Thromboembolic and major bleeding events in relation to perioperative bridging of vitamin K antagonists in 649 fast-track total hip and knee arthroplasties

Background — The benefit of preoperative bridging in surgical patients with continuous anticoagulant therapy is debatable, and drawing of meaningful conclusions may have been limited by mixed procedures with different thromboembolic and bleeding risks in most published studies. Patients and methods — This was an observational cohort treatment study in consecutive primary unilateral total hip and knee arthroplasty patients between January 2010 and November 2013 in 8 Danish fast-track departments. Data were collected prospectively on preoperative comorbidity and anticoagulants in patients with preoperative vitamin K antagonist (VKA) treatment. We performed 30-day follow-up on in-hospital complications and re-admissions through the Danish National Patient Registry and patient records. Results — Of 13,375 procedures, 649 (4.7%) were in VKA patients with a mean age of 73 (SD 9) years and a median length of stay of 3 days (IQR: 2–4). Preoperative bridging was used in 430 (67%), while 215 (33%) were paused. Of 4 arterial thromboembolic events (ATEs) (0.6%), 2 were in paused patients and 2 were in bridged patients (p = 0.6). Of 3 venous thromboembolic events (VTEs) (0.5%), 2 were in paused patients and 1 was in a bridged patient (p = 0.3). Of 8 major bleedings (MBs) (1.2%), 1 was in a paused patient and 7 were in bridged patients (p = 0.3), 5 of whom received therapeutic bridging. Similar results were found in a propensity-matched cohort. Interpretation — In contrast to recent studies in mixed surgical procedures, no statistically significant differences in ATE, VTE, or MB were found between preoperative bridging and pausation of VKA patients. However, the higher number of thromboembolic events in paused patients and the higher number of major bleedings in bridged patients warrant more extensive investigation

Does BMI influence hospital stay and morbidity after fast-track hip and knee arthroplasty?

BACKGROUND AND PURPOSE: Body mass index (BMI) outside the normal range possibly affects the perioperative morbidity and mortality following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in traditional care programs. We determined perioperative morbidity and mortality in such patients who were operated with the fast-track methodology and compared the levels with those in patients with normal BMI. PATIENTS AND METHODS: This was a prospective observational study involving 13,730 procedures (7,194 THA and 6,536 TKA operations) performed in a standardized fast-track setting. Complete 90-day follow-up was achieved using national registries and review of medical records. Patients were grouped according to BMI as being underweight, of normal weight, overweight, obese, very obese, and morbidly obese. RESULTS: Median length of stay (LOS) was 2 (IQR: 2–3) days in all BMI groups. 30-day re-admission rates were around 6% for both THA (6.1%) and TKA (5.9%), without any statistically significant differences between BMI groups in univariate analysis (p > 0.4), but there was a trend of a protective effect of overweight for both THA (p = 0.1) and TKA (p = 0.06). 90-day re-admission rates increased to 8.6% for THA and 8.3% for TKA, which was similar among BMI groups, but there was a trend of lower rates in overweight and obese TKA patients (p = 0.08 and p = 0.06, respectively). When we adjusted for preoperative comorbidity, high BMI in THA patients (very obese and morbidly obese patients only) was associated with a LOS of >4 days (p = 0.001), but not with re-admission. No such relationship existed for TKA. INTERPRETATION: A fast-track setting resulted in similar length of hospital stay and re-admission rates regardless of BMI, except for very obese and morbidly obese THA patients

Current Status and Future Directions of Pain-Related Outcome Measures for Post-Surgical Pain Trials

Background: Clinical trials remain vital in order to: A) develop new treatment interventions, and also, B) to guide optimal use of current interventions for the treatment and prevention of acute and chronic postsurgical pain. Measures of pain (e.g. intensity and relief) and opioid use have been validated for the settings of postsurgical pain and continue to effectively guide research in this field.. Methods: This narrative review considers needs for innovation in postsurgical pain trial outcomes assessment. Results: Future improvements are needed and include: A) more widespread measurement of movement-evoked pain with validation of various procedure-relevant movemen-tevoked pain maneuvers; B) new validated analytical approaches to integrate early postoperative pain scores with opioid use; and, C) closer attention to the measurement of postoperative opioid use after hospital discharge. In addition to these traditional measures, consideration is being given to the use of new pain-relevant outcome domains that include: 1) other symptoms (e.g. nausea and vomiting), 2) recovery of physiological function (e.g. respiratory, gastrointestinal, genitourinary and musculoskeletal), 3) emotional function (e.g. depression, anxiety) and, 4) development of chronic postsurgical pain. Also, there is a need to develop pain-related domains and measures for evaluating both acute and chronic post-operative pain. Finally, evidence suggests that further needs for improvements in safety assessment and reporting in postsurgical pain trials is needed, e.g. by using an agreed upon, standardized collection of outcomes that will be reported as a minimum in all postsurgical pain trials. Conclusions: These proposed advances in outcome measurement methodology are expected to improve the success by which postsurgical pain trials guide improvements in clinical care and patient outcomes

