日間手術在髖膝關節(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THABMI<40Age<75HB>10g/dL無心肺疾病術前不需輪椅術前不長期鴉片(yāpiàn)鎮(zhèn)痛術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常活動術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