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Kang X, Wu J, Xu AY, Su AY, Liu M, Huang J, Zhu W, Zeng C, Duan F, Diebo BG, Daniels AH, He D. Orthostatic Intolerance Following Posterior Lumbar Interbody Fusion: Incidence, Risk Factors, and Impact on Postoperative Recovery - A Prospective Cohort Study. Spine J 2025:S1529-9430(25)00250-5. [PMID: 40349937 DOI: 10.1016/j.spinee.2025.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Revised: 04/21/2025] [Accepted: 05/04/2025] [Indexed: 05/14/2025]
Abstract
BACKGROUND CONTEXT Despite the well-established consensus about the importance of early ambulation, the causes of orthostatic intolerance and its impact on patient recovery after posterior lumbar interbody fusion (PLIF) remain poorly understood. PURPOSE To determine the incidence of orthostatic intolerance and relevant risk factors after PLIF in an enhanced recovery after surgery (ERAS) program. STUDY DESIGN A prospective observational cohort study. PATIENT SAMPLE This study investigated perioperative data collected from 378 patients who underwent PLIF at one center between September 2023 and July 2024. OUTCOME MEASURE Patients' postoperative orthostatic intolerance symptoms were recorded and graded by a standardized evaluation scale. The occurrence of any symptom that resulted in termination of ambulation (dizziness, nausea, vomiting, a feeling of heat, visual disturbances, hypotension, and syncope) was classified as orthostatic intolerance. METHODS Possible risk factors were identified through univariate and multivariate analysis. The length of postoperative hospitalization, catheterization, and ambulation delay in orthostatic intolerance patients versus orthostatic tolerant patients was compared. RESULTS For orthostatic intolerance patients, the median time to first attempted ambulation was 26.0 (IQR: 20.8-31.2) hours after surgery. Overall, the observed incidence of orthostatic intolerance was 15.3%. Univariate analysis showed that a higher incidence of orthostatic intolerance was associated with history of orthostatic intolerance (6 vs 13, P=0.044), low hemoglobin on postoperative day 1 (103.8±14.8g/L vs 110.7±13.3g/L, P<0.001), and high postoperative back pain visual analog scale (VAS) scores while supine [4.0 (2.0) (4.0±1.8) vs 3.0 (1.0) (3.4±1.8), P=0.015]. Multivariate analysis through logistic regression controlling for covariates established the same three variables as independent risk factors: history of orthostatic intolerance (OR=3.029, 95% CI 1.021-8.988, P=0.046), low hemoglobin on postoperative day 1 (OR=2.890, 95% CI 1.566-5.334, P<0.001), and high postoperative back pain VAS scores while supine (OR=1.218, 95% CI 1.030-1.441, P=0.021). Overall, orthostatic intolerance patients had a longer postoperative hospital stay [6.0 (2.0) (6.3±1.8) vs 6.0 (2.0) (5.8±1.8), P=0.013], catheterization period [24.1 (5.2) (26.0±8.9) vs 22.6 (4.7) (22.8±4.0), P=0.042], and ambulation delay [48.2 (6.3) (48.7±7.8) vs 25.0 (4.5) (25.0±3.9), P<0.001] than orthostatic tolerance patients. However, there were no clinically meaningful differences regarding postoperative hospital stay or catheterization period found between the two groups in this study. CONCLUSIONS Orthostatic intolerance is a common complication that prevents early ambulation in ERAS programs after PLIF. Careful monitoring of postoperative hemoglobin levels and administration of postoperative analgesia may reduce the incidence of orthostatic intolerance and promote early ambulation.
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Affiliation(s)
- Xiaoxia Kang
- Department of Spine Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Jiayuan Wu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China; Laboratory for Clinical Medicine, Capital Medical University.
| | - Andrew Y Xu
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Audrey Y Su
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Mingming Liu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China; Laboratory for Clinical Medicine, Capital Medical University
| | - Jie Huang
- Department of Spine Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Wenli Zhu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Cheng Zeng
- Department of Spine Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China; Laboratory for Clinical Medicine, Capital Medical University
| | - Fangfang Duan
- Epidemiological Research Department, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Da He
- Department of Spine Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China; Laboratory for Clinical Medicine, Capital Medical University.
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Cammerman AC, Haslam DW, Currigan DA, Lennon MJ. A randomised trial to assess the impact of midodrine on early mobilisation after elective primary hip replacement surgery. Anaesth Intensive Care 2025; 53:151-160. [PMID: 39921403 DOI: 10.1177/0310057x241290536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2025]
Abstract
Early mobilisation following elective total hip arthroplasty (THA) facilitates quicker rehabilitation, and reduces complications and hospital length of stay. Reasons for delayed mobilisation are multifactorial, but the most common cause is orthostatic intolerance. Midodrine, an oral alpha-1 agonist, is used off-label for perioperative hypotension. However, there are few randomised trials assessing its use in the perioperative setting to improve patient outcomes. The aim of the study was to determine whether midodrine improves early mobilisation following primary THA, and whether this relates to reduced orthostatic intolerance. This prospective, triple-blinded, multicentre study involved 42 patients randomised to either placebo or 20 mg midodrine, 2 h before physiotherapy, on Day 1 postoperatively. The inclusion criteria were adults undergoing elective unilateral THA under spinal anaesthesia. The primary endpoint was the ability to walk 5 m with physiotherapists. Secondary endpoints included the incidence of orthostatic intolerance and hypotension. A preplanned interim analysis showed no statistical difference in ability to mobilise 5 m (78.26% vs 78.95%, P = 1.0). There was no statistically significant difference in the incidence of orthostatic intolerance between the groups 17.4% vs 31.6% (P = 0.45). Pre-emptive use of midodrine did not improve patient mobilisation the morning after elective primary THA and had no significant effect on the incidence of orthostatic hypotension.
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Affiliation(s)
- Adam C Cammerman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Perth WA 6009
| | - Daniel Wl Haslam
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Perth WA 6009
- North West School of Anaesthesia, Royal College of Anaesthetists, Manchester, UK
| | - Dale A Currigan
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Perth WA 6009
- Senior Lecturer, University of Western Australia, Perth WA
| | - Mark J Lennon
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Perth WA 6009
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Dong J, Wei K, Cao J, Wu GM, Min S. Effects of Blood Pressure Management Based on Non-Invasive Heart Function Monitoring on Reducing Postoperative Hypotension in Elderly Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial. J Arthroplasty 2025:S0883-5403(25)00100-7. [PMID: 39894376 DOI: 10.1016/j.arth.2025.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Revised: 01/25/2025] [Accepted: 01/27/2025] [Indexed: 02/04/2025] Open
Abstract
BACKGROUND Postoperative hypotension is a common symptom in elderly patients undergoing total knee arthroplasty (TKA), which is associated with intraoperative blood pressure (BP) management. The study aimed to explore the causes of perioperative hypotension in TKA elderly patients and analyze the effects of BP management strategies based on noninvasive heart function monitoring on reducing postoperative hypotension. METHODS A total of 176 elderly TKA patients were divided into four groups: the tourniquet group (group T), the nontourniquet group (group N), the goal-oriented BP management tourniquet group (group GT), and the goal-oriented BP management nontourniquet group (group GN). Patients in groups T and GT received TKA with a tourniquet. The BP of patients in groups GT and GN was maintained based on noninvasive heart function monitoring. The mean arterial pressure (MAP), index of cardiac contractility (ICON), stroke volume (SV), and other circulatory indicators were measured using the noninvasive cardiometer monitor at five time points, including before anesthesia (T1), after anesthesia (T2), after completion of the osteotomy (T3), after suturing (T4), and after leaving the postanesthesia care unit (T5). The frequency of postoperative hypotension within 24 hours was recorded, and the incidence of hypotension was calculated. RESULTS The ICON, SV, and MAP were lower in groups N and GN than in groups T and GT at T3 (P < 0.05). The ICON, SV, and MAP were lower in group N than in groups GN at T4 and T5 (P < 0.05), and no significant difference was observed between groups T and GT (P > 0.05). The incidence of postoperative hypotension within 24 hours was higher in group N (47.1%) (P = 0.007) than in group GN (21.6%), group T (19.4%), and group GT (14.8%). CONCLUSIONS Postoperative hypotension in elderly patients undergoing TKA with a nontourniquet was associated with decreased myocardial contractility. Enhancing myocardial contractility based on non-invasive cardiac function monitoring reduced the incidence of postoperative hypotension.