Accelerated postoperative rehabilitation: the aeronautic model. Monograph by Adrian Belii

“Fast-track surgery”, called later ”enhanced recovery after surgery”(ERAS) is a relatively new approach to the surgical patient and overall postoperative period. For the first time, the ERAS concept was elaborated and presented by Henrik Kehlet et al. in 1997 [1]. The essence of this concept is that a postoperative morbidity, which is not caused by the imperfect surgical technique, must be sought in the pathophysiological mechanism of the surgical stress. ERAS is based on two pylons: 1. Optimization of clinical pathways for surgical patients; 2. Canceling unnecessary “traditional” treatments and implementation of evidence-based medicine principles instead of them. So far, the ERAS concept has been tested by many teams from different countries on patients with various comorbidities and of different age, who received various types of surgery. Quasi-unanimous conclusion was that the benefits of this approach were obvious: a significant reduction in the length of hospital stay, reduced postoperative morbidity, accelerated patient’s return to homeostasis and cost reduction. ERAS concept can be easily upgraded, reconfigured and/or adapted according to various parameters: patient’s profile, type of surgery or structure of health care system. In this context, the monograph of Dr. Adrian Belii “Accelerated Postoperative Rehabilitation: the Aeronautic Model” [2] provides an original approach that improves and optimizes the perioperative management of elective surgical patients, described by H. Kehlet. From the beginning, I would like to mention the words “aeronautic model” in the title. In the past decade, hospitals tried to borrow the organizational patterns of High Reliability Organizations from nonmedical fields, for example, aviation and nuclear industry. Thus, by analogy the author analyzes functioning of an airport and hospital, where the aircraft is the patient, the crew - the medical team and the flight from point A to point B – the perioperative management and recovery. The monograph has 168 pages, contains 21 tables and 58 figures. The monograph consists of two parts: (1) medical and biological aspects of the aeronautic model of accelerated postoperative rehabilitation and (2) medical management of the aeronautic model. The first part of the monograph consists of six chapters and describes in terms of recent literature data and Dr. Belii’s personal research results the most important aspects of an ERAS protocol. Thus, in the author’s opinion, the quality of postoperative pain management is a particularly important component of “fast-track” surgery, which should rely on the following principles: self-assessment of the pain intensity, pain anticipation and association of painkillers and analgesic techniques. The author also shows that modernization of anesthetic practice shifting to computerized technology of drug delivery (target controlled infusion anesthesia) and new anesthetics provides a better anesthesia management, better adaptation to surgical stress intensity and faster emergence from anesthesia with fewer incidents. An interesting element of this monograph is the proposed ventilation weaning algorithm for the stage of the emergence from anesthesia. In the future, this could be integrated in the software of recovery room ventilators. Testing of the weaning algorithm proved the possibility of reducing the duration of lung ventilation by 40% in the patients that emerge from anesthesia. Other original ideas proposed by the author are the terms “static” and “dynamic element” related with postoperative management. “Static element” is called a treatment which does not modify in a fast and significant way biological parameters of a patient and usually has a supportive or preventive role. In contrast, “dynamic element” is called a treatment that rapidly and significantly influences biological parameters of a patient, hence adequate monitoring of vital signs is mandatory. The second part of the monograph refers to cross-cutting issues, indispensable for modern perioperative care. It refers to risk management modules and healthcare quality assurance, information flow and decision making mechanisms, optimization of the operating suite schedule in a hospital and last but not least, to economic aspects of ERAS programs. In conclusion, I would like to mention that Mr. Adrian Belii’s monograph “Accelerated Postoperative Rehabilitation: the Aeronautic Model” is an original and scientifically valuable paper which I recommend to anyone interested