Subscribe to RSS
DOI: 10.1055/s-0041-1731716
Can We Predict Unplanned Intensive Care Unit Admission in Hip and Knee Arthroplasty?
![](https://www.thieme-connect.de/media/10.1055-s-00031934/202103/lookinside/thumbnails/10-1055-s-0041-1731716_210006oa-1.jpg)
Abstract
Preoperative risk stratification remains important for both patient safety and cost-effective allocation of resources in total joint arthroplasty. Limited literature exists investigating risk factors for unplanned intensive care unit (ICU) admission following arthroplasty. Therefore, the purpose of this study was to assess a broader spectrum of factors that may increase the risk of ICU admission across multiple surgical settings. We retrospectively reviewed 18,169 patients who underwent a hip (40.7%) or knee (59.3%) arthroplasty procedure (primary: n = 13,384, 90%; revision: n = 1,485, 10%) between August 1, 2015, and January 31, 2019, across nine sites at a single institution. Patient demographics, laboratory data, surgical parameters, and preoperative scores on the Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) were recorded. A univariate analysis was conducted to identify differences between patients who required an ICU admission and those with no ICU involvement. Logistic regression was then used to generate predicted risk of ICU Involvement. A total of 147 patients (0.99%) required an ICU admission. Increasing age, higher Charlson's comorbidity index, American Society of Anesthesiologists (ASA) class 3 or greater, elevated blood urea nitrogen (BUN), elevated creatinine, decreased preoperative hemoglobin level, general anesthesia, surgical setting, revision procedure, and lower baseline scores on the KOOS Quality of Life (QOL) subscale (17 vs. 22.5, p = 0.032), VR-12 physical component score (PCS; 24.4 vs 27.1, p = 0.001), and VR-12 mental component score (MCS; 45.9 vs. 49.6, p = 0.003) were associated with a statistically significant increase in the risk of ICU admission. As performance of arthroplasty shifts in both the setting of care and the complexity of patients, identifying patients most at risk of requiring higher acuity of care is important. Preoperative assessment of comorbidities, kidney function, surgical setting, KOOS QOL subscale score, and VR-12 scores may provide guidance for the improvement of value-based care pathways.
Keywords
total hip arthroplasty - total knee arthroplasty - intensive care unit - unplanned admission - outcome scorePublication History
Received: 02 February 2021
Accepted: 30 April 2021
Article published online:
06 July 2021
© 2021. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Ferguson RJ, Palmer AJ, Taylor A, Porter ML, Malchau H, Glyn-Jones S. Hip replacement. Lancet 2018; 392 (10158): 1662-1671
- 2 Price AJ, Alvand A, Troelsen A. et al. Knee replacement. Lancet 2018; 392 (10158): 1672-1682
- 3 Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018; 100 (17) 1455-1460
- 4 Kremers HM, Larson DR, Crowson CS. et al. Prevalence of total hip and knee replacement in the United States. J Bone Jt Surg, Am Vol (CD-ROM Ed) 2014; 97 (17) 1386-1397
- 5 Skogö Nyvang J, Naili JE, Iversen MD, Broström EW, Hedström M. Younger age is associated with greater pain expression among patients with knee or hip osteoarthritis scheduled for a joint arthroplasty. BMC Musculoskelet Disord 2019; 20 (01) 365
- 6 Bayliss LE, Culliford D, Monk AP. et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study. Lancet 2017; 389 (10077): 1424-1430
- 7 Schwartz AM, Farley KX, Guild GN, Bradbury Jr TL. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030. J Arthroplasty 2020; 35 (6S): S79-S85
- 8 Rubin LE, Blood TD, Defillo-Draiby JC. Total hip and knee arthroplasty in patients older than age 80 years. J Am Acad Orthop Surg 2016; 24 (10) 683-690
- 9 Warren JA, George J, Anis HK. et al. Effects of estimated glomerular filtration rate on 30-day mortality and postoperative complications after total hip arthroplasty: a risk stratification instrument. J Arthroplasty 2020; 35 (03) 786-793
- 10 Castano-Betancourt MC, Fruschein Annichino R, de Azevedo E Souza Munhoz M, Gomes Machado E, Lipay MV, Marchi E. Identification of high-risk groups for complication after arthroplasty: predictive value of patient's related risk factors. J Orthop Surg Res 2018; 13 (01) 328
- 11 Kamath AF, McAuliffe CL, Baldwin KD, Lucas JB, Kosseim LM, Israelite CL. Unplanned admission to the intensive care unit after total hip arthroplasty. J Arthroplasty 2012; 27 (06) 1027-32.e1, 2
- 12 Kamath AF, Gutsche JT, Kornfield ZN, Baldwin KD, Kosseim LM, Israelite CL. Prospective study of unplanned admission to the intensive care unit after total hip arthroplasty. J Arthroplasty 2013; 28 (08) 1345-1348
- 13 Hustedt JW, Goltzer O, Bohl DD, Fraser JF, Lara NJ, Spangehl MJ. Calculating the cost and risk of comorbidities in total joint arthroplasty in the United States. J Arthroplasty 2017; 32 (02) 355-361.e1
- 14 Penna S, Bell KL, Kuo FC, Henderson RA, Foltz C, Chen AF. Impact of co-morbidities on the cost of care in primary elective joint arthroplasty. J Arthroplasty 2019; 34 (05) 834-838
- 15 Humbyrd CJ. The ethics of bundled payments in total joint replacement: “cherry picking” and “lemon dropping.”. J Clin Ethics 2018; 29 (01) 62-68
