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Pozzi M, Mariani S, Scanziani M, Passolunghi D, Bruni A, Finazzi A, Lettino M, Foti G, Bellelli G, Marchetto G. The frail patient undergoing cardiac surgery: lessons learned and future perspectives. Front Cardiovasc Med 2023; 10:1295108. [PMID: 38124896 PMCID: PMC10731467 DOI: 10.3389/fcvm.2023.1295108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.
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Affiliation(s)
- Matteo Pozzi
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Silvia Mariani
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
- Division of Cardiac Surgery, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Margherita Scanziani
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Davide Passolunghi
- Division of Cardiac Surgery, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Adriana Bruni
- Acute Geriatrics Unit, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Alberto Finazzi
- Acute Geriatrics Unit, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
- School of Medicine, University of Milan Bicocca, Monza, Italy
| | - Maddalena Lettino
- Department of Cardiovascular Medicine, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
- School of Medicine, University of Milan Bicocca, Monza, Italy
| | - Giuseppe Bellelli
- Acute Geriatrics Unit, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
- School of Medicine, University of Milan Bicocca, Monza, Italy
| | - Giovanni Marchetto
- Division of Cardiac Surgery, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
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Igwe EO, Nealon J, O'Shaughnessy P, Bowden A, Chang HCR, Ho MH, Montayre J, Montgomery A, Rolls K, Chou KR, Chen KH, Traynor V, Smerdely P. Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis. Worldviews Evid Based Nurs 2023. [PMID: 37128953 DOI: 10.1111/wvn.12649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over. METHODS Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed. RESULTS A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted. LINKING EVIDENCE TO ACTION This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.
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Affiliation(s)
- Ezinne Oyidia Igwe
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Jessica Nealon
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Pauline O'Shaughnessy
- School of Mathematics and Applied Statistics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Alera Bowden
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Hui-Chen Rita Chang
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Mu-Hsing Ho
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Jed Montayre
- School of Nursing, Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Kaye Rolls
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Evidence-based Knowledge Translation Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Victoria Traynor
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Peter Smerdely
- School of Population Health, UNSW Medicine, Sydney, New South Wales, Australia
- St George Hospital, Kogarah, New South Wales, Australia
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Honda Y, Takahashi K, Sasanuma N, Itani Y, Nagase M, Uchiyama Y, Tamaki A, Sakaguchi T, Domen K. Predictors of Functional Decline in Activities of Daily Living at Discharge in Patients After Cardiovascular Surgery. Circ J 2021; 85:1020-1026. [PMID: 33642424 DOI: 10.1253/circj.cj-20-0909] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study aimed to investigate the trajectory of functional recovery of activities of daily living (ADL) from the time of admission up to hospital discharge, and explored which preoperative and postoperative variables were independently associated with functional decline in ADL at discharge of patients after cardiovascular surgery.Methods and Results:In this observational study, we evaluated ADL preoperatively and at discharge using the Functional Independence Measure (FIM) in patients after cardiovascular surgery. Functional decline in ADL was defined as scoring 1-5 on any one of the FIM items at discharge. Multiple logistic regression was performed to predict the functional decline in ADL at discharge. We found that 18.8% of elective cardiovascular surgery patients suffered from decreased ADL at discharge. The Mini-Mental State Examination (odds ratio (OR): 0.573, 95% confidence interval (CI): 0.420-0.783), gait speed (OR: 0.032, 95% CI: 0.003-0.304) and initiation of walking around the bed (OR: 1.277, 95% CI: 1.103-1.480) were independently associated with decreased ADL at discharge. CONCLUSIONS A functional decline in ADL at discharge can be predicted using preoperative measures of cognitive function, preoperative gait speed and postoperative day of initiation of walking. These results show that preoperative cognitive screening and gait speed assessments can be used to identify patients who might require careful postoperative planning, and for whom early postoperative rehabilitation is needed to prevent serious functional ADL deficits.
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Affiliation(s)
- Yosuke Honda
- Department of Rehabilitation, Hyogo College of Medicine College Hospital
| | - Keiko Takahashi
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Naoki Sasanuma
- Department of Rehabilitation, Hyogo College of Medicine College Hospital
| | - Yusuke Itani
- Department of Rehabilitation, Hyogo College of Medicine College Hospital
| | - Masahiro Nagase
- Department of Rehabilitation, Hyogo College of Medicine College Hospital
| | - Yuki Uchiyama
- Department of Rehabilitation Medicine, Hyogo College of Medicine
| | - Akira Tamaki
- Department of Physical Therapy, School of Rehabilitation, Hyogo University of Health Sciences
| | | | - Kazuhisa Domen
- Department of Rehabilitation Medicine, Hyogo College of Medicine
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Feedback Training Improves Compliance with Sternal Precaution Guidelines during Functional Mobility: Implications for Optimizing Recovery in Older Patients after Median Sternotomy. Appl Bionics Biomech 2021; 2021:8889502. [PMID: 33574890 PMCID: PMC7857876 DOI: 10.1155/2021/8889502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/30/2020] [Accepted: 01/08/2021] [Indexed: 11/18/2022] Open
Abstract
Patients often need to use their arms to assist with functional activities, but after open heart surgery, pushing with the arms is limited to <10 lb (4.5 kg) to help minimize force across the healing sternum. The main purposes of this study were to determine if older patients (>60 years old) (1) accurately estimated upper extremity (UE) weight bearing force of 10 lb or less and (2) if feedback training improved their ability to limit UE force and pectoralis major muscle contraction during functional activities. An instrumented walker was used to measure UE weight bearing force, and electromyography was used to measure pectoralis major muscle activity simultaneously during 4 functional mobility tasks. After baseline testing, healthy older subjects (n = 30) completed a brief session of visual and auditory concurrent feedback training. Results showed that the self-selected UE force was >10 lb for all tasks (20.0-39.7 lb [9.1-18.0 kg]), but after feedback training, it was significantly reduced (10.6-21.3 lb [4.8-9.7 kg]). During most trials (92%), study participants used >12 lb (5.5 kg) of arm weight bearing force. Pectoralis major muscle peak electromyography activity was <23% of maximal voluntary isometric contraction and was reduced (9.8-14.9%) after feedback training. Older patients may not be able to accurately estimate UE arm force used during weight bearing activities, and visual and auditory feedback improves accuracy and also modulation of pectoralis major muscle activation. Results suggest that an instrumented walker and feedback training could be clinically useful for older patients recovering from open heart surgery.
