Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study.

Study objectiveTo evaluate the effectiveness of preoperative gabapentinoid administration.DesignRetrospective hospital registry study.SettingTertiary referral center (Boston, MA).Patients111,008 adult non-emergency, non-cardiac surgical patients between 2014 and 2018.InterventionsPreoperative administration of gabapentinoids (gabapentin or pregabalin).MeasurementsWe tested the primary hypothesis that preoperative gabapentinoid use was associated with lower odds of hospital readmission within 30 days. Contingent on this hypothesis, we examined whether lower intraoperative opioid utilization mediated this effect. Secondary outcome was postoperative respiratory complications.Main resultsGabapentinoid administration was associated with lower odds of readmission (adjusted odds ratio [OR_adj] 0.80 [95% CI, 0.75–0.85]; p < 0.001). This effect was in part mediated by lower intraoperative opioid utilization in patients receiving gabapentinoids (8.2% [2.4–11.5%]; p = 0.012). Readmissions for gastrointestinal disorders (OR_adj 0.74 [0.60–0.90]; p = 0.003), neuro-psychiatric complications (OR_adj 0.66 [0.49–0.87]; p = 0.004), non-surgical site infections (OR_adj 0.68 [0.52–0.88; p = 0.004) and trauma or poisoning (OR_adj 0.25 [0.16–0.41]; p < 0.001) occurred less frequently in patients receiving gabapentinoids. The risk of postoperative respiratory complications was lower in patients receiving gabapentinoids (OR_adj 0.77 [0.70–0.85]; p < 0.001). Lower doses of pregabalin (< 75 mg) and gabapentin (< 300 mg) compared to both, no and high-dose administration of gabapentinoids, were associated with a lower risk of postoperative respiratory complications (OR_adj 0.61 [0.50–0.75]; p < 0.001 and OR_adj 0.70 [0.53–0.92]; p = 0.012, respectively). These lower gabapentinoid doses prevented 30-day readmission (OR_adj 0.74 [0.65–0.85]; p < 0.001). The results were robust in several sensitivity analyses including surgical procedure defined subgroups and patients undergoing ambulatory surgery.ConclusionsThe preoperative use of pregabalin and gabapentin, up to doses of 75 and 300 mg respectively, mitigates the risks of hospital readmission and postoperative respiratory complications which can in part be explained by lower intraoperative opioid use. Further research is warranted to elucidate mechanisms of the preventive action.     

Preoperative Depression Is Associated With Increased Risk Following Revision Total Joint Arthroplasty

BackgroundThe incidence of revision total hip (rTHA) and knee (rTKA) arthroplasty continues to increase. Preoperative depression is known to influence outcomes following primary arthroplasty. Despite this, it remains unknown whether the same relationship exists for patients undergoing revision procedures. The purpose of this study, therefore, is to investigate this relationship.MethodsThis is a retrospective cohort study. Patients undergoing rTHA and rTKA were identified from the Truven MarketScan database. Patients with a diagnosis of prosthetic joint infection were excluded. Two cohorts were created: those with preoperative depression and those without. We included patients who were enrolled in the database for 1 year preoperatively and postoperatively. Demographic and complication data were collected, and statistical analysis was then performed comparing complications between cohorts.ResultsA total of 10,017 patients undergoing rTHA and 13,973 patients undergoing rTKA were included in this study. Of these, 1305 (13.1%) and 2012 (14.4%) had depression, respectively. Multivariate analysis found that, after rTHA, preoperative depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, prosthetic joint infection, revision surgery, and increased costs (P < .001). Similarly, following rTKA, depression was associated with extended length of stay, nonhome discharge, 90-day readmission, 90-day emergency department visit, revision surgery, and increased costs (P < .001).ConclusionDepression before revision total joint arthroplasty is common and is associated with increased risk of complication and increased healthcare resource utilization following both rTHA and rTKA. Further research will be needed to delineate to what degree this represents a modifiable risk factor.     

