Physiological and psychological influences on postoperative fatigue

A randomized controlled trial of propofol-remifentanil total intravenous anesthesia and sevoflurane-fentanyl anesthesia on early postoperative fatigue in patients undergoing laparoscopic colorectal surgery

PURPOSE

Even after uncomplicated surgery, postoperative fatigue prevalence has been reported to be 30-80% for various surgeries. We evaluated postoperative fatigue according to anesthetic technique in patients who underwent colorectal surgery.

METHODS

One hundred thirty patients who underwent colorectal surgery were randomly assigned to either propofol-remifentanil total intravenous anesthesia (propofol-remifentanil group, n = 65) or sevoflurane-fentanyl anesthesia (sevoflurane-fentanyl group, n = 65). The primary outcome was the prevalence of postoperative fatigue, as defined by the Chalder Fatigue Questionnaire (total score ≥ 16), at 24 h postoperatively. Secondary outcomes were early postoperative complications during hospitalization and laboratory examination.

RESULTS

The final analyses included 127 patients. The prevalence of postoperative fatigue on the 1st postoperative day was lower in the propofol-remifentanil group than the sevoflurane-fentanyl group: 56.3% (36/64) in the propofol-remifentanil group and 73.0% (46/63) in the sevoflurane-fentanyl group (relative risk [RR] = 0.77, 95% confidence interval [CI] 0.59-1.00; P = 0.048). However, there was no difference between the two groups in postoperative fatigue at postoperative day 3. Other postoperative outcomes including the severity of pain and the incidence of nausea/vomiting were not different between the two groups, but postoperative atelectasis on chest X-ray was higher in the sevoflurane-fentanyl group (2/64 [3.1%] vs. 9/63 [14.3%], P = 0.025). C-reactive protein change from preoperative to postoperative day 1 and 5 was significantly lower in the propofol-remifentanil group (P = 0.044).

CONCLUSION

Propofol-remifentanil total intravenous anesthesia was associated with reduced postoperative fatigue at the 1st postoperative day compared with sevoflurane-fentanyl anesthesia. Clinical trial The Korean Clinical Research Registry (study identifier: KCT0006917, principal investigator's name: MiHye Park, date of registration: January 12, 2022).

The effects of dexamethasone, light anesthesia, and tight glucose control on postoperative fatigue and quality of life after major noncardiac surgery: A randomized trial

STUDY OBJECTIVES

The postoperative period is associated with an inflammatory response that may contribute to a number of complications including postoperative fatigue (POF) that impair patients' quality of life (QoL). We studied the impact of three potentially anti-inflammatory interventions (steroid administration, tight intraoperative glucose control, and light anesthesia) on POF and QoL in patients having major noncardiac surgery.

DESIGN

A randomized Trial.

SETTING

Operating room and postoperative recovery area/ICU/hospital floors.

PATIENTS

Patients undergoing major noncardiac surgery.

INTERVENTIONS

Patients were randomized to perioperative IV dexamethasone (a total of 14 mg tapered over 3 days) versus placebo, intensive versus conventional glucose control (target 80-110 vs. 180-200 mg·dL^-1), and light versus deep anesthesia (Bispectral Index target of 55 vs. 35) in a 3-way factorial design.

MEASUREMENTS

In this planned sub-analysis, QoL was measured using SF-12 preoperatively and on postoperative day (POD) 30. POF was measured using Christensen VAS, pre-operatively, POD 1, and POD 3. We assessed the effect of each intervention on POF and on the physical and mental components of SF-12 summary scores with repeated-measures linear regression models.

MAIN RESULTS

326 patients with complete data were included in the SF-12 analysis and 306 were included in the QoL analysis. No difference was found between any of the intervention groups on fatigue or mean 30-day physical and mental components of SF-12 scores, after adjusting for preoperative score and imbalanced baseline variables (all P-value >0.07 for POF and >0.40 for QoL).

CONCLUSIONS

Steroid administration, tight intraoperative glucose control, and light anesthesia do not improve quality of life or postoperative fatigue after major surgery.

Defining the cut-off point of clinically significant postoperative fatigue in three common fatigue scales

PURPOSE

Postoperative fatigue (POF) is an often underestimated problem after surgery. Studies on POF often report fatigue scores without relating this to the clinical relevance for the patients. The aim of this study was to define the cut-off point for clinically significant POF in three commonly applied fatigue scales; the Postoperative Fatigue Scale, Christensen's Fatigue Scale, and the Chalder Fatigue Questionnaire. The identification of cut-off points will make it possible to indicate whether statistically significant findings of increased fatigue are of clinical relevance.

