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Subramanian H, Knight J, Sultan I, Kaczorowski DJ, Subramaniam K. Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression. Semin Cardiothorac Vasc Anesth 2022; 26:295-303. [PMID: 36189933 DOI: 10.1177/10892532221130922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The concept of "pre-habilitation" comprises screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgeries, but may have profound impacts on outcomes, particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of pre-habilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision-making. In this second part of a two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized at out center for cardiac presurgical care. This second installment will focus on alcohol and smoking cessation and the management of frailty, malnutrition, respiratory disease, and depression.
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Affiliation(s)
- Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, 481457University of Pittsburgh Medical center, Pittsburgh, PA, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, 481457University of Pittsburgh Medical center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Cho JS, Shim JK, Kim KS, Lee S, Kwak YL. Impact of preoperative nutritional scores on 1-year postoperative mortality in patients undergoing valvular heart surgery. J Thorac Cardiovasc Surg 2021; 164:1140-1149.e3. [PMID: 33551075 DOI: 10.1016/j.jtcvs.2020.12.099] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/02/2020] [Accepted: 12/20/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Malnutrition is a well-recognized risk factor for poor prognosis and mortality. We investigated whether preoperative malnutrition diagnosed with objective nutritional scores affects 1-year mortality in patients undergoing valvular heart surgery. METHODS In this retrospective cohort observational study, we evaluated the association among the Controlling Nutritional Status score, Prognostic Nutritional Index, and Geriatric Nutritional Risk Index with 1-year mortality in 1927 patients undergoing valvular heart surgery. We identified factors for mortality using multivariable Cox proportional hazard analysis and investigated the utility of nutritional scores for risk stratification. RESULTS Malnutrition, as identified by a high Controlling Nutritional Status score and low Prognostic Nutritional Index and Geriatric Nutritional Risk Index, was significantly associated with higher 1-year mortality. Kaplan-Meier survival curve showed that mortality significantly increased as the severity of malnutrition increased (log-rank test, P < .001). The predicted discrimination (C-index) was 0.79 with the Controlling Nutritional Status score, 0.77 with the Prognostic Nutritional Index, and 0.73 with the Geriatric Nutritional Risk Index. Each nutritional index (Controlling Nutritional Status; hazard ratio, 1.31, 95% confidence interval, 1.21-1.42, P < .001), the European System for Cardiac Operative Risk Evaluation II (hazard ratio, 1.07, 95% confidence interval, 1.04-1.09, P < .001), and chronic kidney disease (hazard ratio, 2.26, 95% confidence interval, 1.31-3.90, P = .003) were independent risk factors for mortality. The Controlling Nutritional Status score added to the European System for Cardiac Operative Risk Evaluation II significantly increased the predictive discrimination ability for mortality (C-index 0.82, 95% confidence interval, 0.78-0.87, P = .014) compared with the Controlling Nutritional Status or European System for Cardiac Operative Risk Evaluation II alone. CONCLUSIONS Preoperative malnutrition as assessed by objective nutritional scores was associated with 1-year mortality after valvular heart surgery. The Controlling Nutritional Status score had the highest predictive ability and, when added to the European System for Cardiac Operative Risk Evaluation II, provided more accurate risk stratification.