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Hill A, Heyland DK, Rossaint R, Arora RC, Engelman DT, Day AG, Stoppe C. Longitudinal Outcomes in Octogenarian Critically Ill Patients with a Focus on Frailty and Cardiac Surgery. J Clin Med 2020; 10:jcm10010012. [PMID: 33374545 PMCID: PMC7793078 DOI: 10.3390/jcm10010012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/13/2020] [Accepted: 12/21/2020] [Indexed: 02/07/2023] Open
Abstract
Cardiac surgery (CSX) can be lifesaving in elderly patients (age ≥ 80 years) but may still be associated with complications and functional decline. Frailty represents a determinant to outcomes in critically ill patients, but little is known about its influence on elderly CSX-patients. This is a secondary exploratory analysis of a multi-center, prospective observational cohort study of 610 elderly patients admitted to the ICU and followed for one year to document long-term outcomes. CSX-ICU-patients (n = 49) were compared to surgical ICU patients (n = 184) with regard to demographics, frailty, and outcomes. Of all surgical patients, 102 (43%) were considered vulnerable or frail. The subdistribution hazard ratio (SHR) of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.54 (95% confidence interval (CI), 0.34, 0.86, p = 0.007). The p-value for effect modification between surgery group (CSX vs. surgical ICU patients) and Clinical Frailty Scale (CFS) group was not significant (p = 0.37) suggesting that the observed difference in the CFS effect between the CSX and surgical ICU patients is consistent with random error. A further subgroup analysis shows that among surgical ICU patients, the SHR of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.49 (95% CI, 0.29, 0.83) while the corresponding SHR for CSX patients was 0.77 (0.32–1.88). In conclusion, preoperative frailty reduced the rate of discharge to home in both surgical and CSX patients, but a larger sample of CSX patients is needed to adequately address this question in this patient group.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care Medicine, University Hospital RWTH, D-52074 Aachen, Germany
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany
- Correspondence: (A.H.); (C.S.)
| | - Daren K. Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen’s University, Kingston General Hospital, Kingston, ON K7L 2V7, Canada;
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH, D-52074 Aachen, Germany;
| | - Rakesh C. Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, Winnipeg, MB R2H 2A6, Canada;
| | - Daniel T. Engelman
- Heart and Vascular Program, Baystate Health, Medical School-Baystate, University of Massachusetts, Springfield, MA 01199, USA;
| | - Andrew G. Day
- KGH Research Institute, Kingston Health Sciences Centre, Kingston, ON K7L 2V7, Canada;
| | - Christian Stoppe
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Würzburg, 97080 Würzburg, Germany
- Correspondence: (A.H.); (C.S.)
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Guenther U, Hoffmann F, Dewald O, Malek R, Brimmers K, Theuerkauf N, Putensen C, Popp J. Preoperative Cognitive Impairment and Postoperative Delirium Predict Decline in Activities of Daily Living after Cardiac Surgery-A Prospective, Observational Cohort Study. Geriatrics (Basel) 2020; 5:geriatrics5040069. [PMID: 33022910 PMCID: PMC7709655 DOI: 10.3390/geriatrics5040069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiac surgery and subsequent treatment in the intensive care unit (ICU) has been shown to be associated with functional decline, especially in elderly patients. Due to the different assessment tools and assessment periods, it remains yet unclear what parameters determine unfavorable outcomes. This study sought to identify risk factors during the entire perioperative period and focused on the decline in activity of daily living (ADL) half a year after cardiac surgery. Follow-ups of 125 patients were available. It was found that in the majority of patients (60%), the mean ADL declined by 4.9 points (95% CI, −6.4 to −3.5; p < 0.000). In the “No decline” -group, the ADL rose by 3.3 points (2.0 to 4.6; p < 0.001). A multiple regression analysis revealed that preoperative cognitive impairment (MMSE ≤ 26; Exp(B) 2.862 (95%CI, 1.192–6.872); p = 0.019) and duration of postoperative delirium ≥ 2 days (Exp(B) 3.534 (1.094–11.411); p = 0.035) was independently associated with ADL decline half a year after the operation and ICU. Of note, preoperative ADL per se was neither associated with baseline cognitive function nor a risk factor for functional decline. We conclude that the preoperative assessment of cognitive function, rather than functional assessments, should be part of risk stratification when planning complex cardiosurgical procedures.
