Preoperative Prescription Research Articles

Prevalence and Risk Factors for Pancreatic Insufficiency After Partial Pancreatectomy

BackgroundThis study aimed to determine the rate, timing, and predictors of diabetes and exocrine pancreatic insufficiency after pancreatectomy in order to inform preoperative patient counseling and risk management strategies. MethodsUsing prescription claims as a surrogate for disease prevalence, IBM Watson Health MarketScan was queried for claims patterns pre- and post-pancreatectomy. Multivariable models explored associations between clinical characteristics and medication use within 2 years of surgery. ResultsIn total, 18.96% of 2,848 pancreaticoduodenectomy (PD) patients and 18.95% of 1,858 distal pancreatectomy (DP) patients had preoperative diabetic medication prescription claims. Fewer (6.6% and 3.88%, respectively) had pancreatic enzyme replacement therapy (PERT) claims. Diabetic medication claims increased to 28.69% after PD and 38.59% after DP [adjusted relative risk (aRR) = 1.36 (95% CI 1.27, 1.46)]. Other associated factors included age > 45, medical comorbidity, and obesity. The incidence of new diabetic medication claims among medication naïve patients was 13.78% for PD and 24.7% for DP (p < 0.001) with a median 4.7 and 4.9 months post-operatively. The prevalence of PERT claims was 55.97% after PD and 17.06% after DP [aRR = 0.32 (0.29, 0.36)]. The incidence of postoperative PERT claims 53.98% (PD) and 14.84% (DP) (p < 0.0001). The median time to new PERT claim was 3.0 (PD) and 3.2 (DP) months, respectively. Claims for both diabetic medications and PERT rose sharply after surgery and plateaued within 6 months. ConclusionsThis study defines prevalence, timing, and predictors for post-pancreatectomy insufficiency to inform preoperative counseling, risk modification strategies, and interventions related to quality of life.

Preoperative opioids before adult spinal deformity surgery associated with increased reoperations and high rates of chronic postoperative opioid use at 3-year follow-up.

To determine the association of preoperative opioid prescriptions with reoperations and postoperative opioid prescriptions after adult spina deformity (ASD) surgery. With the current opioid crisis, patients undergoing surgery for ASD are at particular risk for opioid-related complications due to significant preoperative disability and surgical morbidity. No previous studies consider preoperative opioids in this population. A retrospective cohort study of patients undergoing posterior spinal fusion (7 or more levels) for ASD was performed. All patients had at least 3years of postoperative follow-up 3years postoperatively. Prescriptions for 4 different opioid medications (hydromorphone, oxycodone, hydrocodone, and tramadol) were identified within 3months preoperatively and up to 3years postoperatively. Multivariate regression was utilized to determine the association of preoperative use with reoperations and with postoperative opioid use, controlling for both patient and surgery-related confounding factors. A total of 743 patients were identified and 59.6% (443) had opioid prescriptions within 3months preoperatively. Postoperative opioid prescriptions were identified in 66.9% of patients at 12months postoperatively, and in 54.8% at 36months postoperatively. The 3-year reoperation rate was 11.0% in patients without preoperative prescriptions, 16.0% in patients with preoperative any opioid prescriptions (P = 0.07), and 34.8% in patients with preoperative hydromorphone prescriptions (P < 0.01). In multivariate analysis, preoperative opioid prescriptions were associated with increased reoperations (odds ratio [OR]: 1.62, P = 0.04), and chronic postoperative opioid use (OR: 4.40, P < 0.01). Preoperative hydromorphone prescriptions had the strongest association with both reoperations (OR: 4.96; P < 0.01) and chronic use (OR: 5.19: P = 0.03). In the ASD population, preoperative opioids are associated with both reoperations and chronic opioid use, with hydromorphone having the strongest association. Further investigation of the benefits of preoperative weaning programs is warranted.

Prevalence of chronic opioid use in patients with peripheral arterial disease undergoing revascularization.

