吸菸可能增加關節置換術後併發症機率


  【24drs.com】根據一項發表於美國骨科醫學會(AAOS)2011年年會上的研究結果,接受非緊急髖關節或膝關節置換術的退伍軍人,如果他當時是吸菸者的話,發生術後併發症的風險明顯較高。
  
  這項研究根據一個大型退伍軍人行政(VA)資料庫,分析顯示吸菸與非緊急全關節置換術手術部位及肺部感染風險增加近50%有關。
  
  伯明罕阿拉巴馬大學醫學副教授、同時也是伯明罕阿拉巴馬VA醫學中心風濕免疫科醫師Jasvinder A. Singh表示,對非緊急性外科手術而言,如髖關節或膝關節置換術,術前準備提供了一個戒菸的黃金機會。
  
  研究人員檢驗吸菸對接受非緊急性全髖關節或膝關節置換術退伍軍人術後30天併發症的影響;這項分析包括33,336位於2002年到2008年之間接受手術的退伍軍人,且這些患者都是VA外科品質改善計畫(VASQIP)的部分成員。
  
  【吸菸在接受關節置換術的退伍軍人中很常見】
  Singh醫師觀察到,接受關節置換手術的退伍軍人很常吸菸,接受外科手術的退伍軍人中,大約有36%目前仍在吸菸,比納入VA服務所有退伍軍人的30%以及一般美國大眾的23%高得多。
  
  目前,美國每年大約有75萬件全髖關節與全膝關節置換手術,這個數字預期在未來幾年還會倍數增加;事實上,到了2030年,全髖關節置換手術預計會增加274%,膝關節置換手術會增加673%;更重要的,全髖關節與全膝關節置換術是VA機構最常進行的非心臟外科手術,這些機構提供500萬退伍軍人醫療服務。
  
  他附帶表示,吸菸對於關節置換手術後併發症的影響仍然未知;至少部分是因為不同研究的樣本數目不足。
  
  【仍吸菸者其術後併發症風險上升】
  結果顯示,相較於從未吸菸者,目前仍在吸菸者的手術部位感染(勝算比[OR]為1.41;95%信賴區間[CI]為1.16-1.72)、肺炎(OR為1.53;95% CI為1.10-2.14)或中風(OR為2.61;95% CI為1.26-5.41),以及一年時死亡率(OR為1.63;95% CI為1.31-2.02)都顯著較高。
  
  之前曾吸菸者(已戒菸者),相較於從未吸菸者,發生肺炎(OR為1.34;95% CI為1.00-1.80)與泌尿道感染(OR為1.26;95% CI為1.02-1.55)的機率也顯著較高。
  
  Singh醫師指出,這項研究的強度在於使用典型的VASQIP資料庫,該資料庫是由受過訓練的護士以經過確效的預後定義收集資料,研究發現也有較大的樣本數目做後盾。不過,他提醒,由於這項研究中的患者大多為高齡男性,結果可能無法外推到接受全關節置換之較年輕患者或是女性。
  
  Singh醫師表示,因為大部分全關節置換術是非緊急的,配合吸菸相關併發症顯著的發病率與死亡率,在進行手術前,要求患者們參與術前戒菸計畫是有必要的;戒菸計畫有降低術中與術後風險及併發症的潛力;但是,需要更多研究來找出哪種戒菸計畫對於這些患者是最好的。
  
  伊利諾州芝加哥西北大學骨科主席、同時也是AAOS交流顧問團主席的Michael F. Schafer醫師表示,當許多骨科醫師,就像他一樣,直覺地知道吸菸可能增加全膝關節置換術後併發症風險,包括肺併發症與手術部位感染風險,這項研究提供我們確認其間關聯性很重要的研究數據;我們從這項研究得到的最重要訊息是,打算進行全膝關節置換術的患者應該考慮戒菸。
  
  他表示,他的脊椎疾病患者中,其中一些手術是極度高風險的,他們想要除去這些可能惡化術後預後的因子;除了那些因個人問題必須立即手術的患者,他將會告訴那些患者,直到他們戒菸,醫師才會動這個手術。
  
  這項研究由VA價值審核經費VA IIR IAB 06-038-2,麻州貝德福、伯明罕、華盛頓普吉灣退伍軍人事務部門醫學中心機構使用與資源贊助。Singh醫師與Schafer醫師表示沒有相關資金上的往來。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_logon=W&x_idno=6463&x_classno=0
  

Smoking May Increase Postarthroplasty Complications

By Jill Stein
Medscape Medical News

February 18, 2011 (San Diego, California) — Veterans who are cigarette smokers at the time of elective hip or knee replacement surgery appear to have a significantly increased risk for postoperative complications, according to results of a study reported here at the American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting.