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Affiliation(s)
- Jin Sun Cho
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Sub Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sugeun Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Lopez-Delgado JC, Muñoz-del Rio G, Flordelís-Lasierra JL, Putzu A. Nutrition in Adult Cardiac Surgery: Preoperative Evaluation, Management in the Postoperative Period, and Clinical Implications for Outcomes. J Cardiothorac Vasc Anesth 2019; 33:3143-3162. [DOI: 10.1053/j.jvca.2019.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 04/05/2019] [Accepted: 04/07/2019] [Indexed: 02/07/2023]
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McCann M, Stamp N, Ngui A, Litton E. Cardiac Prehabilitation. J Cardiothorac Vasc Anesth 2019; 33:2255-2265. [DOI: 10.1053/j.jvca.2019.01.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 02/06/2023]
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Stoppe C, Goetzenich A, Whitman G, Ohkuma R, Brown T, Hatzakorzian R, Kristof A, Meybohm P, Mechanick J, Evans A, Yeh D, McDonald B, Chourdakis M, Jones P, Barton R, Tripathi R, Elke G, Liakopoulos O, Agarwala R, Lomivorotov V, Nesterova E, Marx G, Benstoem C, Lemieux M, Heyland DK. Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:131. [PMID: 28583157 PMCID: PMC5460477 DOI: 10.1186/s13054-017-1690-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/02/2017] [Indexed: 12/25/2022]
Abstract
Nutrition support is a necessary therapy for critically ill cardiac surgery patients. However, conclusive evidence for this population, consisting of well-conducted clinical trials is lacking. To clarify optimal strategies to improve outcomes, an international multidisciplinary group of 25 experts from different clinical specialties from Germany, Canada, Greece, USA and Russia discussed potential approaches to identify patients who may benefit from nutrition support, when best to initiate nutrition support, and the potential use of pharmaco-nutrition to modulate the inflammatory response to cardiopulmonary bypass. Despite conspicuous knowledge and evidence gaps, a rational nutritional support therapy is presented to benefit patients undergoing cardiac surgery.
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Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Andreas Goetzenich
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital, RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Glenn Whitman
- Cardiac Surgical Intensive Care, Johns Hopkins Hospital Baltimore, Blalock 618, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Rika Ohkuma
- Cardiac Surgical Intensive Care, Johns Hopkins Hospital Baltimore, Blalock 618, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Trish Brown
- Cardiac Surgical Intensive Care, Johns Hopkins Hospital Baltimore, Blalock 618, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Roupen Hatzakorzian
- Department of Anesthesia, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
| | - Arnold Kristof
- Department of Microbiology and Immunology, McGill University Health Centre, Montreal, Canada
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Jefferey Mechanick
- Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adam Evans
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Bernard McDonald
- Division of Cardiac Anesthesiology and Critical Care Medicine, University of Ottawa Heart Institute, Ruskin Street H2410, Ottawa, ON, K1Y 4W7, Canada
| | - Michael Chourdakis
- Department of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki, 54124, Greece
| | - Philip Jones
- Departments of Anesthesia & Perioperative Medicine and Epidemiology & Biostatistics, University of Western Ontario, London, Canada
| | - Richard Barton
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ravi Tripathi
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 12, 24105, Kiel, Germany
| | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | - Ravi Agarwala
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Ekaterina Nesterova
- Department of Anesthesiology and Intensive Care Medicine, National Pirogov Surgical Medical Center, Moscow, Russia
| | - Gernot Marx
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Carina Benstoem
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital, RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Margot Lemieux
- Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Angada 4, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Angada 4, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 941] [Impact Index Per Article: 134.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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Abstract
