Jianghua Shen, MPharm1, Suying Yan, BPharm, MBA1, Jagadish K. Chhetri, MD, PhD2, Yanqi Chu, MPharm1, Peng Wang, MD, PhD3, Shuai Feng, MD, PhD4, Tianlong Wang, MD, PhD4, Chaodong Wang, MD, PhD2, Guoguang Zhao, MD, PhD5
1Department of Pharmacy, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing
2National Clinical Research Center for Geriatric Diseases, Xuanwu Hospital Capital Medical University, Beijing
3Department of Orthopedic Surgery, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing
4Department of Anesthesiology, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing
5Department of Neurosurgery, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, ChinaDOI: https://doi.org/10.5770/cgj.27.748
ABSTRACT
Background
Older people are prone to multiple chronic diseases and, as a result, require multiple medications. At present, there is no study to verify whether the use of high-risk perioperative medications (HRPOMs) will adversely affect postoperative outcomes in the relatively old patient. In this study, we aimed to analyze the risks of HRPOMs for prolonged length of hospital stay (LOS) in advanced-aged (≥ 75 years) patients undergoing spinal surgery.
Methods
Medical records of advanced-aged patients who underwent spinal surgeries were retrospectively reviewed. Patients were divided into those who had prolonged LOS (≥ eight days) versus those who did not (< eight days). The demographics, medical comorbidities, and perioperative medications were analyzed. Univariate and multivariate regression were used to determine perioperative risk factors for prolonged LOS.
Results
A total of 268 patients were included with a median age of 79 years (interquartile range [IQR]=76, 82) and 127 (47.4%) patients had a prolonged LOS. In multivariate logistic analysis, higher body mass index (odds ratio [OR] = 1.116; 95% CI, 1.031–1.209), operation time (OR) = 1.009; 95% CI, 1.005–1.012), and number of postoperative HRPOMs (OR= 1.910; 95% CI, 1.464–2.492) were identified as independent predictors for prolonged LOS. The use of metformin was associated with lower likelihood of prolonged LOS in diabetic patients (OR = 0.365; 95% CI, 0.157–0.846).
Conclusion
Our results indicate that the higher number of postoperative HRPOMs, rather than a specific HRPOMs type, is a risk factor for prolonged LOS. The continued preoperative use of metformin in patients with diabetes has a positive impact on the postoperative outcomes.
Key words: older adults, length of hospital stay, spinal surgery, HRPOM, high-risk perioperative medication, polypharmacy
Low back pain is the most common musculoskeletal problem globally, with a lifetime prevalence as high as 84%.(1) Symptomatic low back pain can lead to loss of function or the inability to perform basic activities of daily living in older people. In situations where nonsurgical treatments fail, spinal surgery becomes a viable option. However, older patients are known to encounter high risk of perioperative complications, mortality, and prolonged length of hospital stay (LOS).(2–5) Previous studies have shown that age,(6) morbid obesity, metabolic syndrome,(7) and preoperative benzodiazepine use(8) were independent predictors of prolonged LOS after spinal surgery. Additionally, older people are susceptible to multiple comorbid conditions and have to take multiple medications (polypharmacy). Hospitals tend to discontinue certain medications that are considered inappropriate during the perioperative period. However, such withdrawal or withholding of chronic medications was found to be associated with an increased risk for drug-related problems (DRPs).(9,10) For these reasons, it is necessary to review the perioperative medications for older patients all along the care pathway, to identify drugs that potentially imperil the safety of the patients.
In 2019, experts in the China Gerontology Pharmaceutical Alliance have developed an explicit criterion as a tool for reviewing the high-risk perioperative medications (HRPOMs) for older patients(11) (Appendix A). It was the first recommendation to provide guidance on older patient-specific HRPOMs. The recommendation provided a list of HRPOMs that may affect the postoperative outcomes in older patients, and reached a consensus on potential strategies to avoid the associated risks. This recommendation largely fills the gap in geriatric surgery, particularly from the perioperative drug management perspective. It has a narrower list of HRPOMs than that of the American Geriatrics Society (AGS) Beers Criteria,(5) which is an explicit list of potentially inappropriate medications (PIMs) for older adults, and provides drug-specific recommendations.
