Thursday, September 5, 2013

Atrial fibrillation and risk of surgery

Patients with Atrial Fibrillation Undergoing Total Joint Arthroplasty Increase Hospital Burden

Revisiting the concept of the importance of 'what patient the disease has' and the 4 Ps, this article in the most recent JBJS retrospectively compared one hundred and sixty-one patients with atrial fibrillation (Group A) with 161 matched controls (Group B), each having a total hip or a total knee (112 primary hips and 210 knees and eighty-three revisions). The groups were matched on the basis of the involved joint [hip or knee], type of procedure [revision or primary], age, and sex). 

Patients with preoperative atrial fibrillation undergoing total joint arthroplasty had an increased length of hospital stay, increased transfusion requirements, and an increased risk of periprosthetic joint infection and unplanned hospital readmission.

The preoperative length of stay (1.7 versus 0.2 days; p < 0.0001), postoperative length of stay (4.6 versus 3.2 days; p = 0.0002), and total length of stay (6.3 versus 3.4 days; p < 0.0001) were significantly longer for patients with atrial fibrillation. Group A had a significantly higher prevalence of blood transfusion (15.5% versus 3.7%; p = 0.0005) and periprosthetic joint infection (5.6% versus 0.62%; p = 0.0196). The diagnosis of atrial fibrillation (odds ratio, 4.09; 95% confidence interval, 2.05 to 8.18; p < 0.0001) significantly increased the odds of total joint arthroplasty complication and the need for hospital readmission.

Comment: again this indicates that factors beyond the orthopaedic problem can affect the outcome. Recall that markers for "good practice" include a low rate of readmission and a low complication rate as well as a shorter length of stay. Thus when we operate on patients with atrial fibrillation, we need to clearly document this risk factor so that 'our numbers' are not adversely affected by this risk factor. Furthermore, we need to be extra careful with this patients to mitigate the increase risk associated with AF.

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