Orthopedics

Feature Article 

Rates of Perioperative Complications Among Patients Undergoing Orthopedic Trauma Surgery Despite Having Positive Results for Methamphetamine

Thomas Githens, DO; Malcolm R. DeBaun, MD; Sean T. Campbell, MD; Edward J. Wu, MD; L. Henry Goodnough, MD; Paul Lichstein, MD; Christopher Painter, MD; Jeffrey E. Krygier, MD; Julius Bishop, MD; Michael J. Gardner, MD

Abstract

The burden of psychosocial problems, including substance abuse, is high among trauma patients. Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of concerns for an interaction with anesthesia. Methamphetamine theoretically has potential to increase perioperative anesthetic risks. However, the authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients. This study sought to determine the rate of cardiovascular complications in these patients. The authors reviewed the medical records of all patients between 2013 and 2018 who underwent orthopedic trauma surgery at two level I trauma centers in the setting of a methamphetamine-positive urine toxicology screening prior to surgery. Information on demographics, injury, type of surgical intervention, and incidence of perioperative cardiovascular and overall medical complications prior to discharge was recorded. Ninety-four patients were included in the study (mean age, 44 years; range, 16–78 years). Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement and/or provisional stabilization of an open or unstable fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. The overall rates of perioperative cardiovascular complications and perioperative medical complications were 2.1% and 3.2%, respectively. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic. [Orthopedics. 2019; 42(4):192–196.]

Abstract

The burden of psychosocial problems, including substance abuse, is high among trauma patients. Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of concerns for an interaction with anesthesia. Methamphetamine theoretically has potential to increase perioperative anesthetic risks. However, the authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients. This study sought to determine the rate of cardiovascular complications in these patients. The authors reviewed the medical records of all patients between 2013 and 2018 who underwent orthopedic trauma surgery at two level I trauma centers in the setting of a methamphetamine-positive urine toxicology screening prior to surgery. Information on demographics, injury, type of surgical intervention, and incidence of perioperative cardiovascular and overall medical complications prior to discharge was recorded. Ninety-four patients were included in the study (mean age, 44 years; range, 16–78 years). Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement and/or provisional stabilization of an open or unstable fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. The overall rates of perioperative cardiovascular complications and perioperative medical complications were 2.1% and 3.2%, respectively. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic. [Orthopedics. 2019; 42(4):192–196.]

The burden of psychosocial distress, including substance abuse, is high among trauma patients.1 Methamphetamine use is prevalent across the United States, and amphetamine abuse ranks second worldwide among illicit substance use.2–4 According to the 2016 National Survey on Drug Use and Health, 28.6 million individuals had used an illicit drug in the past 30 days and more than 650,000 individuals older than 12 years were current methamphetamine users.5 Population-based studies estimate that approximately 10% of trauma patients test positive for methamphetamine; relative to the severity of their injury, these patients use disproportionately more trauma center resources.6–8

Use of illicit substances is often noted during urine toxicology screening on admission and can delay surgery because of anesthetic concerns. Both acute and chronic methamphetamine exposure, whether from ingestion, inhalation, or injection, are proposed to increase the risk of adverse hemodynamic events in the perioperative period. Acute intoxication leads to the central release of dopamine, serotonin, and norepinephrine, resulting in hypertension, tachycardia, hyperthermia, and insomnia. Chronic abuse can lead to catecholamine depletion and autonomic remodeling.9,10 There are significant anesthetic considerations for acute and chronic methamphetamine use, with both resulting in the potential for increased perioperative risks.10 The acutely intoxicated patient is known to have increased anesthetic requirements, volatile hemodynamics, and increased susceptibility for arrhythmias. Conversely, with chronic abuse, patients will potentially have decreased anesthetic requirements and refractory hypotension only treatable by direct-acting vasoactive agents.11,12 Despite these potential risks, the current authors are unaware of any studies documenting increased rates of cardiovascular complications in the perioperative period among orthopedic trauma patients.

Furthermore, there is little in the anesthetic literature to suggest management strategies for these patient populations. Perioperative guidelines for patients who test positive for illicit drugs are not standardized and often vary by institution.13,14 Urine drug screenings can detect methamphetamine for 3 to 6 days after last use, potentially leading to significant delay in surgical treatment if a clean screening result is required prior to administration of general anesthesia.15 Injury severity occasionally demands surgical attention despite acute substance intoxication, thereby exposing these patients to the potential increased risk of perioperative morbidity and mortality. Therefore, the purpose of this study was to determine the rate of cardiovascular complications in acutely injured patients who underwent orthopedic trauma surgery despite having positive methamphetamine screening results immediately prior to surgery. The authors hypothesized that the overall complication rate in the perioperative period related to cardiopulmonary compromise attributed to methamphetamine use is low in patients undergoing orthopedic trauma surgery.

