1
|
Fuller BM, Driver BE, Roberts MB, Schorr CA, Thompson K, Faine B, Yeary J, Mohr NM, Pappal RD, Stephens RJ, Yan Y, Johnson NJ, Roberts BW. Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial. Trials 2023; 24:753. [PMID: 38001507 PMCID: PMC10675941 DOI: 10.1186/s13063-023-07764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP. METHODS This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat. DISCUSSION The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.
Collapse
Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, 63110, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, 55415, USA
| | - Michael B Roberts
- Department of Institutional Research, Department of Psychology, Philadelphia College of Osteopathic Medicine, Rowland Hall, 514B, 4190 City Avenue, Philadelphia, PA, 19131, USA
| | - Christa A Schorr
- Cooper Research Institute, Cooper University Health Care, One Cooper Plaza, Dorrance, Camden, NJ, 08103, USA
| | - Kathryn Thompson
- Department of Emergency Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes-Jewish Hospital, 1 Barnes Jewish Hospital Plaza, St. Louis, MO, 63110, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA
| | - Ryan D Pappal
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Robert J Stephens
- Department of Medicine, Division of Critical Care Medicine, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, 418E, 2Nd Floor, 600 South Taylor Ave., St. Louis, MO, 63110, USA
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, K152, Camden, NJ, 08103, USA
| |
Collapse
|
2
|
Miller RL, Barnes JD, Mouton R, Braude P, Hinchliffe R. Comprehensive geriatric assessment (CGA) in perioperative care: a systematic review of a complex intervention. BMJ Open 2022; 12:e062729. [PMID: 36270763 PMCID: PMC9594523 DOI: 10.1136/bmjopen-2022-062729] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Comprehensive geriatric assessment (CGA) is a complex intervention applied to older people with evidence of benefit in medical populations. The aim of this systematic review was to describe how CGA is applied to surgical populations in randomised controlled trials. This will provide a basis for design of future studies focused on optimising CGA as a complex intervention. SETTING A systematic review of randomised controlled trials. PARTICIPANTS A systematic search was performed for studies of CGA in the perioperative period across Ovid MEDLINE, Ovid EMBASE, CINAHL and Cochrane CENTRAL, from inception to March 2021. INTERVENTIONS Any randomised controlled trials of perioperative CGA versus 'standard care' were included. OUTCOME MEASURES Qualitative description of CGA. RESULTS 12 121 titles and abstracts were screened, 68 full-text articles were assessed for eligibility and 22 articles included, reporting on 13 trials. 10 trials focused on inpatients with hip fracture, with 7 of these delivering CGA on a geriatric medicine ward, 3 on a surgical ward. The remaining three trials were in elective general surgery all delivering CGA on a surgical ward. CGA components, duration of intervention and personnel delivering the intervention were highly variable across the different studies. Trials favoured postoperative delivery of CGA (11/13). Only four trials reported data on adherence to the CGA intervention. CONCLUSIONS CGA as an intervention is variably described and delivered in randomised controlled trials in the perioperative setting. The reporting of both the intervention and standard care is often poor with little focus on adherence. Future research should focus on clearly defining and standardising the intervention as well as measuring adherence within trials. PROSPERO REGISTRATION NUMBER CRD42020221797.
Collapse
Affiliation(s)
- Rachael Lucia Miller
- Translational Health Sciences, University of Bristol, Bristol, UK
- Vascular Surgery, North Bristol NHS Trust, Bristol, England
| | | | - Ronelle Mouton
- Translational Health Sciences, University of Bristol, Bristol, UK
- Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - Philip Braude
- CLARITY (Collaborate Ageing Research) group, North Bristol NHS Trust, Bristol, UK
| | - Robert Hinchliffe
- Translational Health Sciences, University of Bristol, Bristol, UK
- Vascular Surgery, North Bristol NHS Trust, Bristol, England
| |
Collapse
|
3
|
Lee KM, Ma X, Yang GM, Cheung YB. Inclusion of unexposed clusters improves the precision of fixed effects analysis of stepped‐wedge cluster randomized trials. Stat Med 2022; 41:2923-2938. [DOI: 10.1002/sim.9394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 11/12/2022]
Affiliation(s)
| | - Xiangmei Ma
- Centre for Quantitative Medicine Duke‐NUS Medical School Singapore
| | - Grace Meijuan Yang
- Division of Supportive and Palliative Care National Cancer Centre Singapore Singapore
- Lien Centre for Palliative Care Duke‐NUS Medical School Singapore
| | - Yin Bun Cheung
- Centre for Quantitative Medicine Duke‐NUS Medical School Singapore
- Signature Programme in Health Services & Systems Research Duke‐NUS Medical School Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research Tampere University Tampere Finland
| |
Collapse
|
4
|
Wang Y, Zhao L, Zhang C, An Q, Guo Q, Geng J, Guo Z, Guan Z. Identification of risk factors for postoperative delirium in elderly patients with hip fractures by a risk stratification index model: A retrospective study. Brain Behav 2021; 11:e32420. [PMID: 34806823 PMCID: PMC8671782 DOI: 10.1002/brb3.2420] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/29/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Postoperative delirium is one of the most common and dangerous psychiatric complications after hip surgery. The aim of this study was to investigate the incidence of postoperative delirium in elderly patients after hip fracture surgery and to identify risk factors for such, as part of developing a risk stratification index (RSI) system to predict a patient's risk of postoperative delirium. METHODS Elderly patients (aged 65 years or older) with hip fractures who had received surgical treatment in our hospital between March 2018 and December 2019 were retrospectively included. Clinical data were collected, and multivariate logistic regression analysis was performed to investigate the relevant risk factors of postoperative delirium. An RSI system was developed based on factors identified in the regression analysis. RESULTS Of 272 patients included, 52 (19.12%) experienced postoperative delirium. Drinking history (> 3/ week), the perioperative lactic acid level (Lac > 2 mmol/L), postoperative visual analog score (VAS) > 3, American Society of Anesthesiologists (ASA) physical status > II, application of the bispectral index, and preoperative diabetes were independent risk factors of postoperative delirium. When RSI ≥ 5, the rate of postoperative delirium significantly increased (p < .05). CONCLUSION The RSI system developed here can safely guide postoperative outcomes of elderly patients with hip fractures, and RSI ≥ 5 may be able to predict the onset of postoperative delirium.
Collapse
Affiliation(s)
- Ye Wang
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Lin Zhao
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Changsheng Zhang
- The Anesthesia and Operation Center, The First Medical Center, The Medical School of Chinese PLA, Beijing, China
| | - Qi An
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Qianqian Guo
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Jie Geng
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Zhenggang Guo
- The Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - Zhengpeng Guan
- The Department of Orthopedics, Peking University Shougang Hospital, Beijing, China
| |
Collapse
|
5
|
Burton JK, Craig L, Yong SQ, Siddiqi N, Teale EA, Woodhouse R, Barugh AJ, Shepherd AM, Brunton A, Freeman SC, Sutton AJ, Quinn TJ. Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2021; 11:CD013307. [PMID: 34826144 PMCID: PMC8623130 DOI: 10.1002/14651858.cd013307.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU). SEARCH METHODS We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium. DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium. MAIN RESULTS We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies. Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain. Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias). There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision). No studies of multicomponent interventions reported data on new diagnoses of dementia. Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited. Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm. Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial. Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias). Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.