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Affiliation(s)
- Ulf Guenther
- University Clinic of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Klinikum Oldenburg, University Medicine Oldenburg, 26133 Oldenburg, Germany
- Oldenburg Research Network Emergency- and Intensive Care Medicine (OFNI), Faculty VI—Medicine and Health Sciences, Carl von Ossietzky University, 26111 Oldenburg, Germany;
- Correspondence: ; Tel.: +49-441-403-70773
| | - Falk Hoffmann
- Department of Health Services Research, Division of Outpatient Care and Pharmacoepidemiology, Carl von Ossietzky University of Oldenburg, 26111 Oldenburg, Germany;
| | - Oliver Dewald
- Oldenburg Research Network Emergency- and Intensive Care Medicine (OFNI), Faculty VI—Medicine and Health Sciences, Carl von Ossietzky University, 26111 Oldenburg, Germany;
- University Clinic of Cardiac Surgery, Klinikum Oldenburg, University Medicine Oldenburg, 26133 Oldenburg, Germany
| | - Ramy Malek
- Department of Cardiology, Maria Hilf Hospital, 53474 Bad Neuenahr-Ahrweiler, Germany;
| | - Kathrin Brimmers
- Clinic of Psychiatry, Psychotherapy and Psychosomatic Medicine, LVR Klinik Düren, 52353 Düren, Germany;
| | - Nils Theuerkauf
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, 26105 Bonn, Germany; (N.T.); (C.P.)
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, 26105 Bonn, Germany; (N.T.); (C.P.)
| | - Julius Popp
- Old Age Psychiatry, Department of Psychiatry, Lausanne University Hospital, 1008 Prilly, Switzerland;
- Centre for Gerontopsychiatric Medicine, Department of Geriatric Psychiatry, Hospital of Psychiatry Zürich, 8032 Zürich, Switzerland
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Adib-Hajbaghery M, Miranzadeh S, Tahmouresi M, Azizi-Fini I. Body image before and after coronary artery bypass graft surgery: comparison and its contributing factors. BMC Psychol 2020; 8:78. [PMID: 32746920 PMCID: PMC7398352 DOI: 10.1186/s40359-020-00451-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/27/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cardiovascular diseases are the leading cause of death in the world. Coronary artery bypass graft (CABG) surgery is among the treatment options for coronary artery disease. However, it is associated with significant physical and psychological problems. This study sought to compare body image before and after the surgery and to determine its contributing factors. METHODS This comparative study was conducted in 2017 on a sample of 140 patients consecutively recruited from Shahid Beheshti hospital, Kashan, Iran. Body image was assessed before and 4 weeks after the surgery (T1 and T2) using Multidimensional Body-Self Relations Questionnaire. The independent-sample and paired t tests, one-way analysis of variance, Pearson correlation test, and multiple regression were conducted for data analysis. RESULTS Participants' mean score of body image was 139.60 ± 13.21 at T1 and 160.25 ± 7.75 at T2 and the variation was statistically significant (p = < 0.001). At T1, only the three factors of age (p = 0.005), education at high school diploma and higher levels (p < 0.001), and being housekeeper (P = 0.048) could significantly explain BI (R2 = 0.231). However, at T2, none of the factors were significant predictors for BI (P > 0.05). CONCLUSIONS Candidates for CABG have poor body image. After the surgery, their body image improves significantly. Healthcare providers need to employ programs to improve body image among these patients.
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Affiliation(s)
| | - Sedigheh Miranzadeh
- Medical Surgical Nursing Department, Kashan University of Medical Sciences, Kashan, Iran
| | - Mahsa Tahmouresi
- Medical Surgical Nursing Department, Kashan University of Medical Sciences, Kashan, Iran
| | - Ismail Azizi-Fini
- Medical Surgical Nursing Department, Kashan University of Medical Sciences, Kashan, Iran
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El-Ansary D, LaPier TK, Adams J, Gach R, Triano S, Katijjahbe MA, Hirschhorn AD, Mungovan SF, Lotshaw A, Cahalin LP. An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy. Phys Ther 2019; 99:1587-1601. [PMID: 31504913 DOI: 10.1093/ptj/pzz126] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 03/07/2019] [Accepted: 04/30/2019] [Indexed: 02/07/2023]
Abstract
Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.
