In This Edition
Literature At A Glance
A guide to this month’s studies
- Acute myocardial infarction risk after hip/knee surgery
- Preoperative alcohol cessation minimizes complications in elective surgery
- Early laparoscopic cholecystectomy for gallstone pancreatitis
- Low-dose steroids in shock patients
- Pharmacist intervention did not reduce post-discharge errors
- Hyperbaric oxygen therapy and necrotizing soft-tissue infections
- Worse stroke outcomes on weekends
- Hospital admissions from EDs increasing
- Avoiding intensive glucose control in acute stroke
- Peri-procedural bleeding with dabigatran versus warfarin
Increased Risk of Acute Myocardial Infarction after Hip/Knee Surgery
Clinical question: How long does the risk of acute myocardial infarction (AMI) last after hip or knee replacement surgery, and what factors affect the risk?
Background: AMI is a morbid, perioperative complication of hip/knee surgery. Previous studies have demonstrated an increased risk of AMI post-surgery; however, this is the first study to assess the timing and modifiers of the risk.
Study design: Retrospective cohort study.
Setting: Data from Danish national registries from 1998 to 2007.
Synopsis: All adult patients who received total hip replacement (THR, n=66,524) or total knee replacement (TKR, n=28,703) surgery, as identified by hospital discharge records during a 10-year period, were matched with three age/sex controls without a history of THR or TKR (n=286,165). Patients with prior AMI within six weeks of the index date were excluded (n=437). The patients were followed until death, THR or TKR revision, migration, or the end of the study period.
Thromboprophylaxis was received by 99.1% of THR and TKR patients. The risk of AMI was significantly elevated for two weeks in TKR patients, and for six weeks in THR patients. Age >60 significantly increased the risk of AMI for both study populations. The risk associated with a previous AMI before THR or TKR diminished with increasing time between the two events.
The study was limited by lack of controlling for some AMI risk factors, such as smoking history or BMI.
Bottom line: AMI risk is substantially elevated for six weeks after THR and for two weeks after TKR. Preoperative risk factors to consider include age >60 and AMI within a year.
Citation: Lalmohamed A, Vestergaard P, Klop C, et al. Timing of acute myocardial infarction in patients undergoing total hip or knee replacement. Arch Intern Med. 2012;172:1229-1235.
Preoperative Alcohol Cessation Minimizes Complications of Elective Surgery in Heavy Alcohol Users
Clinical question: Does preoperative alcohol cessation minimize complication rates, mortality, or length of stay (LOS) in heavy alcohol users?
Background: Alcohol abuse is prevalent worldwide and contributes to 1.8 million deaths per year. Heavy alcohol users have an increased risk of postoperative bleeding, cardiopulmonary complications, and infections. It is unknown if preoperative cessation can reduce the risk of postoperative complications.
Study design: Systematic review.
Setting: Two Danish randomized controlled trials.
Synopsis: A Cochrane review identified 671 potential studies, of which 655 were excluded after abstract review. Of the 16 studies remaining, 14 were not randomized controlled trials with preoperative intervention for alcohol cessation. In the two studies that remained (n=69), patients who received preoperative alcohol cessation had fewer postoperative complications (odds ratio=0.22, 95% CI 0.08-0.61, P=0.004). Interventions included disulfiram and medical supervision of alcohol cessation. Investigators found no significant reductions for in-hospital or 30-day mortality.
Limitations of this review include lack of blinding to the treatments, low numbers of included women, and both studies being conducted by the same author.