Delirium: An Independent Predictor of Functional Decline After Cardiac Surgery

OBJECTIVES: To determine whether patients who developed delirium after cardiac surgery were at risk of functional decline. DESIGN: Prospective cohort study. SETTING: Two academic hospitals and a Veterans Affairs Medical Center. PARTICIPANTS: One hundred ninety patients aged 60 and older undergoing elective or urgent cardiac surgery. MEASUREMENTS: Delirium was assessed daily and was diagnosed according to the Confusion Assessment Method. Before surgery and 1 and 12 months postoperatively, patients were assessed for function using the instrumental activities of daily living (IADL) scale. Functional decline was defined as a decrease in ability to perform one IADL at follow‐up. RESULTS: Delirium occurred in 43.1% (n=82) of the patients (mean age 73.7±6.7). Functional decline occurred in 36.3% (n=65/179) at 1 month and in 14.6% (n=26/178) at 12 months. Delirium was associated with greater risk of functional decline at 1 month (relative risk (RR)=1.9, 95% confidence interval (CI)=1.3–2.8) and tended toward greater risk at 12 months (RR=1.9, 95% CI=0.9–3.8). After adjustment for age, cognition, comorbidity, and baseline function, delirium remained significantly associated with functional decline at 1 month (adjusted RR=1.8, 95% CI=1.2–2.6) but not at 12 months (adjusted RR=1.5, 95% CI=0.6–3.3). CONCLUSION: Delirium was independently associated with functional decline at 1 month and had a trend toward association at 12 months. These findings provide justification for intervention trials to evaluate whether delirium prevention or treatment strategies might improve postoperative functional recovery.     

Management Practices and Major Infections After Cardiac Surgery

Background

Infections are the most common noncardiac complication after cardiac surgery, but their incidence across a broad range of operations, as well as the management factors that shape infection risk, remain unknown.

Objectives

This study sought to prospectively examine the frequency of post-operative infections and associated mortality, and modifiable management practices predictive of infections within 65 days from cardiac surgery.

Methods

This study enrolled 5,158 patients and analyzed independently adjudicated infections using a competing risk model (with death as the competing event).

Results

Nearly 5% of patients experienced major infections. Baseline characteristics associated with increased infection risk included chronic lung disease (hazard ratio [HR]: 1.66; 95% confidence interval [CI]: 1.21 to 2.26), heart failure (HR: 1.47; 95% CI: 1.11 to 1.95), and longer surgery (HR: 1.31; 95% CI: 1.21 to 1.41). Practices associated with reduced infection risk included prophylaxis with second-generation cephalosporins (HR: 0.70; 95% CI: 0.52 to 0.94), whereas post-operative antibiotic duration >48 h (HR: 1.92; 95% CI: 1.28 to 2.88), stress hyperglycemia (HR: 1.32; 95% CI: 1.01 to 1.73); intubation time of 24 to 48 h (HR: 1.49; 95% CI: 1.04 to 2.14); and ventilation >48 h (HR: 2.45; 95% CI: 1.66 to 3.63) were associated with increased risk. HRs for infection were similar with either <24 h or <48 h of antibiotic prophylaxis. There was a significant but differential effect of transfusion by surgery type (excluding left ventricular assist device procedures/transplant) (HR: 1.13; 95% CI: 1.07 to 1.20). Major infections substantially increased mortality (HR: 10.02; 95% CI: 6.12 to 16.39).

Conclusions

Major infections dramatically affect survival and readmissions. Second-generation cephalosporins were strongly associated with reduced major infection risk, but optimal duration of antibiotic prophylaxis requires further study. Given practice variations, considerable opportunities exist for improving outcomes and preventing readmissions. (Management Practices and Risk of Infection Following Cardiac Surgery; NCT01089712)     

心脏手术患者围麻醉期液体治疗的研究进展

良好的液体治疗不仅可以维持术中血流动力学稳定和良好的组织器官灌注,还有助于改善患者的预后。但由于心脏手术患者术前的病理生理状态,研究者担忧容量过负荷带来的负面效应会加重心功能的进一步损害,从而对患者预后产生不利影响。现就心脏手术患者围麻醉期液体治疗的争议以及监测方法的进展作一综述。     

脑钠肽在心脏外科手术围手术期的应用进展

脑钠肽是心室肌细胞在室壁牵张力刺激下分泌的一类肽类激素,因其反映心室前后负荷及收缩、舒张功能的敏感性与无创性,广泛用于各种心血管疾病研究中。现主要针对脑钠肽在心脏外科手术围手术期的研究进展做一概述。     

A Novel Interdisciplinary Analgesic Program Reduces Pain and Improves Function in Older Adults After Orthopedic Surgery

OBJECTIVES: To examine the effect of a multicomponent intervention on pain and function after orthopedic surgery.
DESIGN: Controlled prospective propensity score–matched clinical trial.
SETTING: New York City acute rehabilitation hospital.
PARTICIPANTS: Two hundred forty-nine patients admitted to rehabilitation after hip fracture repair (n=51) or hip (n=64) or knee (n=134) arthroplasty.
INTERVENTION: Pain assessment at rest and with physical therapy (PT) by staff using numeric rating scales (1 to 5). Physician protocols for standing analgesia and preemptive analgesia before PT were implemented on the intervention unit. Control unit patients received usual care.
MEASUREMENTS: Pain, analgesic prescribing, gait speed, transfer time, and percentage of PT sessions completed during admission. Pain and difficulty walking at 6, 12, 18, and 24 weeks after discharge.
RESULTS: In multivariable analyses intervention patients were significantly more likely than controls to report no or mild pain at rest (66% vs 49%, P =.004) and with PT (52% vs 38%, P =.02) on average for the first 7 days of rehabilitation, had faster 8-foot-walk times on Days 4 (9.3 seconds vs 13.2 seconds, P =.02) and 7 (6.9 vs 9.2 seconds, P =.02), received more analgesia (23.6 vs 15.6 mg of morphine sulfate equivalents per day, P <.001), were more likely to receive standing orders for analgesia (98% vs 48%, P <.001), and had significantly shorter lengths of stay (10.1 vs 11.3 days, P =.005). At 6 months, intervention patients were less likely than controls to report moderate to severe pain with walking (4% vs 15%, P =.02) and that pain did not interfere with walking (7% vs 18%, P =.004) and were less likely to be taking analgesics (35% vs 51%, P =.03).
CONCLUSION: The intervention improved postoperative pain, reduced chronic pain, and improved function.     

术中超声心动图在心脏外科的应用价值

术中超声心动图包括经食道和心外膜超声心动图 ,在心脏外科体外循环前能完善诊断 ,有效降低围术期的并发症。本文概述该项技术在心脏外科手术中的应用价值。     

Impact of On-Site Cardiac Surgery on Clinical Outcomes After Transfemoral Transcatheter Aortic Valve Replacement

Objectives

This study sought to investigate the outcome of high-risk and inoperable patients with severe symptomatic aortic stenosis undergoing transfemoral transcatheter aortic valve replacement (TAVR) in hospitals with (iOSCS) versus without institutional on-site cardiac surgery (no-iOSCS).