METHODS

We combined data from day 0 (pre-operatively) and day 1, 3, 6, and 30 after surgery in two fatigue-related studies with 442 patients. In order to define clinically significant fatigue, a key question was added in each questionnaire; "Given your current description of fatigue, would you say it has been of considerable significance to you?"; "Yes/No". We analysed each scale's ability to identify clinically significant fatigue, by performing receiver-operating characteristics (ROC) analyses, and calculated the optimal cut-off point between Sensitivity and Specificity.

RESULTS

The average weighted cut-off point for clinically significant POF when measured with the Postoperative Fatigue Scale was ≥ 50 (scale range 0-100), with Christensen's Fatigue Scale ≥ 6 (scale range 1-10) and with the Chalder Fatigue Questionnaire ≥ 16 (scale range 0-33).

CONCLUSION

In three commonly used fatigue scales, we have identified cut-off points for clinically significant fatigue among patients recovering from surgery. This can be particularly valuable for diagnostic purposes and in treatment evaluation. Further, it may be possible to analyse and review data from earlier studies in light of clinical relevance.

Prognostic model for psychological outcomes in ambulatory surgery patients: A prospective study using a structural equation modeling framework

INTRODUCTION

Surgical procedures are increasingly carried out in a day-case setting. Along with this increase, psychological outcomes have become prominent. The objective was to evaluate prospectively the prognostic effects of sociodemographic, medical, and psychological variables assessed before day-case surgery on psychological outcomes after surgery.

METHODS

The study was carried out between October 2010 and September 2011. We analyzed 398 mixed patients, from a randomized controlled trial, undergoing day-case surgery at a university medical center. Structural equation modeling was used to jointly study presurgical prognostic variables relating to sociodemographics (age, sex, nationality, marital status, having children, religion, educational level, employment), medical status (BMI, heart rate), and psychological status associated with anxiety (State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS-A)), fatigue (Multidimensional Fatigue Inventory (MFI)), aggression (State-Trait Anger Scale (STAS)), depressive moods (HADS-D), self-esteem, and self-efficacy. We studied psychological outcomes on day 7 after surgery, including anxiety, fatigue, depressive moods, and aggression regulation.

RESULTS

The final prognostic model comprised the following variables: anxiety (STAI, HADS-A), fatigue (MFI), depression (HADS-D), aggression (STAS), self-efficacy, sex, and having children. The corresponding psychological variables as assessed at baseline were prominent (i.e. standardized regression coefficients ≥ 0.20), with STAI-Trait score being the strongest predictor overall. STAI-State (adjusted R2 = 0.44), STAI-Trait (0.66), HADS-A (0.45) and STAS-Trait (0.54) were best predicted.

CONCLUSION

We provide a prognostic model that adequately predicts multiple postoperative outcomes in day-case surgery. Consequently, this enables timely identification of vulnerable patients who may require additional medical or psychological preventive treatment or-in a worst-case scenario-could be unselected for day-case surgery.

Prevalence of pain 6 months after surgery: a prospective observational study

Background

Pain after surgery is a major issue for patient discomfort and often associated with delayed recovery. The aim of the present study was to evaluate the prevalence of pain and requirement for analgesics up to 6 months after elective surgery, independent if new pain symptoms occurred after surgery or if preoperative pain persisted in the postoperative period.

Methods

A prospective observational single center cohort study was conducted between January 2012 and August 2013. Eligible patients were scheduled to undergo elective surgical interventions including joint (hip, knee arthroplasty), back (nucleotomy, spondylodesis), or urological surgery (cystectomy, prostatectomy, nephrectomy). Pain was assessed on an 11-point numerical rating scale (NRS) before, on postoperative day 2 and 6 months after surgery. Clinical information was collected with structured questionnaires and by telephone interview.

