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The Journal of Frailty & Aging 2023Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that... (Clinical Trial)
Clinical Trial
BACKGROUND
Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that rehabilitation strategies deployed after surgery improve outcomes by building strength.
OBJECTIVES
Examine the feasibility and impact of a novel, multi-faceted prehabilitation intervention for frail patients before surgery.
DESIGN
Single arm clinical trial.
SETTING
Veterans Affairs hospital.
PARTICIPANTS
Patients preparing for major abdominal, urological, thoracic, or cardiac surgery with frailty identified as a Risk Analysis Index≥30.
INTERVENTION
Prehabilitation started in a supervised setting to establish safety and then transitioned to home-based exercise with weekly telephone coaching by exercise physiologists. Prehabilitation included (a)strength and coordination training; (b)respiratory muscle training (IMT); (c)aerobic conditioning; and (d)nutritional coaching and supplementation. Prehabilitation length was tailored to the 4-6 week time lag typically preceding each participant's normally scheduled surgery.
MEASUREMENTS
Functional performance and patient surveys were assessed at baseline, every other week during prehabilitation, and then 30 and 90 days after surgery. Within-person changes were estimated using linear mixed models.
RESULTS
43 patients completed baseline assessments; 36(84%) completed a median 5(range 3-10) weeks of prehabilitation before surgery; 32(74%) were retained through 90-day follow-up. Baseline function was relatively low. Exercise logs show participants completed 94% of supervised exercise, 78% of prescribed IMT and 74% of home-based exercise. Between baseline and day of surgery, timed-up-and-go decreased 2.3 seconds, gait speed increased 0.1 meters/second, six-minute walk test increased 41.7 meters, and the time to complete 5 chair rises decreased 1.6 seconds(all P≤0.007). Maximum and mean inspiratory and expiratory pressures increased 4.5, 7.3, 14.1 and 13.5 centimeters of water, respectively(all P≤0.041).
CONCLUSIONS
Prehabilitation is feasible before major surgery and achieves clinically meaningful improvements in functional performance that may impact postoperative outcomes and recovery. These data support rationale for a larger trial powered to detect differences in postoperative outcomes.
Topics: Humans; Exercise Therapy; Frailty; Physical Functional Performance; Postoperative Complications; Preoperative Care; Preoperative Exercise
PubMed: 38008976
DOI: 10.14283/jfa.2022.42 -
Technology in Cancer Research &... 2022Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to... (Review)
Review
Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to AL have been identified in previous studies. Through early identification and timely adjustment of risk factors, preventive measures can be taken to reduce potential AL. However, there are still many problems associated with AL. The debate about preventive measures such as preoperative mechanical bowel preparation (MBP), intraoperative drainage, and surgical scope also continues. Recently, the gut microbiota has received more attention due to its important role in various diseases. Although the underlying mechanisms of gut microbiota on AL have not been validated completely, new strategies that manipulate intrinsic mechanisms are expected to prevent and treat AL. Moreover, laboratory examinations for AL prediction and methods for blood perfusion assessment are likely to be promoted in clinical practice. This review outlines possible risk factors for AL and suggests some preventive measures in terms of patient, surgery, and gut microbiota.
Topics: Anastomotic Leak; Colorectal Neoplasms; Colorectal Surgery; Humans; Preoperative Care; Risk Factors
PubMed: 36172641
DOI: 10.1177/15330338221118983 -
Journal of Orthopaedic Surgery (Hong... 2020Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of... (Review)
Review
Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.
Topics: Arthritis, Infectious; Arthroplasty, Replacement; Humans; Preoperative Care; Prosthesis-Related Infections; Risk Assessment; Risk Factors
PubMed: 32851909
DOI: 10.1177/2309499020947207 -
JAMA Surgery Aug 2019The number of patients prescribed long-term opioids and benzodiazepines and complications from their long-term use have increased. Information regarding the...
IMPORTANCE
The number of patients prescribed long-term opioids and benzodiazepines and complications from their long-term use have increased. Information regarding the perioperative outcomes of patients prescribed these medications before surgery is limited.
OBJECTIVE
To determine whether patients prescribed opioids and/or benzodiazepines within 6 months preoperatively would have greater short- and long-term mortality and increased opioid consumption postoperatively.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective, single-center, population-based cohort study included all patients 18 years or older, undergoing noncardiac surgical procedures at a national hospital in Iceland from December 12, 2005, to December 31, 2015, with follow-up through May 20, 2016. A propensity score-matched control cohort was generated using individuals from the group that received prescriptions for neither medication class within 6 months preoperatively. Data analysis was performed from April 10, 2018, to March 9, 2019.
EXPOSURES
Patients who filled prescriptions for opioids only, benzodiazepines only, both opioids and benzodiazepines, or neither medication within 6 months preoperatively.
MAIN OUTCOMES AND MEASURES
Long-term survival compared with propensity score-matched controls. Secondary outcomes were 30-day survival and persistent postoperative opioid consumption, defined as a prescription filled more than 3 months postoperatively.
