Abstract and Introduction
Abstract
Background: Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population.
Methods: We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006–2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value >0.1).
Results: Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60–73]/64 [57–71] among short/long-acting compared to 69 [61–76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83–345] vs 256 [IQR, 153–431] with short-acting, and 329 [IQR, 195–540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years.
Conclusions: Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management.
Introduction
Benzodiazepines have a long track record of utilization in the perioperative setting. However, little is known about actual perioperative prescribing patterns. Indications and desired perioperative effects include anxiolysis and stress relief, procedural sedation or hypnosis, awareness prevention, and occasionally postoperative sedation.[1] Moreover, in contrast to other anesthetic agents, benzodiazepines confer minimal impact on cardiovascular hemodynamics, which may be desired in frail patients with cardiovascular disease.[1] Despite these indications, there is growing concern for central nervous system side effects, such as prolonged postoperative sedation and cognitive deterioration, which may prevent rapid recovery.[2] An even greater concern is the associated risk of postoperative delirium, which can occur in any age group, but is most common in older patients.[3,4] Moreover, significant central nervous system deterioration can persist for months, and poor cognitive and functional outcomes can occur far beyond the immediate postoperative period.[3] Therefore, the benefits and risks of benzodiazepines in the perioperative period should be carefully weighed in each clinical context, especially when used in at-risk patients.
Considering the significance of benzodiazepines in perioperative anesthesia as well as associated risks, the current lack of data on perioperative utilization practice is remarkable. Our objective was therefore to investigate national utilization patterns of benzodiazepines among patients undergoing total hip and knee arthroplasty (THA and TKA) surgery, as these reflect high-volume interventions that are increasingly delivered to an older, comorbidity-ridden population. Of specific interest was the differentiation between long- and short-acting benzodiazepines and utilization by patient factors, health care factors, and analgesic regimens. We hypothesized that based on recent evidence in favor of restrictive perioperative benzodiazepine use, a significant decrease in use would be observed over the past decade.
Anesth Analg. 2022;134(3):486-495. © 2022 International Anesthesia Research Society