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Affiliation(s)
- Doa El-Ansary
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology, Melbourne, Victoria, Australia; Department of Surgery, School of Medicine, University of Melbourne, Melbourne, Australia; and Clinical Research Institute, Sydney, Australia. Address all correspondence to Associate Professor El-Ansary at:
| | - Tanya Kinney LaPier
- Department of Physical Therapy, Eastern Washington University, Spokane, Washington. Dr LaPier is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy
| | - Jenny Adams
- Baylor Institute for Rehabilitation, Baylor University Medical Center, Dallas, Texas
| | - Richard Gach
- Department of Rehabilitation Services, Memorial Regional Hospital, Hollywood, Florida
| | - Susan Triano
- Department of Rehabilitation Services, Memorial Regional Hospital, Hollywood, Florida
| | - Md Ali Katijjahbe
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology Department of Physiotherapy, Hospital Canselor Tuanku Muhriz, UKM Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Andrew D Hirschhorn
- MQ Health Physiotherapy and Department of Health Professions, Faculty of Medicine and Health, Macquarie University, Sydney, Australia
| | - Sean F Mungovan
- Department of Health Professions, Faculty of Art, Health and Design, Swinburne University of Technology, Clinical Research Institute and Westmead Private Physiotherapy Services, Westmead Private Hospital, Sydney, Australia
| | - Ana Lotshaw
- Baylor Institute for Rehabilitation, Baylor University Medical Center. Dr Lotshaw is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy
| | - Lawrence P Cahalin
- Department of Physical Therapy, Miller School of Medicine, University of Miami, Coral Gables, Florida
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Pollock Y, Chan CL, Hall K, Englesbe M, Diehl KM, Min L. A novel geriatric assessment tool that predicts postoperative complications in older adults with cancer. J Geriatr Oncol 2019; 11:866-872. [PMID: 31699673 DOI: 10.1016/j.jgo.2019.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Comprehensive geriatric assessment prior to oncologic surgery can help predict surgical outcomes. We tested whether an abbreviated geriatric assessment tool, the Vulnerable Elderly Surgical Pathways and outcomes Assessment (VESPA), would predict post-operative complications among older adults undergoing oncologic surgery. METHOD From 2008 to 2011, geriatric assessments were completed using the VESPA tool for patients age ≥ 70 seen in a pre-operative clinic. The VESPA assessed functional status, mood, cognition, and mobility, and can be completed in <10 min. We selected the subset of patients who underwent oncologic surgery and evaluated the VESPA's ability to predict post-operative surgical complications, geriatric complications (e.g., delirium), length of stay, and geriatric post-discharge needs (e.g., new functional dependence). RESULTS A total of 476 patients who underwent oncologic surgery received the assessment using VESPA. Compared to patients with low VESPA scores (<9), patients with high VESPA scores (≥9) had longer length of stay (mean 6.6 vs. 2.0 days; p < .001), more geriatric complications (39.5% vs. 5.7%; p < .001), more surgical complications (29.5% vs. 11.8%; p < .001), and more likely to have post discharge needs (76.0% vs. 31.7%; p < .001). Using logistic regression, each additional point on the VESPA scale was also associated with increased probability of geriatric complications (OR = 1.3; 95% CI = 1.2-1.4), surgical complications (OR = 1.2; 95% CI = 1.1-1.2), and geriatric post-discharge needs (OR = 1.3; 95% CI = 1.2-1.3). CONCLUSION The VESPA identifies older patients with cancer who are at risk for postoperative surgical and geriatric complications as well as functional needs at hospital discharge.
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Affiliation(s)
- YaoYao Pollock
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA, USA.
| | - Chiao-Li Chan
- Division of Geriatric & Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Karen Hall
- Division of Geriatric & Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Kathleen M Diehl
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lillian Min
- Division of Geriatric & Palliative Medicine, University of Michigan, Ann Arbor, MI, USA; Geriatric Research Education and Clinical Center (GRECC), Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
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Katijjahbe MA, Denehy L, Granger CL, Royse A, Royse C, Logie S, Sturgess T, Md Ali NA, McManus M, Sandy CE, El-Ansary D. Psychometric evaluation of the shortened version of the Functional Difficulties Questionnaire to assess thoracic physical function. Clin Rehabil 2019; 34:132-140. [PMID: 31610700 DOI: 10.1177/0269215519879476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the psychometric properties of the shortened version of the Functional Difficulties Questionnaire (FDQ). DESIGN This is a multisite observational study. SETTING The study was conducted in four tertiary care hospitals in Australia. SUBJECTS A total of 225 participants, following cardiac surgery, were involved in the study. INTERVENTION Participants completed the original 13-item FDQ and other measures of physical function, pain and health-related quality of life. METHOD Item reduction was utilized to develop the shortened version. Reliability was evaluated using intraclass correlation coefficients (ICCs), the smallest detectable change and Bland-Altman plots. The validity and responsiveness were evaluated using correlation. Anchor and distribution-based calculation was used to calculate the minimal clinical important difference (MCID). RESULTS Item reduction resulted in the creation of a 10-item shortened version of the questionnaire (FDQ-s). Within the cohort of cardiac surgery patient, the mean (SD) for the FDQ-s was 38.7 (19.61) at baseline; 15.5 (14.01) at four weeks and 7.9 (12.01) at three months. Validity: excellent internal consistency (Cronbach's α > 0.90) and fair-to-excellent construct validity (>0.4). Reliability: internal consistency was excellent (Cronbach's α > 0.8). The FDQ-s had excellent test-retest reliability (ICC = 0.89-0.92). Strong responsiveness overtime was demonstrated with large effect sizes (Cohen's d > 1.0). The MCID of the FDQ-s was calculated between 4 and 10 out of 100 (in cm). CONCLUSION The FDQ-s demonstrated robust psychometric properties as a measurement tool of physical function of the thoracic region following cardiac surgery.