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Affiliation(s)
- Jun Dong
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ke Wei
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Cao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang M Wu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Tam PK, Ramamurthy G, Rawat L, Huang S, Lim JH. Prevalence and Outcomes of Orthostatic Hypotension in Hemorrhagic Stroke Patients During Hospitalization. Neurol Int 2024; 16:1878-1886. [PMID: 39728760 DOI: 10.3390/neurolint16060134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2024] [Revised: 12/14/2024] [Accepted: 12/18/2024] [Indexed: 12/28/2024] Open
Abstract
BACKGROUND/OBJECTIVES Orthostatic hypotension (OH) is highly prevalent in hospitalized patients and can lead to major consequences. The prevalence of OH among patients with stroke has also been reported to be high in in-patient cohorts. However, no previous analysis has focused exclusively on patients with hemorrhagic stroke, a group that may have a different disease profile, including a greater need for blood pressure control and surgical intervention. This study aims to examine the prevalence of OH, its risk factors, and potential impact in patients who were hospitalized due to hemorrhagic stroke. METHODS A retrospective analysis of in-patient records between 1 January 2021 and 30 April 2023 was conducted for patients with stroke due to intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) who were referred to rehabilitation at a tertiary hospital in Singapore. OH was defined as a drop in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg during the sit-up test as part of the rehabilitation assessment. Additional data collected included demographic information, length of stay, antihypertensive medications used at the time of assessment, comorbidities, and discharge functional outcomes as measured by a modified Rankin Scale. RESULTS A total of 77 patients (65 [84.4%] with ICH and 12 [15.6%] with SAH) were included in the analysis. The prevalence of OH was 37.7%. A history of surgical intervention was identified as the major risk factor for the development of OH (odds ratio 4.28, 95% confidence interval 1.37 to 13.35, p = 0.009). There was no difference in hospital length of stay or discharge modified Rankin Scale scores between the two groups. CONCLUSIONS OH was frequently observed among patients with hemorrhagic stroke during the acute/subacute stage and should be monitored, especially in patients who require surgical intervention.
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Affiliation(s)
- Pui Kit Tam
- Division of Rehabilitation Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117549, Singapore
| | - Guhan Ramamurthy
- BG Institute of Neurosciences, BG Hospital, Tiruchendur, Tuticorin 628216, Tamil Nadu, India
| | - Lavanya Rawat
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117549, Singapore
| | - Serene Huang
- Division of Rehabilitation Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
| | - Jeong Hoon Lim
- Division of Rehabilitation Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117549, Singapore
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Fudeyasu K, Kamiya S, Taito S, Nakashima Y, Asaeda M, Kato T, Toyota Y, Kitano H, Hinata N, Ohno H, Mikami Y. Circulatory characteristics of early mobilization after surgery for bilateral pheochromocytoma: a case report. J Med Case Rep 2024; 18:529. [PMID: 39478603 PMCID: PMC11526685 DOI: 10.1186/s13256-024-04833-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 09/10/2024] [Indexed: 11/02/2024] Open
Abstract
BACKGROUND Surgical treatment of pheochromocytomas is associated with circulatory dynamics instability, necessitating systemic management of the patient in the intensive care unit after surgery. Early mobilization after pheochromocytoma surgery is not described in the guidelines, and to our knowledge, no reports have specifically focused on circulatory dynamics during early mobilization after surgery. CASE PRESENTATION A 31-year-old Japanese woman was diagnosed with bilateral pheochromocytoma and underwent a second-stage adrenalectomy for bilateral pheochromocytoma at our hospital. We evaluated circulatory dynamics during a passive upright posture on postoperative days 1 and 4. She was placed on a tilt bed in the supine position (0° head) for 15 min, passive upright posture (60°) for 15 min, and supine position again for 10 min. In the passive upright posture, both systolic and diastolic blood pressure decreased, and the heart rate increased by 10 bpm over approximately 10 minutes. After the postural change from the passive upright posture to the supine position, the heart rate decreased to a level lower than in the supine prior to the passive upright posture. The same measurements were taken on postoperative day 4. Systolic blood pressure decreased in the passive upright posture, but diastolic blood pressure remained unchanged. The heart rate also increased earlier after passive upright posture compared with that on the day after surgery. When the patient returned to the supine position from the passive upright posture, the heart rate decreased even further compared with its level prior to the passive upright posture, as observed on the day after surgery. CONCLUSION Circulatory dynamics may fluctuate after surgery for pheochromocytoma due to a relative decrease in epinephrine and norepinephrine secretion. In this case, the patient's response may be close to normal by the fourth postoperative day, but circulatory dynamics fluctuations were noted on both the first and fourth postoperative days when the patient was supine after passive upright posture. Although the substantial variability of perioperative circulatory dynamics in patients with pheochromocytoma has improved considerably with the development of perioperative management guidelines, circulatory dynamics should be carefully monitored during early mobilization and after its completion.
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Affiliation(s)
- Kenichi Fudeyasu
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Satoshi Kamiya
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan.
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Yuki Nakashima
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Makoto Asaeda
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Takahiro Kato
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Yukari Toyota
- Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Hiroyuki Kitano
- Department of Urology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Nobuyuki Hinata
- Department of Urology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Haruya Ohno
- Endocrinology and Diabetic Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
| | - Yukio Mikami
- Department of Rehabilitation Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami, Hiroshima, 734-8551, Japan
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Nozawa Y, Harada K, Noma K, Katayama Y, Hamada M, Ozaki T. Association Between Early Mobilization and Postoperative Pneumonia Following Robot-assisted Minimally Invasive Esophagectomy in Patients with Thoracic Esophageal Squamous Cell Carcinoma. Phys Ther Res 2024; 27:121-127. [PMID: 39866387 PMCID: PMC11756562 DOI: 10.1298/ptr.e10293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/31/2024] [Indexed: 01/28/2025]
Abstract
OBJECTIVE The objective of this study was to confirm that early mobilization (EM) could reduce pneumonia in patients undergoing robot-assisted minimally invasive esophagectomy (RAMIE) for thoracic esophageal squamous cell carcinoma (TESCC). METHODS Postoperative pneumonia was defined as physician-diagnosed pneumonia using the Esophagectomy Complications Consensus Group definition of pneumonia with a Clavien-Dindo classification grade II-V on postoperative day (POD) 3-5. EM was defined as achieving an ICU Mobility Scale (IMS) ≥7 by POD 2. Patients were divided into EM (n = 36) and non-EM (n = 35) groups. Barriers to EM included pain, orthostatic intolerance (OI), and orthostatic hypotension. RESULTS The overall incidence of postoperative pneumonia was 12.7%, with a significant difference between the EM (2.8%) and non-EM (22.9%) groups (P = 0.014). The odds ratio was 0.098 in the EM group compared to the non-EM group. A significant difference was found between the two groups in terms of the barriers to EM at POD 2 only for OI, with a higher incidence in the non-EM group. Multivariate logistic regression analysis showed that patients with OI were more likely to be unable to achieve EM than those without OI (odds ratio, 7.030; P = 0.006). CONCLUSION EM within POD 2 may reduce the incidence of postoperative pneumonia in patients undergoing RAMIE for TESCC. Furthermore, it was suggested that OI can have a negative impact on the EM after RAMIE.
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Affiliation(s)
- Yasuaki Nozawa
- Division of Physical Medicine and Rehabilitation, Okayama University Hospital, Japan
| | - Kazuhiro Harada
- Graduate School of Health Science Studies, Kibi International University, Japan
| | - Kazuhiro Noma
- Department of Gastroenterological Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Japan
| | - Yoshimi Katayama
- Division of Physical Medicine and Rehabilitation, Okayama University Hospital, Japan
| | - Masanori Hamada
- Division of Physical Medicine and Rehabilitation, Okayama University Hospital, Japan
| | - Toshifumi Ozaki
- Division of Physical Medicine and Rehabilitation, Okayama University Hospital, Japan
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Yi H, Tang W, Shen Y, Tan L, Zeng F, Yang S. Orthostatic intolerance during early mobilization following thoracoscopic lung resection: a prospective observational study. BMC Surg 2024; 24:265. [PMID: 39285467 PMCID: PMC11403817 DOI: 10.1186/s12893-024-02556-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 09/03/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Early postoperative mobilization is important for enhanced recovery but can be hindered by orthostatic intolerance. However, study on postoperative orthostatic intolerance in thoracoscopic lung resection is limited. Thus, this investigation aims to examine the prevalence and variables contributing to orthostatic intolerance on the first day following thoracoscopic lung cancer resection. METHODS A prospective observational study was conducted from February 01 to May 05, 2023, at the First Affiliated Hospital of Chongqing Medical University. Typically, 215 subjects subjected to thoracoscopic lung resection were enrolled in this study. Their general information, disease, and treatment information were collected, and the occurrence of orthostatic intolerance was recorded. RESULTS Typically, 64 patients (29.77%) demonstrated orthostatic intolerance during early mobilization, and 43.75% failed to walk. The prevalence of nausea, dizziness, and impaired vision was 60.94%, 92.19%, and 25.00%, respectively, and no patient experienced syncope. The factors shown to be independently linked with orthostatic intolerance were being female (OR = 2.98, 1.53 to 5.82) and high pain level during sitting (OR = 2.69, 1.79 to 4.04). Individuals with orthostatic intolerance had a longer postoperative hospital stay with a mean of 5.42 days against 4.25 days (p = 0.003). CONCLUSIONS Orthostatic intolerance was prevalent following thoracoscopic lung cancer resection and affected patients' capability to mobilize and prolonged postoperative hospitalization. Being female and having high pain levels during sitting were identified as independent factors for orthostatic intolerance. This suggests that more emphasis should be given to risky patients, and for these groups, we may optimize pain management to adjust the risk of emerging orthostatic intolerance, facilitating early mobilization and early postoperative rehabilitation.