Opiate use, dependence, and the associated morbidity and mortality are major current public health problems in the United States. Little is known about patterns of opioid use in patients with peripheral arterial disease (PAD). The purpose of this study was to identify the prevalence of chronic preoperative and postoperative prescription opioid use in patients with PAD. A secondary aim was to determine the demographic, comorbid conditions, and operative characteristics associated with chronic opioid use. Using a single-institution database of patients with PAD undergoing open or endovascular lower extremity intervention from 2013 to 2014, data regarding opiate use and associated conditions were abstracted for analysis. Patients were excluded if they did not live in North Carolina or surgery was not for PAD. Preoperative (PreCOU) and postoperative chronic opioid use (PostCOU) were defined as consistent opioid prescription filling in the 3months before and after the index procedure, respectively. Opioid prescription filling was assessed using the North Carolina Controlled Substance Reporting System. Demographics, comorbid conditions, other adjunct pain medication data, and operative characteristics were abstracted from our institutional electronic medical record. Associations with PreCOU were evaluated using the t test, Wilcoxon test, or two-sample median test (continuous), or the χ2 or Fisher exact tests (categorical). A total of 202 patients undergoing open (108; 53.5%) or endovascular (94; 46.5%) revascularization for claudication or critical limb ischemia were identified for analysis. The mean age was 64.6years, and 36% were female. Claudication was the indication for revascularization in 26.7% of patients, and critical limb ischemia was the indication in 73.3% of patients. The median preoperative ankle-brachial index (ABI) was 0.50. Sixty-eight patients (34%) met the definition for PreCOU. PreCOU was associated with female gender, history of chronic musculoskeletal pain, benzodiazepine use, and self-reported illicit drug use. Less than 50% of patients reported use of non-opiate adjunct pain medications. No association was observed between PreCOU and pre- or postoperative ABI, or number of prior lower extremity interventions. Following revascularization, the median ABI was 0.88. PreCOU was not associated with significant differences in postoperative complications, length of stay, or mortality. Overall, 71 patients (35%) met the definition for PostCOU, 14 of whom had no history of preoperative chronic opiate use. Ten patients with PreCOU did not demonstrate PostCOU. Chronic opiate use was common in patients with PAD with a prevalence of approximately 35%, both prior to and following revascularization. Revascularization was associated with a termination of chronic opiate use in less than 15% of patients with PreCOU. Additionally, 10% of patients who did not use opiates chronically before their revascularization did so afterwards. Patients with PAD requiring intervention represent a high-risk group with regards to chronic opiate use. Increased diligence in identifying opioid use among patients with PAD and optimizing the use of non-narcotic adjunct pain medications may result in a lower prevalence of chronic opiate use and its attendant adverse effects.

An Assessment of Antimicrobial Prescription Pattern among Surgical Patients: A Hospital Based Cross Sectional Descriptive Study

Introduction: Antimicrobials are used before, during and after surgery to prevent infections to decrease the duration of hospital stay, increase surgical outcomes and reduce health-related costs. There is inadequate evidence to determine the effective group of antimicrobials to be used in surgical prophylaxis in our settings. Methods: A hospital-based cross-sectional descriptive study involving antimicrobial prescriptions pattern among 223 surgical patients was undertaken. Information on patient’s demographic variables, diagnosis, type of surgery and wound, perioperative antimicrobial use, postoperative complications and number of antimicrobials prescribed from the essential medicine list were recorded. The antibiotic prescription patterns were assessed based on a comparison with international and national guidelines. Results: Among 223 patients, males were predominant with an overall mean age of 42.77 years. The total number of diagnoses was 30, the commonest being appendicitis (21.52%), urinary stone disease (15.69%), hernia (13.90%) and cholelithiasis (11.65%). The common surgeries performed were emergency appendectomy, hernioplasty and laparoscopic cholecystectomy. Eighteen types of drugs from seven different antimicrobial groups were used perioperatively, out of which 73% and 83% were prescribed based on international and national guidelines respectively. Conclusion: The most common antimicrobial used was third-generation cephalosporin. The postoperative antimicrobial rate was found higher compared to preoperative and intraoperative prescriptions and for a longer duration compared to national and international guidelines.

Introduction to Pre-operative Exercise Prescription and Physical Activity Promotion for Clinicians and Exercise Professionals

Introduction to Pre-operative Exercise Prescription and Physical Activity Promotion for Clinicians and Exercise Professionals

Perioperative Opioid Analgesics and Hallux Valgus Correction Surgery: Trends, Risk Factors for Prolonged Use and Complications

In the setting of an opioid epidemic, this study aims to provide evidence on opioid use trends, risk factors for prolonged use, and complications from perioperative opioid consumption in hallux valgus surgery. A national database was queried for patients who underwent hallux valgus correction. Regression analysis identified: (1) risk factors for prolonged postoperative narcotic use; and (2) association between preoperative/prolonged postoperative narcotic use and postoperative complications. A linear regression analysis was used to determine trends. About 20,749 patients were included, of which 3464 patients were prescribed narcotics preoperatively and 4339 were identified as prolonged postoperative narcotic prescription users. Preoperative prescriptions were identified as risk factors for prolonged use. Perioperative narcotic use was observed to be a risk factor for poor outcomes. About 21% of patients were identified as prolonged postoperative narcotic prescription users. Patients undergoing hallux valgus corrective surgery should be counseled regarding their increased risk of complications when using narcotics.

