title: Postoperative respiratory failure necessitating transfer to the intensive care unit in orthopedic surgery patients: risk factors, costs, and outcomes.
abstract: BACKGROUND
  Postoperative pulmonary complications in orthopedic surgery patients have been associated with worse clinical outcomes. Identifying patients with respiratory risk factors requiring enhanced monitoring and management modifications is an important part of postoperative care. Patients with unanticipated respiratory decompensation requiring transfer to the intensive care unit (ICU) have not been studied in sufficient detail.
  
  
  METHODS
  A retrospective case-control study of elective orthopedic surgery patients (knee, hip, shoulder, or spine, n = 51) who developed unanticipated respiratory failure (RF) necessitating transfer to the ICU over a 3-year period was conducted. Controls (n = 153) were frequency matched to cases by gender, age, and surgical procedure. Patient and perioperative care factors, clinical outcomes, and cost of care were examined.
  
  
  RESULTS
  Transfer to the ICU occurred within 48 h of surgery in 73 % of the cases, 31 % required non-invasive ventilation, and 18 % required mechanical ventilation. Cases had a higher prevalence of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and regular psychotropic medication use than controls. Cases received more intravenous opioids during the first 24 postoperative hours, were hospitalized 4 days longer, had higher in-hospital mortality, and had excess hospitalization costs of US$26,571. COPD, OSA, preoperative psychotropic medications, and anesthesia time were associated with risk of RF in a multivariate analysis.
  
  
  CONCLUSIONS
  Unanticipated RF after orthopedic surgery is associated with extended hospitalization, increased mortality, and higher cost of care. Hospital protocols that include risk factor assessment, enhanced monitoring, and a cautious approach to opioid use in high-risk patients may reduce the frequency of this complication.
authors.affiliation: Department of Critical Care Medicine, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407 USA.
authors.forename: Roman
authors.initials: R
authors.lastname: Melamed
authors.affiliation: Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA.
authors.forename: Lori L
authors.initials: LL
authors.lastname: Boland
authors.affiliation: Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA.
authors.forename: James P
authors.initials: JP
authors.lastname: Normington
authors.affiliation: Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA.
authors.forename: Rebecca M
authors.initials: RM
authors.lastname: Prenevost
authors.affiliation: Department of Pharmacy, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA.
authors.forename: Lindsay Y
authors.initials: LY
authors.lastname: Hur
authors.affiliation: Chronic Pain Team, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA.
authors.forename: Leslie F
authors.initials: LF
authors.lastname: Maynard
authors.affiliation: Chronic Pain Team, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA.
authors.forename: Molly A
authors.initials: MA
authors.lastname: McNaughton
authors.affiliation: Division of Applied Research, Allina Health, 2925 Chicago Ave South, Minneapolis, MN USA.
authors.forename: Tyler G
authors.initials: TG
authors.lastname: Kinzy
authors.affiliation: Department of Critical Care Medicine, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407 USA.
authors.forename: Adnan
authors.initials: A
authors.lastname: Masood
authors.affiliation: Internal Medicine Residency Program, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA.
authors.forename: Mehdi
authors.initials: M
authors.lastname: Dastrange
authors.affiliation: Internal Medicine Residency Program, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN USA.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Huguelet
keywords: Critical care medicine; In-hospital; Intensive care unit transfer; Orthopedic procedure; Respiratory failure