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Risk Factors for Postoperative Respiratory Failure Necessitating Transfer to the Intensive Care Unit in Orthopedic Surgery Patients FREE TO VIEW

Roman Melamed, MD; Lori Boland, MPH; James Normington, BA; Rebecca Prenevost, PhD; Lindsay Hur, PharmD; Leslie Maynard; Molly McNaughton; Joseph Huguelet, MD
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Allina Health, Minneapolis, MN

Chest. 2015;148(4_MeetingAbstracts):322A. doi:10.1378/chest.2228884
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SESSION TITLE: Mechanical Ventilation Poster Discussion

SESSION TYPE: Original Investigation Poster Discussion

PRESENTED ON: Tuesday, October 27, 2015 at 02:45 PM - 04:15 PM

PURPOSE: To describe patient characteristics, care factors, and outcomes in orthopedic surgery patients who developed postoperative respiratory failure (RF) requiring transfer to the intensive care unit (ICU) and in control patients who did not develop this complication.

METHODS: A retrospective frequency-matched case control study was conducted among orthopedic surgery patients treated at a single tertiary care facility between 2010 and 2013. Cases were all patients who underwent elective or semi-elective orthopedic surgery (knee, hip, shoulder, or spine) and developed postoperative RF necessitating transfer to the ICU (n=51). Controls (n=153) were randomly selected from among similar orthopedic surgery patients and frequency matched to cases by gender, age, and surgical procedure. Patient and care factors, length of stay, mortality, and cost of care were examined in the two groups.

RESULTS: The mean age of patients was 66 years, 65% were female, and the majority underwent knee (37%) or non-cervical spine (41%) procedures. Transfer to the ICU occurred within 48 hours of surgery in 73% of the cases, and 9 (18%) required mechanical ventilation. Body-mass index was similar in cases and controls, but cases had a higher prevalence of chronic obstructive pulmonary disease (COPD; 22% vs 3%, p<0.0001) and obstructive sleep apnea (OSA; 35% vs 11%, p<0.001) than controls. Postoperatively, cases were more likely to have received patient-controlled analgesia (PCA; 51% vs 31%, p=0.01) and had more intravenous morphine equivalents during the first 24 postoperative hours than controls (median 110 mg vs 73 mg, p=0.006). Cases had longer hospitalizations (9 days versus 3 days) and higher in-hospital mortality (6% vs 0%) than controls. The average cost of hospitalization was significantly higher in cases ($46,456) than controls ($19,885, p<0.0001).

CONCLUSIONS: Acute RF after elective orthopedic surgery is a highly significant complication associated with extended hospitalization, increased mortality and higher cost of care. Risk factors may include preexisting COPD and OSA, use of PCA, and larger doses of opioid analgesics in the initial 24-hr postoperative period.

CLINICAL IMPLICATIONS: Development of hospital protocols that include risk factor assessment as well as enhanced monitoring and a cautious approach to opioid use in patients deemed high-risk may reduce the frequency and cost of this complication.

DISCLOSURE: The following authors have nothing to disclose: Roman Melamed, Lori Boland, James Normington, Rebecca Prenevost, Lindsay Hur, Leslie Maynard, Molly McNaughton, Joseph Huguelet

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