日间手术在髋膝关节置换的应用1-四川大学华西医院.pptx

Same-Day Discharge in Total Joint Arthroplasty May,2018 2016级硕士研究生：罗泽宇 研究生导师：周宗科教授 The demand for TJA is increasing Fast-track TJA:LOS 35kg/m2 2.39 1.06-5.40 0.035 insulin-dependent diabetes 4.02 1.06-15.30 0.041 non-insulin-dependent diabetes 3.27 1.29-8.34 0.013 Age85 5.36 1.09-23.33 0.039 Conclusion No significant differences in overall postoperative complications or readmission were found between matched cohorts of patients who underwent same-day and inpatient hip and knee arthroplasties Limitations Retrospective study The function was not assessed Risk Factors for Complications and readmission should be given more details Article#2 2017.JOA Level of Evidence Level III Retrospective study Article#2 Aim:To compare the predictive ability of the risk assessment of“Outpatient Arthroplasty Risk Assessment Score(OARA)”,“ASA”,“Charlson comorbidity index(CCI)”Design:retrospective study Outcomes:sensitivity of the scales General character:1120 consecutive THA and TKA patients Mean Age 62.3 yrs Mean BMI 32.4 521 knees(53.2%)/458 hips(46.8%)OARA score Indiana university 9 comorbidity areas Low risk:OARA 59 High risk:OARA 60 OARA score J Arthroplasty.2017 Aug;32(8):2325-2331 Three scales Positive predictive value OARA SCORE 59 discharge POD 0 or 1:81.6%ASA 2 discharge POD 0 or 1:56.4%CCI=0 discharge POD 0 or 1:70.3%Conclusion Current medical selection criteria for outpatient TJA,such as ASA,are crude OARA Score represents a more sensitive medical risk stratification for outpatient TJA Article#3 2017.CORR Level of Evidence Level I Randomized study Article#3 Aim:To compare discharged on the same day as the surgery(outpatient,less than 12-hour stay)with those who are discharged after an overnight hospital stay(inpatient)in THAs Design:Multicenter,RCTs Outcomes:postoperative pain;perioperative complications;readmission General character:220 patients,M/F 117/103,age 60.0 8.7 y,BMI 27.9 4.4 kg/m2 Inclusion and exclusion criteria 初次单侧THA BMI40 Age10g/dL 无心肺疾病 术前不需轮椅 术前不长期鸦片镇痛 术后回家有良好照看 Perioperative management Direct anterior approach Spinal anesthesia 24 hours of antibiotic 曲马多 酮咯酸 普瑞巴林 塞来昔布 氢化可的松 磺胺过敏 Discharge criteria 走80英尺 上下楼 知晓家庭康复 上厕所 独立起床 独立日常活动 术后小便 固体食物 疼痛控制良好 生命体征平稳 无晕眩或呕吐 良好的家庭照顾 Demographics General character:220 patients,M/F 117/103,age 60.0 8.7 y,BMI 27.9 4.4 kg/m2 No difference noted between the groups Results Outpatient Inpatient P value VAS PON1 2.8 2.5 3.3 2.3 0.12 VAS POD1 3.7 2.3 2.8 2.1 0.01 VAS POW4 1.7 1.9 1.7 1.9 0.77 HHS POW4 75 18 75 14 0.77 Reoperation 2 1 1 Readmissions 1 4 0.21 Contacts to staff 2.4 1.9 2.4 2.2 0.94 Only VAS POD1 noted a significant difference between the group Conclusion Outpatient THA can be comparable with inpatient with a strict inclusion and discharge criteria Limitations Only 220 THAs were evaluated The applications of blood management,drainage and rehabilitation were not given The cost of patients was not evaluated Take home message Outpatients TJA were comparable with inpatient in selected surgery in safety and complications Outpatients TJA can reduce the LOS and were cost saving Outpatient Arthroplasty Risk Assessment(OARA)score was needed in risk stratification A strict discharge criteria should be meet before discharge Rehabilitation and function should be assessed in future research Perioperative management,surgical and anesthesia technology should be optimal Thanks for your attention！