The recommendation provided for HRPOMs has been endorsed in China. Previous studies have found that 76.3% of older patients undergoing surgery used the HRPOMs.(12,13) Studies suggested an increase in the HRPOMs use to be associated with a higher probability of drug risks.(14) However, the impact of recommended HRPOMs on advanced-aged patients is still lacking.
In this study, we aimed to investigate the association of the recommended HRPOMs with postoperative outcome in advanced-aged spinal surgery patients. Therefore, we designed a retrospective study to examine the association of perioperative medications (chronic disease medications, intraoperative medications, and postoperative medications) with the postoperative LOS in the older patients undergoing spinal surgery.
We conducted a retrospective cohort study of patients aged ≥ 75 years who underwent elective spinal surgery from January 2020 to December 2021 at the Xuanwu Hospital, Capital Medical University, China. The study was approved by the ethics committee of the Hospital. Spinal surgery was defined as undergoing fusion surgeries with instrumentation under general anesthesia. Older patients with conditions such as lumbar disc herniation, lumbar spinal stenosis, cervical spondylotic myelopathy, lumbar spondylolisthesis, or scoliosis underwent spinal surgery.
The primary outcome was the postoperative LOS. Postoperative LOS was defined as the number of days from the surgery till discharge. Postoperative LOS was dichotomized into two groups, Prolonged LOS and Not, using eight days as cut-off, which was the median value for the entire group.
The discharge criteria were as follows: evidence of the primary condition being improved upon surgery and no complaints of discomfort, such as fever; a visual analog scale (VAS) score of less than 3 points for pain assessment, without any form of discharge from the incision, and able to get off the bed and move.
A data collection sheet was used to collect the demographic characteristics (age, gender, body mass index [BMI]) and comorbidities of the relevant patients. The following clinical data was collected: 1) comorbidities: hypertension, hyperlipidemia, diabetes mellitus (DM), ischemic heart disease (IHD), cerebrovascular disease (CVD), solid malignancy, and peripheral vascular disease (PVD); 2) preoperative laboratory values: hemoglobin, serum albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and serum creatinine (SCr); 3) intraoperative values: operative time and blood loss; 4) the American Society of Anesthesiologists (ASA) score and the age-adjusted Charlson Comorbidity Index (aCCI) score; 5) postoperative LOS; 6) information on postoperative complications; 7) list of current medications for chronic diseases and those prescribed after the admission (intra- and postoperative medications). Screening for HRPOMs was performed with Microsoft Excel Visual Basic for Applications and was manually reviewed by two clinical pharmacists (Shen and Chu).
Continuous variables were expressed as mean ± standard deviation (SD) (non-normally distributed continuous variables were expressed as medians [interquartile range]) and categorical variables as the number and percentage of cases. Comparisons between patients with and without prolonged LOS were performed using the Student’s t-test or the Mann-Whitney U test for numerical data and χ2 test or Fisher’s exact test for categorical data. Independent predictors of prolonged LOS were evaluated with the logistic regression method. The risk factors for prolonged LOS were first evaluated with univariate analysis, and the statistically significant variables p< .05 were included in the multivariate analysis with forward conditional elimination method. Data were presented as odds ratios (OR) with 95% confidence intervals (CI).
The Hosmer–Lemeshow test was used to test the goodness of fit for logistic regression models. Discrimination of the model was further assessed by an analysis of the area under receiver operating curve (AUROC). Statistical Package for Social Sciences version 25.0 was used for statistical analyses. A two-tailed p value <.05 was considered significant.