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Affiliation(s)
- Hongjie Yi
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenfeng Tang
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, No.1, Youyi Road, Yuzhong District, Chongqing, 400016, China.
| | - Ying Shen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Tan
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fanshu Zeng
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, No.1, Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Siqi Yang
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, No.1, Youyi Road, Yuzhong District, Chongqing, 400016, China
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Frandsen MN, Varnum C, Foss NB, Mehlsen J, Kehlet H. Time-course of heart rate variability after total hip arthroplasty. J Clin Monit Comput 2024; 38:423-432. [PMID: 37052614 PMCID: PMC10995030 DOI: 10.1007/s10877-023-00992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/03/2023] [Indexed: 04/14/2023]
Abstract
Heart rate variability (HRV) is a measure of the autonomic nervous system function and possibly related to postoperative outcome. Despite several HRV studies in different surgical settings, optimal indices and timepoints for measuring have not been adequately determined. Consequently, there is a need for detailed descriptive procedure-specific studies on the time-course of perioperative HRV within a modern fast-track surgical setting. We measured HRV continuously in 24 patients from 4 days before until 9 days after total hip arthroplasty (THA). Statistical methods included mainly ANOVA and t-tests or Kruskal-Wallis and pairwise Wilcoxon test. Patients completed the Orthostatic Discriminant and Severity Scale five times during the study describing autonomic nervous system dysfunction. Standard deviation between normal-to-normal beats and the total power of HRV were reduced for at least 9 days following THA, with a trend towards increased HRV leading up to the day of surgery. The balance between low- and high-frequency power of HRV was reduced in the postoperative evenings. There was increased orthostatic intolerance symptoms on the first postoperative day, with symptoms of pain, fatigue and weakness decreasing after the first postoperative day. Median hospital stay was 1 day. We provide the first detailed description of perioperative time-course of HRV and orthostatic symptoms in fast-track THA, showing reduced HRV after surgery for at least a week, and that HRV changes are sensitive to time of day and timing before and after surgery. These results are helpful in designing future HRV studies in perioperative risk assessment and outcome.
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Affiliation(s)
- Mikkel Nicklas Frandsen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Claus Varnum
- Department of Orthopedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | - Nicolai Bang Foss
- Department of Anesthesia and Intensive Care, Hvidovre University Hospital, Hvidovre, Denmark
| | - Jesper Mehlsen
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Hristovska AM, Andersen LB, Uldall-Hansen B, Kehlet H, Troelsen A, Gromov K, Foss NB. Postoperative orthostatic intolerance following fast-track unicompartmental knee arthroplasty: incidence and hemodynamics-a prospective observational cohort study. J Orthop Surg Res 2024; 19:214. [PMID: 38561817 PMCID: PMC10983746 DOI: 10.1186/s13018-024-04639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Early postoperative mobilization is essential for early functional recovery but can be inhibited by postoperative orthostatic intolerance (OI). Postoperative OI is common after major surgery, such as total knee arthroplasty (TKA). However, limited data are available after less extensive surgery, such as unicompartmental knee arthroplasty (UKA). We, therefore, investigated the incidence of OI as well as cardiovascular and tissue oxygenation responses during early mobilization after UKA. METHODS This prospective single-centre observational study included 32 patients undergoing primary UKA. Incidence of OI and cardiovascular and tissue oxygenation responses during mobilization were evaluated preoperatively, at 6 and 24 h after surgery. Perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain during mobilization and opioid usage were recorded. RESULTS During mobilization at 6 h after surgery, 4 (14%, 95%CI 4-33%) patients experienced OI; however, no patients terminated the mobilization procedure prematurely. Dizziness and feeling of heat were the most common symptoms. OI was associated with attenuated systolic and mean arterial blood pressure responses in the sitting position (all p < 0.05). At 24 h after surgery, 24 (75%) patients had already been discharged, including three of the four patients with early OI. Only five patients were available for measurements, two of whom experienced OI; one terminated the mobilization procedure due to intolerable symptoms. We observed no statistically significant differences in perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain, or opioid usage between orthostatic intolerant and tolerant patients. CONCLUSIONS The incidence of orthostatic intolerance after fast-track unicompartmental knee arthroplasty is low (~ 15%) and is associated with decreased orthostatic pressure responses. Compared to the previously described orthostatic intolerance incidence of ~ 40% following total knee arthroplasty, early orthostatic intolerance is uncommon after unicompartmental knee arthroplasty, suggesting a procedure-specific component. TRIAL REGISTRATION Prospectively registered at ClinicalTrials.gov; registration number: NCT04195360, registration date: 13.12.2019.
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Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark.
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
| | - Bodil Uldall-Hansen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
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Nag DS, Swain A, Sahu S, Sahoo A, Wadhwa G. Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes. World J Clin Cases 2024; 12:1549-1554. [PMID: 38576736 PMCID: PMC10989428 DOI: 10.12998/wjcc.v12.i9.1549] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/26/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024] Open
Abstract
Knee osteoarthritis is a degenerative disorder of the knee, which leads to joint pain, stiffness, and inactivity and significantly affects the quality of life. With an increased prevalence of obesity and greater life expectancies, total knee arthroplasty (TKA) is now one of the major arthroplasty surgeries performed for knee osteoarthritis. When enhanced recovery after surgery (ERAS) was introduced in TKA, clinical outcomes were enhanced and the economic burden on the healthcare system was reduced. ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response. ERAS aims to enhance the recovery phase, which encompasses multidisciplinary strategies at every step of perioperative care, including the rehabilitation phase. Implementation of ERAS in TKA aids in reducing the length of hospital stay, improving pain management, reducing perioperative complications, and enhancing patient satisfaction. Multidisciplinary collaboration, integrating the expertise of anesthesiologists, orthopedic surgeons, nursing personnel, and other healthcare professionals, is the cornerstone of ERAS in patients undergoing TKA.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Seelora Sahu
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Ayaskant Sahoo
- Department of Anaesthesiology, Manipal Tata Medical College, Jamshedpur 831001, India
| | - Gunjan Wadhwa
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
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Hristovska AM, Uldall-Hansen B, Mehlsen J, Andersen LB, Kehlet H, Foss NB. Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study. Can J Anaesth 2023; 70:1587-1599. [PMID: 37752379 PMCID: PMC10600298 DOI: 10.1007/s12630-023-02556-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 09/28/2023] Open
Abstract
PURPOSE Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids. METHODS This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation. RESULTS Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia. CONCLUSION We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain. STUDY REGISTRATION ClinicalTrials.gov (NCT04499664); registered 5 August 2020.
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Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark.
| | - Bodil Uldall-Hansen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Jesper Mehlsen
- Department of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
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12
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Van Egmond JC, De Esch NHH, Verburg H, Van Dasselaar NT, Mathijssen NMC. Preoperative carbohydrate drink in fast-track primary total knee arthroplasty: a randomized controlled trial of 168 patients. Acta Orthop Belg 2023; 89:485-490. [PMID: 37935233 DOI: 10.52628/89.3.11930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
A key component in fast-track total knee arthroplasty (TKA) is early mobilization. Preoperative fasting might cause orthostatic hypotension and -intolerance which both can interfere with early mobilization. It was hypothesized that consuming a carbohydrate drink 2-3 hours prior to surgery is a viable option to reduce orthostatic hypotension, and as a result, improve rehabilitation. In this randomized controlled trial, all consecutive unilateral primary TKA patients were reviewed for eligibility. Exclusion criteria were American Society of Anesthesiologists (ASA) class above 3, older than 80 years of age, Diabetes Mellitus, and an insufficient comment of Dutch language. Patients were distributed in two groups. The control group was allowed to eat till 6 hours and drink clear fluids till 2 hours before surgery (standard treatment). The intervention group consumed, additionally to the standard treatment, a carbohydrate drink 2-3 hours before surgery. Blood pressure was measured both lying and standing as a measure for orthostatic hypotension during first time postoperative mobilization on day of surgery. A total of 168 patients were included. Prevalence of orthostatic hypotension in the control- and intervention group was 24 patients (34%) and 14 patients (19%) respectively, (p=0.05). Prevalence of orthostatic intolerance was 13 patients (19%) in the control group and 9 patients (13%) in the intervention group (p=0.32). No drink related adverse events occurred. In conclusion, taking a carbohydrate drink 2-3 hours before TKA significantly lowers the number of patients with orthostatic hypotension in early mobilization. However, the clinical relevance of the carbohydrate drink has to be studied further.