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Affiliation(s)
- Mohd Ali Katijjahbe
- Department of Physiotherapy, Hospital Canselor Tuanku Muhriz, Pusat Perubatan University Kebangsaan, Kuala Lumpur, Malaysia.,Department of Health Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Linda Denehy
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Catherine L Granger
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia.,Physiotherapy Department, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Alistair Royse
- Department of Health Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, VIC, Australia.,Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
| | - Colin Royse
- Department of Health Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, VIC, Australia.,Department of Surgery, The University of Melbourne, Parkville, VIC, Australia.,Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
| | - Sarah Logie
- Physiotherapy Department, Melbourne Private Hospital, Parkville, VIC, Australia
| | - Tamica Sturgess
- Department of Physiotherapy, Monash Medical Centre, Clayton, VIC, Australia
| | - Nur Ayub Md Ali
- Heart and Lung Centre, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | | | - Clarke-Errey Sandy
- Statistical Consulting Centre, School of Mathematics and Statistics, The University of Melbourne, Parkville, VIC, Australia
| | - Doa El-Ansary
- Department of Health Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, VIC, Australia.,Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
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Abstract
OBJECTIVES We hypothesized that distinct sets of functional trajectories can be identified in the year before and after major surgery, with unique transition probabilities from pre to postsurgical functional trajectories, and that outcomes would be better among participants undergoing elective versus nonelective surgery. BACKGROUND Major surgery is common and can be highly morbid in older persons. The relationship between the course of disability (ie, functional trajectory) before and after surgery in older adults has not been well-studied for most operations. METHODS Prospective cohort study of 754 community-living persons 70 years or older. The analytic sample included 250 participants who underwent their first major surgery during the study period. RESULTS Before surgery, 4 functional trajectories were identified: no disability (n = 60, 24.0%), and mild (n = 84, 33.6%), moderate (n = 73, 29.2%), and severe (n = 33, 13.2%) disability. After surgery, 4 functional trajectories were identified: rapid (n = 39, 15.6%), gradual (n = 76, 30.4%), partial (n = 70, 28.0%), and little (n = 57, 22.8%) improvement. Rapid improvement was seen for n = 31 (51.7%) participants with no disability before surgery, but was uncommon among those with mild disability (n = 8, 9.5%) and was not observed in the moderate and severe trajectory groups. For participants with mild to moderate disability before surgery, gradual improvement (n = 46, 54.8%) and partial improvement (n = 36, 49.3%) were most common. Most participants with severe disability (n = 27, 81.8%) before surgery exhibited little improvement. Outcomes were better for participants undergoing elective versus nonelective surgery. CONCLUSIONS Functional prognosis in the year after major surgery is highly dependent on premorbid function.
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12
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Zhang Z, Tumin D. Expected social support and recovery of functional status after heart surgery. Disabil Rehabil 2019; 42:1167-1172. [DOI: 10.1080/09638288.2018.1518492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Zhe Zhang
- Department of Sociology, Rice University, Houston, TX, USA
| | - Dmitry Tumin
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, OH, USA
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13
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Short Physical Performance Battery Can Be Utilized to Evaluate Physical Function in Patients After Cardiac Surgery. Cardiopulm Phys Ther J 2018. [DOI: 10.1097/cpt.0000000000000070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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14
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Watt J, Tricco AC, Talbot-Hamon C, Pham B, Rios P, Grudniewicz A, Wong C, Sinclair D, Straus SE. Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis. J Gen Intern Med 2018; 33:500-509. [PMID: 29374358 PMCID: PMC5880753 DOI: 10.1007/s11606-017-4204-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/22/2017] [Accepted: 09/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. METHODS Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. RESULTS Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3-23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2-17.9), frailty (OR 4.1, 95% CI 1.4-11.7), cognitive impairment (OR 2.7, 95% CI 1.9-3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6-2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3-2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4-3.6) and smoking status (OR 1.8 95% CI 1.3-2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52-0.91). DISCUSSION Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.
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Affiliation(s)
- Jennifer Watt
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada.,Institute for Health Policy Management & Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, Ontario, M5T 3M6, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Catherine Talbot-Hamon
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada
| | - Ba' Pham
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Toronto Health Economics and Technology Assessment Collaborative, Faculty of Pharmacy and Institute of Health Policy Management Evaluation, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada
| | - Patricia Rios
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, 55 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
| | - Camilla Wong
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Douglas Sinclair
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Sharon E Straus
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada. .,Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.