A total of 268 patients aged ≥ 75 years out of 315 who underwent spinal surgery were included. Of these, 47 were excluded because of surgery under epidural anesthesia (Figure 1). The demographic and clinical characteristics were shown in Table 1. The median age of the patients was 79 years (interquartile range, IQR = 76, 82), 42.2% of whom were male and had a mean (± standard deviation) BMI of 24.9 (±3.6) kg/m2. The median postoperative LOS was 8 (IQR = 7, 13) days. There were 127 (47.4%) patients with prolonged postoperative LOS.
|
| ||
|
FIGURE 1 The flow chart of the patient selection | ||
TABLE 1 Factors associated with prolonged postoperative hospital stay for patients with spine surgery
The most common comorbidities were hypertension (63.1%), DM (36.6%), IHD (28.0%), CVD (22.4%), psychiatric conditions (17.2%), PVD (16.0%), and hyperlipidemia (14.2%) (Table 1). A total of 46 patients with 66 types of postoperative complications was reported. The most common complications were cardiac dysrhythmias (3.0%), surgical site infection (3.0%), pneumonia (2.6%), urinary tract infection (2.2%), and acute renal injury (1.9%) (Appendix B).
Preoperatively, 1,580 medications (105 classes) were taken for chronic conditions by the study cohort, of which 785 (29 classes) were identified as HRPOMs. The top five most frequently used drugs were for the treatment of CVDs. Most common HRPOMs were: calcium channel blockers (CCB) (49.6%), angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) (38.1%), antiplatelet agents (specifically aspirin) (29.5%), beta-blocking agents (25.4%), non-steroidal anti-inflammatory drugs (NSAID) (18.7%), thiazide diuretics (15.3%), and organic nitrates (14.2%) (Table 1).
Intraoperatively, 3,553 medications (48 classes) were used, of which 78 (5 classes) were identified as HRPOMs. They were glucocorticoids (79.5%), benzodiazepine derivatives (11.9%), NSAID (11.2%), short-acting insulin (5.2%), and opioid analgesics (0.8%, pethidine 1 and tramadol 1). HRPOMs were rarely used in surgery, so only the impact of the number of medications used in surgery on the postoperative hospital stay was analyzed (Appendix C).
Post-surgically, a total of 3,949 medications (64 classes) were prescribed, of which 624 (17 classes) were identified as HRPOMs. The most frequently used HRPOMs were NSAID (97.8%), glucocorticoids (85.4%), benzodiazepine derivatives (23.1%), and nephrotoxic antibiotic (10.1%) (Table 1).
Univariate and multivariate analysis were performed to test the association of individual demographic, comorbidity, preoperative laboratory variables, intraoperative variables, and perioperative medication variable with postoperative LOS. In the univariate analysis, higher BMI, surgical site, operation time, blood loss, number of postoperative HRPOMs, postoperative usage of NSAIDs, and glucocorticoids were significantly associated with the LOS and selected for the multivariate regression analysis. In the multivariate analysis, prolonged postoperative LOS was found to be significantly associated with higher BMI (OR = 1.116; 95% CI, 1.031–1.209; p =.007), operation time (OR = 1.009; 95% CI, 1.005–1.012; p < .001) and number of postoperative HRPOMs (OR= 1.910; 95% CI, 1.464–2.492; p < .001). Preoperative metformin use showed a lower likelihood of having prolonged LOS (OR=0.365; 95% CI, 0.157–0.846; p = .019). There were no significant differences between comorbidities, preoperative laboratory variables, and preoperative medications for chronic diseases, even preoperative HRPOMs (Table 2).
TABLE 2 Bivariate and multivariate analysis of risk for prolonged postoperative hospital stay
Hosmer–Lemeshow test for multivariate models showed a good fit (χ2 = 7.263, p = .509). As shown in Figure 2, the AUROC was 0.799.
|
| ||
|
FIGURE 2 Area under receiver operating characteristic curve for prolonged postoperative hospital stay (model included BMI, operative time, number of postoperative HRPOMs and preoperative use of Metformin for analysis) | ||
There is an increasing demand of spinal surgery procedures in older adults, particularly due to several disabling degenerative diseases of the spine. LOS is at the core of many quality improvement initiatives because it is directly related to health-care quality and costs.(15,16) Prolonged LOS is also associated with an increased incidence of perioperative complications in older patients.(16,17) Thus, it has become important to elucidate modifiable perioperative risk factors that predict the LOS, especially while considering older patients.
