二聚体检查;1675例（22.2%）行下肢静脉超声检查,其中164例发生下肢深静脉血栓（DVT）,20例病人发生肺动脉栓塞（PE）,有5例PE病人住院期间死亡。结论 当前湖北省胃肠道肿瘤病人围手术期下肢静脉超声检查及恰当预防比例偏低,围手术期VTE规范化防治水平有待提高。