Results

Six hundred and forty-four patients gave informed consent, including 54.4 % men (mean age 62.2, SD 14.3). Higher preoperative pain scores were found in patients undergoing joint (mean 7.6; 95 % confidence interval [CI]: 7.2–8.0) and back surgery (mean 7.1, CI: 6.8–7.5) than in patients prior to urological surgery (mean 2.3; CI: 1.8–2.8). After 6 months, about 50 % of patients after joint or back surgery indicated pain levels ≥3/10, compared to 15.9 % of patients after urological surgery (p < .001). 35.3 % of the patients after joint surgery and 41.3 % after back surgery still use pain medication 6 months postoperatively, in contrast to 7.3 % of patients after urological surgery. 13.6 % of patients who underwent back surgery indicated the regular intake of opioids.

Conclusions

Our results reveal that a significant percentage of patients undergoing procedures in joint or back surgery still need pain medication up to 6 months postoperatively due to ongoing pain symptoms. Improved monitoring of pain management is warranted, especially after discharge from hospital, to improve long-term results.

Trial registration

Clinicaltrials.gov (Identifier: NCT01488617); date of registration December 6th 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0261-7) contains supplementary material, which is available to authorized users.

Postoperative fatigue; translation and validation of a revised 10-item short form of the Identity-Consequence Fatigue Scale (ICFS)

OBJECTIVE

Postoperative fatigue is a common problem after otherwise uncomplicated surgery. It may defer patients from resuming their daily activities and is often reported to be among their most severe symptoms. There are few validated instruments for assessing postoperative fatigue. Our aim was to translate into Norwegian and explore a Short Form of the Identity-Consequences Fatigue Scale; a fatigue questionnaire specifically developed to assess postoperative fatigue.

METHODS

The fatigue scale was translated to Norwegian through a forward-backward process, and subsequently validated in a large, mixed surgical population. We performed Principal Component Analyses on the complete 31-item scale and on the 10-item Short Form. The analyses were performed separately on pre- and postoperative data (n=422 and n=315, respectively).

RESULTS

The factor analyses confirmed that the translation was valid and revealed three defined dimensions in the 10-item scale. There was no statistically significant difference between means of reported fatigue when measured with the 31- or 10-item scale. Ninety-eight% of change in fatigue from pre- to postoperative status was retained when using the 10-item scale as compared to the 31-item scale.

CONCLUSION

The abridged, 10-item Short Form performed equal to the 31-item scale and may replace the complete 31-item ICSF scale in exploring the incidence of pre- and post-operative fatigue.

A prospective review of appetite loss and recovery time in primary joint replacement patients

INTRODUCTION

Appetite loss is commonly reported by patients following major surgery, including total joint arthroplasty (TJA). A number of studies have examined related problems, particularly in relation to physiological responses to surgery. However, no published paper has looked specifically at the duration of appetite loss in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients.

METHODS

A simple, established appetite screening tool was administered preoperatively and at 2-week intervals postoperatively in 50 TJA patients until appetite levels returned to preoperative levels. The results were examined for various descriptive parameters and compared using the chi-squared test.

RESULTS

Thirty-three patients underwent TKA and 17 THA. There were 27 female and 23 male patients. No patients were lost to follow-up. The median time for return of appetite in both male and female patients was 4 weeks (interquartile range [IQR]: male, 2-4; female, 4-6). The median time for return of appetite was 4 weeks both in TKA patients (IQR 4-6) and in those undergoing THA (IQR 4-4). The time to return of appetite was not significantly associated with either the gender of the patients (p=0.13) or the type of joint replacement (p=0.49).

CONCLUSIONS

The study provides a clear time frame for return of appetite in uncomplicated primary joint replacements. This is a commonly noted patient problem that has not previously been specifically reviewed.

Effectiveness of psychological support in patients undergoing primary total hip or knee arthroplasty: a controlled cohort study

BACKGROUND

We hypothesised that psychological support would have a significant improvement on the mental and physical recovery of patients undergoing primary total hip or knee arthroplasty.

MATERIALS AND METHODS

200 patients were consecutively alternately assigned (1:1) to receive routine care (control group) or, in addition, psychological support from a professional psychologist (experimental group). The psychological support was provided at the pre-operative visit, during the hospitalisation period and at the rehabilitation centre.