150. The effect of online prescription drug monitoring on opioid prescription habits after single level lumbar fusion

<h3>BACKGROUND CONTEXT</h3> The United States opioid epidemic is a well-documented crisis stemming from increased prescription of narcotics, leading to widespread misuse of both prescription and nonprescription opioid pain relievers. To combat this epidemic, online prescription drug monitoring programs (PDMPs) have been implemented at the state level to track prescriptions of controlled substances and mitigate potential misuse and addiction. <h3>PURPOSE</h3> To evaluate prescription trends of opioids over time following implementation of an online PDMP in patients who underwent single-level lumbar fusion. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort analysis. <h3>PATIENT SAMPLE</h3> Patients 18 years of age or older who underwent single-level lumbar fusion for spinal stenosis, spondylolisthesis, or disc herniation. <h3>OUTCOME MEASURES</h3> Pre- and postoperative per-patient average total opioid prescriptions, prescriptions obtained by private pay, number of prescribers, number of pharmacies, number of pills/liquid doses, refills, duration of use (days), total milligram morphine equivalents (MME) per patient, preoperative opioid naivety (defined as no documented opioid prescription within one year prior to surgery), and postoperative chronic opioid use (defined as filling ten or more prescriptions, or receiving 120 or more days of opioid prescriptions, within the first year after surgery excluding the initial 90-day postoperative period). <h3>Methods</h3> Patients who underwent single-level lumbar fusion between January 1st, 2017 and December 30, 2019 were identified. Patients were placed into one of two cohorts: (1) patients whose procedure occurred during 2017, the first calendar year following implementation of the local online PDMP, and (2) patients whose procedures occurred during 2019. Opioid use data was obtained by searching for each patient in the state government's online PDMP and recording data within the year prior to and the year following the patient's procedure. <h3>Results</h3> A total of 393 patients were included in the study. One hundred seventy-two were included in the 2017 cohort, while 221 were included in the 2019 cohort. Preoperatively, the 2019 cohort obtained significantly greater average of preoperative prescription opioids via private pay compared to 2017 (0.4 ± 1.5 vs 0.1 ± 1.6, p=0.01). Postoperatively, the 2019 cohort obtained on average a greater total number of opioid prescriptions (4.0 ± 6.1 vs 2.8 ± 4.9, p=0.046), and obtained opioid prescriptions from a greater average number of prescribers (1.8 ± 1.4 vs 1.4 ± 1.6, p=0.01) and pharmacies (1.1 ± 0.7 vs 0.8 ± 0.8, p=0.001). <h3>Conclusions</h3> Despite implementation of an online PDMP, increases were found from 2017 to 2019 in per-patient preoperative prescriptions obtained by private pay as well as average total postoperative opioid prescriptions and average number of prescribers and pharmacies. While the exact effect of different strategies aimed at decreasing the misuse and abuse of narcotic medications is unclear, use of an online PDMP is not sufficient to discourage opioid use in patients undergoing single-level lumbar fusion. Future studies should determine the effect of other strategies, such as pain management modalities that do not involve opioid prescriptions, on discouraging opioid abuse. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

9. The impact of nasal screening for methicillin-resistant staphylococcus aureus on surgical site infection after primary lumbar fusion

<h3>BACKGROUND CONTEXT</h3> Surgical site infections (SSI) constitute significant morbidity in spine surgery. Efforts at SSI prevention include preoperative methicillin-resistant Staphylococcus aureus (MRSA) screening and decolonization, with demonstrated success for arthroplasty patients along with vascular and cardiothoracic surgical patients. The variety of surgical approaches and anatomic regions within spine surgery can limit the impact of analyses at the subspecialty level. Despite the success of MRSA nasal screening and decolonization in reducing SSI rates in other disciplines, the impact on spine surgery is less understood. <h3>PURPOSE</h3> To determine the relationship between nasal MRSA testing and operative debridement rates for surgical site infection after primary lumbar fusion. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study at two academic tertiary referral centers. <h3>PATIENT SAMPLE</h3> Adult patients (>18 years) were identified from January 2015 to March 2020 based on CPT codes for spinal instrumentation and fusion. Inclusion criteria were primary instrumented posterior lumbar fusion between 1-3 levels and exclusion criteria were revision surgery, tumor, infection, lateral-only surgery or operative surgeon with fewer than 20 cases. <h3>OUTCOME MEASURES</h3> Operative incision and drainage (I&D) of the index lumbar spine wound within 90-days after surgery was the primary outcome. <h3>METHODS</h3> Chart text, operative reports and laboratory reports were reviewed for data abstraction. Multivariable logistic regression modeling assessed for demographic differences between MRSA testing groups as well as factors contributing to I&D risk. <h3>RESULTS</h3> There were 2,148 patients included with a mean age 62.5 (SD 12.9), 56.9% female, and mean BMI 29.4 (SD 6.2). MRSA testing 90 days prior to surgery was completed in 884 (41.1%) of patients, and 19 (2.2%) of tested patients were colonized with MRSA preoperatively. Thirty-six (1.7%) patients underwent surgical I&D within 90 days of their index procedure for a surgical site infection. I&D risk was not associated with presence or result of MRSA testing, preoperative mupirocin prescriptions, or type of intraoperative antibiotic after controlling for surgeon. I&D risk was associated with higher BMI (5.7% increased risk for every 1 unit increase in BMI or a coefficient of 0.057, 95% confidence interval 0.017 to 0.097, p = 0.005) after controlling for age, diabetes and smoking status. <h3>CONCLUSIONS</h3> The present study demonstrates no difference in surgical I&D rates between patients who underwent MRSA testing, who had positive MRSA colonization or who underwent other interventions aimed at decreasing SSI rates such as preoperative mupirocin decolonization or addition of intraoperative vancomycin. Increased BMI was associated with risk of undergoing an operative I&D for surgical site infection, suggesting that patient factors dominate over clinical interventions in the prevention of surgical site infection after primary lumbar spine fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Exploration of Overdose Risk Score and Postoperative Complications and Health Care Use After Total Knee Arthroplasty

