Tuesday, January 12, 2021

The safety of outpatient shoulder arthroplasty

The Feasibility of Outpatient Shoulder Arthroplasty: Risk Stratification and Predictive Probability Modeling 

These authors sought to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection using a retrospective review of a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. 

A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria. 17% had adverse events. The most common were transfusion, bloodloss anemia, hypotension/shock, syncope,  and pulmonary problems

Factors associated with suitability for discharge included younger age, higher body mass index (BMI), male sex, and prior steroid injection.

Factors associated with adverse events included preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2.

Compared with TSA, reverse TSA was associated with less suitability for discharge.

15,254 patients were identified from the ACS-NSQIP database. 

Factors associated with unsuitability for discharge were female sex, BMI less than 35 kg/m2, American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low preoperative albumin, and hemiarthroplasty.

The lowest risk subgroup included males 55 to 59 years old with no comorbidities nor history of narcotic use. Transfusion was the primary driver of adverse events.

The authors concluded that the majority of patients undergoing shoulder arthroplasty could safely be managed on an outpatient basis. In their institutional database, younger male patients with higher BMI were particularly likely to avoid adverse events, whereas those with certain comorbidities (anemia/blood disorder, heart disease) or history of narcotic use were somewhat more likely to have AEs. The authors found similar results on the national level, with female sex, lower BMI, significant comorbidities, and low preoperative albumin and hematocrit levels being risk factors for AEs. 

Comment: These authors have investigated patient characteristics related to adverse events after shoulder arthroplasty. While this information is helpful, avoiding these risk factors is only one component of the safety of outpatient joint replacement. Some important risk factors not mentioned are (a) history of prior problems with surgery or anesthesia and (b) history of urinary retention.

Other essential elements of successful outpatient arthroplasty include:

(1) Assurance that the patient is emotionally and intellectually "on board" with the plan for same day discharge and their responsibility for self-care and monitoring.

(2) Preoperative identification of family member or close friend who will be with patient during the first 24 hours after surgery and establishment of secure communication pathway between the surgical team and the support person.

(3) Confirmation with anesthesiologist of the plan for outpatient surgery

(4) Scheduling of case for the morning

(5) Preoperative education in wound management, pain management, physical therapy

(6) Call from surgical team to patient the night before and the evening of surgery

(7) Two hour preoperative hydration and calorie boost using clear energy shake

(8) Preoperative analgesic meds (such as Tylenol, Celebrex, Lyrica)


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