Collapse
Affiliation(s)
- Jennifer K Burton
- Academic Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Shun Qi Yong
- MVLS, College of Medicine and Veterinary Life Sciences, University of Glasgow, Glasgow, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
| | - Elizabeth A Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | | | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
6
|
Impact of Tobacco Smoking on Outcomes After Posterior Decompression Surgery in Patients With Cervical Spondylotic Myelopathy: A Retrospective Multicenter Study. Clin Spine Surg 2020; 33:E493-E498. [PMID: 33000929 DOI: 10.1097/bsd.0000000000000984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a case-control study. OBJECTIVE The objective of this study was to clarify the surgical outcomes after cervical posterior decompression in patients who smoked. SUMMARY OF BACKGROUND DATA Smoking is associated with poor outcomes in the field of spinal surgery. However, the impact of tobacco smoking on the outcomes after posterior decompression surgery has not been fully evaluated in patients with cervical spondylotic myelopathy. MATERIALS AND METHODS In this retrospective multicenter study, 587 patients with cervical spondylotic myelopathy were enrolled at 17 institutions in Japan. Patients underwent cervical laminoplasty or laminectomy and were followed up for at least 1 year after surgery. Outcome measures were: preoperative smoking status, perioperative complications, the Japanese Orthopedic Association scale, and the Visual Analog Scale for neck pain. After adjusting for age and sex by exact matching, smoking and nonsmoking groups were compared using an unpaired t test for continuous variables or a χ test for categorical variables. RESULTS There were 182 (31%) current smokers and 405 (69%) nonsmokers including previous smokers. After matching, 158 patients were extracted from each group. Demographic data and surgical information were almost the same between the groups. Regarding postoperative complications, there was no significant difference in the rate of surgical site infection, cerebrospinal fluid leakage, hematoma, segmental motor paralysis, or neurological deficit. However, smokers showed a significantly higher risk for delirium (3.8% vs. 0.0%, P=0.039). Smokers and nonsmokers showed comparable changes in functional recovery according to Japanese Orthopedic Association scores (3.2±2.1 vs. 3.0±2.1, P=0.425) and in neck pain reduction using the Visual Analog Scale (-1.7±3.1 vs. -1.4±2.8, P=0.417) at the final follow-up. CONCLUSIONS Smokers exhibited functional restoration and neck pain reduction after cervical posterior decompression. Attention is required, however, for the postoperative complication of delirium, which could be caused by the acute cessation of tobacco smoking after admission. LEVEL OF EVIDENCE Level III.
Collapse
|
7
|
Emergency Surgery and Male Gender Are Risk Factors of Postoperative Delirium After General or Gastrointestinal Surgery in Elderly Patients: A Multicenter Cohort Study. Int Surg 2020. [DOI: 10.9738/intsurg-d-16-00112.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
The aim of this study was to investigate the incidence and risk factors of postoperative delirium (PD) in elderly patients after general or gastrointestinal surgery.
Summary of background data
Societies worldwide are rapidly aging, and the number of surgeries in elderly patients has been increasing. PD, which adversely influences postoperative course, has thus become more common.
Methods
The Surgery and Anesthesia Network Group of the National Hospital Organization in Japan conducted this retrospective cohort study of patients older than 70 years of age who underwent general or gastrointestinal surgery.
Results
A total of 219 patients from 9 participating institutes underwent surgery between July 2013 and August 2014. We excluded 2 patients who died within 2 weeks after surgery. Of the remaining 217 cases, 31 (14.3%) developed PD. These patients were older (80 versus 76 years, P = 0.013), more likely to be male (74.2 versus 54.8%, P = 0.039), and had higher American Society of Anesthesia Physical Status scores than those without PD. Emergency surgery was more common than elective surgery in the PD group (41.9 versus 10.2%, P < 0.0001). Multivariate analysis showed that male gender (odds ratio, 3.31; 95% confidence interval, 1.32 to 9.39; P = 0.0098) and emergency surgery (odds ratio, 7.47; 95% confidence interval, 2.79 to 20.83; P < 0.0001) were independent risk factors of PD.
Conclusions
The incidence of PD was high in male patients and those undergoing emergency surgery. Effective interventions in these groups will be necessary to improve treatment outcomes in elderly patients.
Collapse
|
8
|
Kobayashi K, Imagama S, Sato K, Kato F, Kanemura T, Yoshihara H, Sakai Y, Shinjo R, Hachiya Y, Osawa Y, Matsubara Y, Ando K, Nishida Y, Ishiguro N. Postoperative Complications Associated With Spine Surgery in Patients Older Than 90 Years: A Multicenter Retrospective Study. Global Spine J 2018; 8:887-891. [PMID: 30560042 PMCID: PMC6293421 DOI: 10.1177/2192568218767430] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN A review of a prospective database. OBJECTIVES Surgery for elderly patients is increasing yearly due to aging of society and the desire for higher quality of life. The goal of the study was to examine perioperative complications in spine surgery in such patients. METHODS A multicenter study of surgical details and perioperative complications was performed in 35 patients aged older than 90 years who underwent spinal surgery, based on a review of a prospective database. The frequency and severity of complications were assessed, and the effects of patient-specific and surgical factors were examined. Major complications were defined as those that were life threatening, required reoperation in the perioperative period or left a permanent injury. Ambulatory function before and after surgery was also analyzed. RESULTS Perioperative complications occurred in 19 of the 35 cases (54%), and included 11 cases of postoperative delirium, most of which occurred after cervical spine surgery. There were 8 major complications (23%), including cerebral infarction (n = 3), coronary heart disease (n = 3), pulmonary embolism (n = 1), and angina (n = 1). Preoperative motor deficit, operative time, estimated blood loss, and instrumented fusion were significantly associated with major complications. An improved postoperative ambulatory status occurred in 61% of cases, with no change in 33%, and worsening in 2 cases (6%). CONCLUSIONS Timing of surgery before paralysis progression and reduced surgical invasiveness are important considerations in treatment of the very elderly. Improved outcomes can be obtained with better management of spine surgery for patients aged 90 years or older.