The adverse outcomes after total knee arthroplasty (TKA) associated with preoperative prescription drug use (ie, use of narcotics, sedatives, and stimulants) have been established but are not well quantified. To test the association of preoperative overdose risk score (ORS) with postoperative health care use. This cohort study was conducted using data on a consecutive sample of individuals who underwent primary TKA from November 2018 through March 2020 at a tertiary care health system. Data were collected using the Orthopaedic Minimal Data Set Episode of Care, a validated data-collection system for all elective orthopedic surgical interventions taking place within the health care system. Outcomes were assessed at 90 days postoperatively. Individuals whose preoperative baseline characteristics or ORS were not provided or who declined to participate were excluded. Data were analyzed from September through October 2020. Patient-specific preoperative ORS, as measured using NarxCare, associated with patterns of prescription drug use. Associations between patient-specific ORS categories and 90-day postoperative health care use (ie, prolonged hospital length of stay [LOS; ie, >2 days], nonhome discharge, all-cause 90-day readmission, emergency department [ED] visits, and reoperation) were evaluated. Outcomes were also compared between a group of individuals with ORS less than 300 vs those with ORS 300 or greater who were propensity score matched (4:1; caliper, 0.1) using demographic characteristics (ie, age, sex, race, body mass index, and smoking status) and baseline comorbidities. Among 4326 individuals who underwent primary TKA, 2623 (60.63%) were women, 3602 individuals (83.26%) were White, the mean (SD) BMI was 32.8 (6.9), and the mean (SD) age was 66.6 (9.2) years; 90-day follow-up was available for the entire cohort. The predominant preoperative diagnosis was osteoarthritis, occurring among 4170 individuals (96.4%). For individuals with an ORS of 300 to 399, there were significantly higher odds of a prolonged LOS (odds ratio [OR], 2.03; 95% CI, 1.46-2.82; P < .001), nonhome discharge (OR, 2.01; 95% CI, 1.37-2.94; P < .001), all-cause 90-day readmission (OR, 1.56; 95% CI, 1.01-2.42; P < .001), and ED visits (OR, 1.62; 95% CI, 1.11-2.38; P = .01) compared with individuals who were prescription drug naive (ie, ORS = 0). Individuals in the highest ORS category (ie, ORS ≥ 500) had the highest ORs for prolonged LOS (OR, 3.71; 95% CI, 2.00-6.87; P < .001), nonhome discharge (OR, 4.09; 95% CI, 2.02-8.29; P < .001), 90-day readmission (OR, 4.41; 95% CI, 2.23-8.71; P < .001), and 90-day reoperation (OR, 6.09; 95% CI, 1.44-25.80; P = .01). Propensity score matching confirmed the association between an ORS of 300 or greater and the incidence of prolonged LOS (244 individuals [11.6%] vs 130 individuals [23.0%]; P < .001), nonhome discharge (176 individuals [8.4%] vs 93 individuals [16.4%]; P < .001), all-cause 90-day readmission (119 individuals [5.7%] vs 65 individuals [11.5%]; P < .001), and all-cause ED visits (198 individuals [9.4%] vs 76 individuals [13.4%]; P = .006). This study found that higher ORS was associated with increased health care use after primary TKA. These findings suggest that an ORS of 300 or greater could be used to designate increased risk and guide the preoperative surgeon-patient discussion to modify prescription drug use patterns.

A Call for Improved Screening of Preoperative Prescription Drug Abuse: A Scalar Assessment Not Limited to Opioids.

Prescription-drug abuse has strained US healthcare. While several investigations highlight an association between opioid use and adverse postoperative outcomes, similar associations with nonopioid prescription-drugs remain under-studied. Furthermore, patients' underlying prescription drug use patterns remain poorly characterized. This perspective details such obstacles which hinder translating literature-reported findings into practice.