BACKGROUND Randomized controlled trials demonstrate the efficacy of arginine-enriched nutritional supplements (immunonutrition) in reducing complications after surgery. The effectiveness of preoperative immunonutrition has not been evaluated in a community setting. OBJECTIVE This study aims to determine whether immunonutrition before elective colorectal surgery improves outcomes in the community at large. DESIGN This is a prospective cohort study with a propensity score-matched comparative effectiveness evaluation. SETTINGS This study was conducted in Washington State hospitals in the Surgical Care Outcomes Assessment Program from 2012 to 2015. PATIENTS Adults undergoing elective colorectal surgery were selected. INTERVENTIONS Surgeons used a preoperative checklist that recommended that patients take oral immunonutrition (237 mL, 3 times daily) for 5 days before elective colorectal resection. MAIN OUTCOME MEASURES Serious adverse events (infection, anastomotic leak, reoperation, and death) and prolonged length of stay were the primary outcomes measured. RESULTS Three thousand three hundred seventy-five patients (mean age 59.9 ± 15.2 years, 56% female) underwent elective colorectal surgery. Patients receiving immunonutrition more commonly were in a higher ASA class (III-V, 44% vs 38%; p = 0.01) or required an ostomy (18% vs 14%; p = 0.02). The rate of serious adverse events was 6.8% vs 8.3% (p = 0.25) and the rate of prolonged length of stay was 13.8% vs 17.3% (p = 0.04) in those who did and did not receive immunonutrition. After propensity score matching, covariates were similar among 960 patients. Although differences in serious adverse events were nonsignificant (relative risk, 0.76; 95% CI, 0.49-1.16), prolonged length of stay (relative risk, 0.77; 95% CI, 0.58-1.01 p = 0.05) was lower in those receiving immunonutrition. LIMITATIONS Patient compliance with the intervention was not measured. Residual confounding, including surgeon-level heterogeneity, may influence estimates of the effect of immunonutrition. CONCLUSIONS Reductions in prolonged length of stay, likely related to fewer complications, support the use of immunonutrition in quality improvement initiatives related to elective colorectal surgery. This population-based study supports previous trials of immunonutrition, but shows a lower magnitude of benefit, perhaps related to compliance or a lower rate of adverse events, highlighting the value of community-based assessments of comparative effectiveness.
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New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. THE LANCET. INFECTIOUS DISEASES 2016; 16:e276-e287. [PMID: 27816413 DOI: 10.1016/s1473-3099(16)30398-x] [Citation(s) in RCA: 452] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/27/2016] [Accepted: 09/13/2016] [Indexed: 12/13/2022]
Abstract
Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.
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Bharadwaj S, Trivax B, Tandon P, Alkam B, Hanouneh I, Steiger E. Should perioperative immunonutrition for elective surgery be the current standard of care? Gastroenterol Rep (Oxf) 2016; 4:87-95. [PMID: 27081153 PMCID: PMC4863194 DOI: 10.1093/gastro/gow008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/23/2016] [Indexed: 12/22/2022] Open
Abstract
Postoperative infectious complications are independently associated with increased hospital length of stay (LOS) and cost and contribute to significant inpatient morbidity. Many strategies such as avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, metabolic control and early mobilization have been used to either prevent or reduce the incidence of postoperative infections. Despite these efforts, it remains a big challenge to our current healthcare system to mitigate the cost of postoperative morbidity. Furthermore, preoperative nutritional status has also been implicated as an independent risk factor for postoperative morbidity. Perioperative nutritional support using enteral and parenteral routes has been shown to decrease postoperative morbidity, especially in high-risk patients. Recently, the role of immunonutrition (IMN) in postoperative infectious complications has been studied extensively. These substrates have been found to positively modulate postsurgical immunosuppression and inflammatory responses. They have also been shown to be cost-effective by decreasing both tpostoperative infectious complications and hospital LOS. In this review, we discuss the postoperative positive outcomes associated with the use of perioperative IMN, their cost-effectiveness, current guidelines and future clinical implications.
