Use of critical care resources after laparoscopic gastric bypass: effect on respiratory complications

BackgroundBefore 2005, all subjects undergoing laparoscopic gastric bypass with a body mass index >50 kg/m², age >40 years, and documented obstructive sleep apnea (OSA) were admitted to the intensive care unit (ICU) in our institution. Starting in January 2005, only patients with a body mass index >60 kg/m² and severe OSA were admitted. This study assessed the incidence of respiratory complications in patients undergoing laparoscopic gastric bypass before and after implementation of the new ICU admission criteria.MethodsThe records of the laparoscopic gastric bypass patients who had undergone laparoscopic gastric bypass from January 2004 to December 2005 were reviewed regarding demographic data (age, sex, body mass index, American Society of Anesthesiologists classification); OSA; use of home continuous positive airway pressure; length of stay in postanesthesia care unit, ICU, and hospital; postoperative ventilation and hypoxemia (oxygen saturation <90%), and unplanned ICU admission.ResultsA total of 250 charts were analyzed (122 from 2004 and 128 from 2005). The demographic data were comparable between the 2 groups. Although OSA was more frequent in the 2004 than in the 2005 cohort (P = .02), the incidence of OSA requiring home continuous positive airway pressure was comparable (P = .47). The length of hospital stay was greater in 2004 than in 2005 (P = .003). More patients were admitted to the ICU in 2004 (P <.001). All unplanned ICU admissions were because of surgical anastomotic/staple line leaks (7 patients in 2004 versus 0 in 2005; P = .006). Overall, the incidence of postoperative respiratory complications was low (6% in 2004 and 4% in 2005) and comparable in both groups.ConclusionLimiting ICU admission after laparoscopic gastric bypass to patients with a body mass index >60 kg/m² and severe OSA did not increase the overall incidence of postoperative respiratory complications or hospital stay.     

Does thoracic injury impair the predictive value of base deficit in trauma patients?

Introduction

Base deficit (BD) has been shown to be a valuable indicator to be predictive of complications and mortality after trauma. Arterial carbon dioxide (PaCO₂) may be influenced by thoracic injuries, potentially diminishing the predictive value of BD. Therefore, the aim of this study was to assess the predictive value of admission BD for mortality and complications in trauma patients with thoracic injuries.

Methods

By a prospective database analysis of patients with an injury to the chest admitted to the University Medical Center Utrecht between 2000 and 2004 were studied. All patients with a blood gas analyses were included. Absolute BD was used for analyses. Clinical outcome parameters were recorded.

Results

The BD was higher in the non-surviving patients compared to the survivors (7.5 vs. 3.8, p < 0.001). Mortality rate of patients with an admission BD of ≥6 was increased in thoracic trauma patients (BD < 6 mortality rate 7%, BD ≥ 6 mortality rate 27%; p < 0.001). In patients who required ICU admittance the BD was increased compared to patients without ICU admission (5.2 vs. 2.9, p < 0.001). Within the subgroup of patients admitted to the ICU, the BD was higher in patients who required ventilation (3.8 vs. 5.5, p = 0.025). Patients who developed chest related complications had increased BD compared with those without complications (4.9 vs. 4.0, p = 0.025), the BD was particularly increased in patients who developed acute respiratory distress syndrome (ARDS) (4.1 vs. 6.4, p = 0.004). Carbon dioxide (PaCO₂) showed a predictive value for mortality (44 vs. 53, p < 0.001), ICU admission (42 vs. 46, p = 0.003) and hospital stay.

Conclusion

Admission BD is a predictive factor in thoracic trauma patients for mortality and chest related complications. Furthermore it is a predictive factor for ICU admission, required ventilation and hospital stay. The use of BD in thoracic trauma patients can potentially identify patients who require additional monitoring or early aggressive therapy.     

Perioperative Morbidity and Mortality Following Bilateral Total Hip Arthroplasty

There is concern about safety of bilateral total hip arthroplasty (THA).This study aims to compare in-hospital complication rates between unilateral, simultaneous and staged bilateral THAs. The Nationwide Inpatient Sample from 2002–2010 was used. Patients and complications were identified using ICD-9-CM codes. In multivariate analysis, bilateral THA had higher risk of systemic complications (Odds ratio (OR): 2.1, P < 0.001) compared to unilateral procedure, whereas no significant difference existed between simultaneous and staged bilateral THAs. The rate of local complications was higher in bilateral versus unilateral (4.96% versus 4.54%, P = 0.009) and in staged versus simultaneous bilateral THAs (OR: 1.75, P = 0.05). Bilateral THA increases risk of systemic complications compared to unilateral surgery and simultaneous bilateral THA appears to be safer than staging during one hospitalization.     

