Association of opioid prescription and perioperative complications in OSA-patients undergoing total joint arthroplasties.
Authors: Eva E. Mörwald MD, Ashley Olson MA, Crispiana Cozowicz MD, Jashvant Poeran MD PhD, Stavros G. Memtsoudis MD PhD FCCP
Background: Obstructive sleep apnea (OSA) has been linked to higher rates of perioperative complications1. Especially pulmonary complications have been suggested to be more common among patients with OSA2. Therefore, practice guidelines recommend minimizing the use of respiratory depressant drugs, specifically opioids, among individuals with OSA, because they potentially worsen pathophysiologic processes associated with OSA3. However, a paucity of evidence exists relating different levels of opioid prescription to perioperative complications.
General Aim: Our aim was to investigate if different levels of opioid prescription are related to perioperative complication risk in patients with OSA. We hypothesized that higher opioid prescription would be associated with higher odds of perioperative complications.
Material and Methods: 107,610 OSA-patients undergoing total knee or hip arthroplasty between 2006 and 2013 were identified in a nationwide database (Premier Perspective Database, Premier Inc., Charlotte, North Carolina) and divided into quartiles according to the amount of opioids prescribed. We then compared those quartiles for odds of perioperative complications using multilevel multivariable logistic regression models. Since only de-identified data was used, this study was exempt from patient consent by the Institutional Review Boards of the Hospital for Special Surgery and Icahn School of Medicine at Mount Sinai.
Results: OSA-patients with higher levels of opioid prescription had increased odds for gastrointestinal complications (OR 1.90, 95% CI 1.47 – 2.46), prolonged length of stay (OR 1.64, 95% CI 1.57 – 1.72) and increased cost of care (OR 1.48, 95% CI 1.40 – 1.57). However, we found lower odds for pulmonary complications (OR 0.85, 95% CI 0.74 – 0.96) for the high prescription quartile.
Conclusion: Higher levels of opioid prescription were associated with higher odds for gastrointestinal complications and adverse effects on cost and length of stay but lower odds for pulmonary complications in OSA-patients undergoing joint arthroplasties. The latter finding is unlikely causal but may indicate the growing awareness among practitioners about potential respiratory complications of OSA in the perioperative setting and how these complications may be aggravated by opioid side effects. It should not be viewed as a finding suggesting that administering high doses of opioids are recommended in an unmonitored setting. Attempts to further reduce opioid prescription in patients with OSA should be continued. Furthermore, since implementation of practice guidelines, institutional policies and utilization of resources for OSA-patients is still suboptimal4,5, further sensitization for risks and possible complications is needed to improve quality and safety of this challenging cohort in the perioperative setting.
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