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Affiliation(s)
- Shishira Bharadwaj
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Brandon Trivax
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Parul Tandon
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Bilal Alkam
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ibrahim Hanouneh
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ezra Steiger
- Center for Human Nutrition, the Cleveland Clinic Foundation, Cleveland, OH, USA
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Ettema R, Schuurmans MJ, Schutijser B, van Baar M, Kamphof N, Kalkman CJ. Feasibility of a nursing intervention to prepare frail older patients for cardiac surgery: a mixed-methods study. Eur J Cardiovasc Nurs 2014; 14:342-51. [PMID: 24821716 DOI: 10.1177/1474515114535511] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 04/22/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Given the growing number of vulnerable, older cardiac surgery patients, the preadmission PREvention Decline in Older Cardiac Surgery patients (PREDOCS) programme was developed to reduce the incidence of postoperative complications. Before the clinical effects of such a complex multicomponent intervention can be evaluated, the feasibility needs to be determined to detect possible problems with the acceptability, compliance and delivery. AIM The purpose of this study was to test the PREDOCS programme on its feasibility and estimate theoretical cost savings. METHODS In a mixed-methods multicentre study, the Medical Research Council (MRC) guidelines concerning testing feasibility were followed, and theoretical cost savings were calculated. We used data from interviews and the continuous data registry at three hospitals. The results were reported following the criteria for reporting the feasibility of complex interventions (CReDECI). RESULTS Twenty-one females and 49 males out of 114 eligible patients completed the intervention and provided full data. Patients were equally satisfied with the usual care and the PREDOCS programme (satisfaction rate respectively standard deviation (SD): 7.5 (95% confidence interval (CI): 6.4-8.7) and 7.6 (6.6-8.6)). The involved nurses were satisfied with the tools for guiding patients to reduce their risk of postoperative complications and considered the PREDOCS programme as complementary to usual care. Integrating PREDOCS into current hospital structures appeared to be difficult. Both patients and nurses indicated that the additional consult was tiresome for the patient. The PREDOCS programme will be cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients. CONCLUSIONS The PREDOCS programme is acceptable for patients and nurses but should be built into the hospital's cardiac surgery pathway or applied in home care.
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Affiliation(s)
- Roelof Ettema
- Faculty of Health Care, University of Applied Science Utrecht, The Netherlands University Medical Centre Utrecht, The Netherlands
| | - Marieke J Schuurmans
- Faculty of Health Care, University of Applied Science Utrecht, The Netherlands University Medical Centre Utrecht, The Netherlands
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Ettema RGA, Hoogendoorn ME, Kalkman CJ, Schuurmans MJ. Development of a nursing intervention to prepare frail older patients for cardiac surgery (the PREDOCS programme), following phase one of the guidelines of the Medical Research Council. Eur J Cardiovasc Nurs 2013; 13:494-505. [DOI: 10.1177/1474515113511715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In older patients undergoing elective cardiac surgery, the timely identification and preparation of patients at risk for frequent postoperative hospital complications provide opportunities to reduce the risk of these complications. Aims: We developed an evidence-based, multi-component nursing intervention (Prevention of Decline in Older Cardiac Surgery Patients; the PREDOCS programme) for application in the preadmission period to improve patients’ physical and psychosocial condition to reduce their risk of postoperative complications. This paper describes in detail the process used to design and develop this multi-component intervention. Methods: In a team of researchers, experts, cardiac surgeons, registered cardiac surgery nurses, and patients, the revised guidelines for developing and evaluating complex interventions of the Medical Research Council (MRC) were followed, including identifying existing evidence, identifying and developing theory and modelling the process and outcomes. Additionally, the criteria for reporting the development of complex interventions in healthcare (CReDECI) were followed. Results: The intervention is administered during a consultation by the nurse two to four weeks before the surgery procedure. The consultation includes three parts: a general part for all patients, a second part in which patients with an increased risk are identified, and a third part in which selected patients are informed about how to prepare themselves for the hospital admission to reduce their risk. Conclusions: Following the MRC guidelines, an extended, stepwise, multi-method procedure was used to develop the multi-component nursing intervention to prepare older patients for cardiac surgery, creating transparency in the assumed working mechanisms. Additionally, a detailed description of the intervention is provided.
