Preoperative Alcohol Use Research Articles

Preoperative Alcohol Use, Postoperative Pain, and Opioid Use After Coronary Artery Bypass Surgery

ObjectivesChronic alcohol use is associated with chronic pain and increased opioid consumption. The association between chronic alcohol use and acute postoperative pain has been minimally studied. Our objective was to explore the association between preoperative alcohol use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG). DesignRetrospective cohort study. SettingSingle academic medical center. ParticipantsPatients having isolated CABG. InterventionsNone Measurements and Main ResultsDemographics, comorbidities, and baseline alcohol consumption were recorded. Primary outcomes were mean pain score and morphine milligram equivalent consumption on postoperative day 0. Among 1,338 patients, there were 764 (57.1%) who had no weekly preoperative alcohol use, 294 (22.0%) who drank ≤ 1 drink per week, 170 (12.7%) who drank 2-7 drinks per week, and 110 (8.2%) who drank 8 or more drinks per week. There was no significant difference in mean pain score on postoperative day 0 in patients who consumed different amounts of alcohol (No alcohol = 5.3 ± 2.2, ≤ 1 drink = 5.2 ± 2.1, 2-7 drinks = 5.3 ± 2.3, 8 or more drinks = 5.4 ± 1.9, P=0.66). There was also no significant difference in median MME use on postoperative day 0 in patients who consumed different amounts of alcohol (No alcohol = 22.5 mg, ≤ 1 drink=21.1 mg, 2-7 drinks = 24.8 mg, 8 or more drinks = 24.5 mg, P=0.14). ConclusionsThere is no apparent association between mild to moderate preoperative alcohol consumption and early postoperative pain and opioid use in CABG patients.

Utility of phosphatidylethanol testing as an objective measure of alcohol use during the preoperative evaluation for bariatric surgery.

The risk of alcohol use disorder increases after bariatric surgery. Preoperative alcohol use is a risk factor, and this is evaluated during the routine preoperative psychosocial evaluation. However, it is not clear whether patients accurately report their alcohol use. To determine whether an objective measure of alcohol use, phosphatidylethanol (PEth) testing, offers utility beyond self-reported alcohol use during the preoperative evaluation for bariatric surgery. Single healthcare system. PEth testing was included as part of the routine laboratory work for 139 patients undergoing evaluation for bariatric surgery. PEth testing results were compared with self-reported alcohol use and scores on the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) questionnaire obtained during the preoperative psychosocial evaluation. PEth testing results were categorized into abstinent, light use, moderate use, or heavy use. There were 85 patients who completed both PEth testing and a preoperative psychosocial evaluation. There were 25 participants (29.4%) who had a positive PEth test; about half had moderate or heavy use values (15.3% of the total sample). The majority of participants with a positive PEth test (82.6%) denied recent alcohol use. Of those with PEth values indicating moderate or heavy use, 61.5% did not have an elevated AUDIT-C score. Patients appeared to underreport their alcohol use during the preoperative psychosocial evaluation. There appears to be utility for routine PEth testing as part of the evaluation process to identify those with risky drinking patterns. Patients with preoperative risky drinking could be educated about their risk and/or referred to programs to mitigate the development of preoperative alcohol misuse.

Impact of preoperative and intraoperative management on outcomes in osteoradionecrosis requiring free flap reconstruction.

Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and outcomes. Multi-institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n=260). Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p=0.03) and 30-day readmission (p=0.04). Patients with FF compromise had higher TSH (p=0.04) and lower albumin levels (p=0.005). Prealbumin levels were lower in patients who required neck washouts (p=0.02) or a second FF (p=0.03). TSH levels were higher in patients undergoing postoperative debridement (p=0.03) or local flap procedures (p=0.04). Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.

Gaps in Alcohol Screening and Intervention Practices in Surgical Healthcare: A Qualitative Study.