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15
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Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial. J Physiother 2018; 64:97-106. [PMID: 29602750 DOI: 10.1016/j.jphys.2018.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 12/23/2022] Open
Abstract
QUESTION In people who have undergone cardiac surgery via median sternotomy, does modifying usual sternal precautions to make them less restrictive improve physical function, pain, kinesiophobia and health-related quality of life? DESIGN Two-centre, randomised, controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS Seventy-two adults who had undergone cardiac surgery via a median sternotomy were included. INTERVENTION Participants were randomly allocated to one of two groups at 4 (SD 1) days after surgery. The control group received the usual advice to restrict their upper limb use for 4 to 6 weeks (ie, restrictive sternal precautions). The experimental group received advice to use pain and discomfort as the safe limits for their upper limb use during daily activities (ie, less restrictive precautions) for the same period. Both groups received postoperative individualised education in hospital and via weekly telephone calls for 6 weeks. OUTCOME MEASURES The primary outcome was physical function assessed by the Short Physical Performance Battery. Secondary outcomes included upper limb function, pain, kinesophobia, and health-related quality of life. Outcomes were measured before hospital discharge and at 4 and 12 weeks postoperatively. Adherence to sternal precautions was recorded. RESULTS There were no statistically significant differences in physical function between the groups at 4 weeks (MD 1.0, 95% CI -0.2 to 2.3) and 12 weeks (MD 0.4, 95% CI -0.9 to 1.6) postoperatively. There were no statistically significant between-group differences in secondary outcomes. CONCLUSION Modified (ie, less restrictive) sternal precautions for people following cardiac surgery had similar effects on physical recovery, pain and health-related quality of life as usual restrictive sternal precautions. Similar outcomes can be anticipated regardless of whether people following cardiac surgery are managed with traditional or modified sternal precautions. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ANZCTRN12615000968572. [Katijjahbe MA, Granger CL, Denehy L, Royse A, Royse C, Bates R, Logie S, Nur Ayub MA, Clarke S, El-Ansary D (2018) Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' Trial): a randomised trial. Journal of Physiotherapy 64: 97-106].
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16
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Watt J, Tricco AC, Talbot-Hamon C, Pham B, Rios P, Grudniewicz A, Wong C, Sinclair D, Straus SE. Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis. BMC Med 2018; 16:2. [PMID: 29325567 PMCID: PMC5765656 DOI: 10.1186/s12916-017-0986-2] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/05/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Elective surgeries can be associated with significant harm to older adults. The present study aimed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery. METHODS Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. Prospective studies reporting prognostic factors associated with postoperative complications (composite outcome of medical and surgical complications), functional decline, mortality, post-hospitalization discharge destination, and prolonged hospitalization among older adults undergoing elective surgery were included. Study characteristics and prognostic factors associated with the outcomes of interest were extracted independently by two reviewers. Random effects meta-analysis models were used to derive pooled effect estimates for prognostic factors and incidences of adverse outcomes. RESULTS Of the 5692 titles and abstracts that were screened for inclusion, 44 studies (12,281 patients) reported on the following adverse postoperative outcomes: postoperative complications (n =28), postoperative mortality (n = 11), length of hospitalization (n = 21), functional decline (n = 6), and destination at discharge from hospital (n = 13). The pooled incidence of postoperative complications was 25.17% (95% confidence interval (CI) 18.03-33.98%, number needed to follow = 4). The geriatric syndromes of frailty (odds ratio (OR) 2.16, 95% CI 1.29-3.62) and cognitive impairment (OR 2.01, 95% CI 1.44-2.81) were associated with developing postoperative complications; however, there was no association with traditionally assessed prognostic factors such as age (OR 1.07, 95% CI 1.00-1.14) or American Society of Anesthesiologists status (OR 2.62, 95% CI 0.78-8.79). Besides frailty, other potentially modifiable prognostic factors, including depressive symptoms (OR 1.77, 95% CI 1.22-2.56) and smoking (OR 2.43, 95% CI 1.32-4.46), were also associated with developing postoperative complications. CONCLUSION Geriatric syndromes are important prognostic factors for postoperative complications. We identified potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care.
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Affiliation(s)
- Jennifer Watt
- Division of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, Ontario, M5T 3M6, Canada
| | - Andrea C Tricco
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario, M5B 1W8, Canada.,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Catherine Talbot-Hamon
- Division of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada
| | - Ba' Pham
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario, M5B 1W8, Canada.,Toronto Health Economics and Technology Assessment Collaborative, Faculty of Pharmacy and Institute of Health Policy Management Evaluation, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada
| | - Patricia Rios
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario, M5B 1W8, Canada
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, 55 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
| | - Camilla Wong
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario, M5B 1W8, Canada
| | - Douglas Sinclair
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario, M5B 1W8, Canada
| | - Sharon E Straus
- Division of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada. .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario, M5B 1W8, Canada.
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17
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Kim S, Duncan PW, Groban L, Segal H, Abbott RM, Williamson JD. Patient-Reported Outcome Measures (PROM) as A Preoperative Assessment Tool. JOURNAL OF ANESTHESIA AND PERIOPERATIVE MEDICINE 2017; 4:274-281. [PMID: 29333531 PMCID: PMC5766034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM OF REVIEW Patient-reported outcomes (PRO) on functional, social, and behavioral factors might be important preoperative predictors of postoperative outcomes. We conducted a literature review to explore associations of preoperative depression, socioeconomic status, social support, functional status/frailty, cognitive status, self-management skills, health literacy, and nutritional status with surgical outcomes. METHODS Two electronic data bases, including PubMed and Google Scholar, were searched linking either depression, socioeconomic status, social support, functional status/frailty, cognitive status, self-management skills, health literacy, or nutritional status with surgery, postoperative complications, or perioperative period within the past 2 decades. RECENT FINDINGS Preoperative depression has been linked to postoperative delirium, complications, persistent pain, longer lengths of stay, and mortality. Socioeconomic status associates with overall and cancer-free survival. Low socioeconomic status has also been connected to medication non- compliance. Social support can predict overall and cancer- free survival, as well as physical, social and emotional quality of life. Poor functional status and frailty have been related to postoperative complications, longer lengths of stay, post-discharge institutionalization, and higher costs. Preoperative cognitive impairment also associates with self-medication management errors, postoperative cognitive impairment, delirium, complications and mortality. In addition, a greater tendency for reduced adherence to preoperative medication instructions has been linked to health illiteracy. Preoperative malnutrition is prevalent and associates with postoperative morbidity. CONCLUSION Efficient and effective assessments of social and behavioral determinants of health, functional status, health literacy, patient's perception of health, and preferences for self-management may improve postoperative management and surgical outcomes, particularly among vulnerable patients undergoing elective surgery who might have subtle physical, social, or psychological deficits or challenges, otherwise missed upon routine evaluation. Patient Reported Outcome Measures (PROMs) can be used to effectively and efficiently collect these factors in the preoperative period, thereby identifying areas that can be intervened preemptively. (Partially Funded by the National Institute on Aging and the Wake Forest University Claude D. Pepper Older Americans Independence Center.).
