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Impact of COVID-19 on Orthopaedic and Trauma Service: An Epidemiological Study.

新型冠状病毒肺炎对骨科和创伤服务的影响: 流行病学研究。

  • 影响因子:3.57
  • DOI:10.2106/JBJS.20.00775
  • 作者列表:"Wong JSH","Cheung KMC
  • 发表时间:2020-07-15
Abstract

BACKGROUND:Coronavirus disease 2019 (COVID-19) has caused substantial disruptions to orthopaedic and trauma services. The purpose of the present study was to quantify its impact on surgical volume, hospitalizations, clinic appointments, and accident and emergency attendances to guide staffing and resource deployment for the sustenance of emergency services. METHODS:Data were retrieved from all 43 Hong Kong public hospitals and 122 outpatient clinics from a population of 7.5 million residents. The "COVID-19 cohort" of patients who received treatment from January 25 to March 27, 2020, was compared with the "control cohort" of patients who received treatment during the same time of year over the past 4 years. Primary outcomes consisted of changes in patient diagnoses, number of operations performed, and hospitalizations during the COVID-19 pandemic. Secondary outcomes included differences in patient age and comorbidity, the nature of operations performed, types of anesthesia for orthopaedic procedures, difference in anesthetic times, wait times, and personal protective equipment (PPE) reserves. RESULTS:A total of 928,278 patient-episodes (32,613 operations, 97,648 hospital admissions, 302,717 accident and emergency attendances, and 495,300 outpatient clinic attendances) were analyzed. Orthopaedic operations were reduced by 44.2%, from a mean (and standard deviation) of 795 ± 115.1 to 443.6 ± 25.8 per week (p < 0.001), with the ratio of emergency to elective operations increasing from 1.27:1 to 3.78:1. Operations for the treatment of upper and lower-limb fractures decreased by 23% (from 98.5 ± 14 to 75.9 ± 15.2 per week; p < 0.001) and 20% (from 210.6 ± 29.5 to 168.4 ± 16.9 per week; p < 0.001), respectively, whereas elective joint replacement and ligamentous reconstruction procedures decreased by 74% to 84% (p < 0.001). Operations for orthopaedic infections such as necrotizing fasciitis and septic arthritis remained similar (p > 0.05). The number of hospitalizations decreased by 41.2% (from 2,365 ± 243 to 1,391 ± 53 per week; p < 0.001), whereas clinical outpatient visits decreased by 29.4% (from 11,693 ± 2,240 to 8,261 ± 1,104 per week; p < 0.001). Patients did not endure longer wait times for emergency operations and accident and emergency consultations (p > 0.05). PPE consumption did not exceed procurement, with net increases in PPE reserves. CONCLUSIONS:Demand for orthopaedic care remains, despite weekly reductions of 351 orthopaedic operations, 974 hospital admissions, and 3,432 clinic attendances. Orthopaedic surgeons and health-care professionals should factor this into consideration during staffing and resource deployment. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

