Halawi Mohamad J, Lyall Vikram, Cote Mark P
Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA.
University of Connecticut School of Medicine, Farmington, CT, USA.
J Clin Orthop Trauma. 2020 Mar;11(Suppl 2):S219-S222. doi: 10.1016/j.jcot.2019.01.007. Epub 2019 Jan 14.
While advancements in surgery and reduced complication rates have made total knee arthroplasty (TKA) one of the most successful and cost-effective procedures in orthopaedic surgery, routine postoperative laboratory tests are still being ordered without evidence as to their necessity. With expansion of the bundled payment models, there may exist an opportunity to cut overall costs while maintaining quality of care by eliminating unnecessary interventions. The objective of this study was to examine the utility of routine postoperative laboratory tests in TKA.
A retrospective review of 319 TKAs performed at a single institution over a 2-year period was performed. The primary outcomes were the rates of acute blood loss anemia requiring transfusion, acute kidney injury (AKI), electrolyte abnormalities, and 90-day emergency department visits and readmissions. Multivariate logistic regression analysis was also performed to identify the risk factors associated with abnormal laboratory values.
89 patients (27.9%) had abnormal postoperative laboratory results, of which 78% were exclusively due to electrolyte (sodium or potassium) abnormalities. The rates of AKI and blood transfusion were 3.8% and 1% respectively. Factors associated with electrolyte abnormalities were abnormal baseline electrolyte levels (p = 0.002 and = 0.006 for sodium and potassium respectively) and anemia (p = 0.049). Factors associated with blood transfusion were ASA score ≥3, preoperative anemia, and no tranexamic acid use. Factors associated with AKI were chronic kidney disease or having at least two of the following: age >65 years, BMI> 35, ASA score ≥3, diabetes, heart disease, and/or anemia. Laboratory results did not change the course of care in 305 of 319 patients (95.6%). There was no increased risk for 90-days ED visits or readmissions with abnormal laboratory values (p = 0.356).
With increasing pressure for cost containment in an era of bundled payment models, the very low rate of laboratory associated interventions suggest that routine postoperative laboratory tests is not justified. Obtaining laboratory after primary, unilateral TKA should be driven by patients' risk factors.
尽管手术技术的进步和并发症发生率的降低使全膝关节置换术（TKA）成为骨科手术中最成功且最具成本效益的手术之一，但术后常规实验室检查仍在无必要证据的情况下被开具。随着捆绑支付模式的推广，可能存在通过消除不必要的干预措施来降低总体成本同时维持医疗质量的机会。本研究的目的是探讨TKA术后常规实验室检查的实用性。
对一家机构在两年内进行的319例TKA手术进行回顾性分析。主要结局指标为需要输血的急性失血贫血发生率、急性肾损伤（AKI）、电解质异常以及90天内急诊就诊和再入院率。还进行了多因素逻辑回归分析以确定与实验室检查值异常相关的危险因素。
89例患者（27.9%）术后实验室检查结果异常，其中78%完全归因于电解质（钠或钾）异常。AKI和输血发生率分别为3.8%和1%。与电解质异常相关的因素为基线电解质水平异常（钠和钾的p值分别为0.002和0.006）和贫血（p = 0.049）。与输血相关的因素为美国麻醉医师协会（ASA）评分≥3、术前贫血以及未使用氨甲环酸。与AKI相关的因素为慢性肾脏病或具备以下至少两项：年龄>65岁、体重指数>35、ASA评分≥3、糖尿病、心脏病和/或贫血。319例患者中有305例（95.6%）的实验室检查结果未改变治疗过程。实验室检查值异常并未增加90天内急诊就诊或再入院的风险（p = 0.356）。
在捆绑支付模式时代，成本控制压力不断增加，与实验室检查相关的干预措施发生率极低，这表明术后常规实验室检查并无正当理由。初次单侧TKA术后进行实验室检查应以患者的危险因素为依据。