Retrospective study on the need of intensive care unit admission after major head and neck surgery

Background : The present article aims to study the pattern and need of Intensive Care Unit admission after major head and neck operations. Methods : A retrospective study was undertaken of the hospital records of patients who underwent major head and neck operations during the period from February 1997 to February 2000 at the Division of Head and Neck Surgery, Department of Surgery, the Chinese University of Hong Kong. Results : A total of 268 consecutive elective major operations were carried out over the 3 year period. The patients’ age ranged from 14 to 82 years with a mean of 55 years. The male to female ratio was 4:1. Forty‐seven patients underwent an operation with a combination of major resection, neck dissection, flap reconstruction and tracheostomy (‘flaps group’). Two hundred and twenty‐one patients had major head and neck operations without the need of flap reconstruction (‘non‐flaps group’). Three (6.3%) out of 47 patients (flaps group) were admitted to intensive care unit (ICU) immediately after the operation. Only one patient (2.2%) out of the remaining 44 patients was admitted for emergency treatment 3 weeks post operation. All four patients recovered uneventfully. In the non‐flaps group of 221 patients, there were 12 (5.4%) planned admissions and 2 (0.96%) unplanned admissions to ICU. In the group of planned admissions, one out of the 12 patients died. The other two patients who were not planned for ICU admission died of basal meningitis that was disease‐related rather than related to the intensity of postoperative care. The overall admission rate to ICU was 18 (6.7%) out of 268 patients. The overall mortality was 1.1% (one planned, two unplanned). Conclusion : The present study showed that it is safe and cost‐effective to discharge the majority of patients after major head and neck operations back to a specialist ward for nursing care.     

Risk Factors for Unplanned Admission to the Intensive Care Unit After Elective Total Joint Arthroplasty

BackgroundDespite improved surgical and anesthesia techniques, as well as advances in perioperative protocols, a number of patients undergoing total joint arthroplasty (TJA) are at risk of serious medical complications that require intensive care unit (ICU) admission. With the recent move toward performing TJA in ambulatory surgical centers and on an outpatient basis, it is important to recognize patients that may require intensive care in the postoperative period. This study aimed to identify risk factors for ICU admission following elective total hip (THA) and knee (TKA) arthroplasty.MethodsWe evaluated 12,342 THA procedures, with 132 ICU admissions, and 10,976 TKA procedures, with 114 ICU admissions from 2005 to 2017. Demographic, preoperative, and surgical variables were collected and compared between cohorts using both univariate and logistic regression analysis.ResultsFor THA, logistic regression analysis demonstrated older age, bilateral procedure, revision surgery, increased Charlson comorbidity index, general anesthesia, increased estimated blood loss, decreased preoperative hemoglobin, and increased preoperative glucose level were independently associated factors for increased risk of ICU admission. For TKA, increased age, increased body mass index, bilateral procedure, revision surgery, increased Charlson comorbidity index, increased estimated blood loss, general anesthesia, and increased preoperative glucose were independently significantly associated with ICU admission.ConclusionIn this study, we identify a number of critical independent risk factors which may place patients at increased risk of ICU admission following THA and TKA. Identification of these risk factors may help surgeons safely select those TJA candidates appropriate for surgery at facilities that do not have ICUs readily available.     

Patterns and Costs of 90-Day Readmission for Surgical and Medical Complications Following Total Hip and Knee Arthroplasty

BackgroundUnplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. We compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.MethodsWe performed a retrospective analysis on unplanned readmissions within 90 days of discharge following elective primary THA/TKA among Medicare patients discharged between April 2013 and March 2016. We categorized unplanned readmissions into groups with and without CMS-defined complications. We compared the location, timing, and payments for unplanned readmissions between both readmission categories.ResultsAmong THA (N = 23,231) and TKA (N = 43,655) patients with unplanned 90-day readmissions, 27.1% (n = 6307) and 16.4% (n = 7173) had CMS-defined surgical complications, respectively. These readmissions with surgical complications were most commonly at the hospital of index procedure (THA: 84%; TKA: 80%) and within 30 days postdischarge (THA: 73%; TKA: 77%). In comparison, it was significantly less likely for patients without CMS-defined surgical complications to be rehospitalized at the index hospital (THA: 63%; TKA: 63%; P < .001) or within 30 days of discharge (THA: 58%; TKA: 59%; P < .001). Generally, payments associated with 90-day readmissions were higher for THA and TKA patients with CMS-defined complications than without (P < .001 for all).ConclusionReadmissions associated with surgical complications following THA and TKA are more likely to occur at the hospital of index surgery, within 30 days of discharge, and cost more than readmissions without CMS-defined surgical complications, yet they account for only 1 in 5 readmissions.     