A cost analysis of treating postoperative periprosthetic femoral fractures following hip replacement surgery in a UK tertiary referral centre

AimThis study aims to evaluate costs associated with periprosthetic femoral fracture (PFF) treatment at a UK tertiary referral centre.MethodsThis study included 128 consecutive PFFs admitted from 02/04/2014–19/05/2020. Financial data were provided by Patient Level Information and Costing Systems. Primary outcomes were median cost and margin. Secondary outcomes were length of stay, blood transfusion, critical care, 30-day readmission, 2-year local complication, 2-year systemic complication, 2-year reoperation and 30-day mortality rates. Statistical comparisons were made between treatment type. Statistical significance was set at p<0.05.ResultsAcross the cohort, median cost was £15,644.00 (IQR £11,031.00-£22,255.00) and median loss was £3757.50 (£599.20-£8296.20). The highest costs were ward stay (£3994.00, IQR £1,765.00-£7,013.00), theatre utilisation (£2962.00, IQR £0.00-£4,286.00) and overheads (£1705.10, IQR £896.70-£2432.20). Cost (£17,455.00 [IQR, £13,194.00-£23,308.00] versus £7697.00 [IQR £3871.00-£10,847.00], p<0.001) and loss (£4890.00 [IQR £1308.00-£10,009.00] versus £1882.00 [IQR £313.00-£3851.00], p = 0.02) were greater in the operative versus the nonoperative group. There was no difference in cost (£17,634.00 [IQR £12,965.00-£22,958.00] versus £17,399.00 [IQR £13,394.00-£23,404.00], p = 0.98) or loss (£5374.00 [IQR £1950.00-£10,143.00] versus £3860.00 [IQR -£95.50-£7601.00], p = 0.21) between the open reduction and internal fixation (ORIF) and revision groups. More patients required blood transfusion in the operative versus the nonoperative group (17 [17.9%] versus 0 [0.0%], p = 0.009). There was no difference in any clinical outcome between the ORIF and revision groups (p>0.05).ConclusionPFF treatment costs are high with inadequate reimbursement from NHS tariff. Work is needed to address this disparity and reduce hospital costs. Cost should not be used to decide between ORIF and revision surgery.     

Preoperative hyponatremia is associated with postoperative major morbidity,prolonged length of stay,non-home discharge,and readmission in total shoulder arthroplasty

IntroductionHyponatremia is a known risk factor for postoperative complications, but prior research has not investigated its outcomes in patients undergoing total shoulder arthroplasty (TSA). The purpose of this study was to determine the association between preoperative hyponatremia and postoperative 30-day major morbidity, 30-day reoperation, length of stay (LOS), non-home discharge, and 30-day readmission.MethodsPatients undergoing anatomic or reverse TSA from 2012 to 2016 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. A multiple logistic regression model was estimated for associated outcomes. An alpha level of 0.005 was used after accounting for Bonferroni correction.ResultsPrimary analysis of 12,437 patients showed significant independent association of preoperative hyponatremia with 30-day major morbidity (OR = 2.00; 99% CI: 1.46–2.73), LOS greater than the 75th percentile (OR = 1.63; 99% CI: 1.31–2.03), non-home discharge (OR = 1.73; 99% CI: 1.08–2.79), and 30-day readmission (OR = 1.69; 99% CI: 1.08–2.64), but not with 30-day reoperation (OR = 1.55; 99% CI: 0.75–3.19).ConclusionPreoperative hyponatremia in TSA was significantly associated with increased odds of 30-day postoperative major morbidity, prolonged LOS, non-home discharge, and 30-day readmission compared to preoperative normonatremia. These findings emphasize the importance of pre-admission testing prior to undergoing elective orthopedic procedures. Additional research is needed to stratify hyponatremia by severity and measure the impact of correcting hyponatremia in patients planning on undergoing TSA.Level of EvidenceLevel III; Retrospective Study-Defined     

A National Cancer Database analysis of the predictors of unplanned 30-day readmission after proctectomy for rectal adenocarcinoma: The CCF RETURN-30 Score