One of the potential strategies is to manage inappropriate medications (i.e., those having negative effects in older patients), as older adults are known to have a high burden of polypharmacy.(18,19) We investigated the perioperative medication risk in advanced-aged patients undergoing spinal surgery based on the new HRPOMs recommendation.(11) The goal of our study was to identify the modifiable factors (primarily medications) that were associated with prolonged LOS after spinal procedures in advanced-aged patients. Our results showed two major findings on medication use: 1) Prolonged LOS was not associated with the type and quantity of HRPOMs used to treat chronic diseases before operation, nor with a specific HRPOM after operation, but with the quantity of HRPOMs after operation; and 2) Preoperative use of metformin showed lower likelihood of prolonged postoperative LOS in patients with diabetes.
Previous studies have shown higher BMI to be associated with increase the LOS in patients undergoing spinal surgeries,(20–22) which was also consistent with our findings. In a previous meta-analysis, obese patients had significantly higher incidence of surgical site infections.(23) Larger incision and greater subcutaneous fat thickness in the surgical region have been suggested as issues that increase the risk of infection, due to its anti-inflammatory cytokines followed by insulin resistance.(24) Another study showed that patients with obesity had a significantly lower fusion rate than non-obese patients. (25) It seems that obesity, by putting a mechanical load on the spine and inflammatory factors, affects the musculoskeletal system and eventually delays the fusion rate in the spine.(26)
In this study, we examined the association of intraoperative factors including operation time, intraoperative blood loss, and the use of intraoperative medication with LOS. The average operation time of patients with prolonged LOS was more than 60 minutes longer than that of patients without prolonged LOS, and was an independent risk factor for prolonged hospital stay after operation. This was consistent with a previous study showing that operation time was an independent predictor for prolonged LOS after anterior lumbar interbody fusion.(27) In general, the longer the operation time or the greater amount of blood loss, the larger the operation scale and the more complicated the operation procedure. The patients may need longer recovery time due to the wider scope of surgery, resulting in prolonged LOS.
The primary aim of this study was to analyze whether the use of newly recommended HRPOMs was associated with prolonged postoperative LOS in advanced-aged spinal surgery patients. While considering chronic disease medication, we found that only NSAID had a marginal statistical significance. This may be the result of the small sample size of this study; further verification using a larger sample size is needed. Previous studies have shown that Metformin can reduce all-cause mortality in patients with type-2 diabetes.(28,29) However, less is known about its potential perioperative implications. Metformin in the perioperative phase was associated with the risk of lactic acidosis(30) and is listed as an HRPOM. However, the benefit of proper perioperative glycemic control might outweigh this theoretical risk.(31) Previous studies revealed an association between Metformin prescriptions provided to individuals with type 2 diabetes before a surgical procedure and improved postoperative outcomes,(32–34) which is consistent with our findings, even in advanced-aged surgical patients. Metformin has well-established anti-inflammatory and anti-oxidative properties. (35,36) The pleiotropic advantages of Metformin may positively modulate the inflammatory response to surgical procedures to improve outcomes.(32) However, this needs to be confirmed in well-controlled prospective studies.
We also found that increased numbers of postoperative medications and HRPOMs were independent risk factors for prolonged LOS. It was easy to understand that longer hospital stay is associated with increased postoperative complications, and therefore more medications were needed. The top four postoperative HRPOMs were NSAID, glucocorticoids, benzodiazepines, and vancomycin. Surgeons often used NSAID which could relieve postoperative pain, and glucocorticoids which could reduce tissue edema. Insomnia in elderly patients may worsen after surgery, and the usual treatment is to continue taking benzodiazepines. Interestingly, in this study, 25 patients who used vancomycin after surgery were all in the prolonged postoperative LOS group. After analyzing the postoperative complications of these patients: seven patients had confirmed or suspected surgical incision infection; eight had confirmed or suspected pulmonary infection; and vancomycin was used to prevent wound infection in four patients following postoperation evalution, because of the high risk of infection. No specific reasons for using vancomycin were reported in the other six patients (Appendix D). In multivariate analysis, no independent risk of these four types of medications was observed for prolonged LOS. However, the number of postoperative HRPOM was an independent risk factor for prolonged LOS. These findings are in line with previous studies suggesting the risk of PIMs on various conditions in older adults.(37,38) Hence, managing polypharmacy, including postoperative medications, could shorten the LOS, irrespective of HRPOMs classes.