Risky alcohol use before surgery is associated with an increased risk of postoperative complications and longer hospital stays. Preoperative alcohol interventions can improve surgical outcomes but are not commonly integrated into routine care. This study sought to better understand patient's and provider's perceptions of alcohol-related surgical health and healthcare practices and illuminate gaps in care and how they could be improved. This study used a descriptive qualitative research design. Data were collected between July 2017 and March 2018. One-on-one interviews assessed domains related to knowledge, gaps in alcohol-related screening and intervention, and interest in enhancing alcohol-related care. Key themes emerged from a process of iterative coding and thematic analysis. Participants included elective surgical patients who met alcohol screening criteria (n = 20) and surgical healthcare providers (n = 9). Participants had modest or low awareness of alcohol-related surgical health risks. Basic alcohol screening was a routine part of care, but results were often discounted or overlooked. Providers did not routinely initiate preoperative alcohol education or intervention. Providers viewed improving alcohol-related clinical practices as a low priority. Patients were interested in receiving alcohol interventions before surgery if they were delivered in a nonjudgement style and focused on surgical health optimization. This study highlights potential gaps in alcohol-related knowledge and care, and found providers place a low priority on alcohol interventions in the perioperative context. Given the high complication rate associated with preoperative alcohol use, these topics are worthy of future research. To be successful strategies to overcome specific barriers to alcohol screening and intervention must address the needs of patients and providers.

Impact of alcohol use on 30-day complication and readmission rates after elective spinal fusion (≥2 levels) for adult spine deformity: a single institutional study of 1,010 patients

Alcohol use has been shown to affect surgical outcomes. However, it is unknown what effect alcohol use has on postoperative complications or readmission rates in spinal fusion surgery. The aim of this study is to determine the impact of preoperative alcohol use on 30-day readmission rates or the complications profile after adult elective spinal fusion for deformity correction (≥2 levels). The medical records of 1,010 adult patients undergoing elective spinal fusion (≥2 levels) for spinal deformities at a major academic institution from 2005 to 2015 were reviewed. We identified 317 (31.4%) patients who had a history of alcohol prior to surgery and 693 (68.6%) patients who had no history of pre-operative alcohol consumption. The demographics, comorbidities, intra- and 30-day post-operative complication and readmission rates were collected for each patient. The primary outcome investigated in this study was the rate of 30-day readmissions and postoperative complication rates. Baseline characteristics were similar between both cohorts. Intraoperative variables and the immediate postoperative complications profile were mostly similar between both cohorts. Overall, there was no significant difference between the 30-day readmission rates or complications profile between the two cohorts. Our study suggests there is no significant difference in 30-day readmission or complication rates among adult patients with or without preoperative alcohol use undergoing elective correction of spinal deformities.

Benefits of Immediate Extubation Following Free Tissue Transfer for Head and Neck Reconstruction

Background Immediate postprocedure extubation (cessation of mechanical ventilation) after free tissue transfer for head and neck reconstruction may improve outcomes, reduce intensive care unit and hospital length of stay, and reduce overall cost compared with delayed extubation in the intensive care unit. Methods Medical records of 180 consecutive patients undergoing free tissue transfer for head and neck reconstruction were reviewed. Patients immediately extubated in the operating room (immediate group, N = 63) were compared with patients who were extubated in the intensive care unit (delayed group, N = 117) by univariate and multivariate analysis. Results Medical complication rates and intensive care unit length of stay were significantly higher in the delayed extubation group (55.5 vs. 12.7%, p < 0.001, and 4.4 vs. 2.9 days, p < 0.001, respectively). Although the rate of preoperative alcohol use was similar between the two groups, significantly fewer patients underwent treatment for alcohol withdrawal or agitation in the immediate extubation group (3.2 vs. 27.4%, p = 0.001). There were no significant differences in surgical complication rates. Conclusion Immediate postprocedure extubation is associated with shorter intensive care unit length of stay, reduced medical complications, and reduced incidence of treatment for agitation/alcohol withdrawal for patients undergoing free tissue transfer for head and neck reconstruction.

A systematic review of behavioural interventions to reduce preoperative alcohol use.