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Gobezie NZ, Endalew NS, Tawuye HY, Aytolign HA. Prevalence and associated factors of postoperative orthostatic intolerance at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022: cross sectional study. BMC Surg 2023; 23:108. [PMID: 37127603 PMCID: PMC10150513 DOI: 10.1186/s12893-023-02015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/24/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Postoperative orthostatic intolerance is an inability to maintain an upright position because of symptoms of cerebral hypoperfusion. It is a common problem in the early postoperative period and hinders early mobilization, however, there is limited information about factors associated with it. Thus, the main aim of this study was to determine the prevalence and identify factors associated with postoperative orthostatic intolerance. METHOD Hospital based cross-sectional study was conducted from April 08 to July 20, 2022, at University of Gondar comprehensive Specialized Hospital. A semi-structured questionnaire containing sociodemographic variables and perioperative factors related to anesthesia and surgery was used for data collection. The presence of postoperative orthostatic intolerance during the first ambulation was evaluated with a standardized symptom checklist which contains symptoms of orthostatic intolerance. Binary logistic regression analysis was performed to assess factors associated with postoperative orthostatic intolerance. In multivariable regression, variables with P-value < 0.05 were considered statistically significant. RESULT A total of 420 patients were included in this study with a response rate of 99.06%. Postoperative orthostatic intolerance was experienced in 254 (60.5%) participants. Being female (AOR = 2.27; 95% CI = 1.06-4.86), low BMI (AOR = 0.79; 95% CI = 0.71-0.95), ASA II and above (AOR = 3.34; 95% CI = 1.34-8.28), low diastolic blood pressure (AOR = 0.82; 95% CI = 0.88-0.99), general anesthesia (AOR = 3.26, 95% CI = 1.31-8.12), high intraoperative blood lose (AOR = 0.93, 95% CI = 0.88-0.99), high postoperative fluid intake (AOR = 2.09, 95% CI = 1.23-3.55), pain before ambulation (AOR = 1.99, 95% CI = 1.28-3.11) and pain during ambulation (AOR = 1.82, 95% CI = 1.23-2.69) were the significant factors associated with orthostatic intolerance. CONCLUSION Our study revealed that postoperative orthostatic intolerance was experienced in nearly two-thirds of participants. During the time of ambulation, assessing patients for the presence of orthostatic intolerance is necessary to reduce the adverse effects of postoperative OI. In addition, maintaining preoperative normotension, reducing intraoperative blood loss and optimizing postoperative pain control is recommended to reduce the risk of postoperative orthostatic intolerance.
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Affiliation(s)
- Negesse Zurbachew Gobezie
- Department of Anesthesia, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Nigussie Simeneh Endalew
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Hailu Yimer Tawuye
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Habtu Adane Aytolign
- Department of Anesthesia, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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Hristovska AM, Uldall-Hansen B, Mehlsen J, Kehlet H, Foss NB. Orthostatic intolerance after intravenous administration of morphine: incidence, haemodynamics and heart rate variability analysis. Anaesthesia 2023; 78:526-528. [PMID: 36517996 DOI: 10.1111/anae.15945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - J Mehlsen
- Copenhagen University Hospital, Copenhagen, Denmark
| | - H Kehlet
- Copenhagen University Hospital, Copenhagen, Denmark
| | - N B Foss
- Copenhagen University Hospital, Copenhagen, Denmark
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15
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Cheng GHM, Tan GKY, Kamarudin MFB, Lee BWW, Mei YY, Tan KG. Steroids Significantly Decrease Postoperative Postural Hypotension in Total Knee Replacement. J Knee Surg 2023; 36:208-215. [PMID: 34237779 DOI: 10.1055/s-0041-1731722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total knee replacement (TKR) is one of the most common orthopaedic procedures performed, and enhanced recovery after surgery (ERAS) has been developed and incorporated into inpatient surgical pathways to improve patient outcomes. Under ERAS recommendations, multimodal prophylaxis has been used to help manage postoperative nausea and vomiting (PONV) following TKR. Dexamethasone is one of the commonly used for this and the anti-inflammatory properties could depress vagal activity, reducing postural hypotension (PH). The hypothesis of this study is that postoperative dexamethasone use is associated with lower rates of early postoperative PH following TKR surgery. In our institution, patients who undergo elective primary TKR are admitted on the day of surgery and follow a standardized ERAS protocol. Data on patients who underwent elective primary TKR under a single adult reconstruction team from September 2017 to March 2020 were reviewed and analyzed. A review of demographic characteristics, surgical data, postoperative medications, and postoperative notes was performed. Binary logistic regression was used to assess the effect of the use of dexamethasone on PH, with an adjusted odds ratio (OR) calculated after accounting for potential confounders. Of the 149 patients were included in the study, 78 had dexamethasone postoperatively, and 71 did not. Patients who had received dexamethasone were statistically less likely to suffer from PH (OR = 0.31, p = 0.03) and less likely to develop PONV (OR = 0.21, p = 0.006). Patients who had received dexamethasone were more likely able to participate in early physiotherapy (OR = 2.42, p = 0.14), and this result was statistically insignificant. The use of postoperative intravenous dexamethasone is significantly associated with lower rates of postoperative PH after TKR. However, more studies are required to assess the optimal dosing amount and frequency, as well as to assess other factors which can enhance early postoperative patient mobilization as part of our goals for ERAS. This therapeutic study reflects level of evidence III.
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Affiliation(s)
- Gloria H M Cheng
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Gabriel K Y Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Bryan W W Lee
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yap Yan Mei
- Department of Physiotherapy, Tan Tock Seng Hospital, Singapore
| | - Kelvin G Tan
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Rodriguez S, Shen TS, Lebrun DG, Della Valle AG, Ast MP, Rodriguez JA. Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors. Bone Jt Open 2022; 3:684-691. [PMID: 36047458 PMCID: PMC9533240 DOI: 10.1302/2633-1462.39.bjo-2022-0106.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aims The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691.
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Affiliation(s)
- Samuel Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Tony S. Shen
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Drake G. Lebrun
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Alejandro G. Della Valle
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Michael P. Ast
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Jose A. Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
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Shahi P, Vaishnav AS, Melissaridou D, Sivaganesan A, Sarmiento JM, Urakawa H, Araghi K, Shinn DJ, Song J, Dalal SS, Iyer S, Sheha ED, Dowdell JE, Qureshi SA. Factors Causing Delay in Discharge in Patients Eligible for Ambulatory Lumbar Fusion Surgery. Spine (Phila Pa 1976) 2022; 47:1137-1144. [PMID: 35797654 DOI: 10.1097/brs.0000000000004380] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF). SUMMARY OF BACKGROUND DATA Assessing postoperative inefficiencies is vital to increase the feasibility of ALF. MATERIALS AND METHODS Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge. RESULTS Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS. CONCLUSIONS Unavailability of PT, surgery after 1 pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Pratyush Shahi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Avani S Vaishnav
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | | | - Ahilan Sivaganesan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA
| | - Jose M Sarmiento
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Hikari Urakawa
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Kasra Araghi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Daniel J Shinn
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Junho Song
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sidhant S Dalal
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sravisht Iyer
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Evan D Sheha
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - James E Dowdell
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz A Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
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18
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Hristovska AM, Andersen LB, Grentoft M, Mehlsen J, Gromov K, Kehlet H, Foss NB. Orthostatic intolerance after fast-track knee arthroplasty: Incidence and hemodynamic pathophysiology. Acta Anaesthesiol Scand 2022; 66:934-943. [PMID: 35680697 DOI: 10.1111/aas.14098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early postoperative mobilization can be hindered by orthostatic intolerance (OI) due to failed orthostatic cardiovascular regulation. The underlying mechanisms are not fully understood and specific data after total knee arthroplasty (TKA) are lacking. Therefore, we evaluated the incidence of OI and the cardiovascular response to mobilization in fast-track TKA. METHODS This prospective observational cohort study included 45 patients scheduled for primary TKA in spinal anesthesia with a multimodal opioid-sparing analgesic regime. OI and the cardiovascular response to sitting and standing were evaluated with a standardized mobilization procedure preoperatively, and at 6h and 24h postoperatively. Hemodynamic variables were measured non-invasively (LiDCO™ Rapid). Perioperative bleeding, fluid balance, surgery duration, postoperative hemoglobin, opioid use and pain during mobilization were recorded. RESULTS Eighteen (44%) and 8 (22%) patients demonstrated OI at 6 and 24h after surgery respectively. Four (10%) and 2 (5%) patients experienced severe OI and terminated the mobilization procedure prematurely. Dizziness was the most common OI symptom during mobilization at 6h. OI was associated with decreased orthostatic responses in systolic, diastolic, mean arterial pressures and heart rate (all p<0.05), while severe OI patients demonstrated impaired diastolic, mean arterial pressures, heart rate and cardiac output responses (all p<0.05). No statistically significant differences in perioperative bleeding, fluid balance, surgery duration, postoperative hemoglobin, pain or opioid use were observed between orthostatic tolerant and intolerant patients. CONCLUSION Early postoperative OI is common following fast-track TKA. Pathophysiologic mechanisms include impaired orthostatic cardiovascular responses. The progression to severe OI symptoms appears to be primarily due to inadequate heart rate response.
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Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Mette Grentoft
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Jesper Mehlsen
- Department of Surgical Pathophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Surgical Pathophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
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19
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Incidence and Risk Factors of Orthostasis After Primary Hip and Knee Arthroplasty. J Arthroplasty 2022; 37:S70-S75. [PMID: 35210145 DOI: 10.1016/j.arth.2022.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/04/2022] [Accepted: 01/15/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Postoperative orthostatic intolerance can limit mobilization after hip and knee arthroplasty. The literature is lacking on the incidence and risk factors associated with orthostatic intolerance after elective arthroplasty. METHODS A retrospective case-control study of primary total hip, total knee, and unicompartmental knee arthroplasty patients was conducted. Patients with orthostatic events were identified, and potential demographic and perioperative risk factors were recorded. Orthostatic intolerance was defined as postoperative syncope, lightheadedness, or dizziness, limiting ambulation and/or requiring medical treatment. Statistical analysis was completed using Pearson's chi-square test for categorical data and t-tests for continuous data. Binary logistic regression was performed. RESULTS A total of 500 consecutive patients were included. The overall incidence of orthostatic intolerance was 18%; 25% in total hip arthroplasty (THA) and 11% in total knee arthroplasty. On univariate analysis, significant risk factors for developing postoperative orthostatic intolerance include older age, female gender, THA surgery, lower American Society of Anesthesiologists class, absence of recreational drug use, lower estimated blood volume, lower preoperative diastolic blood pressure, spinal with monitored anesthesia care (MAC), posterior approach for THA, bupivacaine use in spinal, percent of blood loss, postoperative oxycodone or tramadol use, higher postoperative intravenous fluid volume, and lower postoperative hemoglobin. Multivariate analysis demonstrated persistent significance of female gender, THA surgery, spinal with MAC, bupivacaine use in spinal, and more intravenous fluid administered postoperatively. CONCLUSION Orthostatic intolerance affects a significant number of arthroplasty patients. Awareness of risk factors and modification of perioperative variables linked to orthostatic intolerance may assist the surgeon in choosing the appropriate surgical setting, educating patients, and improving early postoperative recovery.