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Affiliation(s)
- Sunghye Kim
- Department of Internal Medicine, Winston-Salem, NC, USA,Sticht Center on Aging, Winston-Salem, NC, USA
| | - Pamela W. Duncan
- Sticht Center on Aging, Winston-Salem, NC, USA,Department of Neurology, Winston-Salem, NC, USA
| | - Leanne Groban
- Sticht Center on Aging, Winston-Salem, NC, USA,Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hannah Segal
- Fisher Center for Hereditary Cancer AND Clinical Genomics Research, Georgetown University, Washington, D.C., USA
| | | | - Jeff D. Williamson
- Department of Internal Medicine, Winston-Salem, NC, USA,Sticht Center on Aging, Winston-Salem, NC, USA
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18
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Kehler DS, Stammers AN, Tangri N, Hiebert B, Fransoo R, Schultz ASH, Macdonald K, Giacomontonio N, Hassan A, Légaré JF, Arora RC, Duhamel TA. Systematic review of preoperative physical activity and its impact on postcardiac surgical outcomes. BMJ Open 2017; 7:e015712. [PMID: 28801404 PMCID: PMC5724229 DOI: 10.1136/bmjopen-2016-015712] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objective of this systematic review was to study the impact of preoperative physical activity levels on adult cardiac surgical patients' postoperative: (1) major adverse cardiac and cerebrovascular events (MACCEs), (2) adverse events within 30 days, (3) hospital length of stay (HLOS), (4) intensive care unit length of stay (ICU LOS), (5) activities of daily living (ADLs), (6) quality of life, (7) cardiac rehabilitation attendance and (8) physical activity behaviour. METHODS A systematic search of MEDLINE, Embase, AgeLine and Cochrane library for cohort studies was conducted. RESULTS Eleven studies (n=5733 patients) met the inclusion criteria. Only self-reported physical activity tools were used. Few studies used multivariate analyses to compare active versus inactive patients prior to surgery. When comparing patients who were active versus inactive preoperatively, there were mixed findings for MACCE, 30 day adverse events, HLOS and ICU LOS. Of the studies that adjusted for confounding variables, five studies found a protective, independent association between physical activity and MACCE (n=1), 30-day postoperative events (n=2), HLOS (n=1) and ICU LOS (n=1), but two studies found no protective association for 30-day postoperative events (n=1) and postoperative ADLs (n=1). No studies investigated if activity status before surgery impacted quality of life or cardiac rehabilitation attendance postoperatively. Three studies found that active patients prior to surgery were more likely to be inactive postoperatively. CONCLUSION Due to the mixed findings, the literature does not presently support that self-reported preoperative physical activity behaviour is associated with postoperative cardiac surgical outcomes. Future studies should objectively measure physical activity, clearly define outcomes and adjust for clinically relevant variables. REGISTRATION Trial registration number NCT02219815. PROSPERO number CRD42015023606.