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Affiliation(s)
- Roelof GA Ettema
- University of Applied Science Utrecht, Faculty of Health Care, The Netherlands
- University Medical Centre Utrecht, The Netherlands
| | | | | | - Marieke J Schuurmans
- University of Applied Science Utrecht, Faculty of Health Care, The Netherlands
- University Medical Centre Utrecht, The Netherlands
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Miller KR, Wischmeyer PE, Taylor B, McClave SA. An Evidence-Based Approach to Perioperative Nutrition Support in the Elective Surgery Patient. JPEN J Parenter Enteral Nutr 2013; 37:39S-50S. [DOI: 10.1177/0148607113493928] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Keith R. Miller
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Paul E. Wischmeyer
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora
| | | | - Stephen A. McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
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McClave SA, Kozar R, Martindale RG, Heyland DK, Braga M, Carli F, Drover JW, Flum D, Gramlich L, Herndon DN, Ko C, Kudsk KA, Lawson CM, Miller KR, Taylor B, Wischmeyer PE. Summary Points and Consensus Recommendations From the North American Surgical Nutrition Summit. JPEN J Parenter Enteral Nutr 2013; 37:99S-105S. [DOI: 10.1177/0148607113495892] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | - Daren K. Heyland
- Kingston General Hospital, Queens University, Kingston, Ontario, Canada
| | | | | | - John W. Drover
- Kingston General Hospital, Queens University, Kingston, Ontario, Canada
| | | | - Leah Gramlich
- Royal Alexandra Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | - Clifford Ko
- UCLA School of Medicine, Los Angeles, California
| | | | | | | | - Beth Taylor
- Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
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Ettema RGA, Van Koeven H, Peelen LM, Kalkman CJ, Schuurmans MJ. Preadmission interventions to prevent postoperative complications in older cardiac surgery patients: a systematic review. Int J Nurs Stud 2013; 51:251-60. [PMID: 23796313 DOI: 10.1016/j.ijnurstu.2013.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 05/15/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE(S) The literature on postoperative complications in cardiac surgery patients shows high incidences of postoperative complications such as delirium, depression, pressure ulcer, infection, pulmonary complications and atrial fibrillation. These complications are associated with functional and cognitive decline and a decrease in the quality of life after discharge. Several studies attempted to prevent one or more postoperative complications by preoperative interventions. Here we provide a comprehensive overview of both single and multiple component preadmission interventions designed to prevent postoperative complications. METHODS We systematically reviewed the literature following the PRISMA statement guidelines. RESULTS Of 1335 initial citations, 31 were subjected to critical appraisal. Finally, 23 studies were included, of which we derived a list of interventions that can be applied in the preadmission period to effectively reduce postoperative depression, infection, pulmonary complications, atrial fibrillation, prolonged intensive care unit stay and hospital stay in older elective cardiac surgery patients. No high quality studies were found describing effective interventions to prevent postoperative delirium. We did not find studies specifically targeting the prevention of pressure ulcers in this patient population. CONCLUSIONS Multi-component approaches that include different single interventions have the strongest effect in preventing postoperative depression, pulmonary complications, prolonged intensive care unit stay and hospital stay. Postoperative infection can be best prevented by disinfection with chlorhexidine combined with immune-enhancing nutritional supplements. Atrial fibrillation might be prevented by ingestion of N-3 polyunsaturated fatty acids. High quality studies are urgently needed to evaluate preadmission preventive strategies to reduce postoperative delirium or pressure ulcers in older elective cardiac surgery patients.
