Preoperative antihypertensive medication intake and acute kidney injury after major vascular surgery.

OBJECTIVE: Postoperative acute kidney injury (AKI) is frequent after major vascular surgery and is associated with significant morbidity and mortality. It remains unclear whether the administration of combined oral antihypertensive medications on the day of surgery can increase the risk of postoperative AKI. METHODS: We performed a retrospective cohort study of hypertensive patients undergoing elective major vascular surgery to determine the association between the number of antihypertensive medications continued on the morning of surgery and AKI at 48 hours postoperatively. RESULTS: A total of 406 patients who had undergone suprainguinal vascular surgery were included, and 10.3% suffered postoperative AKI. In multivariable analysis, the number of antihypertensive medications taken on the morning of surgery was independently associated with AKI (P = .026). Compared with patients who took no medication, taking one medication (adjusted odds ratio [aOR], 1.58; 95% confidence interval [CI], 0.68-3.75) and taking two or more medications (aOR, 2.70; 95% CI, 1.13-6.44) were associated with a 1.6-fold and 2.7-fold increased risk of postoperative AKI, respectively. Other predictors of AKI were suprarenal surgery (aOR, 3.37; 95% CI, 1.53-7.44), age (aOR, 2.29 per 10 years; 95% CI, 1.40-3.74), length of surgery (aOR, 1.40 per 1 hour; 95% CI, 1.10-1.76), hemoglobin drop (aOR, 1.37 per 10 g/L; 95% CI, 1.10-1.74), and history of coronary artery disease (aOR, 2.33; 95% CI, 1.08-5.00). CONCLUSIONS: In patients undergoing major vascular surgery who are treated with chronic antihypertensive therapy, the administration of antihypertensive drugs on the morning of surgery is independently associated with an increased risk of postoperative AKI. Further prospective studies are needed to confirm this finding.

Frailty as a predictor of hospital length of stay after elective total joint replacements in elderly patients.

BACKGROUND: Total joint replacement procedures are increasing in number because of population aging and osteoarthritis development. Defined as a lack of physiological reserves and the inability to adequately respond to external stressors, frailty may be more common than expected in older patients with degenerative arthritis awaiting total joint replacements. The aim of the present study was to assess associations between frailty and adverse outcomes, frailty prevalence among elderly patients awaiting elective TJR, and agreement between 2 frailty screening instruments. METHODS: We undertook a prospective, observational, pilot study in our institution. We enrolled patients 65 years or older who were awaiting elective knee or hip replacement surgery and evaluated them in our preoperative clinic with planned postoperative hospital length of stay greater than 24 h. Patients were asked to grade their perceived well-being on the Clinical Frailty Scale and to answer questions on the FRAIL Scale. RESULTS: The Clinical Frailty Scale classified 40 patients (45.9%) as robust, 43 patients (49.4%) as prefrail and 4 patients (4.5%) as frail, while the FRAIL Scale categorized 12 patients (13.7%) as robust, 54 patients (62.0%) as prefrail, and 20 patients (22.9%) as frail. Robustness, ascertained on the Clinical Frailty Scale was, while the FRAIL Scale was not, significantly associated with shorter hospital length of stay and fewer discharges to the rehabilitation center. Both scales showed moderate mutual agreement. CONCLUSION: Screening for frailty identified between 5% and 10% of patients at risk of adverse outcomes. The Clinical Frailty Scale was, while the FRAIL scale was not, significantly associated with hospital length of stay and discharge to rehabilitation center in our cohort of total joint replacement patients.

Oral ferrous sulfate does not increase preoperative hemoglobin in patients scheduled for hip or knee arthroplasty.

BACKGROUND: Low hemoglobin (Hb) concentrations before lower limb joint replacement are associated with the need for blood transfusions and increased mortality. To optimize preoperative Hb, blood conservation protocols often recommend oral iron supplements, even in nonanemic patients. OBJECTIVE: To investigate the impact of ferrous sulfate on the change in Hb prior to hip or knee arthroplasty and evaluate the effect of oral iron on hematocrit, mean corpuscular volume (MCV), ferritin, and transferrin saturation, as well as its tolerability and treatment adherence. METHODS: We conducted a prospective, observational cohort study of adults with Hb concentrations between 10 and 15 g/dL who received iron supplementation prior to hip or knee arthroplasty. Systemic inflammatory diseases, vitamin B(12) or folate deficiency, and current use of iron supplements, intravenous iron, or erythropoietin were exclusion criteria. All participants were prescribed ferrous sulfate 300 mg 3 times daily for a minimum of 3 weeks. Complete blood cell counts and iron studies were performed before therapy and surgery. RESULTS: Eighty-seven patients with a mean (SD) Hb of 13.47 (0.84) g/dL were included in the study. Preoperative Hb decreased after treatment with iron (-0.14 [0.53] g/dL, p = 0.015). Hematocrit also declined (-0.6% [1.8%], p = 0.002), whereas ferritin increased (25.8 [38.6] ng/mL, p < 0.001). No significant change was seen in MCV and transferrin saturation. The most common adverse effects were constipation (33.3%), heartburn (13.8%), and abdominal pain (12.6%). The adherence rate was 67.1%. CONCLUSIONS: Oral ferrous sulfate supplementation is not an effective method to increase preoperative Hb in patients scheduled for hip or knee arthroplasty, and its use is associated with adverse effects.

Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs.

INTRODUCTION: An attractive option to reduce hospital length of stay (LOS) after hip or knee joint replacement (THA, TKA) is to follow the Enhanced Recovery After Surgery principles (ERAS) to improve patient experience to a level where they will feel confident to leave for home earlier. The objective of this study was to evaluate the implementation of short-stay protocol following the ERAS principles. HYPOTHESIS: We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital LOS and reduced direct health care costs compared to our standard procedure. MATERIAL AND METHODS: We compared the complications rated according to Clavien-Dindo scale, hospital LOS and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS: Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital LOS for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p<0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489 CAD per THA and 4158 CAD per TKA. DISCUSSION: In many short-stay protocols, focus has shifted from ERAS goals of a reduction in complications and improved recuperation to use length of stay as the main factor of success. Implementation of an ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital LOS, but also in improved patient care and reduced direct health care costs. LEVEL OF EVIDENCE: Level II.