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Hardy PJ, Tavano A, Jacquet SV, Monseur JJ, Bastin ML, Kohnen LP, Haumann AE, Joris JL. The impact of orthostatic intolerance on early ambulation following abdominal surgery in an enhanced recovery programme. Acta Anaesthesiol Scand 2022; 66:454-462. [PMID: 35118648 DOI: 10.1111/aas.14034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/09/2022] [Accepted: 01/19/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prevalence of orthostatic intolerance on the day of surgery is more than 50% after abdominal surgery. The impact of orthostatic intolerance on ambulation on the day of surgery has been little studied. We investigated orthostatic intolerance and walking ability after colorectal and bariatric surgery in an enhanced recovery programme. METHODS Eighty-two patients (colorectal: n = 46, bariatric n = 36) were included and analysed in this prospective study. Walk tests for 2 min (2-MWT) and 6 min (6-MWT) were performed before and 24 h after surgery, and 3 h after surgery for 2-MWT. Orthostatic intolerance characterised by presyncopal symptoms when rising was recorded at the same time points. Multivariate binary logistic regressions modelling the probability of orthostatic intolerance and walking inability were performed taking into account potential risk factors. RESULTS Prevalence of orthostatic intolerance and walking inability was, respectively, 65% and 18% 3-hour after surgery. The day after surgery, patients' performance had greatly improved: approximately 20% of the patients experienced orthostatic intolerance, whilst only 5% of the patients were unable to walk. Adjusted binary logistic regressions demonstrated that age (p = .37), sex (p = .39), BMI (p = .74), duration of anaesthesia (p = .71) and type of surgery (p = .71) did not significantly influence walking ability. CONCLUSION Our study confirms that orthostatic intolerance was frequent (~ 60%) 3-hour after abdominal surgery but prevented a 2-MWT only in ~20% of patients. No risk factors for orthostatic intolerance and walking inability were evidenced.
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Affiliation(s)
- Pierre‐Yves J‐P. Hardy
- Department of Anaesthesia and Intensive Care Medicine CHU Liège University of Liège Liège Belgium
- Groupe francophone de réhabilitation améliorée après chirurgie (GRACE; Francophone group for enhanced recovery after surgery) Beaumont France
| | - Alessandro Tavano
- Department of Anaesthesia and Intensive Care Medicine CHU Liège University of Liège Liège Belgium
| | - Sophie V. Jacquet
- Service of Physical Medicine and Rehabilitation CHU Liège University of Liège Liège Belgium
| | - Justine J. Monseur
- Biostatistics Unit Department of Public Health University of Liège Liège Belgium
| | - Marie‐Hélène L. Bastin
- Service of Physical Medicine and Rehabilitation CHU Liège University of Liège Liège Belgium
| | - Laurent P. Kohnen
- Service of Digestive Surgery CHU Liège University of Liège Liège Belgium
| | | | - Jean L. Joris
- Department of Anaesthesia and Intensive Care Medicine CHU Liège University of Liège Liège Belgium
- Groupe francophone de réhabilitation améliorée après chirurgie (GRACE; Francophone group for enhanced recovery after surgery) Beaumont France
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Analysis of Adverse Effects of Multimodal Gabapentin in Abdominal Wall Reconstruction. Plast Reconstr Surg 2022; 149:733-739. [PMID: 35041638 DOI: 10.1097/prs.0000000000008836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multimodal analgesia, a key component of enhanced recovery after surgery protocols, emphasizes the use of nonopioid analgesics. Preoperative and postoperative gabapentin is often included within multimodal analgesia because it has been shown to reduce postoperative opioid use. However, the role of gabapentin has been questioned because of concerns of adverse effects, particularly in the elderly. In an effort to better understand the specific role of gabapentin within the context of an established enhanced recovery after surgery protocol, the authors studied the prevalence of its adverse effects in patients undergoing abdominal wall reconstruction. METHODS Following institutional review board approval, a retrospective review of a prospectively collected database of 267 consecutive patients who underwent abdominal wall reconstruction performed by a single surgeon was conducted. Demographic variables; operative details; postoperative analgesic use; the presence of dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; and postoperative falls were recorded and analyzed according to postoperative gabapentin administration. RESULTS Two hundred thirteen patients (80 percent) met inclusion criteria, of which 138 (65 percent) received postoperative gabapentin. Postoperative gabapentin use was not associated with dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; or falls. Furthermore, even among those aged 65 years or older, postoperative gabapentin use was not significantly associated with these adverse events. CONCLUSIONS In patients undergoing abdominal wall reconstruction, postoperative gabapentin administration was not associated with an increase in adverse effects. Further prospective analysis may better allow the characterization of the adverse effects of perioperative gabapentin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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22
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Video-Assisted Health Education Promotes Rehabilitation Training of Total Knee Arthroplasty Patients and Reduces Stress and Burnout in Nurses Compared to Oral Education. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5058899. [PMID: 34722765 PMCID: PMC8556099 DOI: 10.1155/2021/5058899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/16/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022]
Abstract
Emerging evidence suggests video-assisted health education being an effective way in promoting rehabilitation. The present study was aimed at evaluating the effectiveness of video-assisted health education in promoting rehabilitation training in postoperative OA patients and at comparing it with oral education. This study was a noncontemporaneous control study involving 179 patients who underwent TKA. For the intervention group, a bedside interactive system that recorded a series of educational videos showing a rehabilitation training program was established. For the control group, oral education having the same content as that in the videos for the intervention group was provided. After education, clinical outcomes such as occurrence of complications, circulating biomarkers of inflammation, and rehabilitation progress of the patients were obtained. Furthermore, job stress and burnout in nurses who participated in the present study were assessed. Results showed that C-reactive protein levels of patients were significantly lower in the intervention group than in the control group (84.54 ± 36.09 vs. 99.45 ± 31.73 mg/L, P = 0.004). Faster achievement of postoperative knee flexion to 90 degrees (21.31 ± 5.83 vs. 35.72 ± 9.93 h, P < 0.001) and first ambulation (19.91 ± 4.57 vs. 50.15 ± 7.00 h, P < 0.001), reduced number of postoperative complications such as postoperative orthostatic intolerance (7 vs. 19, P = 0.008) and constipation (10 vs. 23, P = 0.009), and reduced length of hospital stay (7.51 ± 1.79 vs. 8.21 ± 2.15 days, P = 0.019) in the intervention group in comparison to the control group were noted. Emotional exhaustion and burnout of nurses were reduced significantly in the intervention group than in the control group (21.00 ± 8.04 vs. 36.50 ± 11.22, P = 0.002; 55.90 ± 11.57 vs. 85.50 ± 6.80, P < 0.001, respectively). Reduced personal accomplishments in nurses were improved significantly in the intervention group when compared with the control group (41.90 ± 4.91 vs. 32.80 ± 7.07, P = 0.004). We concluded that video-assisted health education may promote TKA patient recovery and reduce burnout and stress in nurses when compared with oral education. Video-assisted health education could be helpful in situation where manpower of nurse is in shortage.