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Affiliation(s)
- D Scott Kehler
- Health, Leisure & Human Performance Research Institute, Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Canada
| | - Andrew N Stammers
- Health, Leisure & Human Performance Research Institute, Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Canada
| | | | - Brett Hiebert
- Department of Surgery, University of Manitoba and Cardiac Sciences Program, Winnipeg, Canada
| | - Randy Fransoo
- Department of Community Health Sciences and Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada
| | - Annette S H Schultz
- College of Nursing, Faculty of Heath Sciences, University of Manitoba, Winnipeg, Canada
| | | | | | - Ansar Hassan
- Department of Cardiac Surgery, New Brunswick Heart Centre, Saint John Regional Hospital, Saint John, Manitoba, Canada
| | - Jean-Francois Légaré
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Canada
| | - Rakesh C Arora
- Department of Surgery, University of Manitoba and Cardiac Sciences Program, Winnipeg, Canada
| | - Todd A Duhamel
- Health, Leisure & Human Performance Research Institute, Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre, Winnipeg, Canada
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19
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Katijjahbe MA, Denehy L, Granger CL, Royse A, Royse C, Bates R, Logie S, Clarke S, El-Ansary D. The Sternal Management Accelerated Recovery Trial (S.M.A.R.T) - standard restrictive versus an intervention of modified sternal precautions following cardiac surgery via median sternotomy: study protocol for a randomised controlled trial. Trials 2017. [PMID: 28645301 PMCID: PMC5481951 DOI: 10.1186/s13063-017-1974-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background The routine implementation of sternal precautions to prevent sternal complications that restrict the use of the upper limbs is currently worldwide practice following a median sternotomy. However, evidence is limited and drawn primarily from cadaver studies and orthopaedic research. Sternal precautions may delay recovery, prolong hospital discharge and be overly restrictive. Recent research has shown that upper limb exercise reduces post-operative sternal pain and results in minimal micromotion between the sternal edges as measured by ultrasound. The aims of this study are to evaluate the effects of modified sternal precautions on physical function, pain, recovery and health-related quality of life after cardiac surgery. Methods/design This study is a phase II, double-blind, randomised controlled trial with concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. Patients (n = 72) will be recruited following cardiac surgery via a median sternotomy. Sample size calculations were based on the minimal important difference (two points) for the primary outcome: Short Physical Performance Battery. Thirty-six participants are required per group to counter dropout (20%). All participants will be randomised to receive either standard or modified sternal precautions. The intervention group will receive guidelines encouraging the safe use of the upper limbs. Secondary outcomes are upper limb function, pain, kinesiophobia and health-related quality of life. Descriptive statistics will be used to summarise data. The primary hypothesis will be examined by repeated-measures analysis of variance to evaluate the changes from baseline to 4 weeks post-operatively in the intervention arm compared with the usual-care arm. In all tests to be conducted, a p value <0.05 (two-tailed) will be considered statistically significant, and confidence intervals will be reported. Discussion The Sternal Management Accelerated Recovery Trial (S.M.A.R.T.) is a two-centre randomised controlled trial powered and designed to investigate whether the effects of modifying sternal precautions to include the safe use of the upper limbs and trunk impact patients’ physical function and recovery following cardiac surgery via median sternotomy. Trial registration Australian and New Zealand Clinical Trials Registry identifier: ACTRN12615000968572. Registered on 16 September 2015 (prospectively registered). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1974-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Md Ali Katijjahbe
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia. .,Department of Physiotherapy, Hospital Cancelor Tuaku Mukhriz, Pusat Perubatan University Kebangsaan Malaysia, Kuala Lumpur, 56000, Malaysia.
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia
| | - Catherine L Granger
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia.,Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Alistair Royse
- Department of Surgery, University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Surgery, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Colin Royse
- Department of Surgery, University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Surgery, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Rebecca Bates
- Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Sarah Logie
- Physiotherapy Department, Melbourne Private Hospital, Parkville, VIC, 3052, Australia
| | - Sandy Clarke
- Statistical Consulting Centre, School of Mathematics and Statistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Doa El-Ansary
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, VIC, 3053, Australia
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20
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Abstract
As the world's aging population grows, the surgical population is increasingly made up of older adults. Due to changes in physiologic function and increasing comorbidity burden, older adults are at increased risk of morbidity, mortality, and functional decline after surgery. In addition, decision to undergo surgery for the older adult may be based on the postoperative functional outcome rather than survival. Although few studies have evaluated an older adult's function as a postoperative outcome, surgeons are becoming increasingly aware of the importance of maintaining or regaining function in an older patient. Interventions to improve postoperative functional outcomes are being developed and show promising results. This review discusses existing literature on postoperative functional outcomes in older adults and recently developed interventions.
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Affiliation(s)
- Zabecca Brinson
- Department of Surgery (EF, ZB), Department of Medicine (EF, VT), Phillip R Lee Institute for Health Policy Studies (EF), 3333 California St, San Francisco, CA 94118; (415) 885-3606
| | - Victoria L Tang
- Department of Surgery (EF, ZB), Department of Medicine (EF, VT), Phillip R Lee Institute for Health Policy Studies (EF), 3333 California St, San Francisco, CA 94118; (415) 885-3606
| | - Emily Finlayson
- Department of Surgery (EF, ZB), Department of Medicine (EF, VT), Phillip R Lee Institute for Health Policy Studies (EF), 3333 California St, San Francisco, CA 94118; (415) 885-3606
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21
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Eide LSP, Ranhoff AH, Fridlund B, Haaverstad R, Hufthammer KO, Kuiper KKJ, Nordrehaug JE, Norekvål TM. Delirium as a Predictor of Physical and Cognitive Function in Individuals Aged 80 and Older After Transcatheter Aortic Valve Implantation or Surgical Aortic Valve Replacement. J Am Geriatr Soc 2016; 64:1178-86. [DOI: 10.1111/jgs.14165] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Anette H. Ranhoff
- Department of Clinical Science; University of Bergen; Bergen Norway
- Kavli Research Center for Geriatrics and Dementia; Haraldsplass Hospital; Bergen Norway
| | - Bengt Fridlund
- School of Health and Welfare; Jönköping University; Jönköping Sweden
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
| | - Rune Haaverstad
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
| | | | - Karel K. J. Kuiper
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
| | - Jan E. Nordrehaug
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Cardiology; Stavanger University Hospital; Stavanger Norway
| | - Tone M. Norekvål
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Heart Disease; Haukeland University Hospital; Bergen Norway
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