RESULTS

Upon discharge, based on the 'Hospital Anxiety and Depression Scale, a state of anxiety was observed in 12.8 % and 78.9 % of the patients in the experimental and in the control group, respectively (p < 0.0001). A state of depression was observed in 12.8 % and 73.7 % of the patients in the experimental and in the control group, respectively (p < 0.0001). With regard to the 'Physical Component Scale' of the SF-36 questionnaire, a similar temporal trend of values was observed in the two study groups, significantly increasing over time in both groups, taking into consideration both the joint population and the two hip and knee populations separately (p < 0.0001). With regard to the 'Mental Component Scale' of the SF-36 questionnaire, in both the joint population and the two hip and knee populations separately, an exact opposite temporal trend was observed in the experimental group compared to the control group (p < 0.0001), with generally higher scores in the experimental group (p < 0.0001). In patients with hip arthroplasty, the average time to reach the physiotherapy objective (i.e., the patient ability to walk 50 metres independently and to climb 10 steps) was 6.7 ± 1.8 days (range 4-12) in the experimental group and 7.9 ± 2.2 days (range 0-13) in the control group (p = 0.0015).

CONCLUSIONS

In summary, there was a lower incidence of anxiety and depression and better mental well-being in the group of patients who received the psychological support. Within the hip arthroplasty group, the patients who received the psychological support reached the physiotherapy objective 1.2 days earlier than the patients in the control group (p = 0.0015).

LEVEL OF EVIDENCE

Level 3, Non-randomized prospective controlled cohort.

Correlation of psychosocial factor with functional outcome: one year after hip fracture surgery

Objective:This study investigated the correlation of 8 domains of psychosocial factors with functional outcome one year after hip fracture surgery.

A prospective cohort study of patients who had unilateral hip fracture surgery was included. A total of 89 subjects were interviewed between 3rd to 7th day after the hip surgery using the short length Multi-level Assessment Instrument and followed up after 1 year. The functional outcomes were measured through the Harris Hip Score.

All of the psychosocial factors have little to no correlation on the functional recovery of the patient but the cognitive domain had a fair correlation in Harris Hip Score (r=0.46) and is significant (p-value<0.0001)

The study did not find strong correlation between psychosocial factors and functional outcome one year after unilateral hip surgery. Although statistics have shown little effect on psychosocial factors to functional outcome, it may still be prudent to consider every aspect that may contribute to the whole wellbeing of our patients, which includes their psychosocial background.

Surgical resilience: a review of resilience biomarkers and surgical recovery

BACKGROUND

Two distinct and large bodies of literature exist on resilience that are of potential interest for surgical outcomes. First is the literature on the impact of resilience on surgical recovery and wound-healing. Second is the literature on biomarkers for resilience, which largely focuses on neuropeptide Y (NPY), testosterone and dehydroepiandrosterone (DHEA). Despite this activity, there is a dearth of literature linking these two bodies of research by investigating biomarkers for surgical resilience and its impact on surgical recovery. This paper reviews both bodies of literature within the context of surgical recovery.

METHOD

Literature searches within Medline and Embase were conducted for studies and previous reviews of resilience biomarkers and for the impact of individual resilience on surgical recovery. Reference lists of the reviews were searched for additional papers. No systematic review is yet possible due to the novelty of the use of resilience biomarkers within a surgical context.

RESULTS

This is the first review to explore a potential link between resilience biomarkers and surgical recovery. There are a number of biomarkers that correlate with individual resilience levels and resilient individuals exhibit better recovery trajectories following surgery, suggesting a novel use of such biomarkers for the identification of "surgical resilience".

CONCLUSION

By identifying surgical resilience, there is potential for utilising these biomarkers as prognostic indicators of likely recovery trajectories from surgery, which in turn complement individualised peri-operative management.

Activity, sleep and cognition after fast-track hip or knee arthroplasty

Optimized perioperative care after total hip and knee arthroplasty (THA/TKA) has decreased length of stay (LOS) but data on activity, sleep and cognition after discharge are limited. We included 20 patients ≥ 60 years undergoing THA/TKA, monitoring them for 3 days preoperatively and 9 days postoperatively with actigraphs for sleep and activity assessment. Pain scores were recorded daily. Cognition was evaluated by 2 cognitive tests. Results showed a mean age was 70.5 years and mean LOS was 2.6 days. Actigraphs showed increased daytime sleep and decreased motor activity postoperatively. Early postoperatively cognitive decline and increased pain returned to preoperative levels by postoperative day (POD) 5-9. Despite the small sample size the study illustrated that post-discharge activity is decreased and daytime sleep is increased after fast-track THA/TKA, while cognition and pain return to preoperative levels by POD 9. Objective assessment of these recovery parameters may be valuable in future interventional studies to enhance recovery after THA/TKA.