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23
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Huang L, Kehlet H, Petersen RH. Effect of posture on pulmonary function and oxygenation after fast-tracking video-assisted thoracoscopic surgery (VATS) lobectomy: a prospective pilot study. Perioper Med (Lond) 2021; 10:26. [PMID: 34470657 PMCID: PMC8411530 DOI: 10.1186/s13741-021-00199-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/03/2021] [Indexed: 01/08/2023] Open
Abstract
Background Minimally invasive surgery combined with enhanced recovery programmes has improved outcomes after lung cancer surgery and where early mobilisation may be an important factor. However, little is known about pulmonary function and oxygenation during mobilisation after video-assisted pulmonary lobectomy. The aim of this prospective pilot cohort study was to explore the effect of postural changes (from supine to sitting to standing) on pulmonary function and oxygen saturation in a well-defined enhanced recovery programmes setting after video-assisted thoracoscopic surgery lobectomy. Methods A total of 24 patients were evaluated daily for postoperative pain score, pulmonary function (forced expiratory volume 1 s) and oxygen saturation in supine, sitting and standing position from 6 h after surgery to 6 h after chest drain removal. Results Mobilisation from supine to standing position showed a significant 7.9% increase (p = 0.04) in forced expiratory volume in 1 s percentage and oxygen saturation about 1.8% (p< 0.001) without increasing pain (p = 0.809). Conclusions Early mobilisation should be encouraged to enhance recovery after video-assisted thoracoscopic surgery lobectomy by increasing lung function and oxygen delivery. Trial registration • Name of the registry: clinicaltrials.gov • Trial registration number: NCT04508270 • Date of registration: August 11, 2020
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Affiliation(s)
- Lin Huang
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
| | - René Horsleben Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Christopoulos EM, Reijnierse EM, Lange PW, Meskers CGM, Maier AB. Orthostatic Hypotension and Orthostatic Intolerance Symptoms in Geriatric Rehabilitation Inpatients, RESORT. J Am Med Dir Assoc 2021; 22:2468-2477.e2. [PMID: 34478695 DOI: 10.1016/j.jamda.2021.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/09/2021] [Accepted: 08/14/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Orthostatic hypotension (OH) and orthostatic intolerance symptoms are common in older community-dwelling adults and are associated with reduced quality of life and detrimental health outcomes. This study aimed to determine the prevalence, co-occurrence and determinants of OH and orthostatic intolerance symptoms in geriatric rehabilitation inpatients. DESIGN Observational, longitudinal cohort, "REStORing the health of acutely unwell adulTs" (RESORT). SETTING AND PARTICIPANTS Geriatric rehabilitation inpatients (n = 1505) of a tertiary teaching hospital in Melbourne, Australia. METHODS OH was defined as a drop in systolic blood pressure by ≥20 mm Hg and/or diastolic blood pressure by ≥10 mm Hg within three 3 of moving from supine to a standing or sitting position. Symptoms were recorded following the 3 minutes. Determinants included sociodemographics, reason for admission, cognitive health, nutritional status, physical performance, frailty, morbidity, medication use, length of stay (LOS), and number of geriatric conditions. Independent t-tests, Mann-Whitney U tests or χ2 tests were used to analyze differences between inpatients with and without OH and symptoms. Logistic regression analyses were used to ascertain the determinants. RESULTS OH and orthostatic intolerance symptoms were prevalent in 19.8% (standing: 21.4%, sitting: 18.2%) and 22.6% (standing: 25.0%, sitting: 20.2%) of inpatients, respectively. Symptoms were reported by 32.8% of inpatients with OH and 20.1% without OH. Higher number of comorbidities and geriatric conditions, low functional independence, and longer LOS were determinants of OH. Female gender, higher number of morbidities and geriatric conditions, low functional independence, depression risk, poor physical performance, musculoskeletal and "other" reasons for admission, and long LOS during geriatric rehabilitation were determinants of symptoms. CONCLUSIONS AND IMPLICATIONS OH and orthostatic intolerance symptoms occur in one-fifth of geriatric rehabilitation inpatients, however, the co-occurrence is low and determinants differ. Poorer health in patients with orthostatic intolerance symptoms highlights the need to assess symptoms in clinical practice, independent of an OH diagnosis.
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Affiliation(s)
- Elena M Christopoulos
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Esmee M Reijnierse
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia; Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Peter W Lange
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore.
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25
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Öztürk G, Yılmaz E, Aydın M, Baydur H. Effect of using elastic-pressure socks in spinal surgery patients on orthostatic hypotension in the first mobilization. ANZ J Surg 2021; 91:2780-2787. [PMID: 34339102 DOI: 10.1111/ans.17101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) is a common early postoperative finding in patients who undergo major surgery, and it might delay early mobilization, which is the main building block of modern perioperative care programs. The aim of this study was to determine the effect of using thigh-length elastic pressure socks in patients who undergo spinal surgery in development of OH at first mobilization after surgery. METHODS The study was a randomized-controlled intervention study. A total of 70 patients who underwent spinal surgery were included in the study. The patients were allocated randomly to the intervention group (n = 35) who used thigh-length elastic pressure socks and the control group (n = 35) which received no intervention other than routine nursing care. RESULTS It was found in the study that 2.9% of the patients in the intervention group developed OH during the first mobilization after the surgery, and 48.6% of the patients in the control group developed OH at first mobilization. The patients in the intervention group were found to have the risk ratio (RR): 0.06 times less probability of developing OH than the patients in the control group (95% confidence interval [CI]:0.01-0.42). The OH symptoms were lower in the patients in the intervention group. CONCLUSION It was found as a result of the study that using thigh-length elastic pressure socks in spinal surgery patients reduced OH development and symptoms at first mobilization after the surgery.
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Affiliation(s)
- Gülay Öztürk
- Neurosurgery Intensive Care Unit, Health Sciences University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Emel Yılmaz
- Department of Surgical Nursing, Faculty of Health Science, Manisa Celal Bayar University, Manisa, Turkey
| | - Murat Aydın
- Department of Neurosurgery, Health Sciences University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Hakan Baydur
- Department of Social Work, Faculty of Health Science, Manisa Celal Bayar University, Manisa, Turkey
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Brolet EA, Joris JL, Monseur JJ, Donneau AFH, Slim K. Impact of non-steroidal anti-inflammatory drugs on the efficiency of enhanced recovery programmes after colorectal surgery: a retrospective study of the GRACE database. Anaesth Crit Care Pain Med 2021; 40:100880. [PMID: 33965647 DOI: 10.1016/j.accpm.2021.100880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multimodal analgesia is considered a key element of enhanced recovery programmes (ERPs) after colorectal surgery. We investigated the effects of NSAIDs, a major component of multimodal analgesia on adherence to ERP, incidence of postoperative complications, and length of hospital stay (LOS). METHODS This was a retrospective study of the GRACE database that included 8611 patients scheduled for colorectal surgery with an ERP between February 2016 and November 2019. Primary endpoints were adherence to the postoperative protocol, the rate and type of postoperative complications, and LOS. Data are median [IQR] and number (per cent). Multivariate models were used to assess the effects of NSAIDs on these variables taking into account potential confounding factors. RESULTS Data from 8258 patients were analysed and classified into four groups according to whether NSAIDs had been given intra- and/or postoperatively or not at all; 4578 patients were given NSAIDs intra- and/or postoperatively and 3680 patients received no NSAIDs. Use of NSAIDs was significantly (P<0.001) associated with improved adherence to the postoperative protocol (4.0 [3.0-4.0] vs. 3.0 [2.0-4.0] items), a reduced incidence of complications (21.1% vs. 29.2%), and a shortened LOS (5.0 [3.0-7.0] vs. 6.0 [4.0-9.0] days) compared to the no-NSAIDs group. Multivariate analyses adjusted for the confounding factors confirmed a significant (P<0.001) beneficial impact of NSAIDs on these three primary endpoints. CONCLUSION This study suggests that perioperative NSAID use results in better adherence to the postoperative protocol, fewer postoperative in-hospital complications, and shorter LOS after colorectal surgery.
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Affiliation(s)
- Etienne A Brolet
- Department of Anaesthesia and Intensive Care Medicine, CHU Liège, University of Liège, Liège, Belgium
| | - Jean L Joris
- Department of Anaesthesia and Intensive Care Medicine, CHU Liège, University of Liège, Liège, Belgium; Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE, Francophone Group for Enhanced Recovery After Surgery, www.grace-asso.fr), Beaumont, France.
| | - Justine J Monseur
- Biostatistics Unit, Department of Public Health, University of Liège, Liège, Belgium
| | | | - Karem Slim
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE, Francophone Group for Enhanced Recovery After Surgery, www.grace-asso.fr), Beaumont, France; Service of Digestive Surgery and Unit of Ambulatory Surgery, CHU Estaing, 63003 Clermont-Ferrand, France
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- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE, Francophone Group for Enhanced Recovery After Surgery, www.grace-asso.fr), Beaumont, France
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Li ZE, Lu SB, Kong C, Sun WZ, Wang P, Zhang ST. Comparative short-term outcomes of enhanced recovery after surgery (ERAS) program and non-ERAS traditional care in elderly patients undergoing lumbar arthrodesis: a retrospective study. BMC Musculoskelet Disord 2021; 22:283. [PMID: 33731057 PMCID: PMC7968191 DOI: 10.1186/s12891-021-04166-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over non-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with non-ERAS traditional care. Methods During January 2018 to December 2018, patients enrolled received non-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected. Result A total of 127 patients were enrolled, including 67 patients in the non-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6 ± 4.0 days) was significantly less than that of patients treated with non-ERAS traditional care (15.6 ± 3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the non-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%. Conclusions Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than non-ERAS traditional care.