Preoperative analgesic instruction and prescription reduces early home pain after outpatient surgery: a randomized controlled trial.

Home pain remains the most common complication in outpatient surgery. Optimal management requires good information and early availability of analgesics. The main objective of this randomized controlled trial was to compare the effects of pre- vs postoperative analgesic instruction and prescription on postoperative home pain. Patients were randomized into an anesthesia consultation group (AC group) and a standard postoperative group (POP group). The AC group and the POP group received analgesic prescription and instruction during the anesthesia consultation and after surgery, respectively. The primary outcome was the incidence of home pain on postopertive day one (D1). Home pain was defined by at least one episode with a numeric rating scale score > 3/10 at rest. Treatment compliance and postoperative nausea and vomiting (PONV) were also assessed on D1 and postoperative day 7 (D7). One hundred and eighty-six patients were included between May 2017 and May 2018 at Rouen University Hospital, France. Ninety-four patients were randomized to the AC group and 92 to the POP group. On D1, the incidence of pain was 23/94 (24%) in the AC group and 44/92 (48%) in the POP group (P < 0.001). On D1, the rate of treatment compliance was significantly higher in the AC group than in the POP group (85% vs 69%; P = 0.02). There was no statistically significant difference in the incidence of pain or treatment compliance between groups on D7 or in PONV on D1 and on D7. Preoperative analgesic instruction and prescription during anesthesia consultation reduces the incidence of early postoperative home pain in outpatient surgery. www.clinicaltrialsgov (NCT03205189); registered 2 July 2017.

Perioperative adherence to continuous positive airway pressure and its effect on postoperative nocturnal hypoxemia in obstructive sleep apnea patients: a prospective cohort study

BackgroundAlthough continuous positive airway pressure (CPAP) is the first line treatment for obstructive sleep apnea (OSA) patients, the perioperative adherence rate is unclear. The objective of this study was to determine the perioperative adherence rate of patients with OSA with a CPAP prescription and the effect of adherence on nocturnal oxygen saturation.MethodsThis prospective cohort study included adult surgical patients with a diagnosis of OSA with CPAP prescription undergoing elective non-cardiac surgery. Patients were divided into CPAP adherent and non-adherent groups based on duration of usage (≥ 4 h/night). Overnight oximetry was performed preoperatively and on postoperative night 1 and 2 (N1, N2). The primary outcome was adherence rate and the secondary outcome was nocturnal oxygen saturation.ResultsOne hundred and thirty-two patients completed the study. CPAP adherence was 61% preoperatively, 58% on postoperative N1, and 59% on N2. Forty-nine percent were consistently CPAP adherent pre- and postoperatively. Using a linear fixed effects regression, oxygen desaturation index (ODI) was significantly improved by CPAP adherence (p = 0.0011). The interaction term CPAP x N1 was significant (p = 0.0015), suggesting that the effect of CPAP adherence varied on N1 vs preoperatively. There was no benefit of CPAP adherence on postoperative mean SpO2, minimum SpO2, and percentage of sleep duration with SpO2 < 90%. Use of supplemental oxygen therapy was much lower in the CPAP adherent group vs non-adherent group (9.8% vs 46.5%, p < 0.001).ConclusionsAmong patients with a preoperative CPAP prescription, approximately 50% were consistently adherent. CPAP adherence was associated with improved preoperative ODI and the benefit was maintained on N1. These modest effects may be underestimated by a higher severity of OSA in the CPAP adherent group and a higher rate of oxygen supplementation in the non-adherent group.Trial registrationClinicalTrials.Gov registry (NCT02796846).

The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty.

BackgroundOrthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty.MethodsA retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences.ResultsPreoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P < .001). Postoperatively, initial opioid prescriptions were higher in average pills for group 1 (26 pills with an average of 375.6 TMEs) compared to group 2 (18 pills with an average of 199.6 TMEs) (P < .001, P = .122). For the entire postoperative course, patients in group 1 filled prescriptions for an average of 1740.7 TMEs and 84 pills, compared to 461.9 TMEs and 32 pills in group 2 (P = .035, P < .001). In the cohort, 17.8% of group 2 had multiple recorded opioid prescriptions, compared to 70.1% of group 1. There were also significant differences observed in postoperative dependence rates, with 23.0% in group 1 compared to 12.5% in group 2 (P = .043).ConclusionsState-mandated opioid prescribing restrictions have been successful in decreasing opioid prescribing and dependence rates for orthopedic shoulder patients. Further efforts are required to reduce preoperative prescriptions involving chronic shoulder pathology as current legislature has not had an impact on this. Legislative changes may be an effective way to help reduce abuse and opioid dependence in shoulder arthroplasty patients; however, further research is needed.