BackgroundUnplanned 30-day readmission is common after major surgery, including rectal cancer surgery. The present study aimed to assess the rate and predictors of unplanned 30-day readmission after proctectomy for rectal cancer.MethodsThis was a retrospective case-control study using data from the National Cancer Database. Patients with non-metastatic rectal cancer who underwent proctectomy were included, and patients who required readmission within 30 days after discharge were compared to patients who were not readmitted in regard to patient and treatment baseline factors to determine the predictors of 30-day readmission after proctectomy. The main outcome measures were the rate and predictors of 30-day unplanned readmission and the impact of readmission on short-term mortality and overall survival.ResultsA total of 55,181 patients (60.9% men) with a mean age of 61.2 years were included. The 30-day readmission rate was 7.07% (95% confidence interval: 6.9–7.3). A Charlson score of 0 (odds ratio: 0.75, P < .001), Medicare insurance (odds ratio: 0.836, P = .04), and private insurance (odds ratio: 0.73, P = .0003) were predictive of a lower likelihood of 30-day readmission, whereas urban living area (odds ratio: 1.18, P = .01), rural living area (odds ratio: 1.65%, P = .0004), neoadjuvant radiation therapy (odds ratio: 1.37, P = .001), pull-through coloanal anastomosis (odds ratio: 1.37, P = .0005), conversion to open surgery (odds ratio: 1.25, P = .001), and hospital stay ≥6 days (odds ratio: 1.02, P < .001) were predictive of a higher likelihood of 30-day readmission. Readmitted patients had a higher rate of 90-day mortality (3.1% vs 2.1%, P < .001) and a lower 5-year overall survival (67.0% vs 72.7%, P < .001) than non-readmitted patients. Using the weighted ORs of the significant predictors of 30-day readmission, a risk score, the Cleveland Clinic Florida REadmission afTer sUrgery for Rectal caNcer in 30 days (RETURN-30) score, was developed.ConclusionComorbidities, residence in urban or rural areas, neoadjuvant radiation therapy, pull-through coloanal anastomosis, conversion to open surgery, and extended hospital stay were predictive of a higher risk of 30-day readmission. Patients who were readmitted had a higher rate of 90-day mortality and a lower 5-year overall survival.     

Implementing 3D fluoroscopy in the management of tibial plateau fractures: Shorter hospitalization and decline in revision surgery,but increase in the duration of surgery and radiation exposure

BackgroundIntraoperative 3D fluoroscopy (3DRX) is increasingly used in fracture management instead of conventional fluoroscopy (RX), but its effect on the treatment and outcome of tibial plateau fractures (TFs) is not well known. This study aims to evaluate whether the use of 3DRX in the treatment of tibial plateau fractures reduces the number of revision surgeries.MethodsThis retrospective cohort study includes all patients who underwent surgical treatment for TF in a single center from 2014 to 2018. Patient-, fracture-, and treatment characteristics were compared between the 3DRX and RX subgroups. The primary endpoint was the number of patients requiring revision surgery. Secondary endpoints were surgery duration, hospital length of stay, radiation exposure, postoperative complications, and secondary total knee arthroplasty.ResultsEighty-seven patients were included, of which 36 were treated with 3DRX. Three patients in the RX group required revision surgery, while no revision surgery was performed in the 3DRX group (p = 0.265). The use of 3DRX resulted in significantly more intraoperative adjustments (25% versus 6%; p = 0.024) and an increase in surgery duration (by average of 28 min, p = 0.001), without a significant increase in postoperative wound infections (12% versus 19%; p = 0.374) or fracture-related infections (2% versus 2.8%; p = 0.802). The 3DRX group had an average radiation exposure of 7,985 mGy versus 1,273 mGy in the RX group (p<0.001). The hospital length of stay was 1 day shorter in the 3DRX group (5 days versus 4 days; p = 0.058).ConclusionsImplementing 3DRX in treating TFs improves the assessment of fracture alignment and implant position perioperatively, resulting in more intraoperative corrections and no revision surgeries within 6 weeks postoperatively. However, using 3DRX significantly increases perioperative radiation exposure and surgery duration without a significant rise in postoperative infections and a shorter hospital length of stay.     

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database

BackgroundThe aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA.MethodsIn total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications.ResultsCirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls—other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls.ConclusionCirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.     

Transverse posterior wall acetabular fracture pattern is associated with increased risk of periprosthetic joint infection after conversion total hip arthroplasty

IntroductionAcetabular fracture subtypes are associated with varying rates of subsequent conversion total hip arthroplasty (THA) after open reduction internal fixation (ORIF) with transverse posterior wall (TPW) patterns having a higher risk for early conversion. Conversion THA is fraught with complications including increased rates of revision and periprosthetic joint infections (PJI). We aimed to determine if TPW pattern is associated with higher rates of readmissions and complications including PJI after conversion compared to other subtypes.MethodsWe retrospectively reviewed 1,938 acetabular fractures treated with ORIF at our institution from 2005 to 2019, of which 170 underwent conversion that met inclusion criteria, including 80 TPW fracture pattern. Conversion THA outcomes were compared by initial fracture pattern. There was no difference between the TPW and other fracture patterns in age, BMI, comorbidities, surgical variables, length of stay, ICU stay, discharge disposition, or hospital acquired complications related to their initial ORIF procedure. Multivariable analysis was performed to identify independent risk factors for PJI at both 90-days and 1-year after conversion.ResultsTPW fracture had higher risk of PJI after conversion THA at 1-year (16.3% vs 5.6%, p = 0.027). Multivariable analysis revealed TPW independently carried increased risk of 90-day (OR 4.89; 95% CI 1.16–20.52; p = 0.03) and 1-year PJI (OR 6.51; 95% CI 1.56–27.16; p = 0.01) compared to the other acetabular fracture patterns. There was no difference between the fracture cohorts in 90-day or 1-year mechanical complications including dislocation, periprosthetic fracture and revision THA for aseptic etiologies, or 90-day all-cause readmission after the conversion procedure.ConclusionAlthough conversion THA after acetabular ORIF carry high rates of PJI overall, TPW fractures are associated with increased risk for PJI after conversion compared to other fracture patterns at 1-year follow-up. Novel management/treatment of these patients either at the time of ORIF and/or conversion THA procedure are needed to reduce PJI rates.Level of evidenceTherapeutic Level III (retrospective study of consecutive patients undergoing an intervention with analyses of outcomes).     

