Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Authors (including presenting author) :
Chan CW (1), Chan TH (1) , Chan SH (1), Wong SC (2), Ng WY (1), Wong KC (3), Chan PK (4), Cheung CW (2)
Affiliation :
(1)Department of Anaesthesia, Pain and Perioperative Medicine, Queen Mary Hospital, Hong Kong, China
(2) Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
(3) Department of Pharmacy, Queen Mary Hospital, Hong Kong, China
(4) Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong
Introduction :
Osteoarthritis (OA) is the most common joint disease, affecting more than 240 million people worldwide, with more than 32 million in the US. Osteoarthritis is the most frequent cause of limited activity in adults. Hip and knee arthroplasty are common orthopedic procedures used to treat patients with end-stage knee arthritis. The demands for these procedures are increasing with time.
Hip and knee arthroplasty is a rehabilitative surgery aimed at accelerating patient ambulation and reducing the length of hospital stay. To facilitate this process, multidisciplinary Enhanced Recovery After Surgery (ERAS) programs are implemented. This involves surgeons, anesthetists, physiotherapists and nurses who follow an integrated care pathway to facilitate early patient mobilization, thus leading to early hospital discharge. The program is implemented to reduce the hospital length of stay, which can reduce the risks of complications and mortality.
Hip and knee arthroplasty is associated with significant perioperative pain, which can adversely affect recovery by increasing the risk of complications, length of stay, and cost. Severe perioperative pain is associated with an increased risk of infection, myocardial ischemia, respiratory complications and the development of chronic pain. Therefore, effective multimodal analgesia is an essential component in the ERAS program. It combines different oral analgesics to limit opioid use and its related side effects. Cyclooxygenase-2 (COX-2) inhibitors, such as celecoxib, have been shown to relieve pain and reduce opioid use after hip and knee arthroplasty. It is therefore recommended to be used routinely. However, its potential nephrotoxic property has led to its judicious use, especially in patients with preoperative chronic renal impairment.
Postoperative Acute Kidney Injury (AKI) is an independent risk factor for mortality, cardiovascular complications, health care utilization and hospitalization. Acute postoperative kidney injury was significantly correlated with increased length of hospital stay. AKI may complicate up to 10% of primary lower-extremity total joint arthroplasties and up to 25% of periprosthetic joint infections treated with a 2-stage procedure, including placement of an antibiotic-loaded cement spacer in the first stage.
None of the above studies showed the reversibility of AKI in the immediate postoperative period following hip and knee arthroplasty. Moreover, none of the above studies showed a specific evaluation of the impact of perioperative celecoxib as part of routine standard multimodal analgesic protocols on the incidence and severity of AKI, especially for patients with preexisting renal impairment.
Objectives :
This study was to retrospectively review the incidence, severity and duration of AKI with short term perioperative celecoxib. We also aimed to evaluate the impact of perioperative celecoxib on the incidence and severity of AKI in patients with and without preexisting renal impairment
Methodology :
We performed a retrospective review of 1077 patients in our database who underwent elective hip and knee arthroplasty at Queen Mary Hospital, Hong Kong, from January 2018 to December 2021.
Relevant data were retrieved from the computerized medical records system. Patients who were scheduled to undergo hip and knee arthroplasty were routinely assessed by anesthetists in a preoperative assessment clinic. They were enrolled in an ERAS program, and a multimodal analgesic protocol was started. If the patient’s preoperative renal serum creatinine was < 200 μmol/L, 200 mg celecoxib was administered at night immediately before operation day and for 5 days postoperatively. Local Infiltration of Anesthetics (LIA) using 300 mg ropivacaine with 30 mg ketorolac was performed intraoperatively for knee arthroplasty. Serum creatinine level was measured at hospital admission and daily for the first 2 postoperative days.
AKI was defined using Acute Kidney Injury Network (AKIN) classification: Stage 1 = sCr increase greater than or equal to 26.4 mmol/L or an increase of 1.5- 2.0 times from baseline. Stage 2 = sCr increase 2.0-3.0 times from baseline. Stage 3 = sCr increase >3.0 times or requiring dialysis.
To assess the severity and duration of postoperative AKI, serial renal function tests were performed for the first 2 postoperative days and were further performed if there was AKI in postoperative day 2 until the baseline renal function test result was achieved. Celecoxib was stopped and adequate fluid hydration was initiated when there was AKI of Stage 2 using AKIN classification.
Patients were discharged once they met the criteria for discharge according to the ERAS program protocol and without decreasing serum creatinine levels compared with preoperative values.
We collected patients’ demographic data, including age, sex, body weight, and American Society of Anesthesiologists (ASA) status. The type of operation performed and the percentage of patients having preoperative nephrotoxic drugs - Angiotensin Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs) - were retrieved. The incidences of postoperative AKI with and without celecoxib were measured according to AKIN classification. This was further analyzed for patients with and without “preexisting renal impairment”. Definition of “pre-existing impairment” used in this study was serum creatinine (sCr) level > 200 μmol/L at hospital admission. The incidence of AKI during each postoperative day and during the entire hospitalization period was measured
Result & Outcome :
As part of the multimodal analgesic protocol in an enhanced recovery program, 82.5% of our patients received perioperative celecoxib. In this retrospective clinical study of elective hip and knee arthroplasty, the overall postoperative AKI rate was 9.2% in patients taking perioperative celecoxib and 9.5% in those not taking perioperative celecoxib. There was no association between perioperative celecoxib and postoperative AKI. Patients taking perioperative celecoxib probably had no additional AKI risk. For those with perioperative celecoxib, the incidence of AKI was similar for those with preexisting renal impairment and for those with normal renal function. Most patients who developed AKI were cured by postoperative day 5. Appropriate risk stratification is still necessary in prescribing celecoxib for patients with preexisting renal impairment. It is generally safe to administer perioperative NSAIDs even with preexisting renal impairment provided that it is for a short duration with good perioperative fluid management and postoperative monitoring of renal function.
