Preoperative Hyponatremia Is Associated with Reoperation and Prolonged Length of Hospital Stay following Total Knee Arthroplasty

Abstract

Hyponatremia is a risk factor for adverse surgical outcomes, but limited information is available on the prognosis of hyponatremic patients who undergo total knee arthroplasty (TKA). The purpose of this investigation was to compare the incidence of major morbidity (MM), 30-day readmission, 30-day reoperation, and length of hospital stay (LOS) between normonatremic and hypontremic TKA patients.The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all primary TKA procedures. Hyponatremia was defined as <135 mEq/L and normonatremia as 135 to 145 mEq/L; hypernatremic patients (>145 mEq/L) were excluded. Multivariable logistic regression was used to determine the association between hyponatremia and outcomes after adjusting for demographics and comorbidities. An α level of 0.002 was used and calculated using the Bonferroni correction. Our final analysis included 88,103 patients of which 3,763 were hyponatremic and 84,340 were normonatremic preoperatively. In our multivariable models, hyponatremic patients did not have significantly higher odds of experiencing an MM (odds ratio [OR]: 1.05; 99% confidence interval [CI] 0.93–1.19) or readmission (OR: 1.12; 99% CI: 1–1.24). However, patients with hyponatremia did experience significantly greater odds for reoperation (OR: 1.24; 99% CI: 1.05–1.46) and longer hospital stay (OR: 1.15; 99% CI: 1.09–1.21). We found that hyponatremic patients undergoing TKA had increased odds of reoperation and prolonged hospital stay. Preoperative hyponatremia may be a modifiable risk factor for adverse outcomes in patients undergoing TKA, and additional prospective studies are warranted to determine whether preoperative correction of hyponatremia can prevent complications.

Keywords

hyponatremia - total knee arthroplasty - morbidity - length of hospital stay - reoperation