RESULTS
Among 41 170 noncardiac surgical cases in 27 787 individuals (16 004 women [57.6%]; mean [SD] age, 56.3 [18.8] years), a preoperative prescription for opioids only was filled for 7460 cases (17.7%), benzodiazepines only for 3121 (7.4%), and both for 2633 (6.2%). Patients who filled preoperative prescriptions for either medication class had a greater comorbidity burden compared with patients receiving neither medication class (Elixhauser comorbidity index >0 for 16% of patients filling prescriptions for opioids only, 22% for benzodiazepines only, and 21% for both medications compared with 14% for patients filling neither). There was no difference in 30-day (opioids only: 1.3% vs 1.0%; P = .23; benzodiazepines only: 1.9% vs 1.5%; P = .32) or long-term (opioids only: hazard ratio [HR], 1.12 [95% CI, 1.01-1.24]; P = .03; benzodiazepines only: HR, 1.11 [95% CI, 0.98-1.26]; P = .11) survival among the patients receiving opioids or benzodiazepines only compared with controls. However, patients prescribed both opioids and benzodiazepines had greater 30-day mortality (3.2% vs 1.8%; P = .004) and a greater hazard of long-term mortality (HR, 1.41; 95% CI, 1.22-1.64; P < .001). The rate of persistent postoperative opioid consumption was higher for patients filling prescriptions for opioids only (43%), benzodiazepines only (23%), or both (66%) compared with patients filling neither (12%) (P < .001 for all).
CONCLUSIONS AND RELEVANCE
The findings suggest that opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption. These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.
Topics: Analgesics, Opioid; Benzodiazepines; Drug Prescriptions; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pain, Postoperative; Practice Patterns, Physicians'; Preoperative Care; Prognosis; Retrospective Studies; Surgical Procedures, Operative
PubMed: 31215988
DOI: 10.1001/jamasurg.2019.1652 -
Journal of Cancer Research and Clinical... Nov 2023In order to develop a feasible prehabilitation program before surgery of NSCLC, this study aimed to gain insight into beliefs, facilitators, and barriers of (1)...
BACKGROUND
In order to develop a feasible prehabilitation program before surgery of NSCLC, this study aimed to gain insight into beliefs, facilitators, and barriers of (1) healthcare professionals to refer patients to a prehabilitation program, (2) patients to participate in and adhere to a prehabilitation program, and (3) informal caregivers to support their loved ones.
METHODS
Semi-structured interviews were conducted with healthcare professionals, patients who underwent surgery for NSCLC, and their informal caregivers. The capability, opportunity, and motivation for behavior-model (COM-B) guided the development of the interview questions. Results were analyzed thematically.
RESULTS
The interviews were conducted with twelve healthcare professionals, seventeen patients, and sixteen informal caregivers. Four main themes were identified: (1) content of prehabilitation and referral, (2) organizational factors, (3) personal factors for participation, and (4) environmental factors. Healthcare professionals mentioned that multiple professionals should facilitate the referral of patients to prehabilitation within primary and secondary healthcare involved in prehabilitation, considering the short preoperative period. Patients did not know that a better preoperative physical fitness and nutritional status would make a difference in the risk of postoperative complications. Patients indicated that they want to receive information about the aim and possibilities of prehabilitation. Most patients preferred a group-based physical exercise training program organized in their living context in primary care. Informal caregivers could support their loved one when prehabilitation takes place by doing exercises together.
CONCLUSION
A prehabilitation program should be started as soon as possible after the diagnosis of lung cancer. Receiving information about the purpose and effects of prehabilitation in a consult with a physician seems crucial to patients and informal caregivers to be involved in prehabilitation. Support of loved ones in the patient's own living context is essential for adherence to a prehabilitation program.
Topics: Humans; Lung Neoplasms; Preoperative Exercise; Preoperative Care; Exercise; Carcinoma, Non-Small-Cell Lung
PubMed: 37668792
DOI: 10.1007/s00432-023-05298-6 -
Journal of Reconstructive Microsurgery Mar 2022The benefits of preoperative perforator imaging for microsurgical reconstruction have been well established in the literature. (Review)
Review
BACKGROUND
The benefits of preoperative perforator imaging for microsurgical reconstruction have been well established in the literature.
METHODS
An extensive literature review was performed to determine the most commonly used modalities, and their applicability, advantages and disadvantages.
RESULTS
The review demonstrated varioius findings including decreases in operative time and cost with the use of CT angiography to identification of perforators for inclusion in flap design with hand-held Doppler ultrasound. Modalities like MR angiography offer alternatives for patients with contrast allergies or renal dysfunction while maintaining a high level of clarity and fidelity. Although the use of conventional angiography has decreased due to the availability of less invasive alternatives, it continues to serve a role in the preoperative evaluation of patients for lower extremity reconstruction. Duplex ultrasonography has been of great interest recently as an inexpensive, risk free, and extraordinarily accurate diagnostic tool. Emerging technologies such as indocyanine green fluorescence angiography and dynamic infrared thermography provide real-time information about tissue vascularity and perfusion without requiring radiation exposure.