The strength of this study was the inclusion of a single type of surgery, thus avoiding the influence of surgical diversity on the outcome. Most importantly, this is the first study to investigate the relationship between HRPOMs (in accordance with a recent guideline) and clinical outcome (which was prolonged LOS) in advanced-aged patients.
This study had the limitation of a retrospective design with limited data availability, such as information on involved levels of spinal surgery, and detailed evaluation of postoperative complications. This study was single-centered, with limited sample size, and lacked a detailed analysis of additional laboratory test results. Large scale prospective studies may be implemented in the future to confirm our findings and take into account additional diseases or conditions that are associated with high use of HRPOMs.
Our study showed that the number of postoperative HRPOMs was associated with prolonged LOS after spinal surgery in relatively older patients. Reducing polypharmacy by targeting HRPOMs may be helpful in reducing the postoperative LOS. Metformin may have a positive effect on reducing the postoperative LOS in older diabetic patients. Our results add to the notion of the great importance of a multidisciplinary approach, such as involvement of pharmacists in improving geriatric care, even in surgical settings.
We thank all the staff who participated in this study.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare there are none.
This research was supported by the Beijing Municipal Medical Science Institute-Public Welfare Development Reform Pilot Project (Capital Medical Research No. 2019-2) to Dr. Guoguang Zhao.
1. Allen RT, Rihn JA, Glassman SD, Currier B, Albert TJ, Phillips FM. An evidence-based approach to spine surgery. Am J Med Qual. 2009 Nov 1;24(6 Suppl):15S–24S.
Crossref PubMed
2. Best NM, Sasso RC. Outpatient lumbar spine decompression in 233 patients 65 years of age or older. Spine. 2007 May 1; 32(10):1135–39; discussion 1140.
Crossref PubMed
3. Benz RJ, Ibrahim ZG, Afshar P, Garfin SR. Predicting complications in elderly patients undergoing lumbar decompression. Clin Orthop Relat Res. 2001 Mar 1;384:116–21.
Crossref
4. Carreon LY, Puno RM, Dimar JR, Glassman SD, Johnson JR. Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am. 2003 Nov 1 ;85(11):2089–92.
Crossref PubMed
5. Fick DM, Semla TP, Steinman M, Beizer J, Brandt N, Dombrowski R, et al. American Geriatrics Society 2019 Updated AGS Beers Criteria(R) for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674–94.
Crossref
6. Nie H, Hao J, Peng C, Ou Y, Quan Z, An H. Clinical outcomes of discectomy in octogenarian patients with lumbar disc herniation. Clin Spine Surg. 2013 Apr;26(2):74–78.
7. Memtsoudis SG, Kirksey M, Ma Y, Chiu YL, Mazumdar M, Pumberger M, et al. Metabolic syndrome and lumbar spine fusion surgery: epidemiology and perioperative outcomes. Spine. 2012 May 15;37(11):989–95.
Crossref PMC
8. Walid MS, Zaytseva NV. Prevalence of mood-altering and opioid medication use among spine surgery candidates and relationship with hospital cost. J Clin Neurosci. 2010 May 1;17(5):597–600.
Crossref PubMed
9. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016 Jan 1;124(1):25–34.
Crossref
10. Shen J, Yu Y, Wang C, Chu Y, Yan S. Association of preoperative medication with postoperative length of stay in elderly patients undergoing hip fracture surgery. Aging Clin Exp Res. 2021 Mar;33(3):641–49.