The study, based on information from a large Veterans Administration (VA) database, showed that current smoking is independently associated with an approximately 50% increase in surgical site infections and pulmonary complications after elective total joint arthroplasty.

"For an elective surgery such as total hip or knee replacement, the preoperative period provides a golden opportunity for quitting smoking," said Jasvinder A. Singh, MD, who is a staff rheumatologist with the Birmingham, Alabama VA Medical Center, and associated professor of medicine at the University of Alabama, Birmingham.

The investigators examined the impact of smoking on 30-day postoperative complications in veterans after elective primary total hip and total knee replacement. The analysis consisted of 33,336 veterans who had their operations between 2002 and 2008 and were part of the VA Surgical Quality Improvement Program (VASQIP).

Smoking Prevalent in Veterans Undergoing Joint Replacement

Cigarette smoking is common in veterans undergoing surgery, Dr. Singh observed. Around 36% of veterans undergoing surgery are current smokers, much higher than the 30% smoking rate for all veterans using VA services and the 23% rate for the general American population.

Currently, roughly 750,000 total hip and total knee arthroplasties are performed yearly in the United States, and the numbers are expected to increase exponentially in the coming years. In fact, by 2030, it is anticipated that there will be a 274% increase in the number of hip replacement procedures and a 673% increase in the number of knee replacement procedures. Importantly, total hip and total knee replacement surgeries are among the most common noncardiac surgical procedures performed in VA facilities, which provide healthcare to 5 million veterans.

The effect of smoking on complications after joint replacement surgery is not clear; this is at least partially due to the small sample size in the various studies to date, he added.

Increased Postoperative Risk Seen in Current Smokers

Results showed that current smokers were significantly more likely than never smokers to have surgical site infections (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.16 to 1.72), pneumonia (OR, 1.53; 95% CI, 1.10 to 2.14), stroke (OR, 2.61; 95% CI, 1.26 to 5.41), and 1-year mortality (OR, 1.63; 95% CI, 1.31 to 2.02).

Former smokers were significantly more likely than nonsmokers to have pneumonia (OR, 1.34; 95% CI, 1.00 to 1.80) and urinary tract infections (OR, 1.26; 95% CI, 1.02 to 1.55).

Dr. Singh said that a strength of the study is the use of state-of the-art VASQIP, databases, from which data were abstracted by trained nurses using validated outcome definitions. The study findings are also bolstered by the large sample size.

He cautioned that it might not be possible to extrapolate the findings to younger patients or women undergoing total joint arthroplasty because most patients in the study were older men.

"Given the elective nature of most total joint arthroplasty procedures, coupled with the significant morbidity and mortality associated with smoking-related complications, a strong case can be made for requiring patients to participate in a preoperative smoking cessation program before undergoing joint replacement surgery," Dr. Singh said. "Smoking cessation programs have the potential to decrease perioperative and postoperative risk and complications."

He also noted that more research is needed to identify which type of smoking cessation program is optimal in these patients.

"While many orthopaedic surgeons like myself had intuitively known that smoking increases the risk of complications after [total knee arthroplasty], including pulmonary complications and surgical site infections, this study provides very strong data to document the link," Michael F. Schafer, MD, chair of the Department of Orthopaedic Surgery at Northwestern University in Chicago, Illinois, and chair of the Communications Cabinet for the AAOS, told Medscape Medical News. "The important message to emerge from this study is that patients considering [total knee arthroplasty] should consider smoking cessation."

"In my spine patients, some of the surgery I do is extremely high risk," he said. "We want to eliminate all of the variables that can possibly complicate surgical outcome, like smoking. So in patients who are not absolutely incapacitated by their problem, I will tell them that I won't do their surgery until they stop smoking."

The study was supported by the VA merit review grant VA IIR IAB 06-038-2 and the use and resources of facilities at the Department of Veterans Affairs Medical Centers at Bedford, Massachusetts; Birmingham, Alabama; and Puget Sound, Washington. Dr. Singh and Dr. Schafer have disclosed no relevant financial relationships.

American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting. Abstract 473. Presented February 17, 2011.

    
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