Comparison of Topical and Intravenous Tranexamic Acid on Blood Loss and Transfusion Rates in Total Hip Arthroplasty

The objective of this study was to determine whether topical tranexamic acid (TXA) carried similar hemostatic effect compared with intravenous TXA in total hip arthroplasty (THA). Three hundred and three THA patients were enrolled and randomized into 3 groups: no TXA group, topical and intravenous TXA group. The results showed that the topical and intravenous TXA group had reduced but similar blood transfusion rates (5.88% v. s. 5.94%, P = 0.816). No significant difference was detected in total blood loss between the two TXA groups [(963.4 ± 421.3) ml vs. (958.5 ± 422) ml P = 0.733]. We conclude that topical use of TXA was equally effective and safe compared with intravenous TXA in reducing blood loss and transfusion rate following THA without substantial complications.     

Early hospital readmission in the trauma population: Are the risk factors different?

Introduction

Hospital readmission rates will soon impact Medicare reimbursements. While risk factors for readmission have been described for medical and elective surgical patients, little is known about their predictive value specifically in trauma patients.

Patients and methods

We retrospectively identified all admissions after trauma resuscitation to our urban level 1 trauma centre from 1/1/2004 to 8/31/2010. All patients discharged alive were included. Data collected included demographics, Injury Severity Score (ISS), and length of stay (LOS). We analyzed these index admissions for the development of complications that have previously been shown to be associated with readmission. Readmissions that occurred within 30 days of index admission were identified. Univariable and multivariable analyses were performed. p < 0.05 was considered significant.

Results

We identified 10,306 index admissions, with 447 (4.3%) early (within 30 days) readmissions. Mean ISS was 11.1 (SD 10.4). On multivariable analysis, African-American race (OR 1.3, p = 0.009), pre-existing chronic obstructive pulmonary disease (COPD) (OR 1.5, p = 0.02), and diabetes mellitus (OR 1.8, p < 0.001) were associated with readmission, along with higher ISS (OR 1.01, p < 0.001), ICU admission (OR 2.1, p < 0.001), and increased LOS (OR 1.01, p < 0.001). Among many in-hospital complications examined, only the development of surgical site infection (SSI) (OR 1.9, p = 0.02) was associated with increased risk of readmission.

Conclusions

Trauma patients have a low risk of readmission. In contrast to elective surgical patients, the only modifiable risk factor for readmission in our trauma population was SSI. Other risk factors may present clinicians with opportunities for targeted interventions, such as proactive follow up or early phone contact. With future changes to health care policy, clinicians may have even greater motivation to prevent readmission.     

Topical Application of Tranexamic Acid in Primary Total Hip Arthroplasty: A Randomized Double-Blind Controlled Trial

So far, studies of topical tranexamic acid (TXA) in total hip arthroplasty (THA) were still lacking and controversial. We conducted this randomized double-blind controlled trial which included 101 patients to assess the effect of a high-dose 3 g topical TXA in THA. The results showed that 3 g topical TXA could significantly reduce transfusions from 22.4% to 5.7% (P < 0.05) without increasing the risk of deep vein thrombosis (DVT), pulmonary embolism (PE) and other complications. In addition, topical TXA significantly reduced total blood loss, reduced drain blood loss, and the drops of HB and HCT in topical TXA group were lower than control group. We concluded that 3 g topical TXA was effective and safe in reducing bleeding and transfusions in THA.     

Risk Versus Reward: Total Joint Arthroplasty Outcomes After Various Solid Organ Transplantations

Clinical outcomes were retrospectively reviewed for 76 primary total hip (THA) and total knee arthroplasties (TKA) performed after kidney, liver, cardiac, and lung transplantation with follow-up of 30.2 and 41.2 months, respectively. For the THA and TKA cohorts, there were a high rate of medical complications (29% and 33%), increased hospital length of stay (4.2 and 3.7 days), and more reoperations (7.2% and 9.1%). Only 1 (1.8%) periprosthetic infection was documented for THAs but 3 (14.2%) TKAs required two-stage revisions for infection. All transplant cohorts demonstrated significant increases (P < 0.05) in HHS and KSS scores with majority of patients reporting overall good or excellent outcomes (82%–100%). These results suggest that various organ transplant patients may accept higher surgical risks for rewarding outcomes.     

