Low Serum Albumin Levels are Associated with Increased 30-Day Cardiopulmonary Complications, Reoperation, and Readmission Rates Following Total Shoulder Arthroplasty

Abstract

Background: Hypoalbuminemia has been associated with several medical complications following surgery in a variety of orthopedic procedures. Hypoalbuminemia has previously been shown to have an increased risk for transfusions, hospital stay longer than three days, and mortality following total shoulder arthroplasty (TSA). This study seeks to further assess the relationship between low serum albumin and morbidity to allow surgeons to both preoperatively optimize patients and assess the risk of surgery prior to TSA.

Methods: The American College of Surgeons National Surgical Quality Improvement Program® database was queried to identify 14,494 TSA patients, 6,129 (42.23%) who met inclusion criteria. Patients who had shoulder hemiarthroplasty, revision TSA, or incomplete serum albumin data were excluded. Demographic factors, preoperative comorbidities, and acute complication rates were assessed between hypoalbuminemic (n=485; 7.91%) and a propensity-matched control cohort (n=485), controlling for differences in patient demographics and comorbidities. Multivariate propensity-adjusted logistic regression analyses were used to assess hypoalbuminemia as an independent risk factor for specific postoperative complications.

Results: Hypoalbuminemic patients undergoing TSA demonstrated significantly higher rates of pulmonary complications (p=0.006), unplanned intubation (p=0.014), DVT/PE (p=0.014), cardiac complications (p=0.033), infectious complications (p=0.025), blood transfusions (p<0.001), reoperation (p=0.007), extended length of stay (> 4 days) (p=0.036), unplanned readmission (p=0.001), and mortality (p=0.025) in the 30-day postoperative period when compared to the propensity-matched control cohort. On multivariate regression analyses, hypoalbuminemia independently increased the risk for pulmonary complications (OR 9.678, p=0.031), blood transfusions (OR 2.539, p<0.001), reoperation (OR 5.461, p=0.032), and readmission (OR 2.607, p=0.007).

Conclusions: Hypoalbuminemic patients undergoing TSA had increased rates of overall cardiac and pulmonary complications, unplanned intubations, DVT/PE's, overall infectious complications, increased incidence of blood transfusions, reoperation, extended LOS (> 4 days), readmission, and death. Multivariate analyses demonstrated that low albumin was independently associated with increased risk for pulmonary complications, blood transfusions, reoperation, and readmission. Preoperative albumin levels in patients undergoing TSA may help with preoperative risk stratification and optimization.Level of evidence: III.

Keywords: albumin; blood transfusion; cardiac; complication; hypoalbuminemia; mortality; pulmonary; readmission; reoperation; total shoulder arthroplasty; unplanned intubation.