Is the length of time in acute burn surgery associated with poorer outcomes?

BACKGROUND

Acute wound closure surgery improves outcomes, after burn particularly mortality, but also imposes physiological stress on the patient. The duration of surgery is associated with adverse outcomes in other populations. This study aimed to examine if extended acute burn surgery duration was associated with poorer in-hospital outcomes.

METHODS

This retrospective cohort study included adult burn patients who required a single wound closure surgery at Royal Perth Hospital between 2004 and 2011. Multivariable regression analyses were used to assess the influence of patient and injury factors on surgery duration and length of stay (LOS).

RESULTS

Surgery duration independently increased LOS (incidence rate ratio [IRR]=1.004, p<0.001). This translates to a predicted 13% increase in LOS for a 30min increase in surgery 'knife to skin' time. Total body surface area (TBSA) was identified as a significant predictor of surgery duration (IRR=1.047, p<0.001), estimating that a 10% TBSA increase results in a 59% increase in surgery duration.

CONCLUSION

The results show that surgery duration is associated with LOS after adjusting for size of burn and other factors. The study justifies the need to explore strategies to reduce acute burn surgery duration.

Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial

BACKGROUND

Two wounds are created after abdominal surgery. The surgical insult to the peritoneal cavity and viscera has not been emphasized as a target for interventions. In animal models vagotomy blunts the intraperitoneal response to induced inflammation. This is not feasible in humans. However a transient chemical afferentectomy after colectomy by using neuraxial blockade (epidural) and intraperitoneal blockade may be possible. We investigated the effects of intraoperative instillation and postoperative infusion of intraperitoneal local anesthetic (IPLA) on recovery parameters after colectomy, in the setting of an established enhanced recovery after surgery (ERAS) program.

METHODS

Double blinded, randomized, placebo controlled design. The study group (IPLA) received instillation of intraperitoneal ropivacaine (75 mg) before dissection and postoperative infusion of 0.2% solution at 4 mL/hour for 3 days continuously. The placebo group (NS) was treated as above with 0.9% saline solution. All patients were cared for under ERAS standardized perioperative care. Epidural infusion was stopped on day 2. Patients were discharged from day 3 onwards once criteria met. Perioperative data, surgical recovery score (SRS), complications, and length of stay were recorded. Systemic cytokines response, neuroendocrine parameters, pain measures and opioid use data were collected. Patients were followed up for 60 days.

RESULTS

Sixty patients were recruited. Patients were equivalently matched at baseline. There were no local anesthetic related adverse events. The complication rate, including anastomotic leak rate, was equivalent between groups. IPLA group had better SRS scores for the duration of intraperitoneal infusion. Pain and opioid use was reduced in the IPLA group. Systemic cytokine and cortisol response was diminished in the IPLA group. IPLA group had consistently higher systemic ropivacaine levels than placebo group.

CONCLUSION

Instillation and infusion of intraperitoneal ropivacaine after colectomy improves early surgical recovery. This was associated with a blunting of postsurgical systemic cytokines and cortisol. Patients also had significantly reduced pain and opioid use over and above the effect of an epidural infusion. Therefore a transient chemical afferentectomy with clinical benefit is possible with this method. A longer IPLA infusion duration needs to be studied. This study is registered at clinicaltrials.gov and carries the ID number NCT00722709.

Randomized clinical trial of the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy

Background

Recent data have suggested a relationship between postoperative fatigue and the peritoneal cytokine response after surgery. The aim of this study was to test the hypothesis that preoperative administration of glucocorticoids before surgery would decrease fatigue and enhance recovery, by reducing the peritoneal production of cytokines.

Methods

In a double-blind randomized controlled study, patients undergoing elective, open colonic resection were administered 8 mg dexamethasone or normal saline. Patients were treated within an enhanced recovery after surgery programme. Primary outcomes were cytokine levels in peritoneal drain fluid and fatigue as measured by the Identity–Consequence Fatigue Scale (ICFS).

Results

Baseline parameters were similar for 29 patients in the dexamethasone group and 31 in the placebo group. Patients who received dexamethasone had lower ICFS scores on days 3 and 7. Dexamethasone was associated with significantly lower peritoneal fluid interleukin (IL) 6 and IL-13 concentrations on day 1, and these correlated with changes in the ICFS score. There was no significant increase in adverse events in the dexamethasone group.