789 Improving Compliance of The MUST Tool Through Multiple Interventions, Improves Documentation and Assessment of Nutritional Status in Trauma and Orthopaedic Patients Undergoing Surgery

Abstract Introduction The Malnutrition Universal Screening Tool (MUST) is a nationally validated risk tool, used to identify adults who are malnourished. 40% of surgical patients are malnourished which significantly impacts the outcomes of elderly patients. The primary aim of this study was to ascertain its utilisation in elderly patients undergoing trauma and orthopaedic surgery in a district general hospital. Method We completed a closed-loop audit from October2019-June2020 over two, three-week periods Inclusion criteria was age ≥65 years, and patients undergoing surgery. Data collected included MUST score, nutritional support, pre-operative fasting time, and prescription of fluids. Our intervention included departmental teaching sessions, posters, and the addition of the MUST tool to clerking proformas. Results We included analysis of 70 patients. Following our intervention, admission MUST score calculation improved by 8%, and providing nutritional support increased by 21%. However, there was no improvement in reducing pre-operative fasting time and prescription of pre-operative fluids. Conclusions Through our intervention’s documentation and assessment of nutritional status in elderly patients has improved. However further work must be completed to reduce time spent ‘nil-by-mouth’ and prescribe fluids for maintenance before surgery. This requires better pre-operative planning and communication between the surgical and ward-based teams.

NarxCare Scores Greater Than 300 Are Associated with Adverse Outcomes After Primary THA.

The association between preoperative prescription drug use (narcotics, sedatives, and stimulants) and complications and/or greater healthcare utilization (length of stay, discharge disposition, readmission, emergency department visits, and reoperation) after total joint arthroplasty has been established but not well quantified. The NarxCare score (NCS) is a weighted scalar measure of overall prescription opioid, sedative, and stimulant use. Higher scores reflect riskier drug-use patterns, which are calculated based on (1) the number of prescribing providers, (2) the number of dispensing pharmacies, (3) milligram equivalence doses, (4) coprescribed potentiating drugs, and (5) overlapping prescription days. The aforementioned factors have not been incorporated into association measures between preoperative prescription drug use and adverse events after THA. In addition, the utility of the NCS as a scalar measure in predicting post-THA complications has not been explored. (1) Is the NarxCare score (NCS) associated with 90-day readmission, reoperation, emergency department visits, length of stay, and discharge disposition after primary THA; and are there NCS thresholds associated with a higher risk for those adverse outcomes if such an association exists? (2) Is there an association between the type of preoperative active drug prescription and the aforementioned outcomes? Of 3040 primary unilateral THAs performed between November 2018 and December 2019, 92% (2787) had complete baseline information and were subsequently included. The cohort with missing baseline information (NCS or demographic/racial determinants; 8%) had similar BMI distribution but slightly younger age and a lower Charlson Comorbidity Index (CCI). Outcomes in this retrospective study of a longitudinally maintained institutional database included 90-day readmissions (all-cause, procedure, and nonprocedure-related), reoperations, 90-day emergency department (ED) visits, prolonged length of stay (> 2 days), and discharge disposition (home or nonhome). The association between the NCS category and THA outcomes was analyzed through multivariable regression analyses and a confirmatory propensity score-matched comparison based on age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, which removed significant differences at baseline. A similar regression model was constructed to evaluate the association between the type of preoperative active drug prescription (opioids, sedatives, and stimulants) and adverse outcomes after THA. After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, an NCS of 300 to 399 was associated with a higher odds of 90-day all-cause readmission (odds ratio 2.0 [95% confidence interval 1.1 to 3.3]; p = 0.02), procedure-related readmission (OR 3.3 [95% CI 1.4 to 7.9]; p = 0.006), length of stay > 2 days (OR 2.2 [95% CI 1.5 to 3.2]; p < 0.001), and nonhome discharge (OR 2.0 [95% CI 1.3 to 3.1]; p = 0.002). A score of 400 to 499 demonstrated a similar pattern, in addition to a higher odds of 90-day emergency department visits (OR 2.2 [95% CI 1.2 to 3.9]; p = 0.01). After controlling for potentially confounding variables like age, gender, race, BMI, smoking status, CCI, insurance status, preoperative diagnosis, and surgical approach, we found no clinically important association between an active opioid prescription and 90-day all-cause readmission (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.05), procedure-related readmission (OR 1.003 [95% CI 1.001 to 1.006]; p = 0.02), length of stay > 2 days (OR 1.003 [95% CI 1.002 to 1.005]; p < 0.001), or nonhome discharge (OR 1.002 [95% CI 1.001 to 1.003]; p = 0.019); the large size of the database allowed us to find statistical associations, but the effect sizes are so small that the finding is unlikely to be clinically meaningful. A similarly small association that is unlikely to be clinically important was found between active sedative use and 90-day ED visits (OR 1.002 [95% CI 1.001 to 1.004]; p = 0.02). Preoperative prescription drug use, as reflected by higher NCSs, has a dose-response association with adverse outcomes after THA. Surgeons may use the preoperative NCS to initiate and guide a patient-centered discussion regarding possible postoperative risks associated with prescription drug-use patterns (sedatives, opioids, or stimulants). An interdisciplinary approach can then be initiated to mitigate unfavorable patterns of prescription drug use and subsequently lower patient NCSs. However, given its nature and its reflection of drug-use patterns rather than patients' current health status, the NCS does not qualify as a basis for surgical denial or ineligibility. Level III, diagnostic study.

