Multidisciplinary management to decrease perioperative complications in senile patients with hypoxaemia in high altitudes during primary hip arthroplasty: data from our cohort study

Abstract

Editor-The successful hip arthroplasty (HA) can greatly relieve pain and improve the quality of postoperative life, in patients suffering severe hip diseases including osteoarthritis or fracture. 1 2 However, patient-and surgery-related factors have been linked to a decrease in the quality of life, both perioperatively and later. 3 4 Age, anaesthesia, hypoxaemia, hypotension and anaemia appear to be associated with the development of postoperative outcomes, including delirium in geriatric patients after orthopaedic surgery. 5 6 Surprisingly, few studies have tested the associations between anaesthesia, chronic hypoxaemia, high altitude, patient age, perioperative management and serious adverse events (SAEs) during hip arthroplasty. In view of the above and increasing international recognition that perioperative management demanding a multidisciplinary approach 3 7 does affect patient outcome, we designed a multidisciplinary perioperative management plan for primary hip replacement.Firstly, we retrospectively explored cases of primary HA and then conducted regression analyses to identify outcome risk factors. We found the intraoperative hypotension and general anaesthesia were the independent risk factors for postoperative serious adverse events (SAEs, including ICU admission, malignant arrhythmia, delirium, etc.) with odds ratio (OR) 4.29 and 95% confidence interval (CI) (1.66-11.10), and OR 5.09 with 95% CI (1.96-13.24) respectively. And we conclude that intraoperative hypotension (a mean arterial pressure that was decreased by 30% for more than 3 min) were risk markers of postoperative SAEs in high altitude practice.Secondly, we conducted a multidisciplinary management implementation in patients with moderate to severe hypoxaemia. Then the subsequent patients were shared with shorter postoperative length of stay, of which the median were decreased from 15 days to 11 after implementation (P < 0.001). The perioperative SAE ratios decreased from 21.1% (32/152) initially to 9.4% (18/192) after modification (P ¼ 0.002). The all-cause mortality rate within 30 days decreased by 80% (P ¼ 0.040).A systematic approach optimized to achieve stable haemodynamics with combined-spinal epidural anaesthesia (the most popular method in HA in this hospital) was associated with improved outcome up to 30 days after operation. We must now postulate that a randomized trial is necessary to determine if the multidisciplinary management programme can improve patient outcomes, additional to just measures of hypotension or method of anaesthesia. However, high-quality prospective studies are required to confirm these findings and to establish evidencebased clinical guidelines. Declaration of interestNone declared.

Effects of preoperative chronic hypoxemia on geriatrics outcomes after hip arthroplasty

“…The general anesthesia and intraoperative hypotension remained the independent risk factors for pSAEs with OR of 4.08 (95%CI: 2.12–8.91) and 4.92 (95%CI: 1.91–11.29), respectively, while the preoperative CH presented by decreasing its risk with OR = .57 (95%CI: .21–.93) ( P  < .05, data were similar with those reported as before in our study [17] ).…”

“…[ 24 ] When it comes to anesthetic techniques, we have detected CSEA is far superior to general anesthesia in geriatric patients with CH undergoing HA. [ 17 , 25 ]…”

Perioperative multidisciplinary implementation enhancing recovery after hip arthroplasty in geriatrics with preoperative chronic hypoxaemia

“…When it comes to anaesthesia techniques, in our previous practice, we found CSE anaesthesia supervisor to general anaesthesia in the geriatric patients with preoperative chronic hypoxaemia undergoing THA or hemiarthroplasty 22 . It was similar to those in retrospective analysis with large sample size 23,24 .…”