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Affiliation(s)
- Zhong-En Li
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Shi-Bao Lu
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China. .,National Clinical Research Center for Geriatric Diseases, Beijing, China.
| | - Chao Kong
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Wen-Zhi Sun
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Peng Wang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Si-Tao Zhang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China
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28
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Chu E, Zhang C, Musikantow DR, Turagam MK, Langan N, Sofi A, Choudry S, Syros G, Miller MA, Koruth JS, Whang W, Dukkipati SR, Reddy VY. Barriers and financial impact of same-day discharge after atrial fibrillation ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:711-719. [PMID: 33686695 DOI: 10.1111/pace.14217] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/17/2021] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Same-day discharge (SDD) after atrial fibrillation (AF) ablation is increasingly being considered. This study examined the barriers and financial impact associated with SDD in a contemporary cohort of patients undergoing elective AF ablation. METHODS A single center retrospective review was conducted of the 249 first case-of-the-day outpatient AF ablations performed in 2019 to evaluate the proportion of patients that could have undergone SDD. Barriers to SDD were defined as any intervention that prevented SDD by 8 p.m. The financial impact of SDD was based on savings from avoidance of the overnight hospital stay and revenue related to management of chest pain facilitated by a vacant hospital bed. RESULTS SDD could have occurred in 157 patients (63%) without change in management and in up to 200 patients (80%) if avoidable barriers were addressed. Barriers to SDD included non-clinical logistical issues (43%), prolonged post-procedure recovery (42%) and minor procedural complications (15%). On multivariate analysis, factors associated with barriers to SDD included increasing age (P = .01), left ventricular ejection fraction ≤ 35% (P = .04), and severely dilated left atrium (P = .04). The financial gain from SDD would have ranged from $1,110,096 (assuming discharge of 63% of eligible patients) to $1,480,128 (assuming 80% discharge) over the course of a year. CONCLUSIONS Up to 80% of patients undergoing outpatient AF ablation were amenable to SDD if avoidable delays in care had been anticipated. Based on reduced hospital operating expenses and increased revenue from management of individuals with chest pain, this would translate to a financial savings of ∼$1.5 million.
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Affiliation(s)
- Edward Chu
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chi Zhang
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel R Musikantow
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohit K Turagam
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Noelle Langan
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aamir Sofi
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Subbarao Choudry
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Georgios Syros
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marc A Miller
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Whang
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Frassanito L, Vergari A, Nestorini R, Cerulli G, Placella G, Pace V, Rossi M. Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery. Musculoskelet Surg 2020; 104:87-92. [PMID: 31054080 DOI: 10.1007/s12306-019-00603-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols aim to develop peri-operative multidisciplinary programs to shorten length of hospital stay (LOS) and reduce complications, readmissions and costs for patients undergoing major surgery. The aim of this study is to evaluate the effects of an ERAS pathway for total hip (THR) and knee (TKR) replacement surgery in terms of length of stay, incidence of complications and patient satisfaction. METHODS Patients scheduled for hip and knee replacement were included in the study. The main aspects of this program were preoperative education/physical therapy, rational choice of the anesthetic technique, optimization of multimodal analgesia, reduction of incidence of urinary retention and catheterization, active management of risk for blood loss and deep vein thrombosis, and early mobilization of the patients. All patients had 6 months predicted and planned follow-up appointments. Primary outcomes of the study were the mean LOS, readmission and complication rates. Secondary Outcomes were percentage of Knee Injury & Osteoarthritis Outcome Score (KOOS) and Hip disability and Osteoarthritis Outcome Score (HOOS) increase and patient's satisfaction. RESULTS We consecutively enrolled 207 patients who underwent total joint arthroplasty, 78 hip and 129 knee joint replacements. The mean length of stay (LOS) for patients of the two groups was 4.3 days for ASA 3-4 patients subjected to TKR and THR, in ASA 1-2 patients 3.6 days for TKR and 3.9 days for THR respectively. Postoperative satisfaction level was higher than 7 (very satisfied) in 94.4% of the cases. All patients were discharged home: 61.8% continued physical therapy in complete autonomy, 23.7% supported by a home-physiotherapist and only 14.5% needed the attendance to a physiotherapy center on a daily basis. The overall incidence of major complications was 3.4%. CONCLUSIONS The implementation of an ERAS program for hip and knee replacement surgery allows early patient's discharge and a quick return to independency in the daily activities. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- L Frassanito
- Area Anestesiologia, Rianimazione, Terapie Intensive e Terapia del Dolore, Fondazione Policlinico A. Gemelli, Rome, Italy.
- Istituto di Anestesia e Rianimazione, Fondazione Policlinico A. Gemelli, Largo A. Gemelli n. 8, 00168, Rome, Italy.
| | - A Vergari
- Area Anestesiologia, Rianimazione, Terapie Intensive e Terapia del Dolore, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - R Nestorini
- Area Anestesiologia, Rianimazione, Terapie Intensive e Terapia del Dolore, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - G Cerulli
- Area Invecchiamento, Ortopedia e Riabilitazione, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - G Placella
- U. O. Ortopedia e Traumatologia, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - V Pace
- Royal National Orthopedic Hospital, Stanmore, London, UK
| | - M Rossi
- Area Anestesiologia, Rianimazione, Terapie Intensive e Terapia del Dolore, Fondazione Policlinico A. Gemelli, Rome, Italy
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Kehlet H. History and future challenges in fast-track hip and knee arthroplasty. DER ORTHOPADE 2020; 49:290-292. [DOI: 10.1007/s00132-020-03865-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Foss NB, Kehlet H. Challenges in optimising recovery after emergency laparotomy. Anaesthesia 2020; 75 Suppl 1:e83-e89. [PMID: 31903571 DOI: 10.1111/anae.14902] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2019] [Indexed: 12/19/2022]
Abstract
Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Kehlet H. Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia 2020; 75 Suppl 1:e54-e61. [DOI: 10.1111/anae.14860] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 12/15/2022]
Affiliation(s)
- H. Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet Copenhagen University Copenhagen Denmark
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Coenders MJ, Mathijssen NMC, Vehmeijer SBW. Three and a half years’ experience with outpatient total hip arthroplasty. Bone Joint J 2020; 102-B:82-89. [DOI: 10.1302/0301-620x.102b1.bjj-2019-0045.r2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Aims The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA). Methods In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered. Results Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol. Conclusion These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82–89
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Affiliation(s)
- Michel J. Coenders
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Nina M. C. Mathijssen
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
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Munk-Madsen P, Eriksen JR, Kehlet H, Gögenur I. Why still in hospital after laparoscopic colorectal surgery within an enhanced recovery programme? Colorectal Dis 2019; 21:1438-1444. [PMID: 31309661 DOI: 10.1111/codi.14762] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/03/2019] [Indexed: 02/08/2023]
Abstract
AIM Enhanced recovery after surgery programmes in elective colorectal surgery have been developed and implemented widely, but a subgroup of patients may still require longer hospital stays than expected. The aim of this study was to identify and describe factors compromising early postoperative recovery by asking 'why is the patient still in hospital today?' after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery programme. METHOD Patients undergoing elective laparoscopic colorectal cancer resection were evaluated postoperatively with predefined potential reasons for still being in hospital. The primary outcome was 'reason for still being in hospital' on postoperative day 0-4 and secondarily length of stay with a focus on differences between patients with and without a stoma. RESULTS Ninety-six patients having colorectal cancer surgery were included. The median length of stay for the whole group was 3 days (range 1-14). The four dominant causes for patients without a stoma to be in hospital were lack of gastrointestinal function, lack of early mobilization, lack of normal micturition and nausea. Patients with a stoma stayed in hospital due to stoma training, lack of gastrointestinal function, lack of free micturition and a miscellaneous 'others' group. CONCLUSION Delayed gastrointestinal function, insufficient mobilization, poor urinary function and stoma care training have been characterized as dominant compromising factors for postoperative recovery. Together with a focus on frailty, future studies should focus on improving early mobilization, prevention and treatment of postoperative urinary retention and improved stoma care training, in order to minimize delay in postoperative recovery and discharge.
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Affiliation(s)
- P Munk-Madsen
- Centre for Surgical Science, Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - J R Eriksen
- Centre for Surgical Science, Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - H Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, København N, Denmark
| | - I Gögenur
- Centre for Surgical Science, Department of Surgery, Zealand University Hospital, Roskilde, Denmark
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/rehabilitation
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/rehabilitation
- Humans
- Length of Stay
- Multiple Chronic Conditions
- Patient Care Management/methods
- Patient Care Planning
- Postoperative Complications/classification
- Postoperative Complications/etiology
- Postoperative Complications/therapy
- Prognosis
- Rehabilitation/methods
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Affiliation(s)
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark and The Lundbeck
- Foundation Centre for Fast-track Hip and Knee replacement, Copenhagen, Denmark
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Eriksen JR, Munk-Madsen P, Kehlet H, Gögenur I. Orthostatic intolerance in enhanced recovery laparoscopic colorectal resection. Acta Anaesthesiol Scand 2019; 63:171-177. [PMID: 30094811 DOI: 10.1111/aas.13238] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 07/15/2018] [Accepted: 07/17/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) and intolerance (OI) are common findings in the early postoperative period after major surgery and may delay early mobilization. The mechanism of impaired orthostatic competence and OI symptoms is not fully understood, and specific data after colorectal surgery with well-defined perioperative care regimens and mobilization protocols are lacking. The aim of this study was to investigate the prevalence, possible risk factors and the impact of OI in patients undergoing elective minimal invasive colorectal cancer resection. METHODS A prospective single-centre study with an optimal enhanced recovery program and multimodal analgesic treatment. OI and OH were evaluated using a well-defined mobilization protocol preoperatively and 6 hour and 24 hour postoperatively. RESULTS A total of 100 patients were included in the data analysis. The overall median length of stay was 3 days (1-38). OI was observed in 53% of the patients 6 hour postoperatively and in 24% at 24 hour. OI at 6 hour postoperatively was associated with younger age, lower BMI, and female gender. At 24 hour postoperatively, female gender and ASA class >1 was associated with OI. Opioid consumption and intravenous fluid during the first 24 hour was not associated with OI. Postoperative complications were equally observed between patients with and without OI. Although not statistically significant, patients with OI at 24 hour postoperatively had prolonged LOS (mean 4.0 vs 7.5 days, P = 0.069) compared with patients without OI. CONCLUSION Postoperative orthostatic intolerance is a common problem during the first 24 hour following laparoscopic colorectal resection and may be followed by delayed recovery.