Collapse
Affiliation(s)
| | - Shiro Imagama
- Nagoya University Graduate School of Medicine, Nagoya, Japan,Shiro Imagama, Department of Orthopedic
Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward,
Aichi 466-8550, Japan.
| | - Koji Sato
- Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | | | | | | | - Yoshihito Sakai
- National Center for Geriatrics and Gerontology, Aichi, Japan
| | | | | | | | | | - Kei Ando
- Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Naoki Ishiguro
- Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
9
|
Zhang J, Gao J, Guo G, Li S, Zhan G, Xie Z, Yang C, Luo A. Anesthesia and surgery induce delirium-like behavior in susceptible mice: the role of oxidative stress. Am J Transl Res 2018; 10:2435-2444. [PMID: 30210682 PMCID: PMC6129548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/20/2018] [Indexed: 06/08/2023]
Abstract
Anesthesia and surgery (A + S) are risk factors for patients to develop postoperative delirium (POD). However, the pathogenesis of POD remains largely to be determined. We employed battery of behavioral tests including open-filed test (OFT), elevated plus maze test (EPMT) and buried food test (BFT) to investigate the role of oxidative stress in the development of POD and to explore the therapeutic target for POD in mice after A + S (simple laparotomy under 1.4% isoflurane anesthesia). We initially found that 6 hours after A + S, mice failed to alter the behavioral changes in OFT and the adenosine triphosphate (ATP) level in hippocampus. After hierarchical cluster analysis, however, there was a significant change in the behavior tests between POD unsusceptible (non-POD) and susceptible (POD-like) mice. Interestingly, cyclosporine A, an inhibitor of mitochondrial permeability transition pore (mPTP) opening, exerted pharmacologically beneficial effects on symptoms, decreased reactive oxygen species (ROS) and ATP, and increased superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) levels in the hippocampus of POD-like mice. These findings suggest that abnormally activated oxidative stress might be involved in the underlying mechanisms of POD. Novel therapeutic agents targeting inhibition of oxidative stress would provide an available strategy for POD treatment.
Collapse
Affiliation(s)
- Jie Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Jie Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Guojun Guo
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Shan Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Gaofeng Zhan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Zhongcong Xie
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical SchoolCharlestown, MA, US
| | - Chun Yang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| |
Collapse
|
10
|
Postoperative Delirium in Severely Burned Patients Undergoing Early Escharotomy: Incidence, Risk Factors, and Outcomes. J Burn Care Res 2018; 38:e370-e376. [PMID: 27388882 DOI: 10.1097/bcr.0000000000000397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The aim of this study is to investigate the incidence, related risk factors, and outcomes of postoperative delirium (POD) in severely burned patients undergoing early escharotomy. This study included 385 severely burned patients (injured <1 week; TBSA, 31-50% or 11-20%; American Society of Anesthesiologists physical status, II-IV) aged 18 to 65 years, who underwent early escharotomy between October 2014 and December 2015, and were selected by cluster sampling. The authors excluded patients with preoperative delirium or diagnosed dementia, depression, or cognitive dysfunction. Preoperative, perioperative, intraoperative, and postoperative information, such as demographic characteristics, vital signs, and health history were collected. The Confusion Assessment Method was used once daily for 5 days after surgery to identify POD. Stepwise binary logistic regression analysis was used to identify the risk factors for POD, t-tests, and χ tests were performed to compare the outcomes of patients with and without the condition. Fifty-six (14.55%) of the patients in the sample were diagnosed with POD. Stepwise binary logistic regression showed that the significant risk factors for POD in severely burned patients undergoing early escharotomy were advanced age (>50 years old), a history of alcohol consumption (>3/week), high American Society of Anesthesiologists classification (III or IV), time between injury and surgery (>2 days), number of previous escharotomies (>2), combined intravenous and inhalation anesthesia, no bispectral index applied, long duration surgery (>180 min), and intraoperative hypotension (mean arterial pressure < 55 mm Hg). On the basis of the different odds ratios, the authors established a weighted model. When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). Further, POD was associated with more postoperative complications, including hepatic and renal function impairment and hypernatremia, as well as prolonged hospitalization, increased medical costs, and higher mortality.
Collapse
|
11
|
Kobayashi K, Imagama S, Ando K, Ishiguro N, Yamashita M, Eguchi Y, Matsumoto M, Ishii K, Hikata T, Seki S, Terai H, Suzuki A, Tamai K, Aramomi M, Ishikawa T, Kimura A, Inoue H, Inoue G, Miyagi M, Saito W, Yamada K, Hongo M, Nishimura H, Suzuki H, Nakano A, Watanabe K, Chikuda H, Ohya J, Aoki Y, Shimizu M, Futatsugi T, Mukaiyama K, Hasegawa M, Kiyasu K, Iizuka H, Iizuka Y, Kobayashi R, Nishida K, Kakutani K, Nakajima H, Murakami H, Demura S, Kato S, Yoshioka K, Namikawa T, Watanabe K, Nakanishi K, Nakagawa Y, Yoshimoto M, Fujiwara H, Nishida N, Imajo Y, Yamazaki M, Sakane M, Abe T, Fujii K, Kaito T, Furuya T, Orita S, Ohtori S. Complications Associated With Spine Surgery in Patients Aged 80 Years or Older: Japan Association of Spine Surgeons with Ambition (JASA) Multicenter Study. Global Spine J 2017; 7:636-641. [PMID: 28989842 PMCID: PMC5624380 DOI: 10.1177/2192568217716144] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
STUDY DESIGN Retrospective study of registry data. OBJECTIVES Aging of society and recent advances in surgical techniques and general anesthesia have increased the demand for spinal surgery in elderly patients. Many complications have been described in elderly patients, but a multicenter study of perioperative complications in spinal surgery in patients aged 80 years or older has not been reported. Therefore, the goal of the study was to analyze complications associated with spine surgery in patients aged 80 years or older with cervical, thoracic, or lumbar lesions. METHODS A multicenter study was performed in patients aged 80 years or older who underwent 262 spinal surgeries at 35 facilities. The frequency and severity of complications were examined for perioperative complications, including intraoperative and postoperative complications, and for major postoperative complications that were potentially life threatening, required reoperation in the perioperative period, or left a permanent injury. RESULTS Perioperative complications occurred in 75 of the 262 surgeries (29%) and 33 were major complications (13%). In multivariate logistic regression, age over 85 years (hazard ratio [HR] = 1.007, P = 0.025) and estimated blood loss ≥500 g (HR = 3.076, P = .004) were significantly associated with perioperative complications, and an operative time ≥180 min (HR = 2.78, P = .007) was significantly associated with major complications. CONCLUSIONS Elderly patients aged 80 years or older with comorbidities are at higher risk for complications. Increased surgical invasion, and particularly a long operative time, can cause serious complications that may be life threatening. Therefore, careful decisions are required with regard to the surgical indication and procedure in elderly patients.
Collapse
Affiliation(s)
| | - Shiro Imagama
- Nagoya University, Nagoya, Japan,Shiro Imagama, Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi 466-8550, Japan.
| | - Kei Ando
- Nagoya University, Nagoya, Japan
| | | | - Masaomi Yamashita
- Japan Community Health Care Organization Funabashi Central Hospital, Chiba, Japan
| | | | | | - Ken Ishii
- Keio University School of Medicine, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | | - Gen Inoue
- Kitasato University, Kanagawa, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Haku Iizuka
- Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yoichi Iizuka
- Gunma University Graduate School of Medicine, Gunma, Japan
| | | | | | | | | | | | | | | | | | | | - Kei Watanabe
- Niigata University, Niigata, Japan,Sado General Hospital, Niigata, Japan
| | | | | | | | | | - Norihiro Nishida
- Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yasuaki Imajo
- Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | | | | | - Tetsuya Abe
- University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kengo Fujii
- University of Tsukuba, Tsukuba, Ibaraki, Japan
| | | | | | | | | |
Collapse
|
12
|
Kobayashi K, Imagama S, Ando K, Ishiguro N, Yamashita M, Eguchi Y, Matsumoto M, Ishii K, Hikata T, Seki S, Terai H, Suzuki A, Tamai K, Aramomi M, Ishikawa T, Kimura A, Inoue H, Inoue G, Miyagi M, Saito W, Yamada K, Hongo M, Matsuoka Y, Suzuki H, Nakano A, Watanabe K, Chikuda H, Ohya J, Aoki Y, Shimizu M, Futatsugi T, Mukaiyama K, Hasegawa M, Kiyasu K, Iizuka H, Iizuka Y, Kobayashi R, Nishida K, Kakutani K, Nakajima H, Murakami H, Demura S, Kato S, Yoshioka K, Namikawa T, Watanabe K, Nakanishi K, Nakagawa Y, Yoshimoto M, Fujiwara H, Nishida N, Imajo Y, Yamazaki M, Sakane M, Abe T, Fujii K, Kaito T, Furuya T, Orita S, Ohtori S. Risk Factors for Delirium After Spine Surgery in Extremely Elderly Patients Aged 80 Years or Older and Review of the Literature: Japan Association of Spine Surgeons with Ambition Multicenter Study. Global Spine J 2017; 7:560-566. [PMID: 28894686 PMCID: PMC5582715 DOI: 10.1177/2192568217700115] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
STUDY DESIGN Retrospective database analysis. OBJECTIVE Spine surgeries in elderly patients have increased in recent years due to aging of society and recent advances in surgical techniques, and postoperative complications have become more of a concern. Postoperative delirium is a common complication in elderly patients that impairs recovery and increases morbidity and mortality. The objective of the study was to analyze postoperative delirium associated with spine surgery in patients aged 80 years or older with cervical, thoracic, and lumbar lesions. METHODS A retrospective multicenter study was performed in 262 patients 80 years of age or older who underwent spine surgeries at 35 facilities. Postoperative complications, incidence of postoperative delirium, and hazard ratios of patient-specific and surgical risk factors were examined. RESULTS Postoperative complications occurred in 59 of the 262 spine surgeries (23%). Postoperative delirium was the most frequent complication, occurring in 15 of 262 patients (5.7%), and was significantly associated with hypertension, cerebrovascular disease, cervical lesion surgery, and greater estimated blood loss (P < .05). In multivariate logistic regression using perioperative factors, cervical lesion surgery (odds ratio = 4.27, P < .05) and estimated blood loss ≥300 mL (odds ratio = 4.52, P < .05) were significantly associated with postoperative delirium. CONCLUSIONS Cervical lesion surgery and greater blood loss were perioperative risk factors for delirium in extremely elderly patients after spine surgery. Hypertension and cerebrovascular disease were significant risk factors for postoperative delirium, and careful management is required for patients with such risk factors.
Collapse
Affiliation(s)
| | - Shiro Imagama
- Nagoya University, Nagoya, Aichi, Japan,Shiro Imagama, Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai Showa-ward, Aichi 466-8550, Japan.
| | - Kei Ando
- Nagoya University, Nagoya, Aichi, Japan
| | | | | | - Yawara Eguchi
- Shimoshizu National Hospital, Yotsukaido-shi, Chiba, Japan
| | | | - Ken Ishii
- Keio University, Shinjuku-ku, Tokyo, Japan
| | | | - Shoji Seki
- University of Toyama, Toyama-shi, Toyama, Japan
| | | | | | - Koji Tamai
- Osaka City University, Abeno-ku, Osaka, Japan
| | | | | | - Atsushi Kimura
- Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Hirokazu Inoue
- Jichi Medical University, Shimotsuke-shi, Tochigi, Japan
| | - Gen Inoue
- Kitasato University, Sagamihara-shi, Kanagawa, Japan
| | | | - Wataru Saito
- Kitasato University, Sagamihara-shi, Kanagawa, Japan
| | - Kei Yamada
- Kurume University, Kurume-shi, Fukuoka, Japan
| | | | | | | | | | | | | | - Junichi Ohya
- The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | | | | | | | | | | | | | - Haku Iizuka
- Gunma University, Maebashi-shi, Gunma, Japan
| | | | | | | | | | | | | | | | | | | | | | - Kei Watanabe
- Niigata University, Niigata-shi, Niigata, Japan,Sado General Hospital, Sado-shi, Niigata, Japan
| | | | | | | | | | | | | | | | | | - Tetsuya Abe
- University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kengo Fujii
- University of Tsukuba, Tsukuba, Ibaraki, Japan
| | | | | | | | | |
Collapse
|
13
|
Barker D, D'Este C, Campbell MJ, McElduff P. Minimum number of clusters and comparison of analysis methods for cross sectional stepped wedge cluster randomised trials with binary outcomes: A simulation study. Trials 2017; 18:119. [PMID: 28279222 PMCID: PMC5345156 DOI: 10.1186/s13063-017-1862-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 02/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stepped wedge cluster randomised trials frequently involve a relatively small number of clusters. The most common frameworks used to analyse data from these types of trials are generalised estimating equations and generalised linear mixed models. A topic of much research into these methods has been their application to cluster randomised trial data and, in particular, the number of clusters required to make reasonable inferences about the intervention effect. However, for stepped wedge trials, which have been claimed by many researchers to have a statistical power advantage over the parallel cluster randomised trial, the minimum number of clusters required has not been investigated. METHODS We conducted a simulation study where we considered the most commonly used methods suggested in the literature to analyse cross-sectional stepped wedge cluster randomised trial data. We compared the per cent bias, the type I error rate and power of these methods in a stepped wedge trial setting with a binary outcome, where there are few clusters available and when the appropriate adjustment for a time trend is made, which by design may be confounding the intervention effect. RESULTS We found that the generalised linear mixed modelling approach is the most consistent when few clusters are available. We also found that none of the common analysis methods for stepped wedge trials were both unbiased and maintained a 5% type I error rate when there were only three clusters. CONCLUSIONS Of the commonly used analysis approaches, we recommend the generalised linear mixed model for small stepped wedge trials with binary outcomes. We also suggest that in a stepped wedge design with three steps, at least two clusters be randomised at each step, to ensure that the intervention effect estimator maintains the nominal 5% significance level and is also reasonably unbiased.
Collapse
Affiliation(s)
- Daniel Barker
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia. .,CCEB, University of Newcastle, HMRI Building, Level 4 West, University Drive, Callaghan, NSW, 2308, Australia.
| | - Catherine D'Este
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia.,National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australia
| | - Michael J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
| | - Patrick McElduff
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia.,Health Policy Analysis Pty Ltd, Sydney, NSW, Australia
| |
Collapse
|
14
|
Dupuis M, Kuczewski E, Villeneuve L, Bin-Dorel S, Haine M, Falandry C, Gilbert T, Passot G, Glehen O, Bonnefoy M. Age Nutrition Chirugie (ANC) study: impact of a geriatric intervention on the screening and management of undernutrition in elderly patients operated on for colon cancer, a stepped wedge controlled trial. BMC Geriatr 2017; 17:10. [PMID: 28061830 PMCID: PMC5219771 DOI: 10.1186/s12877-016-0402-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 12/21/2016] [Indexed: 01/16/2023] Open
Abstract
Background Undernutrition prior to major abdominal surgery is frequent and increases morbidity and mortality, especially in older patients. The management of undernutrition reduces postoperative complications. Nutritional management should be a priority in patient care during the preoperative period. However undernutrition is rarely detected and the guidelines are infrequently followed. Preoperative undernutrition screening should allow a better implementation of the guidelines. Methods/design The ANC (“Age Nutrition Chirurgie”) study is an interventional, comparative, prospective, multicenter, randomized protocol based on the stepped wedge trial design. For the intervention, the surgeon will inform the patient of the establishment of a systematic preoperative geriatric assessment that will allow the preoperative diagnosis of the nutritional status and the implementation of an adjusted nutritional support in accordance with the nutritional guidelines. The primary outcome measure is to determine the impact of the geriatric intervention on the level of perioperative nutritional management, in accordance with the current European guidelines. The implementation of the intervention in the five participating centers will be rolled-out sequentially over six time periods (every six months). Investigators must recommend that all patients aged 70 years or over and who are consulting for a surgery for a colorectal cancer should consider participating in this study. Discussion The ANC study is based on an original methodology, the stepped wedge trial design, which is appropriate for evaluating the implementation of a geriatric and nutritional assessment during the perioperative period. We describe the purpose of this geriatric intervention, which is expected to apply the ESPEN and SFNEP recommendations through the establishment of an undernutrition screening and a management program for patients with cancer. This intervention should allow a decrease in patient morbidity and mortality due to undernutrition. Trial registration This study is registered in ClinicalTrials.gov NCT02084524 on March 11, 2014 (retrospectively registered).
Collapse
Affiliation(s)
- Marine Dupuis
- Unité de Recherche Clinique, Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.
| | - Elisabetta Kuczewski
- Service d'Hygiène Épidémiologie Infectiovigilance et Prévention, Hospices Civils de Lyon, Lyon, France
| | - Laurent Villeneuve
- Unité de Recherche Clinique, Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, EAM Parcours Santé Systémique, 4128, Lyon, France.,Université Lyon 1, Lyon, France
| | - Sylvie Bin-Dorel
- Unité de Recherche Clinique, Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, EAM Parcours Santé Systémique, 4128, Lyon, France.,Université Lyon 1, Lyon, France
| | - Max Haine
- Service de Médecine Gériatrique, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Claire Falandry
- Université Lyon 1, EMR 3738, Oullins, France.,Oncologie Médicale, Centre d'Investigation des Thérapeutiques en Oncologie et Hématologie de Lyon (CITOHL), Centre Hospitalier Lyon-Sud, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), Lyon, France
| | - Thomas Gilbert
- Service de Médecine Gériatrique, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Guillaume Passot
- Université Lyon 1, EMR 3738, Oullins, France.,Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Olivier Glehen
- Université Lyon 1, EMR 3738, Oullins, France.,Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Marc Bonnefoy
- Université Lyon 1, Lyon, France.,Service de Médecine Gériatrique, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France.,INSERM U1060, Laboratoire CarMeN (cardiovasculaire, métabolisme, diabétologie et nutrition), Université Claude Bernard Lyon 1, Pierre-Bénite, France
| |
Collapse
|
15
|
Barker D, McElduff P, D'Este C, Campbell MJ. Stepped wedge cluster randomised trials: a review of the statistical methodology used and available. BMC Med Res Methodol 2016; 16:69. [PMID: 27267471 PMCID: PMC4895892 DOI: 10.1186/s12874-016-0176-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials. METHODS Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design. RESULTS This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used. CONCLUSIONS Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.
Collapse
Affiliation(s)
- D Barker
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - P McElduff
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - C D'Este
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, 0200, Australia
| | - M J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
| |
Collapse
|
16
|
Beard E, Lewis JJ, Copas A, Davey C, Osrin D, Baio G, Thompson JA, Fielding KL, Omar RZ, Ononge S, Hargreaves J, Prost A. Stepped wedge randomised controlled trials: systematic review of studies published between 2010 and 2014. Trials 2015; 16:353. [PMID: 26278881 PMCID: PMC4538902 DOI: 10.1186/s13063-015-0839-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/01/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In a stepped wedge, cluster randomised trial, clusters receive the intervention at different time points, and the order in which they received it is randomised. Previous systematic reviews of stepped wedge trials have documented a steady rise in their use between 1987 and 2010, which was attributed to the design's perceived logistical and analytical advantages. However, the interventions included in these systematic reviews were often poorly reported and did not adequately describe the analysis and/or methodology used. Since 2010, a number of additional stepped wedge trials have been published. This article aims to update previous systematic reviews, and consider what interventions were tested and the rationale given for using a stepped wedge design. METHODS We searched PubMed, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Web of Science, the Cochrane Library and the Current Controlled Trials Register for articles published between January 2010 and May 2014. We considered stepped wedge randomised controlled trials in all fields of research. We independently extracted data from retrieved articles and reviewed them. Interventions were then coded using the functions specified by the Behaviour Change Wheel, and for behaviour change techniques using a validated taxonomy. RESULTS Our review identified 37 stepped wedge trials, reported in 10 articles presenting trial results, one conference abstract, 21 protocol or study design articles and five trial registrations. These were mostly conducted in developed countries (n = 30), and within healthcare organisations (n = 28). A total of 33 of the interventions were educationally based, with the most commonly used behaviour change techniques being 'instruction on how to perform a behaviour' (n = 32) and 'persuasive source' (n = 25). Authors gave a wide range of reasons for the use of the stepped wedge trial design, including ethical considerations, logistical, financial and methodological. The adequacy of reporting varied across studies: many did not provide sufficient detail regarding the methodology or calculation of the required sample size. CONCLUSIONS The popularity of stepped wedge trials has increased since 2010, predominantly in high-income countries. However, there is a need for further guidance on their reporting and analysis.
Collapse
Affiliation(s)
- Emma Beard
- Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - James J Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Andrew Copas
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
| | - Calum Davey
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Gianluca Baio
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Jennifer A Thompson
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Katherine L Fielding
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - James Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| |
Collapse
|
17
|
Prost A, Binik A, Abubakar I, Roy A, De Allegri M, Mouchoux C, Dreischulte T, Ayles H, Lewis JJ, Osrin D. Logistic, ethical, and political dimensions of stepped wedge trials: critical review and case studies. Trials 2015; 16:351. [PMID: 26278521 PMCID: PMC4538739 DOI: 10.1186/s13063-015-0837-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background Three arguments are usually invoked in favour of stepped wedge cluster randomised controlled trials: the logistic convenience of implementing an intervention in phases, the ethical benefit of providing the intervention to all clusters, and the potential to enhance the social acceptability of cluster randomised controlled trials. Are these alleged benefits real? We explored the logistic, ethical, and political dimensions of stepped wedge trials using case studies of six recent evaluations. Methods We identified completed or ongoing stepped wedge evaluations using two systematic reviews. We then purposively selected six with a focus on public health in high, middle, and low-income settings. We interviewed their authors about the logistic, ethical, and social issues faced by their teams. Two authors reviewed interview transcripts, identified emerging issues through qualitative thematic analysis, reflected upon them in the context of the literature, and invited all participants to co-author the manuscript. Results Our analysis raises three main points. First, the phased implementation of interventions can alleviate problems linked to simultaneous roll-out, but also brings new challenges. Issues to consider include the feasibility of organising intervention activities according to a randomised sequence, estimating time lags in implementation and effects, and accommodating policy changes during the trial period. Second, stepped wedge trials, like parallel cluster trials, require equipoise: without it, randomising participants to a control condition, even for a short time, remains problematic. In stepped wedge trials, equipoise is likely to lie in the degree of effect, effectiveness in a specific operational milieu, and the balance of benefit and harm, including the social value of better evaluation. Third, the strongest arguments for a stepped wedge design are logistic and political rather than ethical. The design is advantageous when simultaneous roll-out is impractical and when it increases the acceptability of using counterfactuals. Conclusions The logistic convenience of phased implementation is context-dependent, and may be vitiated by the additional requirements of phasing. The potential for stepped wedge trials to enhance the social acceptability of cluster randomised trials is real, but their ethical legitimacy still rests on demonstrating equipoise and its configuration for each research question and setting.
Collapse
Affiliation(s)
- Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | | | | | - Anjana Roy
- Public Health England (PHE), Colindale, UK.
| | - Manuela De Allegri
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany.
| | | | | | - Helen Ayles
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - James J Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| |
Collapse
|
18
|
Abraha I, Trotta F, Rimland JM, Cruz-Jentoft A, Lozano-Montoya I, Soiza RL, Pierini V, Dessì Fulgheri P, Lattanzio F, O’Mahony D, Cherubini A. Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series. PLoS One 2015; 10:e0123090. [PMID: 26062023 PMCID: PMC4465742 DOI: 10.1371/journal.pone.0123090] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/27/2015] [Indexed: 01/08/2023] Open
Abstract
Background Non-pharmacological intervention (e.g. multidisciplinary interventions, music therapy, bright light therapy, educational interventions etc.) are alternative interventions that can be used in older subjects. There are plenty reviews of non-pharmacological interventions for the prevention and treatment of delirium in older patients and clinicians need a synthesized, methodologically sound document for their decision making. Methods and Findings We performed a systematic overview of systematic reviews (SRs) of comparative studies concerning non-pharmacological intervention to treat or prevent delirium in older patients. The PubMed, Cochrane Database of Systematic Reviews, EMBASE, CINHAL, and PsychINFO (April 28th, 2014) were searched for relevant articles. AMSTAR was used to assess the quality of the SRs. The GRADE approach was used to assess the quality of primary studies. The elements of the multicomponent interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis. Risk ratios were estimated using a random-effects model. Twenty-four SRs with 31 primary studies satisfied the inclusion criteria. Based on the AMSTAR criteria twelve reviews resulted of moderate quality and three resulted of high quality. Overall, multicomponent non-pharmacological interventions significantly reduced the incidence of delirium in surgical wards [2 randomized trials (RCTs): relative risk (RR) 0.71, 95% Confidence Interval (CI) 0.59 to 0.86, I2=0%; (GRADE evidence: moderate)] and in medical wards [2 CCTs: RR 0.65, 95%CI 0.49 to 0.86, I2=0%; (GRADE evidence: moderate)]. There is no evidence supporting the efficacy of non-pharmacological interventions to prevent delirium in low risk populations (i.e. low rate of delirium in the control group)[1 RCT: RR 1.75, 95%CI 0.50 to 6.10 (GRADE evidence: very low)]. For patients who have developed delirium, the available evidence does not support the efficacy of multicomponent non-pharmacological interventions to treat delirium. Among single component interventions only staff education, reorientation protocol (GRADE evidence: very low)] and Geriatric Risk Assessment MedGuide software [hazard ratio 0.42, 95%CI 0.35 to 0.52, (GRADE evidence: moderate)] resulted effective in preventing delirium. Conclusions In older patients multi-component non-pharmacological interventions as well as some single-components intervention were effective in preventing delirium but not to treat delirium.
Collapse
Affiliation(s)
- Iosief Abraha
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
- * E-mail:
| | - Fabiana Trotta
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Joseph M. Rimland
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | | | | | - Roy L. Soiza
- Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, United Kingdom
| | - Valentina Pierini
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Paolo Dessì Fulgheri
- Clinica di Medicina Interna e Geriatria, Politecnica University of the Marche Region, Ancona, Italy
| | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - Denis O’Mahony
- Department of Medicine, University College Cork, Cork, Ireland
| | - Antonio Cherubini
- Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| |
Collapse
|
19
|
Fatemi Y, Jacobson RM. The stepped wedge cluster randomized trial and its potential for child health services research: a narrative review. Acad Pediatr 2015; 15:128-33. [PMID: 25613913 DOI: 10.1016/j.acap.2014.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 10/13/2014] [Accepted: 10/26/2014] [Indexed: 11/25/2022]
Affiliation(s)
| | - Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
20
|
van Meenen LCC, van Meenen DMP, de Rooij SE, ter Riet G. Risk Prediction Models for Postoperative Delirium: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2014; 62:2383-90. [DOI: 10.1111/jgs.13138] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Sophia E. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Gerben ter Riet
- Department of General Practice; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
| |
Collapse
|
21
|
Lee E, Kim J. Cost-benefit analysis of a delirium prevention strategy in the intensive care unit. Nurs Crit Care 2014; 21:367-373. [PMID: 25351583 DOI: 10.1111/nicc.12124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 04/23/2014] [Accepted: 07/07/2014] [Indexed: 11/27/2022]
Abstract
AIMS The aim of this study was to evaluate the effect of a delirium prevention strategy. BACKGROUND A high prevalence has been reported for delirium after liver transplantation surgery in the intensive care unit (ICU). Delirium increases treatment costs because of treatment delays, prolonged hospital stays and other associated complications. Despite all those problems associated with delirium, a systemic prevention strategy does not exist yet. DESIGN This study used an economic evaluation design by reviewing relevant medical records. METHODS Study objects were 130 patients who were admitted to the ICU after liver transplantation surgery. After looking at the medical records of these patients, we divided them into two groups according to the application of the prevention strategy. This study analysed the costs and benefits of the prevention strategy between the groups. RESULTS The prevalence rate of delirium was 35·3% in the prevention-care group and 51·6% in the usual-care group. A sum of $38·4 was invested for the prevention strategy in opposite to the expected total costs of $5578 for a probable treatment. Thus, the net benefit was $5539·6 with a benefit ratio of 145·3 CONCLUSIONS: A strategy is necessary for the delirium prevention of patients in the ICU to decrease the economic burden. RELEVANCE TO CLINICAL PRACTICE This study demonstrated that a prevention strategy was cost-effective because of its low input costs. With low additional investment, it is expected that this prevention strategy will be more available to other patients in the future.
Collapse
Affiliation(s)
- Eunhee Lee
- College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea
| | | |
Collapse
|
22
|
Oh SH, Park EJ, Jin Y, Piao J, Lee SM. Automatic delirium prediction system in a Korean surgical intensive care unit. Nurs Crit Care 2013; 19:281-91. [PMID: 24165109 DOI: 10.1111/nicc.12048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 07/18/2013] [Accepted: 07/25/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND In Korea, regular screening for delirium is not considered essential. In addition, delirium is often associated with vague concepts, making it harder to identify high-risk patients and impeding decision-making. AIMS To assess the impact of the Automatic PREdiction of DELirium in Intensive Care Units (APREDEL-ICU) system on nursing-sensitive and patient outcomes for surgical ICU patients and to evaluate nurse satisfaction with the system and its usability. METHODS A pre-post research design was adopted. Our study included 724 patients admitted before the implementation of the APREDEL-ICU (January to December 2010) and 1111 patients admitted after the system was installed (May 2011 to April 2012). The APREDEL-ICU uses a pop-up window message to inform the nursing staff of patients at risk for delirium, allowing evidence-based nursing interventions to be applied to the identified patients. A total of 42 nurses were surveyed to determine the system's usability and their level of satisfaction with it. RESULTS After the implementation of APREDEL-ICU, high-risk patients, determined using a prediction algorithm, showed a slight decrease in the incidence of delirium, but the changes were not significant. However, significant decreases in the number and duration of analgesic/narcotic therapies were observed after the implementation of the system. Nurse self-evaluation results showed an improvement in all categories of knowledge regarding delirium care. CONCLUSION The use of a prediction and alerting system for ICU patients at high risk of delirium showed a potential increase in the quality of delirium care, including early detection and proper intervention.
Collapse
Affiliation(s)
- Suk-Hwa Oh
- Surgical Intensive Care Unit, Seoul St. Mary's Hospital, Seoul, Korea
| | | | | | | | | |
Collapse
|
23
|
Lee J, Jung J, Noh JS, Yoo S, Hong YS. Perioperative psycho-educational intervention can reduce postoperative delirium in patients after cardiac surgery: a pilot study. Int J Psychiatry Med 2013; 45:143-58. [PMID: 23977818 DOI: 10.2190/pm.45.2.d] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Postoperative delirium after cardiac surgery is associated with many consequences such as poorer functional recovery, more frequent postoperative complications, higher mortality, increased length of hospital stay, and higher hospital costs. The aim of this study was to evaluate the efficacy of perioperative psycho-educational intervention in preventing postoperative delirium in post cardiac surgery patients. METHOD We conducted a comparative retrospective study between 49 patients who had received perioperative psycho-educational intervention and 46 patients who had received standard care. The primary outcome was the incidence of postoperative delirium. Secondary outcomes included length of ICU stay, and severity and duration of postoperative delirium among the patients who had developed delirium. RESULTS The incidence of postoperative delirium was significantly lower in the intervention group than that in the control group (12.24% vs. 34.78%, P = 0.009). Among the patients who had developed postoperative delirium, there was no statistical difference between the two groups regarding secondary outcomes. CONCLUSIONS Our results show that the patients who received perioperative psycho-educational intervention were associated with a lower incidence of postoperative delirium after cardiac surgery than those who received standard care. Clinicians would be able to implement this psycho-educational intervention as part of routine practice to reduce delirium.
Collapse
Affiliation(s)
- Jeewon Lee
- Department of Thoracic & Cardiovascular Surgery, Ajou University Medical Center, School of Medicine, Suwon, Korea
| | | | | | | | | |
Collapse
|
24
|
Mézière A, Paillaud E, Belmin J, Pariel S, Herbaud S, Canouï-Poitrine F, Le Thuaut A, Marty J, Plaud B. Delirium in older people after proximal femoral fracture repair: Role of a preoperative screening cognitive test. ACTA ACUST UNITED AC 2013; 32:e91-6. [DOI: 10.1016/j.annfar.2013.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/06/2013] [Indexed: 11/30/2022]
|
25
|
The clinical and economic costs of delirium after surgical resection for esophageal malignancy. Ann Surg 2013; 258:77-81. [PMID: 23426343 DOI: 10.1097/sla.0b013e31828545c1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of this study was to identify preoperative risk factors and postoperative consequences that are associated with the occurrence of delirium after esophagectomy for malignancy. BACKGROUND Delirium is an underdiagnosed, serious complication after major surgery, particularly in the elderly population. METHODS All patients undergoing esophagectomy for cancer (1991-2011) were included. Patients with and without delirium were compared with respect to medical comorbidities, use of neoadjuvant therapy, operative outcomes, postoperative complications, overall cost, and survival. RESULTS Of the 500 patients included in this analysis, 46 (9.2%) patients developed postoperative delirium. Patients with delirium had higher ASA and Charlson comorbidity index scores. Delirium was associated with a longer hospital (14 ± 7.5 vs 10.9 ± 5.7; P < 0.05) and intensive care unit stay (3.6 ± 3.8 vs 2.7 ± 16.9; P < 0.05) and an increased incidence of pulmonary complications and increased hospital costs. Delirium was preceded by another complication in 32.6% of cases but by a septic complication in only 19.6% of cases. Age was the only preoperative predictor of postoperative delirium in multivariate modeling (P < 0.05). No differences were noted in the use of neoadjuvant chemoradiotherapy or survival. CONCLUSIONS This study demonstrates that postoperative delirium is associated with a more complicated and costly recovery after esophagectomy and that age is independently predictive of its development. Delirium has often been thought to be the sequela of other complications; however, this study demonstrates that it presents in isolation or precedes other complications in 67.4% of cases. Focused screening will likely allow targeted preventative strategies to be used in the perioperative period to reduce complications and costs associated with delirium.