Apixaban and Rivaroxaban Decrease Deep Venous Thrombosis But Not Other Complications After Total Hip and Total Knee Arthroplasty

Apixaban and rivaroxaban are oral direct factor Xa (FXa) inhibitors used for VTE prevention after total hip (THA) and total knee arthroplasty (TKA). A meta-analysis of level I studies comparing rivaroxaban 10 mg daily or apixaban 2.5 mg twice daily to enoxaparin for the prevention of VTE after THA or TKA was performed analyzing efficacy and safety outcomes. Seven studies met the inclusion criteria including 24,385 patients. Oral FXa inhibitors were superior to enoxaparin in preventing DVT (p < 0.00001). There was no difference in the rate of PE, death, major bleeding, blood transfusion requirement, reoperation for bleeding or postoperative wound infections. Oral FXa inhibitors are superior to enoxaparin in preventing DVT after THA and TKA. There is no difference in the rate of PE, death, or postoperative wound complications.     

Incidence of complications in the post-anesthesia care unit and associated healthcare utilization in patients undergoing non-cardiac surgery requiring neuromuscular blockade 2005–2013: A single center study

Study objectiveThe use of neuromuscular blockade agents (NMBA), had been associated with significant residual post-operative paralysis and morbidity. There is a lack of clinical evidence on incidence of postoperative complications within the post-anesthesia care unit (PACU) in patients exposed to intraoperative NMBA's. This study aims to estimate the incidence of post-operative complications associated with use of NMBAs and assessing its association with healthcare resource utilization.DesignRetrospective cohort.SettingPost-anesthesia care unit in tertiary care center.PatientsAdults having non-cardiac surgery and receiving NMBAs between April-2005 and December-2013MeasurementsWe assessed: 1) incidences of major and minor PACU complications, 2) incidence of any postoperative complication in patients receiving a NMBA reversal (neostigmine) vs. without. 3) We secondarily assessed the relationship between PACU complications and use of healthcare resources.Main resultsThe incidence of any major complications was 2.1% and that of any minor complication was 35.2%. ICU admission rate was 1.3% in patients without any complications, versus 5.2% in patients with any minor and 30.6% in patients with any major complication. ICU length of stay was prolonged in patients with any major (52.1 ± 203 h), compared to patients with any minor (6.2 ± 64 h) and with no complications (1.7 ± 28 h). Patients who received a NMBA and neostigmine, compared to without neostigmine, had a lower incidence of any major complication (1.7% vs. 6.05%), rate of re-intubation (0.8% vs. 4.6%) and unplanned ICU admission (0.8% vs. 3.2%).ConclusionsThis study documents that incidence of major PACU complications after non-cardiac surgery was 2.1%, with the most frequent complications being re-intubation and ICU admission. Patients receiving NMBA reversal were at a lower risk of re-intubation and unplanned ICU admission, justifying routine use of reversals. Complete NMBA reversals are crucial in reducing preventable patient harm and healthcare utilization.     

In the media: Burns as a method of assault

Aim

The aims of this study were to determine whether a change occurred in the pattern of assault burn injury cases hospitalised to the adult state burns unit, Western Australia, from 2004 to mid-year of 2012, and to compare patient and burn characteristics of adult assault burns with those admitted for unintentional burns.

Methods

Study data were obtained from the Royal Perth Hospital (RPH) Burns Minimum Dataset (BMDS). Aggregated data of unintentional burn admissions during the same period were provided by the BMDS data manager to enable comparisons with assault burn patients.

Results

Assault burn admissions during 2004–2012 accounted for approximately 1% of all adult burn hospitalisations. All assault victims were burned by either thermal or scald agents. A high rate of intubation (24%) and ICU admission (1 in 3 cases) was observed in the fire assault group. The six assault cases undergoing intubation were severe burns, median TBSA 50%, most commonly affecting the face, head and torso, half of these cases had inhalational injuries and also required escharotomies.Comparison of admissions by calendar period showed no statistically significant differences in demographic, burn cause or TBSA%. However, statistically significant differences were found for pre-morbid psychiatric history (15% vs. 58%, p = 0.025) and concomitant fractures or dislocations (46% vs. 2%), p = 0.011).