• References

• 1 Siracuse BL, Chamberlain RS. A preoperative scale for determining surgical readmission risk after total hip replacement. JAMA Surg 2016; 151 (08) 701-709
• 2 Upadhyay A, Jaber BL, Madias NE. Incidence and prevalence of hyponatremia. Am J Med 2006; 119 (07) (Suppl. 01) S30-S35
• 3 Cecconi M, Hochrieser H, Chew M. , et al; European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. Preoperative abnormalities in serum sodium concentrations are associated with higher in-hospital mortality in patients undergoing major surgery. Br J Anaesth 2016; 116 (01) 63-69
• 4 Hennrikus E, Ou G, Kinney B. , et al. Prevalence, timing, causes, and outcomes of hyponatremia in hospitalized orthopaedic surgery patients. J Bone Joint Surg Am 2015; 97 (22) 1824-1832
• 5 Leung AA, McAlister FA, Rogers Jr SO, Pazo V, Wright A, Bates DW. Preoperative hyponatremia and perioperative complications. Arch Intern Med 2012; 172 (19) 1474-1481
• 6 Mc Causland FR, Wright J, Waikar SS. Association of serum sodium with morbidity and mortality in hospitalized patients undergoing major orthopedic surgery. J Hosp Med 2014; 9 (05) 297-302
• 7 Sah AP. Hyponatremia after primary hip and knee arthroplasty: incidence and associated risk factors. Am J Orthop 2014; 43 (04) E69-E73
• 8 Wang P, Huang G, Tam N. , et al. Influence of preoperative sodium concentration on outcome of patients with hepatitis B virus cirrhosis after liver transplantation. Eur J Gastroenterol Hepatol 2016; 28 (10) 1210-1215
• 9 Carniol ET, Marchiano E, Brady JS. , et al. Head and neck microvascular free flap reconstruction: an analysis of unplanned readmissions. Laryngoscope 2017; 127 (02) 325-330
• 10 Baker D, Sherrod B, McGwin Jr G, Ponce B, Gilbert S. Complications and 30-day outcomes associated with venous thromboembolism in the pediatric orthopaedic surgical population. J Am Acad Orthop Surg 2016; 24 (03) 196-206
• 11 Allen SJ. Marker or mechanism? Dysnatraemia and outcomes in the perioperative period. Br J Anaesth 2016; 116 (02) 155-157
• 12 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (04) 780-785
• 13 Centers for Medicare and Medicaid. Bundled Payments for Care Improvement (BPCI) Initiative: General Information. Avaialable at: https://innovation.cms.gov/initiatives/bundled-payments/ . Accessed November 16, 2016
• 14 Pulido L, Parvizi J, Macgibeny M. , et al. In hospital complications after total joint arthroplasty. J Arthroplasty 2008; 23 (06) (Suppl. 01) 139-145
• 15 Meller MM, Toossi N, Johanson NA, Gonzalez MH, Son M-S, Lau EC. Risk and cost of 90-day complications in morbidly and superobese patients after total knee arthroplasty. J Arthroplasty 2016; 31 (10) 2091-2098
• 16 Baser O, Supina D, Sengupta N, Wang L, Kwong L. Clinical and cost outcomes of venous thromboembolism in Medicare patients undergoing total hip replacement or total knee replacement surgery. Curr Med Res Opin 2011; 27 (02) 423-429
• 17 Clair AJ, Evangelista PJ, Lajam CM, Slover JD, Bosco JA, Iorio R. cost analysis of total joint arthroplasty readmissions in a Bundled Payment Care Improvement initiative. J Arthroplasty 2016; 31 (09) 1862-1865
• 18 Pugely AJ, Martin CT, Gao Y, Schweizer ML, Callaghan JJ. The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty. J Arthroplasty 2015; 30 (9, Suppl): 47-50
• 19 Pugely AJ, Callaghan JJ, Martin CT, Cram P, Gao Y. Incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP. J Arthroplasty 2013; 28 (09) 1499-1504
• 20 Khuri SF, Henderson WG, Daley J. , et al; Principal Investigators of the Patient Safety in Surgery Study. Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg 2008; 248 (02) 329-336
• 21 Shiloach M, Frencher Jr SK, Steeger JE. , et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2010; 210 (01) 6-16
• 22 ACS NSQIP Participant Use Data File. American College of Surgeons. Available at: https://www.facs.org/quality-programs/acs-nsqip/program-specifics/participant-use . Accessed November 9, 2016
• 23 Biswas M, Davies JS. Hyponatraemia in clinical practice. Postgrad Med J 2007; 83 (980) 373-378
• 24 Chan KKW, Xie F, Willan AR, Pullenayegum EM. Underestimation of variance of predicted health utilities derived from multiattribute utility instruments. Med Decis Making 2017; 37 (03) 262-272
• 25 Hamilton BH, Ko CY, Richards K, Hall BL. Missing data in the American College of Surgeons National Surgical Quality Improvement Program are not missing at random: implications and potential impact on quality assessments. J Am Coll Surg 2010; 210 (02) 125-139.e2
• 26 Greenland S, Finkle WD. A critical look at methods for handling missing covariates in epidemiologic regression analyses. Am J Epidemiol 1995; 142 (12) 1255-1264
• 27 Crestanello JA, Phillips G, Firstenberg MS. , et al. Preoperative hyponatremia predicts outcomes after cardiac surgery. J Surg Res 2013; 181 (01) 60-66
• 28 Wald R, Jaber BL, Price LL, Upadhyay A, Madias NE. Impact of hospital-associated hyponatremia on selected outcomes. Arch Intern Med 2010; 170 (03) 294-302
• 29 Amin A, Deitelzweig S, Christian R. , et al. Evaluation of incremental healthcare resource burden and readmission rates associated with hospitalized hyponatremic patients in the US. J Hosp Med 2012; 7 (08) 634-639
• 30 Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med 2009; 122 (09) 857-865
• 31 Tanenbaum JE, Knapik DM, Fitzgerald SJ, Marcus RE. National incidence of reportable quality metrics in the knee arthroplasty population. J Arthroplasty 2017; 32 (10) 2941-2946
• 32 Hoorn EJ, Zietse R. Hyponatremia and mortality: moving beyond associations. Am J Kidney Dis 2013; 62 (01) 139-149
• 33 Gheorghiade M, Rossi JS, Cotts W. , et al. Characterization and prognostic value of persistent hyponatremia in patients with severe heart failure in the ESCAPE Trial. Arch Intern Med 2007; 167 (18) 1998-2005
• 34 Tribouilloy C, Buiciuc O, Rusinaru D, Malaquin D, Lévy F, Peltier M. Long-term outcome after a first episode of heart failure. A prospective 7-year study. Int J Cardiol 2010; 140 (03) 309-314
• 35 Jenq C-C, Tsai M-H, Tian Y-C. , et al. Serum sodium predicts prognosis in critically ill cirrhotic patients. J Clin Gastroenterol 2010; 44 (03) 220-226
• 36 Borroni G, Maggi A, Sangiovanni A, Cazzaniga M, Salerno F. Clinical relevance of hyponatraemia for the hospital outcome of cirrhotic patients. Dig Liver Dis 2000; 32 (07) 605-610
• 37 Goldberg A, Hammerman H, Petcherski S. , et al. Hyponatremia and long-term mortality in survivors of acute ST-elevation myocardial infarction. Arch Intern Med 2006; 166 (07) 781-786
• 38 Goldberg A, Hammerman H, Petcherski S. , et al. Prognostic importance of hyponatremia in acute ST-elevation myocardial infarction. Am J Med 2004; 117 (04) 242-248
• 39 Singla I, Zahid M, Good CB, Macioce A, Sonel AF. Effect of hyponatremia (<135 mEq/L) on outcome in patients with non-ST-elevation acute coronary syndrome. Am J Cardiol 2007; 100 (03) 406-408
• 40 Scherz N, Labarère J, Méan M, Ibrahim SA, Fine MJ, Aujesky D. Prognostic importance of hyponatremia in patients with acute pulmonary embolism. Am J Respir Crit Care Med 2010; 182 (09) 1178-1183
• 41 Zilberberg MD, Exuzides A, Spalding J. , et al. Hyponatremia and hospital outcomes among patients with pneumonia: a retrospective cohort study. BMC Pulm Med 2008; 8: 16
• 42 Nair V, Niederman MS, Masani N, Fishbane S. Hyponatremia in community-acquired pneumonia. Am J Nephrol 2007; 27 (02) 184-190
• 43 Waikar SS, Curhan GC, Brunelli SM. Mortality associated with low serum sodium concentration in maintenance hemodialysis. Am J Med 2011; 124 (01) 77-84
• 44 Kovesdy CP, Lott EH, Lu JL. , et al. Hyponatremia, hypernatremia, and mortality in patients with chronic kidney disease with and without congestive heart failure. Circulation 2012; 125 (05) 677-684
• 45 Hoorn EJ, Zietse R. Hyponatremia and mortality: how innocent is the bystander?. Clin J Am Soc Nephrol 2011; 6 (05) 951-953
• 46 Lawson EH, Louie R, Zingmond DS. , et al. A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications. Ann Surg 2012; 256 (06) 973-981