下肢关节置换术后加速康复方案：利用观察性数据确定最佳组件组合。

Enhanced Recovery After Surgery Protocols in Lower Extremity Joint Arthroplasty: Using Observational Data to Identify the Optimal Combination of Components.

机构信息

Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.

Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY.

出版信息

J Arthroplasty. 2021 Aug;36(8):2722-2728. doi: 10.1016/j.arth.2021.03.003. Epub 2021 Mar 5.

DOI:10.1016/j.arth.2021.03.003

PMID:33757714

Abstract

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are increasingly used in orthopedic surgery. Data are lacking on which combinations of ERAS components are (1) the most commonly used and (2) the most effective in terms of outcomes.

METHODS

This retrospective cohort study utilized claims data (Premier Healthcare, n = 1,539,432 total joint arthroplasties, 2006-2016). Eight ERAS components were defined: (A) regional anesthesia, (B) multimodal analgesia, (C) tranexamic acid, (D) antiemetics on day of surgery, (E) early physical therapy, and avoidance of (F) urinary catheters, (G) patient-controlled analgesia, and (H) drains. Outcomes were length of stay, "any complication," and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.

RESULTS

In 2006-2012 and 2013-2016, the most common ERAS combinations were B/D/E/F/G/H (20%, n = 172,397) and B/C/D/E/F/G/H (17%, n = 120,266), respectively. The only difference between the most commonly used ERAS combinations over the years is the addition of C (addition of tranexamic acid to the protocol). The most pronounced beneficial effects in 2006-2012 were seen for combination A/B/D/E/F/G/H (6% of cases vs less prevalent ERAS combinations) for the outcome of "any complication" (OR 0.87, CI 0.83-0.91, P < .0001). In 2013-2016, the strongest effects were seen for combination B/C/D/E/F/G/H (17% of cases) also for the outcome of "any complication" (OR 0.86, CI 0.83-0.89, P < .0001). Relatively minor differences existed between ERAS protocols for the other outcomes.

CONCLUSION

Despite varying ERAS protocols, maximum benefits in terms of complication reduction differed minimally. Further study may elucidate the balance between an increasing number of ERAS components and incremental benefits realized.

LEVEL OF EVIDENCE

III.

摘要

背景

加速康复外科（ERAS）方案在矫形外科中越来越多地使用。关于 ERAS 成分中（1）最常用的组合和（2）在结果方面最有效的组合的数据尚缺乏。

方法

这项回顾性队列研究利用了索赔数据（Premier Healthcare，共 1539432 例全关节置换术，2006-2016 年）。定义了 8 个 ERAS 成分：（A）区域麻醉，（B）多模式镇痛，（C）氨甲环酸，（D）手术当天止吐药，（E）早期物理治疗和避免（F）导尿管，（G）患者自控镇痛，和（H）引流。结果是住院时间、“任何并发症”和住院费用。混合效应模型测量了最常见的 ERAS 组合与结果之间的关联。报告了比值比（OR）和 95%置信区间（CI）。

结果

在 2006-2012 年和 2013-2016 年，最常见的 ERAS 组合分别为 B/D/E/F/G/H（20%，n=172397）和 B/C/D/E/F/G/H（17%，n=120266）。多年来最常用的 ERAS 组合之间唯一的区别是 C 的添加（将氨甲环酸添加到方案中）。在 2006-2012 年，效果最明显的是 A/B/D/E/F/G/H 组合（占病例的 6%，与不太常见的 ERAS 组合相比），“任何并发症”的结果（OR 0.87，CI 0.83-0.91，P<0.0001）。在 2013-2016 年，B/C/D/E/F/G/H 组合（占病例的 17%）对“任何并发症”的结果也有最强的效果（OR 0.86，CI 0.83-0.89，P<0.0001）。对于其他结果，ERAS 方案之间存在相对较小的差异。