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CLINICAL RESEARCH

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

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

Abstract

Introduction

Chronic obstructive pulmonary disease (COPD) includes a spectrum of pulmonary diseases typically characterized by a decreased forced expiratory volume to forced vital capacity ratio and includes diseases such as emphysema, cystic fibrosis, and asthma [14]. COPD has been shown to be strongly associated with a variety of medical complications [3, 23]. As the prevalence of COPD continues to rise, elucidating COPD’s effects on postoperative complications has become a more pressing matter [3, 23]. COPD has been reported to increase rates of numerous complications after various surgical procedures including postoperative atrial fibrillation, pneumonia, and increased morbidity, mortality, length of stay, and unplanned readmission rates [10, 13, 17, 25]. The effects of COPD on postoperative complications have also been well explored in various arthroplasty procedures. However, the majority of these studies have only focused on lower extremity arthroplasties, including TKA and THA. Some complications that COPD has been associated with in lower extremity arthroplasty include, but are not limited to, reintubation and return to the operating room [12, 23, 24].

As both the rate of total shoulder arthroplasty (TSA) and prevalence of COPD continue to rise, it is important to delineate the specific effects of COPD on postoperative complications in TSA. To the best of our knowledge, no studies have analyzed COPD as a risk factor for shoulder arthroplasty. Yakubek et al. [23] and Gu et al. [12] previously examined COPD’s effects on postoperative complications in TKA and revision TKA (rTKA), respectively. However, even between these similar procedures, differences in severe postoperative results were noted. Although COPD was found to be an independent risk factor for acute renal failure and wound dehiscence in the rTKA population, these results did not hold true for the primary TKA population. Although the effects of COPD on postoperative complications have been previously explored in TKA, THA, and rTKA, the differences in anatomy and surgical techniques between the knee and shoulder preclude any accurate extrapolation of these lower extremity arthroplasty results to the TSA population. Identifying specific risk factors for complications after surgery is imperative for adequate preoperative optimization. This is especially important in TSA because the demand for primary TSA is projected to rise by 333.3% and 755.4% in patients ≤ 55 years of age and those > 55 years of age, respectively, from 2011 to 2030 [19]. Therefore, given the increasing demand and prevalence of TSA, specific analysis of COPD as a risk factor for postoperative complications after TSA is warranted.

This current study sought to delineate what serious postoperative complications are associated with a history of COPD in the 30-day postoperative period after TSA by utilizing the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. In doing so, surgeons can be better equipped to help prevent high-risk postoperative complications associated with COPD from precipitating and thereby help reduce morbidity and/or mortality in this specific patient population. Therefore, we asked: What serious postoperative complications are patients with COPD at risk for within the 30-day postoperative period after TSA?

Materials and Methods

The National Surgical Quality Improvement Program® (NSQIP) database is maintained by the American College of Surgeons (ACS). In this study, we queried the NSQIP database for all patients who had undergone primary TSA from 2005 to 2016 using Current Procedural Terminology (CPT) code 23472; CPT code 23472 includes both reverse TSA and anatomic TSA. Since the first NSQIP database release in 2005, the ACS has released an increasingly larger patient registry every year with the most recent release in 2016. To increase statistical power and analyze the largest sample of patients undergoing TSA, all patients undergoing primary TSA from the entire NSQIP database (2005-2016) were isolated and included in this study to yield the largest sample size for analysis. Patients who underwent shoulder hemiarthroplasties (CPT code 23470) and revision shoulder arthroplasties (CPT codes 23473 and 23474) were excluded from this study. All 14,494 included patients were ≥ 18 years old, and all patients were stratified by presence or lack of a preoperative history of COPD. We abstracted from the database the patients’ demographic factors, comorbidities, and perioperative/postoperative complications. The analyses conducted in this retrospective study were exempt from institutional review board review because the patient files were deidentified and publicly available from the ACS-NSQIP surgical database.