Materials and Methods

Institutional review board approval was obtained for this retrospective chart review. The medical records of all patients who underwent orthopedic surgery for a diagnosis of fracture, soft tissue injury, or infection of the extremities (excluding the hand) between 2013 and 2018 at two level I trauma centers were reviewed. Patients were included in this series if they had a positive result on methamphetamine urine toxicology screening as an inpatient up to 2 days prior to surgery without documentation of clearance from the system based on a subsequent screening. Demographics, injury, American Society of Anesthesiologists physical status score, type of anesthesia, type of surgical intervention, and timing of the most recent positive urine screening were recorded. The primary outcome was the presence of a perioperative cardiovascular complication. Any medical complication prior to discharge was recorded as a secondary outcome. Descriptive statistics were performed.

Results

Ninety-four patients, 75 male and 19 female, were included in the study. Mean age was 44 years (range, 16–78 years). Regarding American Society of Anesthesiologists status, 41 (44%) patients were class II, 35 (37%) patients were class III, and 7 (7%) patients were class IV. Because the remaining patients had incomplete records, their status could not be determined. Twenty-six (28%) patients had multiple injuries. Thirteen (14%) patients had debridement or provisional stabilization of a fracture, 18 (19%) had treatment for an infection, and 63 (67%) had definitive fracture surgery. Eighty-eight (94%) of the patients had a positive result on screening on the day of surgery, 6 patients had a positive result on screening 1 day prior to surgery, and 1 patient had a positive result on screening 2 days prior to surgery. Seventy-seven (82%) of the patients had general anesthesia. The rest of the patients received local, regional, spinal, or monitored anesthesia (Table 1).

Patient Characteristics

Table 1:

Patient Characteristics

The overall rate of perioperative complications was 3.2% (3 of 94 patients). The overall rate of perioperative cardiovascular complications was 2.1% (2 of 94 patients), but only 1 of these complications was attributable to methamphetamine use. In this case, surgery was aborted in the operating room secondary to hypotension attributed to methamphetamine use. This was a young male patient with a history of chronic methamphetamine use who was indicated for surgical treatment of a displaced forearm fracture. On hospital day 2, he was taken to the operating room. On induction of anesthesia, he developed persistent hypotension refractory to intravenous fluid bolus and aggressive pharmacological vascular support. This was attributed to persistent vasoplegia resulting from chronic methamphetamine use. Hemodynamic stability was eventually achieved and maintained, permitting the patient to return to the operating room on hospital day 6 for successful open reduction and internal fixation of the forearm fracture without further complication. The other cardiovascular complication was death attributed to intraoperative hypovolemic shock secondary to traumatic injuries. The third complication was aspiration pneumonia in a patient during the perioperative period prior to discharge (Table 2).

Patient Complications

Table 2:

Patient Complications

Discussion

In this study, the authors analyzed 94 cases of orthopedic surgical intervention in the setting of a positive methamphetamine screening result. Ninety-four percent of the patients had a positive result on screening on the day of surgery, and all of the patients had surgery within 2 days of screening. The rate of perioperative cardiopulmonary complications in this group was 2.1%, consistent with widely accepted existing perioperative risk estimations. According to recent estimations projected by the American College of Cardiology and the American Heart Association in the Perioperative Cardiovascular Evaluation and Care in Noncardiac Surgery guidelines, fewer than 5% of orthopedic surgery patients develop postoperative cardiac complications.16 In general, orthopedic trauma patients are at increased risk (7%) of developing major perioperative complications compared with non-trauma orthopedic surgery patients (2%).17 Despite concurrent positive results on methamphetamine testing, the cohort of patients in this study remained consistent with this estimation. Additionally, the current patient population was within the low to intermediate risk range (0% to 5%) for having an adverse cardiovascular event based on established norms for surgical procedure alone not taking into account individual comorbidities.18 When stratified according to the Surgical Mortality Probability Model, a tool used to predict 30-day mortality after non-cardiac surgery based on American Society of Anesthesiologists status, surgical procedure risk, and urgency, the majority of the current patient cohort was equally split between Surgical Mortality Probability Model class 1 and class 2 (49% and 48%, respectively), conferring a predicted risk of 0% to 5%. Two (0.02%) patients were considered Surgical Mortality Probability Model class 3, conferring a predicted risk of greater than 10%; however, neither of these patients experienced any documented complications.19 Intraoperative course was altered due to methamphetamine use for only 1 patient. This case was canceled in the operating room due to hypotension attributed to chronic methamphetamine use.

Although the authors' reported perioperative complication rate among patients with positive results for methamphetamine does not seem to be increased compared with widely established norms for orthopedic trauma patients, the rate of cardiovascular complications (2.1%) was greater than that established for orthopedic trauma patients through analysis of the American College of Surgeons National Surgical Quality Improvement Program database (1.3%).20 The importance of this finding should be further investigated through larger studies.