- 16 Oh C, Gold H, Slover J. Diagnosis of depression and other patient factors impacts length of stay after total knee arthroplasty. Arthroplast Today 2020; 6 (01) 77-80
- 17 Beam E, Osmon D. Prosthetic joint infection update. Infect Dis Clin North Am 2018; 32 (04) 843-859
- 18 Sukhonthamarn K, Grosso MJ, Sherman MB, Restrepo C, Parvizi J. Risk factors for unplanned admission to the intensive care unit after elective total joint arthroplasty. J Arthroplasty 2020; 35 (07) 1937-1940
- 19 Kamath AF, McAuliffe CL, Kosseim LM, Pio F, Hume E. Malnutrition in joint arthroplasty: prospective stud indicates risk of unplanned ICU admission. Arch Bone Jt Surg 2016; 4 (02) 128-131
- 20 Klausing A, Martini M, Wimmer MD, Gravius S, Wirtz DC, Randau TM. Postoperative medical complications and intermediate care unit/intensive care unit admission in joint replacement surgery: a prospective risk model. J Arthroplasty 2019; 34 (04) 717-722
- 21 Piuzzi NS, Strnad GJ, Sakr Esa WA. et al; Cleveland Clinic Orthopaedic Arthroplasty Group. The main predictors of length of stay after total knee arthroplasty: patient-related or procedure-related risk factors. J Bone Joint Surg Am 2019; 101 (12) 1093-1101
- 22 Cleveland Clinic OME Arthroplasty Group.. Understanding the main predictors of length of stay after total hip arthroplasty: patient-related or procedure-related risk factors?. J Arthroplasty 2021; 36 (05) 1663-1670
- 23 Goh GSH, Liow MHL, Pang HN, Tay DKJ, Lo NN, Yeo SJ. Patients with poor baseline mental health undergoing unicompartmental knee arthroplasty have poorer outcomes. J Arthroplasty 2018; 33 (08) 2428-2434
- 24 Maxwell MJ, Moran CG, Moppett IK. Development and validation of a preoperative scoring system to predict 30 day mortality in patients undergoing hip fracture surgery. Br J Anaesth 2008; 101 (04) 511-517
- 25 Hirose J, Ide J, Irie H, Kikukawa K, Mizuta H. New equations for predicting postoperative risk in patients with hip fracture. Clin Orthop Relat Res 2009; 467 (12) 3327-3333
- 26 Wuerz TH, Regenbogen SE, Ehrenfeld JM. et al. The surgical Apgar score in hip and knee arthroplasty. Clin Orthop Relat Res 2011; 469 (04) 1119-1126
- 27 Goodman SM, Mehta BY, Mandl LA. et al. Validation of the hip disability and osteoarthritis outcome score and knee injury and osteoarthritis outcome score pain and function subscales for use in total hip replacement and total knee replacement clinical trials. J Arthroplasty 2020; 35 (05) 1200-1207.e4
- 28 Snyder DJ, Bienstock DM, Keswani A. et al. Preoperative patient-reported outcomes and clinical characteristics as predictors of 90-day cost/utilization and complications. J Arthroplasty 2019; 34 (05) 839-845
- 29 Rasouli MR, Menendez ME, Sayadipour A, Purtill JJ, Parvizi J. Direct cost and complications associated with total joint arthroplasty in patients with preoperative anxiety and depression. J Arthroplasty 2016; 31 (02) 533-536
- 30 Wilson JM, Farley KX, Erens GA, Bradbury TL, Guild GN. Preoperative depression is associated with increased risk following revision total joint arthroplasty. J Arthroplasty 2020; 35 (04) 1048-1053
- 31 Mathew AR, Hogarth L, Leventhal AM, Cook JW, Hitsman B. Cigarette smoking and depression comorbidity: systematic review and proposed theoretical model. Addiction 2017; 112 (03) 401-412
- 32 Pavkovic B, Zaric M, Markovic M, Klacar M, Huljic A, Caricic A. Double screening for dual disorder, alcoholism and depression. Psychiatry Res 2018; 270: 483-489
- 33 Dash S, Clarke G, Berk M, Jacka FN. The gut microbiome and diet in psychiatry: focus on depression. Curr Opin Psychiatry 2015; 28 (01) 1-6
- 34 Resende VAC, Neto AC, Nunes C, Andrade R, Espregueira-Mendes J, Lopes S. Higher age, female gender, osteoarthritis and blood transfusion protect against periprosthetic joint infection in total hip or knee arthroplasties: a systematic review and meta-analysis. Knee Surg Sport Traumatol Arthrosc 2018; 29 (01) 8-43
- 35 Eka A, Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann Transl Med 2015; 3 (16) 233
- 36 Kong L, Cao J, Zhang Y, Ding W, Shen Y. Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J 2017; 14 (03) 529-536
- 37 Van Herck P, Vanhaecht K, Deneckere S. et al. Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract 2010; 16 (01) 39-49
- 38 Trevisan C, Klumpp R, Auriemma L, Compagnoni R. An algorithm for predicting blood loss and transfusion risk after total hip arthroplasty. Transfus Apheresis Sci 2018; 57 (02) 272-276
- 39 Fitz-Henry J. The ASA classification and peri-operative risk. Ann R Coll Surg Engl 2011; 93 (03) 185-187
- 40 Anakwe RE, Jenkins PJ, Moran M. Predicting dissatisfaction after total hip arthroplasty: a study of 850 patients. J Arthroplasty 2011; 26 (02) 209-213
- 41 Halawi MJ, Chiu D, Gronbeck C, Savoy L, Williams VJ, Cote MP. Psychological distress independently predicts prolonged hospitalization after primary total hip and knee arthroplasty. J Arthroplasty 2019; 34 (08) 1598-1601
- 42 AbdelSalam H, Restrepo C, Tarity TD, Sangster W, Parvizi J. Predictors of intensive care unit admission after total joint arthroplasty. J Arthroplasty 2012; 27 (05) 720-725