The ACS-NSQIP database contains 274 variables pertaining to each surgical patient—providing a thorough medical history in the preoperative, perioperative, and postoperative periods. Postoperative information on complications is collected for a total of 30 days. However, only demographic factors, preoperative comorbidities, and postoperative complications that were provided for > 85% of the patients were analyzed in this retrospective study. Demographics included in this study were age, sex, and race. To perform exploratory univariate analyses of these categorical variables (detailed in the Appendix, https://links.lww.com/CORR/A104) that would help inform our more definitive multivariate analyses that might identify independent associations between COPD and the complications of interest, we abstracted data from the database on the following other medical comorbidities: smoking status, diabetes mellitus, dyspnea, hematologic disorders, pneumonia, ascites, congestive heart failure, angina, hypertension being treated with medications, acute renal failure, disseminated cancer, previous wound infections, steroid use for chronic conditions, weight loss > 10% of their body weight in the past 6 months, preoperative blood transfusions of ≥ 1 unit of red blood cells, functional status, and American Society of Anesthesiologists (ASA) class for physical status. The type of anesthesia administered for the operation was also analyzed for differences between patients with a history of COPD and those without.

Patients’ serum laboratory values for sodium, blood urea nitrogen, creatinine, albumin, white blood cells, hematocrit, and platelet count were examined as continuous variables for differences in mean between patients with a history of COPD and those without (Appendix 1).

The complications of interest were categorical variables and included superficial incisional surgical site infection (SSI), deep incisional SSI, organ space SSI, wound disruption, pneumonia, unplanned intubation, ventilator dependence for > 48 hours, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, cardiac arrest, myocardial infarction, pulmonary embolism, deep venous thromboembolism (DVT), bleeding requiring transfusions, systemic sepsis, septic shock, Clostridium difficile colitis, unplanned return to the operating room, and extended length of stay in the hospital (> 30 days) (Appendix 1).

A total of 14,494 patients who had undergone primary TSA from 2005 to 2016 were included in this current study. Of these patients, 931 (6%) patients had a history of COPD, whereas 13,563 (94%) patients did not have a history of COPD. Those with a history of COPD were older than those without (70.47 versus 68.94 years, p < 0.001; Table 1). There was a larger proportion of female patients (588 of 931 [63%]) who had undergone TSA among those who had COPD than among those who did not have COPD (7555 of 13,563 [56%], p < 0.001). There were no differences in race or the type of anesthesia administered between the two cohorts (Table 1). Additionally, patients with COPD were more likely to have a preoperative history of smoking, bleeding disorders, diabetes mellitus, dyspnea, congestive heart failure, hypertension, steroid use for chronic conditions, and to have a dependent functional status (Table 1). Patients with COPD were also more likely to have an ASA class of III or IV and lower mean serum albumin (Table 1).

Table 1.
Table 1.:
Demographics and preoperative characteristics of patients undergoing primary total shoulder arthroplasty
Table 1-A.
Table 1-A.:
Demographics and preoperative characteristics of patients undergoing primary total shoulder arthroplasty

Statistical Analysis

Univariate statistical analyses of categorical demographic and other clinical characteristics of patients were performed using Pearson chi-square tests to analyze the differences between patients with a history of COPD and those without. Continuous demographic variables such as age and laboratory values were statistically analyzed using independent t-tests. To control for the demographics and comorbidities with a statistically significant p value (p ≤ 0.05), multivariate analyses were conducted by using a logistic regression model to assess COPD as an independent risk factor for the analyzed surgical outcomes and complications. After controlling for age, gender, smoking history, diabetes mellitus, dyspnea, hematologic disorders, congestive heart failure, hypertension requiring medications, steroid use, and functional dependence, multivariate logistic regression analyses yielded odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative complications associated with a history of COPD. For all statistical analyses, p values ≤ 0.05 were considered significant for this retrospective study. All statistical analyses were performed using IBM® SPSS® Statistics Version 25 software (IBM Corp, Armonk, NY, USA).

Results

COPD is an independent risk factor for three complications: pneumonia (OR, 2.793; 95% 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). Multivariate analyses did not find a history of COPD to be independently associated with an increased risk of SSIs, wound dehiscence, unplanned intubation, pulmonary embolisms, failure to wean off a ventilator within 48 hours, urinary tract infection, strokes, cardiac arrest, DVT, myocardial infarction, systemic sepsis, C. difficile infections, and extended length of hospital stay for > 30 days (Table 2).