Prescribing Trends in Post-operative Pain Management After Urologic Surgery: A Quality Care Investigation for Healthcare Providers

To assess prescribing and refilling trends of narcotics in postoperative urology patients at our institution. Although the opioid epidemic remains a public health threat, no series has assessed prescribing patterns across urologic surgery disciplines following discharge. All urologic surgeries were retrospectively reviewed from May 2017-April 2018. Demographics, comorbidities, and postoperative pain management strategies were analyzed. Narcotics usage following surgery were reported in total morphine equivalents (TME). Opioid refill rate was characterized by medical specialty and stratified by urologic discipline. 817 cases were reviewed. Mean age and TME at discharge was 57±15.6 years and 35.43±19.5 mg, respectively. 13.6% (mean age 55±15.9) received a narcotic refill following discharge (mean TME/refill 37.7±28.9 mg). A higher proportion of patients with a pre-operative opioid prescription received a refill compared to opioid naïve patients (38.2% vs 21.6%, P < .01). Refill rate did not differ between urologic subspecialties (P = .3). Urologists were only responsible for 20.4% of all refills filled, despite all patients continuing follow-up with their surgeon. Procedures with the highest rates of post-operative refills were in oncology, male reconstruction/trauma and endourology. Patients with a history of chronic pain (OR 1.9, CI 1.1-3.3) preoperative narcotic prescription (OR 1.6, CI 1.0-2.6), and higher ASA score (OR 1.8, CI 1.6-2.8) were more likely to obtain a postoperative opioid prescription refill. Approximately 1 in 7 postoperative urology patients receive a postoperative narcotics refill; however, nearly two-thirds receive refills exclusively from non-urologic providers. Attempts to avoid overprescribing of postoperative narcotics need to account for both surgeon and nonsurgeon sources of opioid refills.

Pre-Operative Prescription of Erythrocyte Concentrates in Surgery and Gyneco-Obstetrics at Cuk

Background: The practice of blood transfusion is common at the University Clinics of Kinshasa (CUK), with a trend towards a decrease in average transfusion rates between 2015 and 2016. However a gap persists between the still insufficient donation and the needs in blood derivatives. Objective: The objective of this work was to assess the level of need according to the efficient management of red cell concentrates and according to certain bioclinical components. Methods: A literature review was conducted in patients operated in Surgery and Obstetrics-Gynaecology during the period of January 2014 to December 2016. The Haematology and Immuno-transfusion unit of CUK were used as reference for the Surgical and Obstetric Gynaecology Services. Results: In a total of 1512 patient records from the two surgical departments analysed, the mean pretransfusion haemoglobinemia was 9.6 ± 2.5g/dL. Unjustified prescriptions and unjustified expenditures were more associated with Surgery, Obstetrics and restrictive transfusion strategy. Advanced age, preoperative haemoglobinemia collapse and surgical services were independent predictors of the number of bags ordered. Conclusion: Inadequate prescribing of unwarranted blood bags was pejorative in patients transfused from a low socioeconomic level. Further prospective studies are needed. They could include other parameters not addressed in this study such as the quality of the prescriber, the surgeon who operated and the duration of delivery of the unit ordered.

Are Patients Taking Benzodiazepines at Increased Risk for Complications Following Primary Total Knee Arthroplasty?

