日間手術(shù)在髖膝關(guān)節(jié)置換的應用

Same-DayDischargeinTotalJointArthroplastyMay,

20182016級碩士(shuòshì)研究生：羅澤宇研究生導師：周宗科教授第一頁，共三十二頁。整理課件ThedemandforTJAisincreasingFast-trackTJA:LOS<3daysOutpatient:dischargedonsamedaypostoperative(lessthan12-hourstay)FinancialanalysisOutpatientTJAwouldsave$300millionannuallyIntroduction第二頁，共三十二頁。整理課件IntroductionSafetyisprimaryfactortobeconcernedComplication,

mortality,readmissionandreoperationRiskfactorandpatientselectionGeneralcondition:age,gender,BMIHistoricalorcurrentdisease:diabetes,cardiacdisease,pulmonarydisease,renaldiseaseSurgicalprocedureGeneralorregionalorspinalanesthesiaStandardorminiincisionTourniquet,drainagePerioperativemanagementanddischargePostoperativefunction

andrehabilitation第三頁，共三十二頁。整理課件Article#12017.JBJSLevelofEvidenceLevelIIIRetrospectivestudy第四頁，共三十二頁。整理課件Article#1Aim:tocomparematchedcohortsofpatientswhounderwentsame-dayandinpatienthiporkneearthroplastyintermsofpostoperativecomplicationsand30-dayreadmissionratesDesign:retrospectivematchedcohortsstudyDatasource:ACS-NSQIPregistryfrom517UShospitalfrom2005-2014Outcomes:complications,readmissionratesGeneralcharacter:177,818

patients,

1,236

outpatients,176,582inpatients第五頁，共三十二頁。整理課件Demographics第六頁，共三十二頁。整理課件Adverseevents第七頁，共三十二頁。整理課件AdverseeventsinTHA第八頁，共三十二頁。整理課件AdverseeventsinTKA第九頁，共三十二頁。整理課件AdverseeventsinUKA第十頁，共三十二頁。整理課件RiskfactorofcomplicationFactorsRelativerisk95%confidenceinterval(CI)PvalueBMI>35kg/m22.39

1.06-5.400.035insulin-dependentdiabetes4.021.06-15.300.041non-insulin-dependentdiabetes3.271.29-8.340.013Age>855.361.09-23.330.039第十一頁，共三十二頁。整理課件ConclusionNosignificantdifferencesinoverallpostoperativecomplicationsorreadmissionwerefoundbetweenmatchedcohortsofpatientswhounderwentsame-dayandinpatienthipandkneearthroplasties

第十二頁，共三十二頁。整理課件LimitationsRetrospectivestudyThefunctionwasnotassessedRiskFactorsforComplicationsandreadmissionshouldbegivenmoredetails

第十三頁，共三十二頁。整理課件Article#22017.JOALevelofEvidenceLevelIIIRetrospectivestudy第十四頁，共三十二頁。整理課件Article#2Aim:Tocomparethepredictiveabilityoftheriskassessmentof“OutpatientArthroplastyRiskAssessmentScore(OARA)”,“ASA”,“Charlsoncomorbidityindex(CCI)”Design:retrospectivestudyOutcomes:sensitivityofthescalesGeneralcharacter:1120consecutiveTHAandTKApatientsMeanAge62.3yrsMeanBMI32.4521knees(53.2%)/458hips(46.8%)

第十五頁，共三十二頁。整理課件OARAscoreIndianauniversity9comorbidityareasLowrisk:OARA≤59Highrisk:OARA≥60

第十六頁，共三十二頁。整理課件OARAscoreJArthroplasty.2017Aug;32(8):2325-2331第十七頁，共三十二頁。整理課件Threescales第十八頁，共三十二頁。整理課件PositivepredictivevalueOARASCORE≤59dischargePOD0or1:

81.6%ASA≤2dischargePOD0or1:

56.4%CCI=0dischargePOD0or1:

70.3%

第十九頁，共三十二頁。整理課件ConclusionCurrentmedicalselectioncriteriaforoutpatient

TJA,suchasASA,arecrude

OARAScorerepresentsamoresensitivemedicalriskstratificationforoutpatientTJA

第二十頁，共三十二頁。整理課件Article#32017.CORRLevelofEvidenceLevelIRandomizedstudy第二十一頁，共三十二頁。整理課件Article#3Aim:Tocomparedischargedonthesamedayasthesurgery(‘‘outpatient,’’lessthan12-hourstay)withthosewhoaredischargedafteranovernighthospitalstay(‘‘inpatient’’)inTHAsDesign:Multicenter,RCTsOutcomes:postoperativepain;perioperativecomplications;readmissionGeneralcharacter:220patients,M/F117/103,age60.0±8.7y,BMI27.9±4.4kg/m2第二十二頁，共三十二頁。整理課件Inclusionandexclusioncriteria初次單側(cè)THABMI<40Age<75HB>10g/dL無心肺疾病術(shù)前不需輪椅術(shù)前不長期鴉片(yāpiàn)鎮(zhèn)痛術(shù)后回家有良好照看第二十三頁，共三十二頁。整理課件PerioperativemanagementDirectanteriorapproachSpinalanesthesia24hoursofantibiotic

曲馬多酮咯酸普瑞巴林(bālín)塞來昔布氫化可的松磺胺(huánɡàn)過敏第二十四頁，共三十二頁。整理課件Dischargecriteria走80英尺上下樓知曉家庭康復上廁所獨立起床獨立日?；顒有g(shù)后小便固體食物疼痛控制良好生命體征平穩(wěn)(píngwěn)無暈?；驀I吐良好的家庭照顧

第二十五頁，共三十二頁。整理課件DemographicsGeneralcharacter:220patients,M/F117/103,age60.0±8.7y,BMI27.9±4.4kg/m2Nodifferencenotedbetweenthegroups第二十六頁，共三十二頁。整理課件ResultsOutpatientInpatientPvalueVASPON12.8±2.53.3±2.30.12

VASPOD13.7±2.32.8±2.1

0.01VASPOW41.7±1.9

1.7±1.9

0.77HHSPOW475±1875±140.77Reoperation211Readmissions140.21Contactstostaff2.4±1.9

2.4±2.2

0.94OnlyVASPOD1notedasignificantdifferencebetweenthegroup第二十七頁，共三十二頁。整理課件ConclusionOutpatientTHAcanbecomparablewithinpatientwithastrictinclusionanddischargecriteria

第二十八頁，共三十二頁。整理課件LimitationsOnly220THAswereevaluatedTheapplicationsofbloodmanagement,drainageandrehabilitationwerenotgivenThecostofpatientswasnotevaluated第二十九頁，共三十二頁。整理課件TakehomemessageOutpatientsTJAwerecomparablewithinpatientinselectedsurgeryinsafetyandcomplicationsOutpatientsTJAcanreducetheLOSandwerecostsavingOutpatientArthroplastyRiskAssessment(OARA)scorewasneededinriskstratificationAstrictdischargecriteriashouldbemeetbeforedischargeRehabilitationandfunctionshouldbeassessedinfutureresearchPerioperativemanagement,surgicalandanesthesiatechnologyshouldbeoptimal第三十頁，共三十二頁。整理