Conclusion

Preoperative administration of dexamethasone resulted in a significant reduction in early postoperative fatigue, associated with an attenuated early peritoneal cytokine response. Peritoneal production of cytokines may therefore be important in postoperative recovery. Registration number: ACTRN12607000066482 (http://www.anzctr.org.au/).

Gait during hydrokinesitherapy following total hip arthroplasty

PURPOSE

To obtain gait parameters during hydrotherapy (HT) in patients who were referred for rehabilitation after total hip arthroprostheses.

METHOD

The study had a cohort prospective design. Patients who underwent primary total hip arthroplasty (THA) followed a HT rehabilitation program. Twenty-one consecutive patients were enrolled. Five of them dropped out for various reasons, independently of HT. Therefore 16 patients could be evaluated (5 men and 11 women). Sixteen age-matched healthy volunteers were the control subjects. Nine patients had a right THA and 7 a left THA. On average HT duration was 15.7 days (SD 3.8).

RESULTS

The patients presented with a mean speed of 749 meters per hour (SD 146) at the baseline. At the last session the mean speed was 1175 meters per hour (SD 396). The mean stance duration was 1.59 s (SD 0.28) on the operated side and 1.67 (SD 0.27) on the non-operated side. By contrast, the mean swing duration was 1.02 s (SD 0.20) on the operated side and 0.95 s (SD 0.16) on the non-operated side. The differences in balance were statistically significant. The step duration was the same on both sides. At the beginning of HT the stance/swing ratio was 1.62 (SD 0.40) on the operated side, whereas it was 1.74 (SD 0.42) on the non-operated side. In the controls the ratio was 1.45. During HT both values fluctuated but the trend was toward a better coherence over time. At the beginning the mean stride length was 0.484 meters (SD 0.116) and the value became 0.628 (SD 0.131) after 15 training sessions. At the individual level, recovery occurred in a non-linear fashion, but the mean regression line had a coefficient of 27.1 and the intercept was at 560.3.

CONCLUSIONS

The study design permits accurate definition of stride parameters during rehabilitation which allows optimization of the programme. Increase in speed and regain of balance are monitored on a daily basis and they appear as the targets of a HT programme.

Early discharge following hip arthroplasty: patients' acceptance masks doubts and concerns

OBJECTIVE

To describe patients' experience of accelerated discharge after hip arthroplasty in order to test the acceptability to patients of economically driven shortening of post-operative stay.

METHODS

Patients (n = 35) who had received primary total hip replacement up to 12 weeks previously were recruited from two UK orthopaedic units, one of which has pioneered short post-operative stay (3-4 days), and another one of which retains a traditional regimen of discharge after 6-7 days. Patients were interviewed about their experience of care, focusing particularly on their views related to length of stay and with particular attention to patients' well-known tendency to mask critical views of their care. Transcripts were analysed thematically to identify the ways that patients evaluated their care and whether these differed between sites.

RESULTS

Patients were primarily concerned with how attentive and informative hospital staff had been and did not refer to length of stay spontaneously. When prompted about this, they did not question their discharge time, although those in the more traditional unit could not countenance more rapid discharge. Patients in the unit with accelerated discharge described concerns about the consequences of early discharge for them or their family, particularly managing pain and mobility problems at home and needing more support.

CONCLUSIONS

Patients' traditional beliefs about the necessity of prolonged convalescence are not a barrier to early discharge after hip arthroplasty. Nevertheless, some patients' acceptance of early discharge masks doubts and concerns. More intensive post-operative management may be needed if clinical care is not to suffer.

Relationships between fatigue and early postoperative recovery outcomes over time in elderly patients undergoing coronary artery bypass graft surgery

BACKGROUND

Despite successful coronary artery bypass graft (CABG) surgery, some patients continue to experience fatigue after their surgery.

OBJECTIVE

The purpose of this secondary analysis study was to examine the relationships of fatigue and early recovery outcomes (psychosocial and physiologic functioning, and physical activity) over time (6 weeks and 3 months) among older adult subjects, age 65 years and older, after CABG surgery. Comparison groups were those subjects who had fatigue at 3 weeks after surgery and nonfatigued subjects.

DESIGN

A prospective, comparative design was used for this secondary analysis study.