Preoperative alcohol use is associated with an increase in postoperative morbidity and mortality. Short-term abstinence prior to elective surgery has been shown to reduce postoperative risks. Therefore, behavioural intervention (BI) targeting risky drinking may have significant utility in preventing surgical complications. The literature was systematically reviewed to identify the scope and outcomes of BIs aiming to reduce alcohol use in risky drinkers before they underwent surgery. Five databases were searched using PRISMA criteria. Of 1243 studies identified, four met pre-established inclusion criteria: (i) implementation of a BI prior to an elective surgery; (ii) the BI-targeted alcohol use among risky drinkers; and (iii) printed in English. Two studies indicated significant reductions in alcohol use at follow ups, and one study demonstrated reductions in postoperative risks. These findings are encouraging, but in light of methodological limitations, the efficacy of preoperative BIs for risky drinking could not be determined. Future efforts to screen and implement BIs addressing alcohol use in preoperative patients should carefully define risky drinking, allow ample time for recruitment prior to surgery, implement empirically supported interventions, examine the impact of relevant covariates, and consider the statistical power needed to detect change in postoperative complications. Given the strong link between preoperative alcohol use and postoperative risks, additional research on preoperative BIs is critically needed. Existing research suggests several promising directions for research that may enhance future intervention efforts with this high-risk population. [Fernandez AC, Claborn KR, Borsari B. A systematic review of behavioural interventions to reduce preoperative alcohol use. Drug Alcohol Rev 2015;34:508-20].

Risk factors for alcohol relapse after liver transplantation for alcoholic cirrhosis in Japan

Alcoholic liver cirrhosis (ALC) is an established indication for liver transplantation (LT). Most LT procedures in Japan are living donor liver transplantation (LDLT) because of an extreme shortage of deceased donors. Social circumstances enabling LDLT could be favorable for preventing relapse. The aims of this retrospective study were to analyze the outcomes of LDLT for ALC and to evaluate risk factors for relapse in this cohort. One hundred ninety-five subjects underwent LT [LDLT (n = 187), deceased donor LT (n = 5), or domino LT (n = 3)] for ALC in Japan from November 1997 to December 2011. Risk factors for alcohol relapse and the impact of relapse on outcomes were analyzed for 140 patients after the exclusion of 26 patients who died in the hospital and 29 patients without information about alcohol relapse. The incidence of alcohol consumption after LT was 22.9%. The risk factors for patient survival were a donor age ≥ 50 years (P < 0.01) and a Model for End-Stage Liver Disease score ≥ 19 (P = 0.03). The 10-year patient survival rates were 21.9% and 73.8% for patients who had relapsed and patients who had not relapsed 18 months after LT, respectively (P = 0.01). The relapse rates were 50.0%, 34.5%, 13.3%, 19.7%, and 14.3% for patients who had received livers from parents, siblings, spouses, sons/daughters, and deceased or domino donors, respectively. A history of treatment for psychological diseases other than alcoholism before LT was a significant indicator for the risk of recidivism (P = 0.02), and noncompliance with clinic visits after LT and smoking after transplantation were promising indicators for the risk of recidivism (P = 0.06, and P = 0.05, respectively). Preoperative alcohol consumption was not a risk factor. In conclusion, rather than selecting patients on the basis of preoperative alcohol use, we should provide sociomedical support to improve adherence after LT for ALC in Japan.

Pharmacologic Risk Factors for Post-Operative Delirium in Total Joint Arthroplasty Patients: A Case–Control Study

Total joint arthroplasty (TJA) patients are at increased risk of post-operative delirium (POD) given their demographics and functional impairment. Certain pharmacologic agents are known to cause delirium, but those that cause delirium following TJA are unknown. Our aim was to explore if specific anesthetic agents, opiate pain medications, or benzodiazepines are associated with POD following TJA. A matched case (n=98)-control (n=365) design and conditional logistic regression model were used to examine risk factors for POD among TJA patients at our institution from 2006 to 2010. The model was adjusted for gender, pre-operative alcohol use, and pre-operative depression. Our data suggest that isoflurane and benzodiazepines are associated with an increased risk of delirium in TJA patients and should be used with caution. Hydromorphone and morphine did not increase the risk of delirium in TJA patients and may be considered for post-operative pain control.

Prevalence of preoperative alcohol abuse among patients seeking weight-loss surgery