It has been well established in the literature that illicit substance abuse is common among trauma patients. Patients with positive screening results for methamphetamine are more likely to be admitted to the intensive care unit and require overall longer hospital stays when compared with control populations.7,8,21 Surprisingly, there is no clear association between positive methamphetamine screening results on admission and in-hospital mortality.22,23 Patients who present in the setting of trauma with positive results for methamphetamine are routinely considered to be at high risk for cardiovascular complications during general anesthesia based on the drug's known physiologic effects.24,25 Methamphetamine is a potent sympathetic stimulant, and it has been implicated in cases of cardiac arrest, myocardial instability, intracranial hypertension, pulmonary arterial hypertension, refractory hypotension, hyperpyrexia, and tachycardia.9,21 These cardiovascular complications are often the direct cause of death in methamphetamine overdose.26 Depending on the chronicity of use, the typical required dose of inhaled anesthetic can be either increased or decreased, thereby presenting a challenging and potentially hazardous anesthetic environment. Occasionally, despite positive screening for methamphetamine, an injury demands surgical attention. In orthopedics, such injuries typically include unstable pelvic injuries, open fractures, irreducible dislocations, compartment syndrome, and severe soft tissue injuries or infections.

The complication rate for methamphetamine-positive patients who undergo general anesthesia for urgent or emergent traumatic injuries has not been established. This study found the overall risk of cardiovascular complications to be low in this patient population. The overall perioperative complication rate was 3.2%. Despite the majority of the patients being subjected to general anesthesia, only 1 patient's complication (1.1%) was directly attributed to methamphetamine use. This complication could have been potentially catastrophic for this patient.

This study had several limitations. First, because this was a small, retrospective case series of only two trauma centers, the results may not be generalizable. This study was observational, with no dedicated control group. The retrospective design increased the risk for confounding factors and precluded the ability to reach definitive conclusions regarding the true impact of methamphetamine use on the cardiovascular system in the perioperative period. Additionally, methamphetamine use was inferred by positive results on urine screening, which has limits of detection. It is possible that some patients under the influence of methamphetamine were not included in this study because their screening had negative results. Additionally, illicit substance use tends to vary regionally, so the current sample may not be representative of the general population. The authors have found these data to be useful for providing evidence to support informed consent between patients, their families, and other physicians regarding the risks of undergoing general anesthesia for urgent or emergent orthopedic surgery in the setting of a positive result for methamphetamine. Given the results of this pilot study, a rigorous multicenter study would be useful to further elucidate the objective risk posed by methamphetamine use for perioperative outcomes in orthopedic trauma surgery.

Conclusion

In this retrospective series, the overall risk of cardiovascular complications was 2.1% among orthopedic trauma patients with positive results for methamphetamine. This study provides both a baseline understanding of the complication rate for methamphetamine-positive orthopedic trauma patients during general anesthesia and justification for larger multicenter studies to further investigate this topic.

References

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Patient Characteristics

CharacteristicValue
Sex
  Male75 (80%)
  Female19 (20%)
ASA classification
  I0 (0%)
  II41 (44%)
  III35 (37%)
  IV7 (7%)
  Not available11 (11%)
Injury
  Definitive treatment63 (67%)
  Polytrauma26 (28%)
  Infection18 (19%)
  Provisional debridementa13 (14%)
Time from positive screening to surgery, d
  088 (94%)
  16 (6%)
  21 (1%)
Type of anesthesia
  General77 (82%)
  Local/monitored16 (17%)
  Spinal1 (1%)

Patient Complications

ComplicationDescription
HypotensionChronic methamphetamine user with displaced forearm fracture who developed persistent hypotension intraoperatively refractory to intravenous fluid bolus and aggressive pharmacological vascular support
Hypovolemic shockPolytraumatized patient who died intraoperatively secondary to traumatic injuries
Aspiration pneumoniaPatient developed aspiration pneumonia postoperatively, was treated with intravenous antibiotics, and was discharged with an oral regimen
Authors

The authors are from the Department of Orthopaedic Surgery (TG, MRD, STC, EJW, LHG, PL, CP, JB, MJG), Stanford University Hospital, Redwood City, and the Department of Orthopaedic Surgery (JEK), Santa Clara Valley Medical Center, San Jose, California.

The authors have no relevant financial relationships to disclose.

The authors thank Arlene Garcia and Sam Jiang for help coordinating this study.

Correspondence should be addressed to: Thomas Githens, DO, Department of Orthopaedic Surgery, Stanford University Hospital, 450 Broadway St, Pavilion C, 4th Fl, Redwood City, CA 94063-6342 ( tgithens@stanford.edu).

Received: January 09, 2019
Accepted: April 16, 2019
Posted Online: May 28, 2019

10.3928/01477447-20190523-01

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