摘要

背景: 冠状病毒疾病2019 (新型冠状病毒肺炎) 对骨科和创伤服务造成了严重的干扰。本研究的目的是量化其对手术量、住院、门诊预约以及事故和急诊的影响,以指导维持急诊服务的人员配备和资源调配。 方法: 从所有43家香港公立医院和122个门诊诊所的750万名居民中检索数据。将2020年1月25日至3月27日接受治疗的患者 “新型冠状病毒肺炎队列” 与过去4年中同一时间接受治疗的患者 “对照队列” 进行比较。主要结局包括新型冠状病毒肺炎大流行期间患者诊断、手术次数和住院次数的变化。次要结局包括患者年龄和合并症、手术性质、骨科手术麻醉类型、麻醉时间、等待时间和个人防护装备 (PPE) 储备的差异. 结果: 共分析了928,278例患者 (32,613例手术,97,648例住院,302,717例事故和急诊,495,300例门诊)。骨科手术减少了44.2%,平均 (和标准偏差) 从每周795 ± 115.1减少到443.6 ± 25.8 (p <0.001),急诊手术与择期手术的比例从1.27:1增加到3.78:1。上下肢骨折的手术治疗分别下降了23% (从每周98.5 ± 14下降到75.9 ± 15.2; p < 0.001) 和20% (从每周210.6 ± 29.5下降到168.4 ± 16.9; p <0.001),而选择性关节置换和韧带重建手术减少了74% 至84% (p <0.001)。坏死性筋膜炎和化脓性关节炎等骨科感染的手术仍然相似 (p> 0.05)。住院次数减少了41.2% (从每周2,365 ± 243到1,391 ± 53; p <0.001),而临床门诊次数减少了29.4% (从每周11,693 ± 2,240到8,261 ± 1,104; p <0.001)。患者不能忍受较长时间的急诊手术和急症会诊等待时间 (p> 0.05)。个人防护装备的消耗没有超过采购,个人防护装备储备净增加。 结论: 尽管每周减少351例骨科手术、974例住院和3,432例门诊就诊,但对骨科护理的需求仍然存在。整形外科医生和保健专业人员应在人员配置和资源部署中考虑到这一点。 证据级别: 预后级别III。有关证据级别的完整描述,请参见作者说明。

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发表时间:2020-01-01
DOI:10.1213/ANE.0000000000003975
作者列表:["Uppal V","Retter S","Casey M","Sancheti S","Matheson K","McKeen DM"]

METHODS:BACKGROUND:Fentanyl and morphine are the 2 most commonly added opioids to bupivacaine for spinal anesthesia during cesarean delivery. Numerous clinical trials have assessed efficacy and safety of different doses of fentanyl added to intrathecal bupivacaine for spinal anesthesia, yet its benefit, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS:Key electronic databases (PubMed, Embase, and Cochrane Library) were searched for randomized controlled trials in the cesarean delivery population. The primary outcome was the failure rate of spinal anesthesia, as assessed by the need for either conversion to general anesthesia or intraoperative analgesic supplementation. Two reviewers independently extracted the data using a standardized electronic form. Results are expressed as relative risks or mean differences with 95% CIs. RESULTS:Seventeen randomized controlled clinical trials (most judged as low or unclear risk of bias) with 1064 participants provided data for the meta-analysis. Fentanyl added to intrathecal bupivacaine alone reduced the need for intraoperative supplemental analgesia (relative risk, 0.18; 95% CI, 0.11-0.27; number needed to treat, 4) and the incidence of nausea/vomiting (relative risk, 0.41; 95% CI, 0.24-0.70; number needed to treat, 6.5), with longer time to first postoperative analgesia request (mean difference, 91 minutes; 95% CI, 69-113). No difference was observed regarding the need for conversion to general anesthesia (relative risk, 0.67; 95% CI, 0.12-3.57), the incidence of hypotension, the onset of sensory block, or the duration of motor block. However, the addition of intrathecal fentanyl was associated with higher incidence of intraoperative pruritus (relative risk, 5.89; 95% CI, 2.07-16.79; number needed to harm, 13.5). The inclusion of fentanyl to intrathecal bupivacaine-morphine compared to intrathecal bupivacaine-morphine alone conferred a similar benefit, with a significantly reduced need for intraoperative supplemental analgesia (relative risk, 0.16; 95% CI, 0.03-0.95; number needed to treat, 9). Analysis using a funnel plot indicated a possibility of publication bias in included studies. CONCLUSIONS:Current evidence suggests a benefit of using fentanyl as both an additive to intrathecal bupivacaine alone and to intrathecal bupivacaine combined with morphine for cesarean delivery under spinal anesthesia. The possibility of publication bias, small sample size, and high risk of bias in some of the included studies warrant treating the results with caution.

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DOI:10.1213/ANE.0000000000004012
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