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Affiliation(s)
- Roelof G A Ettema
- Nursing and Paramedical Care for People With Chronic Illnesses, University of Applied Science Utrecht, Faculty of Health Care, Bolognalaan 101, 3584 CJ Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, Department of Epidemiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Heleen Van Koeven
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Linda M Peelen
- Julius Center for Health Sciences and Primary Care, Department of Epidemiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Cor J Kalkman
- Professor of Anesthesiology, Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marieke J Schuurmans
- Nursing and Paramedical Care for People With Chronic Illnesses, University of Applied Science Utrecht, Faculty of Health Care, Bolognalaan 101, 3584 CJ Utrecht, The Netherlands; Professor of Nursing Science, Department of Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Giger-Pabst U, Lange J, Maurer C, Bucher C, Schreiber V, Schlumpf R, Kocher T, Schweizer W, Krähenbühl S, Krähenbühl L. Short-term preoperative supplementation of an immunoenriched diet does not improve clinical outcome in well-nourished patients undergoing abdominal cancer surgery. Nutrition 2013; 29:724-9. [PMID: 23352174 DOI: 10.1016/j.nut.2012.10.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 10/13/2012] [Accepted: 10/13/2012] [Indexed: 01/14/2023]
Abstract
OBJECTIVE A recent study suggested that the anti-inflammatory effect of immunonutrition starts after only two d. We therefore investigated the effect of an immunoenriched oral diet administered for three d preoperatively. METHODS In this prospective, randomized, double-blind, placebo-controlled study, well-nourished patients (Nutrition Risk Screening 2002 <3) with gastrointestinal cancer who were scheduled for major elective abdominal cancer surgery were randomly assigned to either 750 mL of an immunoenriched formula (IEF group) or 750 mL of an isocaloric, isonitrogenous placebo diet (Con group) for 3 consecutive d preoperatively. RESULTS A total of 108 patients (IEF group: n = 55; Con group: n = 53) were randomized. The two groups were comparable for all baseline and surgical characteristics. The overall mortality was 2.8% and not significantly different between the two groups (IEF group: 3.6% vs. Con group: 1.9%, P = 1.00). Intention-to-treat analysis showed no difference for the incidence of postoperative overall (IEF group: 29% vs. Con group: 30%; P = 1.00) and infectious (IEF group: 15% vs. Con group: 17%; P = 0.79) complications. Length of hospital stay was 12 ± 4.9 d in the IEF group and 11.6 ± 5.3 d in the Con group (P = 0.68). CONCLUSIONS Preoperative oral supplementation with an immunoenriched diet for 3 d preoperatively did not improve postoperative outcome compared with the placebo in well-nourished patients with elective gastrointestinal cancer surgery.
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Affiliation(s)
- Urs Giger-Pabst
- Department of Surgery, Marienhospital Herne, Clinic of the Ruhr University Bochum, Germany.
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Petrat F, Boengler K, Schulz R, de Groot H. Glycine, a simple physiological compound protecting by yet puzzling mechanism(s) against ischaemia-reperfusion injury: current knowledge. Br J Pharmacol 2012; 165:2059-72. [PMID: 22044190 DOI: 10.1111/j.1476-5381.2011.01711.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Ischaemia is amongst the leading causes of death. Despite this importance, there are only a few therapeutic approaches to protect from ischaemia-reperfusion injury (IRI). In experimental studies, the amino acid glycine effectively protected from IRI. In the prevention of IRI by glycine in cells and isolated perfused or cold-stored organs (tissues), direct cytoprotection plays a crucial role, most likely by prevention of the formation of pathological plasma membrane pores. Under in vivo conditions, the mechanism of protection by glycine is less clear, partly due to the physiological presence of the amino acid. Here, inhibition of the inflammatory response in the injured tissue is considered to contribute decisively to the glycine-induced reduction of IRI. However, attenuation of IRI recently achieved in experimental animals by low-dose glycine treatment regimens suggests additional/other (unknown) protective mechanisms. Despite the convincing experimental evidence and the large therapeutic width of glycine, there are only a few clinical trials on the protection from IRI by glycine with ambivalent results. Thus, both the mechanism(s) behind the protection of glycine against IRI in vivo and its true clinical potential remain to be addressed in future experimental studies/clinical trials.