SAMPLE

Subjects in this study were drawn from the control group of subjects enrolled in the larger parent study. Subjects (N = 119) were dichotomized into fatigue (n = 66) and nonfatigued (n = 53) groups on the basis of their 3-week self-reports of postoperative fatigue.

RESULTS

At 6 weeks after surgery, fatigued subjects had significantly (P < .05) more impaired psychosocial functioning (role-emotional [t = 1.9], social [t = 2.6], and mental [t = 1.9] functioning) on the basis of the Medical Outcome Study Short Form 36. They had significantly (P < .005) higher mean hospital anxiety (t = -3.6) and depression (t = -2.9) subscale scores, respectively. Anxiety (t = -2.3, P < .05) remained significantly (P < .05) impaired at 3 months. At 6 weeks, role physical functioning, measured by the Medical Outcome Study Short Form 36, was significantly impaired (t = 2.4, P < .01). There were no significant differences in physical activity variables as measured by an RT3 accelerometer (Stayhealthy, Inc., Monrovia, CA) and self-report diary.

CONCLUSIONS

Persistent fatigue can hamper early recovery after CABG surgery. Tailored interventions are needed to address fatigue management and improve patient outcomes.

Behavioral alterations and severity of pain in cats recovering at home following elective ovariohysterectomy or castration

OBJECTIVE

To identify behavioral alterations in client-owned cats recovering at home following elective ovariohysterectomy or castration and determine owner perceptions regarding severity of postoperative pain.

DESIGN

Cohort study. Animals-145 cats undergoing elective ovariohysterectomy (n = 80) or castration (65) at 4 veterinary clinics in Finland.

PROCEDURES

Owners were asked to complete a questionnaire on their cats' behavior during the 3 days after surgery. Owners were also asked to indicate their perceptions of the severity of postoperative pain during these days by use of a 100-mm visual analog scale.

RESULTS

Owners consistently indicated that there were changes in their cats' behavior, with the most commonly reported alterations being a decrease in overall activity level, an increase in the amount of time spent sleeping, a decrease in playfulness, and altered way of movement. Changes (ie, either an increase or decrease) in aggressive behavior were rare. Median pain score the day of surgery was 15.0 mm for male cats and 25.0 mm for female cats. Behavior score was significantly associated with day of observation, type of surgery (ovariohysterectomy vs castration), owner-assigned pain score, and veterinary clinic.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that behavioral alterations can be detected for several days after surgery in cats recovering at home following ovariohysterectomy or castration and emphasized owner concerns about the existence of postoperative pain.

Minimal access colonic surgery: is it truly minimally invasive?

Laparoscopic colonic surgery has an established role in the management of both benign and malignant conditions. Proposed benefits from laparoscopic surgery include decreased pain, decreased metabolic disturbance to the patient and faster recovery. It is now generally accepted that pro-inflammatory mediators, including cytokines, are to a great extent responsible for the metabolic changes associated with injury and surgery, and that these metabolic changes are related to postoperative recovery. Cytokine levels in the serum are decreased after major laparoscopic colorectal surgery compared with open surgery. However, the cytokine concentration in abdominal drain fluid is the same independent of the size of the incision and these concentrations are far higher than those found in the serum suggesting that the peritoneal would from the surgery itself is more important to metabolic events than the skin wound used to access the abdominal cavity to perform the operation. When looked at critically in programmes where patients are optimally managed perioperatively, there appears to be minimal metabolic benefit from performing a major colonic resection using minimal access surgery. Thus, it appears that the wound is critical when the operation involves only minor peritoneal disruption, such as in laparoscopic cholecystectomy, but when large peritoneal defects are created, such as in major colorectal surgery, then the skin wound becomes irrelevant to metabolism and hence recovery. Thus, minimal access does not necessarily equate to minimal invasion and the terms should not be used interchangeably in the context of laparoscopic colorectal surgery.

Effects of music-based therapy on distress following knee arthroplasty

Anxiety and depression are frequent after total knee arthroplasty (TKA). Musical intervention can benefit many, including severe patients (agitated older people with dementia and terminal-ill patients) and surgical cases. This pilot study was aimed at verifying whether music therapy is beneficial after TKA. Reducing anxiety and depression is has a positive effect for the wellbeing of patients and is likely to have positive effects on outcome. In their pilot study, the authors found that a positive and specific effect of singing on depression was seen and that music therapy may be recommended after TKA instead of a pharmacological intervention.