Opioid use trends in patients undergoing elective thoracic and lumbar spine surgery

BackgroundOpioid use in North America has increased rapidly in recent years. Preoperative opioid use is associated with several negative outcomes. Our objectives were to assess patterns of opioid use over time in Canadian patients who undergo spine surgery and to determine the effect of spine surgery on 1-year postoperative opioid use.MethodsA retrospective analysis was performed on prospectively collected data from the Canadian Spine Outcomes and Research Network for patients undergoing elective thoracic and lumbar surgery. Self-reported opioid use at baseline, before surgery and at 1 year after surgery was compared. Baseline opioid use was compared by age, sex, radiologic diagnosis and presenting complaint. All patients meeting eligibility criteria from 2008 to 2017 were included.ResultsA total of 3134 patients provided baseline opioid use data. No significant change in the proportion of patients taking daily (range 32.3%–38.2%) or intermittent (range 13.7%–22.5%) opioids was found from pre-2014 to 2017. Among patients who waited more than 6 weeks for surgery, the frequency of opioid use did not differ significantly between the baseline and preoperative time points. Significantly more patients using opioids had a chief complaint of back pain or radiculopathy than neurogenic claudication (p < 0.001), and significantly more were under 65 years of age than aged 65 years or older (p < 0.001). Approximately 41% of patients on daily opioids at baseline remained so at 1 year after surgery.ConclusionThese data suggest that additional opioid reduction strategies are needed in the population of patients undergoing elective thoracic and lumbar spine surgery. Spine surgeons can be involved in identifying patients taking opioids preoperatively, emphasizing the risks of continued opioid use and referring patients to appropriate evidence-based treatment programs.     

Are preoperative depression and anxiety associated with patient-reported outcomes,health care payments,and opioid use after anterior discectomy and fusion?

BACKGROUND CONTEXTDepression and anxiety are common psychiatric conditions among US adults, and anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal surgeries. Mental health conditions can affect physical health, and thus have the potential to contribute to adverse outcomes after spine surgery; however, a comprehensive assessment of long-term outcomes and the additive economic burden of these conditions in patients undergoing ACDF has not been well described.PURPOSEOur goal was to assess the associations between depression/anxiety and adverse outcomes and health-resource utilization after anterior cervical discectomy and fusion (ACDF).STUDY DESIGNRetrospective database study.PATIENT SAMPLEWe retrospectively analyzed a private administrative health claims database to identify patients who underwent ACDF in the United States from 2010 to 2013. A total of 16,306 patients met our inclusion criteria. Mean (± standard deviation) patient age was 50±7.9 years. Approximately 4,800 patients (30%) had a depression diagnosis and 4,000 (25%) had a diagnosis of anxiety.OUTCOME MEASURESThe primary outcomes of interest were intensive care unit admission, multiday hospitalization, discharge disposition, 30- and 90-day hospital readmission, 1- and 2-year rates of revision surgery, and chronic postoperative opioid use. Secondary outcomes were 1- and 2-year total cumulative health care payments and cumulative postoperative opioid consumption.METHODSRegression models controlled for demographic and medical covariates, alpha=0.05.RESULTSA preoperative diagnosis of depression was associated with higher odds of multiday hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01–1.19), 90-day readmission (OR 1.71, 95% CI 1.46–2.02), revision surgery within 2 years (OR 1.43 95% CI 1.16–1.76), and chronic postoperative opioid use (OR 1.58, 95% CI 1.45–1.72) and an increase of $5,915 in adjusted 2-year health care payments (p<.001). Patients with a preoperative diagnosis of anxiety had higher odds of multiday hospitalization (OR 1.15, 95% CI 1.06–1.25), revision surgery within 2 years (OR 1.33, 95% CI 1.07–1.65), and chronic postoperative opioid use (OR 1.62, 95% CI 1.48–1.77) and an increase of $4,471 in adjusted 2-year health care payments (p<.001). Neither anxiety nor depression was associated with intensive care unit admission, discharge disposition, 30-day readmission, revision surgery within 1 year, 1-year cumulative health care payments, or cumulative postoperative opioid consumption.CONCLUSIONSPatients with preoperative diagnoses of depression or anxiety have a greater likelihood of adverse outcomes, increased opioid consumption, and increased cumulative health care payments after ACDF compared with patients without depression or anxiety.     