BackgroundBenzodiazepines are commonly taken by patients who are undergoing total knee arthroplasty (TKA), but there is a paucity of studies evaluating any associations. Therefore, we hoped to study if patients taking preoperative benzodiazepines would have increased complications following TKA. MethodsUsing a nationwide database, from 2010 to 2019, we evaluated patients undergoing primary TKA who either did or did not have a preoperative record of benzodiazepine prescription. We performed a multivariable logistic regression analysis, adjusting for multiple variables (age, gender, obesity, and Charlson comorbidity index), to determine the association of preoperative benzodiazepine use and adverse events in a matched cohort. Furthermore, we stratified patients by one vs multiple preoperative benzodiazepine prescription(s). We evaluated 90-day and 2-year rates of revision, resection, femur fracture fixation, manipulation under anesthesia (MUA), and delirium. ResultsPatients filling more than one preoperative benzodiazepine prescription had increased adjusted odds of 90-day (odds ratio [OR] = 1.198, confidence interval [CI] = 1.086-1.320) and 2-year (OR = 1.188, CI = 1.125-1.254) revision; 90-day resection (OR = 1.430, CI = 1.125-1.817); 90-day (OR = 1.639, CI = 1.255-2.141) and 2-year (OR = 1.646, CI = 1.412-1.919) femur fracture fixation; and 2-year delirium (OR = 2.288, CI = 1.564-3.382). Preoperative benzodiazepine users had decreased adjusted odds of 90-day (OR = 0.670, CI = 0.639-0.702) and 2-year (OR = 0.702, CI = 0.671-0.734) MUA. ConclusionAfter controlling for multiple variables, benzodiazepine use was associated with increased rates of revision, resection, femur fracture fixation, and delirium. Furthermore, benzodiazepine use was also associated with a decreased rate of MUA. Orthopaedic professionals can counsel patients taking this group of medications about the associated adverse events. Future studies should assess the use of other muscle relaxants in the prevention of knee stiffness and MUA.

Chronic Preoperative Opioids Are Associated With Revision After Rotator Cuff Repair

We sought to clarify the relationship between chronic preoperative opioids and complications following rotator cuff repair. Specifically, we assessed revision, a definitive postoperative end point for surgical outcome. This study used PearlDiver, a United States national insurance claims database. All patients undergoing rotator cuff repair from 2008 to 2018 were identified and stratified based on a minimum of 2 opioid prescriptions within the 6 months before surgery, with 1 prescription occurring within 0 to 3 months before surgery and a second prescription within 4 to 6 months before surgery. Univariate logistic regressions of risk factors were conducted, followed by multivariate analysis of comorbidities, including ongoing preoperative opioids, any preoperative nonsteroidal anti-inflammatory drug (NSAID) prescriptions, age, sex, diabetes, tobacco, and obesity. In total, 28,939 patients undergoing rotator cuff repair were identified, of whom 10,695 had opioid prescriptions within both 0 to 3 months and 4 to 6 months before index rotator cuff repair, whereas 18,244 had no opioid prescriptions within the 6-month preoperative period. In total, 977 (3.4%) patients underwent revision within 6 months, which increased to 1311 (4.5%) within 1 year of the index procedure. In the multivariate analysis controlling for age, preoperative NSAID prescriptions, tobacco, diabetes, obesity, and sex, we observed a significant association between chronic preoperative opioid prescriptions and rotator cuff repair revision (6-month odds ratio 1.12; P= .021, 1-year odds ratio 1.43; P < .001) following index procedure. We report increased rates of revision within both 6 months and 1 year in patients with prolonged preoperative opioid prescriptions. The opioid cohort had greater rates of preoperative NSAID use and tobacco use, which also were observed to be independent risk factors for revision at both timepoints. III; Retrospective comparative study.

Does the Strengthen Opioid Misuse Prevention Act Reduce Opioid Prescriptions Associated With Hand Surgery?

PURPOSE: The opioid epidemic has become a leading cause of death in America. Various states have put into effect legislation to limit the amount of opioids that can be prescribed. In North Carolina, The Strengthen Opioid Misuse Prevention (STOP) Act came into effect January 1, 2018, which outlined new limitations on prescribing opioids to no more than 7 days after surgery. However, the efficacy of state mandated opioid laws have not been evaluated in hand surgery. METHODS AND MATERIALS: A single-center retrospective chart review was performed for patients who underwent hand surgery between January 2015 and December 2019. Patients were excluded if they were under 12 years of age, had a multisystem trauma, inpatient admission for more than 48 hours, or had incomplete records. A review of the North Carolina Controlled Substances Database (PMP Aware) was conducted to assess for preoperative and perioperative (within 30 days of surgery) prescriptions filled. The total amount of opioids filled was converted to morphine milligram equivalents (MME). The average MME was compared between those who underwent surgery prior to and after initiation of the STOP Act. Subgroup analysis was performed in patients who underwent different types of surgery including metacarpal, tendon, phalangeal, and amputation. Additional analysis was performed to evaluate the patients who received excessive amount of opioids (>600 MME). RESULTS: Of the 500 patients who met inclusion criteria for the study, 175 were in the before group and 325 were in the after group. The demographics, patient risk factors, and complications did not differ between groups. There was an overall 69.3% decrease in opioids dispensed per patient. This statistically significant decrease was also observed in metacarpal and tendon groups (84.2% and 60.9%, respectively). Although there was an observed decrease in the phalangeal and amputation groups, this finding did not reach statistical significance. Overall, there is a higher percentage of patients who received less than 300 MME after the STOP Act was enacted (84% versus 56%). CONCLUSIONS: Following implementation of the STOP Act, there has been a marked and statistically significant decrease in opioid prescription patterns associated with hand surgery. Additional multicenter and multistate studies should be considered.