It has been hypothesized that alcohol metabolism is altered after weight-loss surgery (WLS), with a few studies suggesting a high prevalence of postoperative problem drinking. However, many of these studies were methodologically limited by lack of preoperative alcohol use data, high loss to follow-up, and/or nonsystematic ascertainment of alcohol (ETOH) intake. We sought to systematically characterize ETOH use among WLS patients before surgery. We recruited patients seeking WLS from May 2008 through November 2010 from two bariatric centers in Boston (response rate 75 %). Alcohol intake and problem-drinking behavior was systematically assessed in detail via phone interview among 653 obese patients before WLS. We used multivariable models to characterize alcohol drinking patterns and to examine the relationship between problem drinking and the likelihood of proceeding with WLS. At baseline, 29 % were nondrinkers, 55 % were social drinkers, and 16 % were problem drinkers, including 4 % who displayed alcohol abuse behavior. After adjustment, men and younger adults were significantly more likely to be high-risk drinkers. Problem drinkers were as likely as social drinkers to proceed with WLS. Results from this large representative study suggest a high prevalence of high-risk alcohol use behavior among patients seeking WLS. Detailed assessment of alcohol use may be warranted in clinical settings and in studies of alcohol use and WLS.

Paper 37: Outcome of Worker's Compensation Patients Following Arthroscopic Full-Thickness Rotator Cuff Repair

Outcomes following rotator cuff repair in workers compensation patients are generally reported to be inferior to the general population. The purpose of this study is to evaluate the outcome of arthroscopic rotator cuff repair in workers compensation patients and to identify prognostic factors which may help predict the ability to return to pre-injury level of work. A retrospective cohort of 78 consecutive adult patients (mean age 54.9 +/− 8.2 years) was evaluated at a minimum 1 year follow-up following arthroscopic repair of full-thickness rotator cuff tears. Exclusion criteria included patients presenting with partial-thickness or irreparable tears, subscapularis involvement and/or revision surgery. Multiple variables including preoperative work level, gender, medical comorbidities, alcohol or tobacco use, and tear size were recorded. Contingency table analysis was used to identify significant associations between these variables and return to work at preoperative levels, time to maximum medical improvement (MMI) and failure of repair requiring revision. Patients were evaluated at an average follow-up of 2.5yrs (range 1.0-6.4, sd 1.1). 89.7% of patients returned to their preoperative level of work, at an average time to MMI of 7.6 +/− 2.6 months. 5.1% of patients had failure of their repairs requiring revision. Preoperative work level, smoking status, gender and tear size did not influence return to work status, MMI or failure rate in this population. A history of preoperative alcohol use (>6 beers/wk) was significantly associated with not returning to preoperative work levels following surgery (p=0.011). Nondiabetics and patients who did not drink alcohol (<6 beers/wk) were significantly less likely to have repair failure requiring revision (p=0.012 and 0.009, respectively). Compensable patients undergoing arthroscopic full-thickness rotator cuff repair return to preoperative levels of work in the majority of cases, regardless of preoperative work level, smoking status, gender or tear size. Diabetes and reported alcohol use may predict a less likely return to work and a higher failure rate in these patients.

Are Preoperative Depressive Symptoms Associated With Postoperative Delirium in Geriatric Surgical Patients?

Delirium is common in older surgical patients and predicts negative health outcomes. Whether depressive symptoms are prevalent and predict the development of postoperative delirium in elderly surgical patients has not been investigated. Our study aimed to examine the prevalence and prognostic importance of preoperative depressive symptoms in older surgical patients. Patients at least 65 years of age who were scheduled for major noncardiac surgery were recruited. Preoperatively, patients were screened for symptoms of depression using the 15-point Geriatric Depression Scale (GDS). Postoperative delirium was measured using the Confusion Assessment Method. The associations between covariates and preoperative depression, and postoperative delirium were determined by multivariate logistic regression. In the 219 patients studied, the mean age was 73.6 +/- 6 years, 12% of patients reported six or more depressive symptoms, and 32% reported three to five depressive symptoms. By multivariate logistic regression, patient characteristics associated with six or more symptoms of depression included <12 years of education, moderate to severe limitation in functional status, and drinking more than two alcoholic beverages per day. Postoperatively, 46% of patients developed delirium. Patients with a greater number of preoperative depressive symptoms were more likely to develop postoperative delirium (p =.048) and experience a longer duration of postoperative delirium (p =.027). Even after adjusting for covariates associated with depression and postoperative delirium--including age, educational level, functional status, and preoperative alcohol use--patients with more than six preoperative depressive symptoms were still significantly more likely to have a longer duration of postoperative delirium than did those patients with fewer than two depressive symptoms (odds ratio = 2.69, confidence interval = 1.04-6.93). Preoperative screening for the presence of depressive symptoms can be performed easily in elderly patients, and yields useful prognostic information relating to postoperative delirium.