Spinal Versus General Anesthesia in Total Knee Arthroplasty: Are There Differences in Complication and Readmission Rates?

BackgroundSpinal anesthesia (SP) utilization continues to expand in total knee arthroplasty (TKA). However, little is known regarding differences in complication rates between spinal and general anesthesia used for primary TKA. Therefore, the purpose of this study is to compare the length of stay (LOS), operative time, and readmission and revision rates between patients who received spinal and general anesthesia during TKA.MethodsThe American Joint Replacement Registry (AJRR) was used to identify primary elective TKA patients from 2017 to 2020. Patients were divided into 2 cohorts, general (GN) and SP, based on the mode of anesthesia administered during the index surgery. In total, 270,251 TKAs were identified, of which 126,970 (47.0%) received general anesthesia and 143,281 (53.0%) received spinal anesthesia. Length of stay, operative time, 90-day readmission, and 90-day revisions were compared between the 2 groups. Multivariable logistic regression analyses were used to adjust for potential confounders.ResultsAfter accounting for confounding factors, SP was associated with a lower risk of having a LOS greater than 3 days (odds ratio [OR] 0.470, 95% confidence interval [CI] 0.454-0.487, P < .0001), but a slightly higher likelihood of having a longer operative time (OR 1.075, 95% CI 1.056-1.094, P < .0001). SP was also linked to lower rates of 90-day readmission (OR 0.845, 95% CI 0.790-0.904, P < .0001) and lower risk of 90-day all-cause revision (OR 0.506, 95% CI 0.462-0.555, P < .0001).ConclusionSP was associated with a lower 90-day readmission rate and a lower risk of 90-day revision. These findings support the best practice guidelines of The Joint Commission to use spinal anesthesia when possible as part of an enhanced recovery after surgery (ERAS) pathway.     

Factors that predict 30-day readmission after bariatric surgery: experience of a publicly funded Canadian centre

BackgroundHospital readmissions after bariatric surgery can significantly increase health care costs. Rates of readmission after bariatric surgery have ranged from 0.6% to 11.3%, but the rate of complications and the factors that predict readmission have not been well characterized in Canada. The objective of this study was to characterize readmission rates and the factors that predict 30-day readmission in a Canadian centre.MethodsA retrospective study was performed on all patients who underwent bariatric surgery between 2010 and 2015 in a single Canadian centre. Procedures included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB). Prospectively collected data were extracted from an administrative database. Multivariable logistic regression analysis was performed to determine which factors predict 30-day readmission.ResultsA total of 1468 patients had bariatric surgery (51.0% LRYGB, 40.5% LSG, 8.6% LAGB) during the 6-year study period, with an overall 30-day readmission rate of 7.5%. LRYGB was associated with a higher readmission rate (11.4%) than LSG (3.7%) or LAGB (1.6%). Common reasons for readmission were infection (24.8%), pain (17.4%) and nausea or vomiting (10.1%). Multivariable analysis identified 3 factors that independently predicted readmission: length of stay greater than 4 days (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.03–4.63, p = 0.042), LRYGB (OR 5.21, 95% CI 1.19–22.73, p = 0.028) and acute renal failure (OR 14.10, 95% CI 1.07–186.29, p = 0.045).ConclusionReadmissions after bariatric surgery were most commonly caused by potentially preventable factors, such as pain, nausea or vomiting. Strategies to identify and address factors associated with readmission may reduce readmissions and health care costs after bariatric surgery in a publicly funded health care system.     

Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants

Background: Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes.Methods: This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times.Results: Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses.Conclusion: Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.     

Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Knee Arthroplasty: A Review of 3015 Cases

BackgroundA higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.MethodsPatients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.ResultsA total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.ConclusionOverall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay.