Cardiac Surgery in Elderly Patients

Influence of mild cognitive impairment on clinical and functional prognosis in older candidates for cardiac surgery

Introduction

In this study, we analyzed the prognostic impact of mild cognitive impairment (MCI) prior to cardiac surgery on 12-month clinical outcomes in older patients.

Method

We performed a longitudinal prospective study of 48 patients undergoing cardiac surgery and 26 neurologically healthy participants aged 65 years or older. All participants underwent a neuropsychological assessment. Functional status, quality of life and frailty were assessed in candidates for surgery. One year after surgery, 24 patients remained in the study.

Results

Mild cognitive impairment (MCI) was diagnosed in 35% of the patients at baseline. Postsurgical changes in functionality consisted of a tendency toward impaired basic activities of daily living (BADL) in the MCI group and a statistically significant worsening in instrumental activities of daily living (IADL) in women with MCI. Changes in quality of life consisted of a significant improvement in anxiety-depression in the MCI group and a tendency toward greater pain-discomfort in the non-MCI group. Cognitive status significantly declined only in the non-MCI group. Neither group showed significant changes in frailty. Relative risk analysis showed that patients with a diagnosis of MCI at baseline had a higher risk of cognitive decline at follow-up, while those without a diagnosis of MCI at baseline had a lower risk of impaired IADL. No association was found between MCI and resource use. Preoperative impairment in memory, visuospatial and executive functions was significantly associated with loss of quality of life at follow-up. Impairment of memory and visuospatial function was significantly associated with cognitive decline. Preserved memory was associated with a lower risk of impaired BADL at follow-up.

Conclusion

The present study provides clue on the impact of MCI in candidates for cardiac surgery. Preoperative detection of cognitive impairment could be highly valuable to help guide pre- and post-operative management.

Risk factors for decreased cardiac output after coronary artery bypass grafting: a prospective cohort study

BACKGROUND

No previous study has investigated the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after coronary artery bypass grafting (CABG).

AIMS

This study aimed to identify the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after CABG.

METHODS

This was a prospective cohort study performed at a cardiac university hospital in São Paulo, Brazil and 257 adult patients undergoing CABG were included. Potential risk factors for low cardiac output in the immediate post-operative period were investigated using the patients' medical records. Univariate analysis and logistic regression were used to identify the predictive risk factors of decreased cardiac output. The area under the receiver operating characteristic curve was calculated as a measure of accuracy. The variables that could not be analysed through logistic regression were analysed through Fisher's exact test.

RESULTS

One hundred and ninety-five patients had low cardiac output in the immediate post-operative period. The predictive risk factors included age ⩾60 years, decreased left ventricle ejection fraction, not using the radial artery graft, positive fluid balance and post-operative arrhythmia that differed from the pre-operative arrhythmia. This model predicted the outcome with a sensitivity of 62.9%, a specificity of 87.2% and an accuracy of 81.5%. The variables analysed through Fisher's exact test included heart failure, re-exploration and bleeding-related re-exploration.

CONCLUSIONS

The predictive risk factors for the nursing diagnosis of risk for decreased cardiac output after CABG were found. These results can be used to direct nurses in patient monitoring, staff training and nursing team staffing.

Major liver resections in the elderly-is an aggressive approach justified?

BACKGROUND AND AIMS

As the mean life expectancy rises, the incidence of patients 75 years of age and older who present with colorectal liver metastases continues to increase. The purpose of our study was to evaluate the outcome of major hepatic resections in the elderly population.

PATIENT AND METHODS

From April 1998 to December 2006, 572 consecutive patients with colorectal liver metastases were treated at our Institution. Of these, 59 were 75 years or older. There was an intent to proceed with major liver resections in all cases. Data were analyzed according to diagnosis, comorbidities, extent of liver resection, postoperative complications, overall survival, and disease-free survival.

RESULTS

Surgical treatment included right hepatectomies (n = 8), left hepatectomies (n = 4), and sectionectomies (more than three segments; n = 33). Fourteen (n = 14) patients received an explorative laparotomy alone. Morbidity and hospital mortality were 10% and 3%, respectively. Overall survival of 1, 3, and 5 years was 90%, 64%, and 33%, respectively. The corresponding disease-free survival was 74%, 42%, and 32%. Resection margin (R class) was the only predictor of survival by both uni- and multivariate analyses.

CONCLUSION

Hepatic resections can be performed safely in selected patients 75 years of age or older.

Systematic review: indicators to evaluate effectiveness of clinical pathways for gastrointestinal surgery

BACKGROUND

A systematic review on clinical pathways for gastrointestinal surgery was performed. The aim was to study indicators that are used to evaluate these clinical pathways and to study which effects of clinical pathways are reported.

METHODS

A search was performed for the period from January 2000 to November 2006 in MEDLINE, EMBASE and CINAHL. The Leuven Clinical Pathway Compass was used to categorize the indicators reported in literature.

RESULTS

Twenty-three studies were selected, of which 16 were controlled studies. The studies assessed most frequently complication rates, re-admissions, mortality and length of stay. More specific indicators like time to start defecation and time to return to enteral feeding were reported as well. None of the studies reported adverse effects in any of the domains of the Clinical Pathway Compass.

CONCLUSION

Clinical pathways for gastrointestinal surgery can enhance efficiency of care without adverse effects on outcome. Specific indicators to evaluate these clinical pathways are time to return to enteral feeding and time to defecate. Furthermore, additional to complication rates, number of re-admissions, mortality and length of stay, indicators such as the number of re-operations, pain scores and intensive care unit admission can be assessed to monitor effectiveness and patient safety of the clinical pathways.