Crossref
11. Wang K, Shen J, Jiang D, Xing X, Zhan S, Yan S. Development of a list of high-risk perioperative medications for the elderly: a Delphi method. Expert Opin Drug Saf. 2019 Sep 2;18(9):853–59.
Crossref PubMed
12. Dong N, He D, Wu XY, Zhang HX. High-risk medications in elderly patients in our hospital based on list of high-risk perioperative medications. Chin J Pharmacovigil. 2020 Oct 15;17(10):692–96.
13. Shen JH, Jiang RQ, Wang ZM, Liu JM, Chu YQ, Yan SY. Long-term medication evaluation of elderly orthopedics patients based on the list of high-risk perioperative medications for elders in China. Chin J Pharmacoepidemiol. 2021;30(10):683–686.
14. Dong N, Wang Y, Wu XY, Zhang HX. Evaluation of safety and risk factors analysis of elderly surgical patients in a hospital. Chin J Pharmacoepidemiol. 2021;30(9):590–95.
15. Jain N, Virk SS, Phillips FM, Yu E, Khan SN. A 90-day bundled payment for primary single-level lumbar discectomy/decompression: what does “big data” say? Clin Spine Surg. 2018 Apr 1; 31(3):120–26.
Crossref
16. Ansari SF, Yan H, Zou J, Worth RM, Barbaro NM. Hospital length of stay and readmission rate for neurosurgical patients. Neurosurgery. 2018 Feb 1;82(2):173–81.
Crossref
17. Klineberg EO, Passias PG, Jalai CM, Worley N, Sciubba DM, Burton DC, et al. Predicting extended length of hospital stay in an adult spinal deformity surgical population. Spine. 2016 Jul 1;41(13):E798–E805.
Crossref
18. Abe N, Kakamu T, Kumagai T, Hidaka T, Masuishi Y, Endo S, et al. Polypharmacy at admission prolongs length of hospitalization in gastrointestinal surgery patients. Geriatr Gerontol Int. 2020 Nov;20(11):1085–90.
Crossref PubMed PMC
19. Hoel RW, Connolly RM, Takahashi PY. Polypharmacy management in older patients. Mayo Clin Proc. 2021 Jan 1;96(1):242–56.
Crossref PubMed
20. Tabatabai S, Do Q, Min J, Tang CJ, Pleasants D, Sands LP, et al. Obesity and perioperative outcomes in older surgical patients undergoing elective spine and major arthroplasty surgery. J Clin Anesth. 2021 Dec 1;75:110475.
Crossref PubMed PMC
21. Puvanesarajah V, Werner BC, Cancienne JM, Jain A, Pehlivan H, Shimer AL, et al. Morbid obesity and lumbar fusion in patients older than 65 years: complications, readmissions, costs, and length of stay. Spine. 2017 Jan 15;42(2):122–27.
Crossref
22. Villavicencio A, Lee Nelson E, Rajpal S, Vivek N, Burneikiene S. The impact of BMI on operating room time, blood loss, and hospital stay in patients undergoing spinal fusion. Clin Neurol Neurosurg. 2019 Apr 1;179:19–22.
Crossref PubMed
23. Goyal A, Elminawy M, Kerezoudis P, Lu VM, Yolcu Y, Alvi MA, et al. Impact of obesity on outcomes following lumbar spine surgery: a systematic review and meta-analysis. Clin Neurol Neurosurg. 2019 Feb 1;177:27–36.
Crossref
24. Wisse BE. The inflammatory syndrome: the role of adipose tissue cytokines in metabolic disorders linked to obesity. J Am Soc Nephrol. 2004 Nov 1;15(11):2792–800.
Crossref PubMed
25. Khalooeifard R, Oraee-Yazdani S, Vahdat Shariatpanahi Z. Obesity and posterior spine fusion surgery: a prospective observational study. Int J Orthop Trauma Nurs. 2022 May 1;45: 100920.