Table 2.
Table 2.:
Multivariate analysis assessing COPD as an independent risk factor for postoperative complications after total shoulder arthroplasty compared with a non-COPD cohort

Discussion

COPD has been previously reported to increase the risks of numerous severe postoperative complications for various surgical procedures. As the prevalence of COPD and incidence of TSA continue to rise, it is becoming increasingly imperative to elucidate the role of COPD on postoperative complications so that surgeons may take measures to prevent them from precipitating. Although the effects of COPD on postoperative complications have been explored in TKA, rTKA, and THA, these results cannot be reliably applied to TSA complications. Therefore, the primary goal of our study was to determine the impact COPD had on the risk for specific postoperative complications within 30 days after TSA. In doing so, surgeons can preemptively prepare for anticipated postoperative complications after TSA in patients with a history of COPD to help decrease morbidity and/or mortality. We found a history of COPD to be an independent factor for postoperative pneumonia, bleeding that resulted in transfusions, and septic shock.

This study had several limitations. In various years, multiple variables were not reported for every patient, and thus this study was limited to patients who had all pertinent variables recorded, reducing the power of the analysis. For example, our study only included the demographics, preoperative comorbidities, and postoperative complications in which complete data were reported for > 85% of the patients. By only including these variables, more serious complications such as peripheral nerve disease and coma that may have been associated with a history of COPD were possibly excluded. Another potential limitation of this study is a lack of specifiers for the etiology and severity of COPD, because the study analyzed complications associated with a history of COPD. COPD can be caused by a multitude of pathophysiological mechanisms, including obesity, asthma, and smoking. However, each represents a distinct mechanism of disease and patient population that further represents potential confounding variables. Additionally, the current severity of the disease may vary among patients at the time of surgery. This is important to note because the severity of COPD can potentially impact the outcome. For example, all patients with well-managed, controlled COPD were assigned into the COPD cohort because they were positive for a history of COPD. Someone who had been managing their COPD well may not have as many severe complications, suggesting that using a history of COPD in assessing risk for complications may have yielded slightly higher estimates. However, in light of the fact that COPD is a chronic condition, it is likely that patients were still experiencing at least some of the condition’s symptoms; therefore, this potential limitation may not have as great of an influence on our results. A third weakness of this study is that we included all patients who underwent TSA regardless of the underlying etiology (that is, fracture, arthritis, or rotator cuff arthropathy), another potential confounding variable. For example, patients undergoing TSA coming in for emergent treatment resulting from trauma would almost certainly be at an increased risk for complications compared with those undergoing elective TSA, regardless of their COPD history. In light of this limitation, readers should interpret the findings from this study within the appropriate context because a large majority of patients undergoing TSA have elective surgery. There are several inherent limitations to database studies as well. The possibility of inaccurate data recording and reporting is a potential limitation that must be considered. CPT codes are also designed for insurance purposes and are not inherently designed for research purposes. Coding bias can skew the data as a result of inappropriate reporting based on financial incentive [26]. Furthermore, databases do not report clinical outcomes such as neurologic or functional assessment that report success or failure of the procedure in question [26]. Finally, the absence of any pulmonary function parameters within the ACS-NSQIP database is a unique limitation specific to this study. Having such information, including pulmonary function tests and oxygen use, can prove useful in formulating specific guideline recommendations based off of quantitative preoperative pulmonary functional assessments.

