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Patients With Chronic Obstructive Pulmonary Disease Are at Higher Risk for Pneumonia, Septic Shock, and Blood Transfusions After Total Shoulder Arthroplasty

Lee, Ryan, MBA; Lee, Danny, BS; Mamidi, Ishwarya S., BS; Probasco, William V., MS, MD; Heyer, Jessica H., MD; Pandarinath, Rajeev, MD

Clinical Orthopaedics and Related Research®: February 2019 - Volume 477 - Issue 2 - p 416–423
doi: 10.1097/CORR.0000000000000531

Background Chronic obstructive pulmonary disease (COPD) has been associated with several complications after surgery, including pneumonia, myocardial infarction, septic shock, and mortality. To the authors’ knowledge, there has been no work analyzing the impact of COPD on complications after total shoulder arthroplasty (TSA). Although previous work has elucidated the complications COPD has on TKA and THA, extrapolating the results of lower extremity arthroplasty to TSA may prove to be inaccurate. Compared with lower extremity arthroplasty, TSA is a relatively new procedure that has only recently gained popularity. Therefore, this study seeks to elucidate COPD’s effects on complications in TSA specifically so that postoperative care can be tailored for these patient populations. Assessing these patients may enable surgeons to implement preoperative precautionary measures to prevent serious adverse events in these patients.

Questions/purposes What serious postoperative complications are patients with COPD at risk for within the 30-day postoperative period after TSA?

Methods The American College of Surgeons National Surgical Quality Improvement Program® (ACS-NSQIP) database was queried to identify 14,494 patients who had undergone TSA between 2005 and 2016, excluding patients who had undergone hemiarthroplasties of the shoulder and revision shoulder arthroplasties. The ACS-NSQIP database was utilized in this study for the comprehensive preoperative and postoperative medical histories it provides for each patient for 274 characteristics. Among the 14,494 patients undergoing TSA, 931 (6%) patients who had a history of COPD were identified, and the two cohorts—COPD and non-COPD—were analyzed for differences in their demographic factors, comorbidities, and acute complications occurring within 30 days of their procedure. Univariate analyses were utilized to assess differences in the prevalence of demographic features, comorbidities, and perioperative/postoperative outcomes after surgery. Multivariate regression analyses were used to assess COPD as an independent risk factor associated with complications.

Results COPD is an independent risk factor for three complications after TSA: pneumonia (odds ratio [OR], 2.793; 95% confidence interval [CI], 1.426-5.471; p = 0.003), bleeding resulting in transfusion (OR, 1.577; 95% CI, 1.155-2.154; p = 0.004), and septic shock (OR, 9.259; 95% CI, 2.140-40.057; p = 0.003).

Conclusions In light of the increased risk of these serious complications, surgeons should have a lower threshold of suspicion for infection in patients with COPD after TSA so that adequate measures can be taken before developing severe infectious complications including pneumonia and septic shock. Surgeons may also consider administering tranexamic acid in patients with COPD undergoing TSA to reduce the amount of blood transfusions necessary. Future work through randomized control trials analyzing (1) the effectiveness of more aggressive infection prophylaxis in decreasing the risk of pneumonia/septic shock; and (2) the use of tranexamic acid in decreasing blood transfusion requirements in patients with COPD undergoing TSA is warranted.

Level of Evidence Level III, therapeutic study.

R. Lee, D. Lee, I. S. Mamidi, The George Washington University School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA

W. V. Probasco, J. H. Heyer, R. Pandarinath, Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA

R. Lee, The George Washington University School of Medicine and Health Sciences, The George Washington University, 2300 I Street NW, Washington, DC 20037, USA, email:

Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Received June 15, 2018

Accepted September 26, 2018

© 2019 Lippincott Williams & Wilkins LWW
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