Crossref PubMed
26. Anandacoomarasamy A, Caterson I, Sambrook P, Fransen M, March L. The impact of obesity on the musculoskeletal system. Int J Obes. 2008 Feb;32(2):211–22.
Crossref
27. Kuo CC, Hess RM, Khan A, Pollina J, Mullin JP. Factors affecting postoperative length of stay in patients undergoing anterior lumbar interbody fusion. World Neurosurg. 2021 Nov 1; 155:e538–e547.
Crossref PubMed
28. Charytan DM, Solomon SD, Ivanovich P, Remuzzi G, Cooper ME, McGill JB, et al. Metformin use and cardiovascular events in patients with type 2 diabetes and chronic kidney disease. Diabetes Obes Metab. 2019 May;21(5):1199–208.
Crossref PubMed
29. Jong CB, Chen KY, Hsieh MY, Su FY, Wu CC, Voon WC, et al. Metformin was associated with lower all-cause mortality in type 2 diabetes with acute coronary syndrome: A Nationwide registry with propensity score-matched analysis. Int J Cardiol. 2019 Sep 15;291:152–57.
Crossref PubMed
30. Cheisson G, Jacqueminet S, Cosson E, Ichai C, Leguerrier AM, Nicolescu-Catargi B, et al. Perioperative management of adult diabetic patients. Preoperative period. Anaesth Crit Care Pain Med. 2018 Jun 1;37:S9–S19.
Crossref PubMed
31. Flory J, Lipska K. Metformin in 2019. JAMA. 2019 May 21;321(19):1926–927.
Crossref PubMed PMC
32. Reitz KM, Marroquin OC, Zenati MS, Kennedy J, Korytkowski M, Tzeng E, et al. Association between preoperative metformin exposure and postoperative outcomes in adults with type 2 diabetes. JAMA Surg. 2020 Jan 1;155(6):e200416.
Crossref PubMed PMC
33. Wilson JM, Farley KX, Broida SE, Bradbury TL, Guild GN. Metformin use is associated with fewer complications in patients with type-2 diabetes undergoing total knee arthroplasty: a propensity score-matched analysis. J Bone Joint Surg. 2021;103(7):601–08.
Crossref PubMed
34. Chakraborty A, Chowdhury S, Bhattacharyya M. Effect of metformin on oxidative stress, nitrosative stress and inflammatory biomarkers in type 2 diabetes patients. Diabetes Res Clin Pract. 2011 Jul 1;93(1):56–62.
Crossref
35. Markowicz-Piasecka M, Huttunen KM, Mateusiak L, Mikiciuk-Olasik E, Sikora J. Is metformin a perfect drug? Updates in pharmacokinetics and pharmacodynamics. Curr Pharm Design. 2017 May 1;23(17):2532–50.
Crossref
36. Shi L, Tan GS, Zhang K. Relationship of the serum CRP level with the efficacy of metformin in the treatment of type 2 diabetes mellitus: a meta-analysis. J Clin Lab Anal. 2016 Jan;30(1):13–22.
Crossref
37. Wang S, Ren W, Tan X, Lv X, Liu Y, Gong Y. High-risk perioperative medications in the Chinese elderly population. Clin Interv Aging. 2021 Jun 24;16:1201–13.
Crossref PubMed PMC
38. Nagai T, Nagaoka M, Tanimoto K, Tomizuka Y, Uei H, Nakanishi K. Relationship between potentially inappropriate medications and functional prognosis in elderly patients with distal radius fracture: a retrospective cohort study. J Orthopaed Surg Res. 2020 Dec;15:321.
Crossref
APPENDIX A The list of high-risk perioperative medications for older patients in China
|
| ||
|
APPENDIX B Postoperative complications | ||
|
| ||
|
APPENDIX C Intraoperative medication (*indicates HRPOMs) | ||
APPENDIX D Postoperative complications in patients receiving vancomycin
Correspondence to: Chaodong Wang, md, phd, National Clinical Research Center for Geriatric Diseases, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China, E-mail: cdongwang01@126.com
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 27, No. 4, DECEMBER 2024