The current study demonstrated that COPD is associated with risk of pneumonia, blood transfusions, and septic shock. Other studies have analyzed postoperative complications of patients with COPD undergoing total joint arthroplasties as well [6, 16]. Two studies in 2017 and 2018 analyzing THA and TKA reported that having a history of COPD did not increase the risk for certain complications such as unplanned intubation or myocardial infarction in their multivariate analyses [23, 24]. The results from this current study suggest that although a history of COPD independently increases the risk for postoperative pneumonia, septic shock, and bleeding requiring transfusions, it does not qualify as a risk factor for myocardial infarction. Previous studies suggest that exacerbation of COPD increases the risk for acute postoperative myocardial infarction through systemic inflammation, bronchoconstriction, and alveolar hypoxia [9, 18, 20, 22]. This seeming contradiction of results could be attributed to the fact that the increased risk of myocardial infarction was limited to within 1 to 5 days in previous reports, whereas the current study included 30 days of postoperative data. Increasing COPD severity has also been known to correlate with increasing respiratory airway inflammation. Because these patients are in a state of chronic systemic/vascular inflammation and vasodilation, iatrogenic tissue trauma likely leads to an exaggerated inflammatory response that predisposes these patients to cardiovascular complications, strokes, and mortality [5-7, 11, 15, 16]. The overgrowth of Lactobacillus and Burkholderia genus bacteria has also been implicated in respiratory damage in patients with COPD [15, 21]. Coupled with the aforementioned systemic vasodilation and cardiovascular complications associated with COPD, this overgrowth of bacteria most likely contributes to the higher incidence of septic shock and pneumonia in these patients. Although this current study supports COPD as an independent risk factor for pneumonia and septic shock, the exact mechanism of COPD’s role in precipitating these events remains incompletely understood. Additionally, the exact pathophysiology of COPD causing hemorrhage has not been clearly established; however, multiple studies have established COPD’s association with excessive bleeding related to surgical procedures [1, 4, 24]. This study reaffirms the role of COPD as an independent risk factor for bleeding requiring transfusions specifically in TSA.

The results of the current study pose interesting implications for surgical practice. The use of prophylactic antibiotics in orthopaedic procedures has been well explored. Prophylactic second-generation cephalosporins have been shown to decrease the incidence of SSIs and, therefore, the morbidity and mortality attributed to these infectious complications [8]. However, there remains controversy as to the timing of administration, choice of antibiotic prophylaxis, and duration of antibiotic use [8]. There also continues to remain a paucity of research on how to mitigate postoperative pneumonia and septic shock specifically as postoperative complications in various orthopaedic procedures, including TSA. Although the use of prophylactic third-generation cephalosporins is not usually recommended for surgery, in light of the serious infectious complications reported in this study, surgeons may wish to initiate more aggressive infection prophylaxis with cefotaxime in patients with COPD undergoing TSA. The risks/benefits between preventing pneumonia/septic shock and selection for antimicrobial-resistant organisms in these patients must, however, be carefully weighed. Future randomized control trials analyzing the effectiveness of such aggressive infection prophylaxis for patients with COPD in decreasing the incidence of pneumonia/septic shock are warranted. Previous research has failed to demonstrate the effectiveness of preoperative autologous donation/infusion, intraoperative blood salvage, and preoperative erythropoietin in decreasing the amount of blood transfusions necessary during TSA [2]. However, a recent meta-analysis examining the effectiveness of tranexamic acid (TXA) in TSA has demonstrated decreased postoperative hemoglobin reduction, drainage volume, and total blood loss without a concurrent increase in risk of complications [27]. In light of the findings of the current study, we recommend that all patients with COPD receive TXA prophylaxis for blood loss before undergoing TSA. However, future randomized control trials examining the effectiveness of TXA in reducing blood loss in TSA for patients with COPD specifically are needed before becoming a standard of care.

In conclusion, this study better establishes COPD as a risk factor independently associated with pneumonia, septic shock, and bleeding resulting in transfusion after TSA. By identifying patients with COPD preoperatively, surgeons can more appropriately counsel their patients about the risks of postoperative complications. Based on the results of this study, we recommend TXA prophylaxis in patients with COPD undergoing TSA to reduce blood transfusion needs. In addition, third-generation cephalosporins may be considered for antimicrobial prophylaxis in patients with COPD given the elevated risk of pneumonia and septic shock. However, future randomized control trials analyzing the effectiveness of both TXA and third-generation cephalosporins in reducing these complications after TSA in patients with COPD are needed.

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