Collapse
|
26
|
Kitson AL, Schultz TJ, Long L, Shanks A, Wiechula R, Chapman I, Soenen S. The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project). BMC Health Serv Res 2013; 13:299. [PMID: 23924302 PMCID: PMC3750564 DOI: 10.1186/1472-6963-13-299] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 08/05/2013] [Indexed: 01/09/2023] Open
Abstract
Background Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital. Methods/Design A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool. Discussion Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions. Trial registration ACTRN12611000020987
Collapse
Affiliation(s)
- Alison L Kitson
- School of Nursing and Centre for Evidence-Based Practice SA (CEBSA), University of Adelaide, Adelaide, SA 5005, Australia.
| | | | | | | | | | | | | |
Collapse
|
27
|
Zhang H, Lu Y, Liu M, Zou Z, Wang L, Xu FY, Shi XY. Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R47. [PMID: 23506796 PMCID: PMC3672487 DOI: 10.1186/cc12566] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 03/12/2013] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The ideal measures to prevent postoperative delirium remain unestablished. We conducted this systematic review and meta-analysis to clarify the significance of potential interventions. METHODS The PRISMA statement guidelines were followed. Two researchers searched MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles published in English before August 2012. Additional sources included reference lists from reviews and related articles from 'Google Scholar'. Randomized clinical trials (RCTs) on interventions seeking to prevent postoperative delirium in adult patients were included. Data extraction and methodological quality assessment were performed using predefined data fields and scoring system. Meta-analysis was accomplished for studies that used similar strategies. The primary outcome measure was the incidence of postoperative delirium. We further tested whether interventions effective in preventing postoperative delirium shortened the length of hospital stay. RESULTS We identified 38 RCTs with interventions ranging from perioperative managements to pharmacological, psychological or multicomponent interventions. Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95). Both typical (three RCTs with 965 patients, RR=0.71; 95% CI=0.54 to 0.93) and atypical antipsychotics (three RCTs with 627 patients, RR=0.36; 95% CI=0.26 to 0.50) decreased delirium occurrence when compared to placebos. Multicomponent interventions (two RCTs with 325 patients, RR=0.71; 95% CI=0.58 to 0.86) were effective in preventing delirium. No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44). Effective prevention of postoperative delirium did not shorten the length of hospital stay (10 RCTs with 1,636 patients, pooled SMD (standard mean difference)=-0.06; 95% CI=-0.16 to 0.04). CONCLUSIONS The included studies showed great inconsistencies in definition, incidence, severity and duration of postoperative delirium. Meta-analysis supported dexmedetomidine sedation, multicomponent interventions and antipsychotics were useful in preventing postoperative delirium.
Collapse
|
28
|
|
29
|
Fassier T, Favre H, Piriou V. [How to assess the impact of morbimortality conferences on healthcare quality and safety in ICU ?]. ACTA ACUST UNITED AC 2012; 31:609-16. [PMID: 22766465 DOI: 10.1016/j.annfar.2012.04.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 04/19/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the morbidity and mortality conferences (MMC) impact in intensive care unit (ICU) setting on quality of care and patients' safety. DATA SOURCES A review of English and French articles in Medline database (1990-2011) related to MMC in the ICU. Keywords used: "morbidity (and) mortality conference(s)", "intensive care unit", "intensive/critical care medicine". Additional studies identified by hand search in French national guidelines about MMCs and in the Annales Françaises d'Anesthésie Réanimation and Réanimation journals index. Identification and preliminary analysis performed using title and abstract, for every study related to MMC in the ICU. STUDY SELECTION Only original studies about MMC in the ICU setting that reported an assessment were included. Papers reporting guidelines and methods for MMC implementation were excluded. DATA EXTRACTION Extraction used predefined data fields, including study design, MMC characteristics, assessment methods and results. DATA SYNTHESIS Studies about MMC in the ICU are recent and scarce. Results comparison and synthesis are impaired by discrepancies in study designs. Although the effectiveness of MMC is not evidence-based, data are consistent for their positive impact on quality of care and patient safety in the ICU. CONCLUSION Further studies are required to assess the impact of MMC in the ICU. Based on this literature review, a 4-level evaluation scheme can be suggested: 1) evaluation of MMC implementation in care units and facilities; 2) evaluation of MMC organization; 3) evaluation of MMC on quality of care; 4) evaluation of MMC impact on patients' mortality and morbidity.
Collapse
Affiliation(s)
- T Fassier
- EAM, « Santé, Individus, Société », faculté de médecine Laënnec, université de Lyon, France
| | | | | |
Collapse
|
30
|
Rathier MO, Baker WL. A review of recent clinical trials and guidelines on the prevention and management of delirium in hospitalized older patients. Hosp Pract (1995) 2011; 39:96-106. [PMID: 22056829 DOI: 10.3810/hp.2011.10.928] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Treatment of acute illness in older adults is frequently complicated by the presence of delirium. Delirium is characterized by the development of an altered mental status over the course of hours to days, and can have a fluctuating course. Patients with delirium have difficulty paying attention to their environment, have disorganized thinking, and usually have an altered level of consciousness. While scientists continue to elucidate the pathophysiologic mechanisms associated with delirium, clinicians can identify patients at risk for delirium and diagnose it using valid instruments, such as the Confusion Assessment Method and Confusion Assessment Method for the Intensive Care Unit. Delirium is an independent risk factor for death, institutionalization, and dementia, and resolves in many patients by the time of hospital discharge. For patients admitted to medical units, optimal management of delirium includes reassessment of medications, pain, sleep, nutrition, mobility, need for physical restraints, and bowel and bladder function. The use of antipsychotic medication to sedate delirious patients should be restricted to patients in danger of harming themselves or others and should be used when nonpharmacologic means fail. Multicomponent interventions performed by the hospital care team that address risk factors can prevent delirium in patients in medical units and those undergoing hip fracture repair. This includes attention to the depth of sedation during spinal anesthesia and the addition of regional nerve blocks to patient-controlled analgesia in orthopedic patients, both of which may reduce postoperative delirium. Perioperative use of antipsychotics may further reduce the incidence of delirium, although hospital length of stay has not been routinely reduced. Appropriate management of analgesia, sedation, and delirium in the intensive care unit is also associated with reduced duration of mechanical ventilation, as well as intensive care unit and hospital length of stay. The use of dexmedetomidine, an α-adrenergic receptor agonist, for sedation may reduce intensive care unit length of stay when compared with use of benzodiazepines.
Collapse
Affiliation(s)
- Margaret O Rathier
- University of Connecticut Health Center, Center on Aging, Farmington, CT, USA.
| | | |
Collapse
|