Conclusions

While the proportion of assault burn admissions per total burn admissions steadily increased from 0.4% in 2009 to 1.5% in mid-2012, this proportion did not exceed that peak level observed of 2.1% for 2004.     

Factors affecting survival in adult patients with massive burns

Objective: To identify treatment-related factors associated with mortality in massively burned adult patients. Methods: This retrospective cohort study examined survival outcomes at a burn unit of 54 beds and 10 burn ICU beds, totaling 900 admissions per year. The cases of 102 adult patients, admitted consecutively from January 1993 to October 2007, with massive burns (burn area > 70% of the total body surface area, TBSA) were studied. Relevant variables were recorded from the initial injury and throughout the hospital course. Survival analysis, based on univariate and stepwise multivariate Cox proportional hazards regression, was performed to determine which variables predicted mortality. Results: The overall mortality rate was 30.4%. Burn size, severe inhalation injury, full-thickness burns, serum creatinine levels, inotropic support, platelet counts < 20,000 per mm³, sepsis and ventilator dependency were significantly associated with mortality as determined by univariate analysis. Only sepsis, ventilator dependency and platelet counts were significant independent predictors of mortality as determined by multivariate analysis. Conclusions: Sepsis, ventilator dependence (indicating severe respiratory complications), and low platelet counts (indicating thrombocytopenia) are associated with increased mortality risk in adult patients with massive burns. Methods should be sought to ameliorate these complications during treatment in burn-care units.     

Fibrosis in Hepatitis C Patients Predicts Complications After Elective Total Joint Arthroplasty

Effects of Hepatitis C on total hip (THA) and total knee arthroplasty (TKA) outcomes are poorly understood. Seventy-two hepatitis C patients underwent 77 primary THA or TKA and were retrospectively identified, stratified by fibrosis and thrombocytopenia and compared to matched controls. Overall, Hepatitis C and control patients had similar outcomes. After TKA, fibrotic hepatitis C patients demonstrated a greater average hemoglobin drop than non-fibrotic hepatitis C patients (4.9 versus 3.8, P = 0.023), greater deep infection rate (21% versus 0%, P = 0.047), and rate of cellulitis (21% versus 0%, P = 0.047). Thrombocytopenia showed a trend toward greater infections. Prior to fibrosis, Hepatitis C patients appear to be at no increased risk of complication after joint arthroplasty. Evaluation of fibrosis may predict poor outcome in Hepatitis C patients.     

Are Bilateral Total Joint Arthroplasty Patients at a Higher Risk of Developing Pulmonary Embolism Following Total Hip and Knee Surgery?

Despite developments in prophylactic methods, venous thromboembolism (VTE) continues to be a serious complication following total joint arthroplasty. The new AAOS/ACCP guidelines on preventing pulmonary embolism (PE) after total hip/knee arthroplasty (THA/TKA) do not make specific recommendations for bilateral vs. unilateral procedures. In-patient PE rates were examined for patients undergoing unilateral or simultaneous bilateral TKA/THA at our institution in 2011. Of the 7,437 THA/TKA surgeries completed at our institution in 2011, 36 patients suffered from PE (0.48%). The rate of PE for unilateral TKA was 0.61% vs. 1.87% for bilateral (P < 0.001) and for unilateral THA was 0.17% vs. 0.52% for bilateral THA. Despite patients being screened before being cleared to undergo bilateral THA/TKA, they remain at higher risk for VTE.     

Outcomes of Primary Total Joint Arthroplasty After Lung Transplantation

Lung transplantation is increasingly common with improving survival rates. Post-transplant patients can be expected to seek total hip (THA) and knee arthroplasty (TKA) to improve their quality of life. Outcomes of 20 primary total joint arthroplasties (15 THA, 5 TKA) in 14 patients with lung transplantation were reviewed. Clinical follow-up time averaged 27.5 and 42.8 months for THA and TKA respectively. Arthroplasty indications included osteonecrosis, osteoarthritis, and fracture. All patients subjectively reported good or excellent outcomes with a final average Harris Hip Score of 88.7, Knee Society objective and functional score of 92.0. There were 4 minor and 1 major acute perioperative complications. 1 late TKA infection was successfully treated with two-stage revision. The mortality rate was 28.5% (4/14 patients) at an average 20.6 months following but unrelated to arthroplasty. Overall, total joint arthroplasty can be safely performed and provide good functional outcomes in lung transplant recipients.     

Critical care usage after major gastrointestinal and liver surgery: a prospective,multicentre observational study

Background

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.