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Affiliation(s)
- Frank Petrat
- Institut für Physiologische Chemie, Universitätsklinikum Essen, Essen, Germany
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Zhong X, Li X, Qian L, Xu Y, Lu Y, Zhang J, Li N, Zhu X, Ben J, Yang Q, Chen Q. Glycine attenuates myocardial ischemia-reperfusion injury by inhibiting myocardial apoptosis in rats. J Biomed Res 2012; 26:346-54. [PMID: 23554770 PMCID: PMC3613731 DOI: 10.7555/jbr.26.20110124] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 11/23/2011] [Accepted: 02/21/2012] [Indexed: 11/03/2022] Open
Abstract
Glycine is a well-documented cytoprotective agent. However, whether it has a protective effect against myocardial ischemia-reperfusion injury in vivo is still unknown. By using an open-chest anesthetized rat model, we found that glycine reduced the infarct size by 21% in ischemia-reperfusion injury rats compared with that in the vehicle-treated MI/R rats. The left ventricular ejection fraction and fractional shortening were increased by 19.11% and 30.98%, respectively, in glycine-treated rats. The plasma creatine kinase levels in ischemia-reperfusion injury rats decreased following glycine treatment. Importantly, administration of glycine significantly inhibited apoptosis in post-ischemia-reperfusion myocardium, which was accompanied by suppression of phosphorylated p38 mitogen-activated protein kinase and c-Jun NH2-terminal kinase, as well as the Fas ligand. These results suggest that glycine attenuates myocardial ischemia-reperfusion injury in vivo by inhibiting cardiomyocytes apoptosis.
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Affiliation(s)
- Xiaozheng Zhong
- Atherosclerosis Research Center, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev 2012; 11:278-96. [PMID: 22212388 DOI: 10.1016/j.arr.2011.12.008] [Citation(s) in RCA: 252] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/04/2011] [Accepted: 12/14/2011] [Indexed: 12/16/2022]
Abstract
Disease-related malnutrition is common, detrimentally affecting the patient and healthcare economy. Although use of high protein oral nutritional supplements (ONS) has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness, there is a lack of systematically obtained evidence to support these recommendations. This systematic review involving 36 randomised controlled trials (RCT) (n=3790) (mean age 74 years; 83% of trials in patients >65 years) and a series of meta-analyses of high protein ONS (>20% energy from protein) demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group. These included reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830); reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546); improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219); increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001). There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein). The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits, with economic implications.
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Affiliation(s)
- A L Cawood
- Institute of Human Nutrition, University of Southampton, UK.
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Abstract
The concept of hormesis, or low-dose U-shaped responses, is now well established in toxicology and pharmacology but requires development in medicine and therapeutics. In doing so, care must be taken to not confuse metaphorical and chemical uses of the term hormesis. Low dose, continuous adaptive responses are fundamentally different than conventional pharmacology, and they may improve the scientific underpinning for complementary medicine, nutrition and lifestyle therapies.
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Doig GS, Simpson F, Sweetman EA. Evidence-based nutrition support in the intensive care unit: an update on reported trial quality. Curr Opin Clin Nutr Metab Care 2009; 12:201-6. [PMID: 19202392 DOI: 10.1097/mco.0b013e32832182b0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Meta-epidemiological reviews report that trials of nutritional support in critical illness rarely fulfil basic quality requirements, with overall quality rated as 'worse than poor'. This update reviews recently published trials to determine whether current evidence meets or exceeds basic quality requirements. RECENT FINDINGS Although recent trials were significantly more likely to report blinding, there is a concerning trend towards a decrease in overall trial quality. Many recent trials fail to report the use of 'any' of three key validity criteria: use of blinding, presentation of intention-to-treat analysis and the maintenance allocation concealment. SUMMARY Future researchers must improve the quality with which trials are conducted and reported. Submitting a clinical trial to an approved registry prior to enrolling patients provides transparency of conduct. Investigators must ensure that an intention-to-treat analysis is reported, especially when a subset efficacy analysis is presented, even if the intention-to-treat analysis requires imputing missing data values. Investigators also need to improve reporting details concerning allocation concealment and blinding. Finally, until investigators, editors and reviewers embrace these measures, we strongly recommend that readers should become familiar with the appropriate evidence-based medicine users' guides so that they can base clinical decisions on valid studies.
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Affiliation(s)
- Gordon S Doig
- Northern Clinical School, University of Sydney, Sydney, Australia.
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Bibliography. Current world literature. Nutrition and metabolism. Curr Opin Lipidol 2009; 20:63-72. [PMID: 19106709 DOI: 10.1097/mol.0b013e32832402a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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