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Affiliation(s)
- Jens R. Eriksen
- Department of Surgery; Colorectal Cancer Unit; Zealand University Hospital; Roskilde Denmark
| | - Pia Munk-Madsen
- Department of Surgery; Colorectal Cancer Unit; Zealand University Hospital; Roskilde Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Ismail Gögenur
- Department of Surgery; Colorectal Cancer Unit; Zealand University Hospital; Roskilde Denmark
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Lindberg-Larsen V, Petersen PB, Jans Ø, Beck T, Kehlet H. Effect of pre-operative methylprednisolone on orthostatic hypotension during early mobilization after total hip arthroplasty. Acta Anaesthesiol Scand 2018; 62:882-892. [PMID: 29573263 DOI: 10.1111/aas.13108] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 02/13/2018] [Accepted: 02/17/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) and intolerance (OI) are common after total hip arthroplasty (THA) and may delay early mobilization. The pathology of OH and OI includes a dysregulated post-operative vasopressor response, by a hitherto unknown mechanism. We hypothesized that OI could be related to the inflammatory stress response which is inhibited by steroid administration. Consequently, this study evaluated the effect of a pre-operative high-dose methylprednisolone on OH and OI early after THA. METHODS Randomized, double-blind, placebo-controlled study in 59 patients undergoing elective unilateral THA with spinal anesthesia and a standardized multimodal analgesic regime. Patients were allocated (1 : 1) to pre-operative intravenous (IV) methylprednisolone (MP) 125 mg or isotonic saline (C). OH, OI and cardiovascular responses to sitting and standing were evaluated using a standardized mobilization protocol pre-operatively, 6, and 24 h after surgery. Systolic and diastolic arterial pressure and heart rate were measured non-invasively (Nexfin® ). The systemic inflammation was monitored by the C-reactive protein (CRP) response. RESULTS At 6 h post-operatively, 11 (38%) versus 11 (37%) patients had OH in group MP and group C, respectively (RR 1.02 (0.60 to 1.75; P = 1.00)), whereas OI was present in 9 (31%) versus 13 (43%) patients (RR 0.76 (0.42 to 1.36; P = 0.42)), respectively. At 24 h post-operatively, the prevalence of OH and OI did not differ between groups, though CRP levels were significantly reduced in group MP (P < 0.001). CONCLUSION Pre-operative administration of 125 mg methylprednisolone IV did not reduce OH or OI compared with placebo despite a reduced inflammatory response.
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Affiliation(s)
- V. Lindberg-Larsen
- Section for Surgical Pathophysiology 7621; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- The Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty; Copenhagen Denmark
| | - P. B. Petersen
- Section for Surgical Pathophysiology 7621; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- The Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty; Copenhagen Denmark
| | - Ø. Jans
- The Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty; Copenhagen Denmark
| | - T. Beck
- Department of Orthopaedic Surgery; Copenhagen University Hospital, Bispebjerg and Frederiksberg; Copenhagen Denmark
| | - H. Kehlet
- Section for Surgical Pathophysiology 7621; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- The Lundbeck Foundation Centre for Fast-Track Hip and Knee Arthroplasty; Copenhagen Denmark
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Abstract
As a result of the introduction of fast-track programs, the length of hospital stay after arthroplasty has decreased to a point where some patients meet the discharge criteria on the day of surgery. In several studies, well-established fast-track centers have demonstrated the feasibility of outpatient procedures in selected patients. However, in literature the term "outpatient" is sometimes also used for patients who spend one or more nights in hospital. We therefore propose to use "outpatient" solely for patients who are discharged to their own home on the day of surgery and do not have an overnight stay at either the hospital or another non-home facility. Also, several challenges need to be overcome before this becomes an established procedure. The combination of preoperative high-dose steroids and multimodal opioid-sparing analgesia has enhanced patient recovery after arthroplasty, but efforts to control undesirable pathophysiological responses will be a prerequisite to improve the success rate of an outpatient setting. Also, care must be taken to avoid extra activities or investments solely to enable discharge on the day of surgery. Further cost analyses will have to be performed to establish the true financial benefit of outpatient treatment.
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Affiliation(s)
- Stephan B W Vehmeijer
- Department of Orthopedic Surgery, Reinier de Graaf Groep, Delft, The Netherlands,Department of Orthopedic Surgery, Orthoparc, Bosch en Duin, The Netherlands,Correspondence:
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
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Hanada M, Tawara Y, Miyazaki T, Sato S, Morimoto Y, Oikawa M, Niwa H, Eishi K, Nagayasu T, Eguchi S, Kozu R. Incidence of orthostatic hypotension and cardiovascular response to postoperative early mobilization in patients undergoing cardiothoracic and abdominal surgery. BMC Surg 2017; 17:111. [PMID: 29183368 PMCID: PMC5704500 DOI: 10.1186/s12893-017-0314-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In cardiothoracic and abdominal surgery, postoperative complications remain major clinical problems. Early mobilization has been widely practiced and is an important component in preventing complications, including orthostatic hypotension (OH) during postoperative management. We investigated cardiovascular response during early mobilization and the incidence of OH after cardiothoracic and abdominal surgery. METHODS In this prospective observational study, we consecutively analyzed data from 495 patients who underwent elective cardiothoracic and abdominal surgery. We examined the incidence of OH, and the independent risk factors associated with OH during early mobilization after major surgery. Multivariate logistic regression was performed using various characteristics of patients to identify OH-related independent factors. RESULTS OH was observed in 191 (39%) of 495 patients. The incidence of OH in cardiac, thoracic, and abdominal groups was 39 (33%) of 119, 95 (46%) of 208, and 57 (34%) of 168 patients, respectively. Male sex (OR 1.538; p = 0.03) and epidural anesthesia (OR 2.906; p < 0.001) were independently associated with OH on multivariate analysis. CONCLUSIONS These results demonstrate that approximately 40% patients experience OH during early mobilization after cardiothoracic and abdominal surgery. Sex was identified as an independent factor for OH during early mobilization after all three types of surgeries, while epidural anesthesia was only identified after thoracic surgery. Therefore, the frequent occurrence of OH during postoperative early mobilization should be recognized. TRIAL REGISTRATION University hospital Medical Information Network Center (UMIN-CTR) number UMIN000018632 . (Registered on 1st October, 2008).
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Affiliation(s)
- Masatoshi Hanada
- Cardiorespiratory Division, Department of Rehabilitation Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Yuichi Tawara
- Department of Cardiopulmonary Rehabilitation Science, Unit of Rehabilitation Sciences, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takuro Miyazaki
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yosuke Morimoto
- Cardiorespiratory Division, Department of Rehabilitation Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Masato Oikawa
- Cardiorespiratory Division, Department of Rehabilitation Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.,Department of Cardiopulmonary Rehabilitation Science, Unit of Rehabilitation Sciences, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroshi Niwa
- Division of Thoracic Surgery, Respiratory Disease Center, Seirei Mikatahara General Hospital, 3458 Mikatahara, Hamamatsu, 433-8558, Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular surgery, Nagasaki University Graduate School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Ryo Kozu
- Cardiorespiratory Division, Department of Rehabilitation Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.,Department of Cardiopulmonary Rehabilitation Science, Unit of Rehabilitation Sciences, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Gromov K, Kjærsgaard-Andersen P, Revald P, Kehlet H, Husted H. Feasibility of outpatient total hip and knee arthroplasty in unselected patients. Acta Orthop 2017; 88:516-521. [PMID: 28426262 PMCID: PMC5560215 DOI: 10.1080/17453674.2017.1314158] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The number of patients who are suitable for outpatient total hip and knee arthroplasty (THA and TKA) in an unselected patient population remains unknown. The purpose of this prospective 2-center study was to identify the number of patients suitable for outpatient THA and TKA in an unselected patient population, to investigate the proportion of patients who were discharged on the day of surgery (DOS), and to identify reasons for not being discharged on the DOS. Patients and methods - All consecutive, unselected patients who were referred to 2 participating centers and who were scheduled for primary THA and TKA were screened for eligibility for outpatient surgery with discharge to home on DOS. If patients did not fulfill the discharge criteria, the reasons preventing discharge were noted. Odds factors with relative risk intervals for not being discharged on DOS were identified while adjusting for age, sex, ASA score, BMI and distance to home. Results - Of the 557 patients who were referred to the participating surgeons during the study period, 54% were potentially eligible for outpatient surgery. Actual DOS discharge occurred in 13-15% of the 557 patients. Female sex and surgery late in the day increased the odds of not being discharged on the DOS. Interpretation - This study shows that even in unselected THA and TKA patients, same-day discharge is feasible in about 15% of patients. Future studies should evaluate safety aspects and economic benefits.
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Affiliation(s)
- Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark.,Correspondence:
| | - Per Kjærsgaard-Andersen
- Departement of Orthopedic Surgery, Vejle Hospital, Vejle;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
| | - Peter Revald
- Departement of Orthopedic Surgery, Vejle Hospital, Vejle;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre;,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Denmark
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