Self-perceived distress and self-perceived functional recovery after recent total hip and knee arthroplasty

The research was aimed at verifying whether psychological distress and depression are associated to reduced functional improvement following arthroplasty. Thirty-six patients with total knee arthroplasty (TKA) and 36 patients total hip arthroplasty (THA) were enrolled at the beginning of their rehabilitation. The mean age in TKA patients was 71.3+/-7.8 years (S.D.). The mean age in THA patients was 67.9+/-8.4 years. The Western Ontario and MacMasters Universities Osteoarthritis Index (WOMAC) and the Hospital Anxiety and Depression (HAD) were applied. Forty-four percent of THA and 58% of TKA showed over-threshold HAD scores at admission. The proportion was even higher considering HAD-Depression sub-scale, where 55% of THA and 61% of TKA patients had over-threshold scores. Lack of depression prompted better functional outcome in TKA. The effect of depression on TKA functional improvement was still significant after adjusting for age and sex. No association was found for THA patients. In order to maximize rehabilitation benefit it is then suggested that patients with recent TKA intervention are screened for distress and depression at admission and that psychological symptoms are treated if over-threshold.

Salivary cortisol as a predictor of postoperative fatigue

OBJECTIVE

Some patients with chronic fatigue syndrome (CFS) exhibit low basal cortisol levels, but it is not known whether low cortisol is a cause of CFS, predates the onset of CFS symptoms, or is an epiphenomenon caused by the behavioral changes typical of CFS. Because elective surgery is one of the few predictable risk factors for chronic fatigue, in this study, we followed a cohort of surgery patients from before to 6 months after their operation to test these theories.

METHOD

One hundred sixty-one patients completed fatigue questionnaires and provided salivary cortisol samples before undergoing an elective inpatient surgical procedure, and then 2 days, 3 weeks, and 6 months afterward.

RESULTS

Controlling for relevant demographic and surgical variables and for preoperative fatigue, low preoperative cortisol did not predict postoperative fatigue severity on any occasion (p > .05). Similarly, there was no correlation between low postoperative cortisol and postoperative fatigue severity at 3 weeks or 6 months (p > .05). Although 16 patients met our case definition for "chronic fatigue" at the 6-month follow up, low preoperative and low postoperative cortisol did not significantly predict fatigue caseness (p > .05).

CONCLUSIONS

Any association between chronic fatigue and low cortisol would seem to develop after the onset of fatigue symptoms. Low cortisol is therefore unlikely to be the primary cause of chronic fatigue states.

The brain: a psychoneuroimmunological approach

PURPOSE OF REVIEW

An overview is provided that discusses brain dysfunctions in intensive care unit patients in the context of psychoneuroimmunology. Recent findings are discussed within the context of the relationship between behavioural aspects and immune functions. The concept of 'sickness behaviour' is introduced to understand the more differential aspects of stress, fatigue and mood.

RECENT FINDINGS

Psychoneuroimmunology is a relatively new field of study that investigates interactions between behaviour and the immune system, mediated by the nervous system. 'Sickness behaviour' describes behavioural changes or reactions of an (infected) organism to cope with illness. Sickness behaviour should be seen as an adaptation to an infection that also influences the process of recovery or further illness.

SUMMARY

There are plausible explanations of how psychological factors (such as aspects of mood) might influence immunity and immune system-mediated disease. There is substantial evidence that psychological factors can influence both cellular and humoral indicators of immune status and function. There are consistent and convincing reports of links between stress and disease onset and progression.

Anaesthesia, surgery, and challenges in postoperative recovery

Surgical injury can be followed by pain, nausea, vomiting and ileus, stress-induced catabolism, impaired pulmonary function, increased cardiac demands, and risk of thromboembolism. These problems can lead to complications, need for treatment in hospital, postoperative fatigue, and delayed convalescence. Development of safe and short-acting anaesthetics, improved pain relief by early intervention with multimodal analgesia, and stress reduction by regional anaesthetic techniques, beta-blockade, or glucocorticoids have provided important possibilities for enhanced recovery. When these techniques are combined with a change in perioperative care a pronounced enhancement of recovery and decrease in hospital stay can be achieved, even in major operations. The anaesthetist has an important role in facilitating early postoperative recovery by provision of minimally-invasive anaesthesia and pain relief, and by collaborating with surgeons, surgical nurses, and physiotherapists to reduce risk and pain.