CONCLUSION
This article presents an in-depth review of the various imaging modalities available to reconstructive surgeons and includes hand held Doppler ultrasound, CT angiography, MR angiography, conventional angiography, duplex ultrasonography, Indocyanine Green Fluorescence Angiography and Dynamic Infrared Thermography.
Topics: Angiography; Computed Tomography Angiography; Humans; Perforator Flap; Preoperative Care; Plastic Surgery Procedures; Surgical Flaps
PubMed: 34688218
DOI: 10.1055/s-0041-1736316 -
BMC Musculoskeletal Disorders Jul 2022Long-term fasting for elective surgery has been proven unnecessary based on established guidelines. Instead, preoperative carbohydrate loading 2 h before surgery and...
BACKGROUND
Long-term fasting for elective surgery has been proven unnecessary based on established guidelines. Instead, preoperative carbohydrate loading 2 h before surgery and recommencing oral nutrition intake as soon as possible after surgery is recommended. This study was performed to analyze the compliance with and effect of abbreviated perioperative fasting management in patients undergoing surgical repair of fresh fractures based on current guidelines.
METHODS
Patients with fresh fractures were retrospectively analyzed from the prospectively collected database about perioperative managements based on enhanced recovery of surgery (ERAS) from May 2019 to July 2019 at our hospital. A carbohydrate-enriched beverage was recommended up to 2 h before surgery for all surgical patients except those with contraindications. Postoperatively, oral clear liquids were allowed once the patients had regained full consciousness, and solid food was allowed 1 to 2 h later according to the patients' willingness. The perioperative fasting time was recorded and the patients' subjective comfort with respect to thirst and hunger was assessed using an interview-assisted questionnaire.
RESULTS
In total, 306 patients were enrolled in this study. The compliance rate of preoperative carbohydrate loading was 71.6%, and 93.5% of patients began ingestion of oral liquids within 2 h after surgery. The median (interquartile range) preoperative fasting time for liquids and solids was 8 (5.2-12.9) and 19 (15.7-22) hours, respectively. The median postoperative fasting time for liquids and solids was 1 (0.5-1.9) and 2.8 (2.2-3.5) hours, respectively. A total of 70.3% and 74.2% of patients reported no thirst and hunger during the perioperative period, respectively. Logistic regression analysis showed that the preoperative fasting time for liquids was an independent risk factor for perioperative hunger. No risk factor was identified for perioperative thirst. No adverse events such as aspiration pneumonia or gastroesophageal reflux were observed.
CONCLUSIONS
In this study of a real clinical practice setting, abbreviated perioperative fasting management was carried out with high compliance in patients with fresh fractures. The preoperative fasting time should be further shortened to further improve patients' subjective comfort.
Topics: Elective Surgical Procedures; Fasting; Guideline Adherence; Humans; Preoperative Care; Retrospective Studies
PubMed: 35858882
DOI: 10.1186/s12891-022-05574-5 -
The British Journal of Radiology Aug 2019Pre-operative spine tumour embolization is a useful adjunct to minimize operative complications and blood loss during complex resections. While the efficacy of this... (Review)
Review
Pre-operative spine tumour embolization is a useful adjunct to minimize operative complications and blood loss during complex resections. While the efficacy of this procedure has been well studied, relatively little is documented regarding how to optimize technical parameters for tumour characteristics. This pictorial case series seeks to review our centre's experience over the last decade in using a range of embolization techniques. As experience with this procedure has matured, we propose an approach based on the patient's vascular anatomy and tumour angioarchitecture. This includes the use of coils as protective barriers rather than primary embolics; particle embolization to permeate fine capillary networks; consideration for liquid embolic agents in the presence of large caliber tumour vessels with associated arteriovenous shunting; and percutaneous intralesional embolization when endovascular access is insufficient to achieve the desired outcome. In many cases, a combination of these methods is needed, and close communication with the surgeon ensures the best outcome. Despite these advances, continued work is needed to determine how to optimize complete devascularization, and thus surgical benefit, while safely sparing critical neuroanatomical structures.
Topics: Embolization, Therapeutic; Humans; Preoperative Care; Spinal Neoplasms
PubMed: 30817177
DOI: 10.1259/bjr.20180899 -
Journal of Clinical Anesthesia Nov 2022Rising patient numbers, with increasing complexity, challenge the sustainability of the current preoperative process. We evaluated whether an electronic screening...
STUDY OBJECTIVE
Rising patient numbers, with increasing complexity, challenge the sustainability of the current preoperative process. We evaluated whether an electronic screening application can distinguish patients that need a preoperative consultation from low-risk patients that can be first seen on the day of surgery.
DESIGN
Prospective cohort study.
SETTING
Preoperative clinic of a tertiary academic hospital.
PATIENTS
1395 adult patients scheduled for surgery or procedural sedation.
INTERVENTIONS
We assessed a novel electronic preoperative screening application which consists of a questionnaire with a maximum of 185 questions regarding the patient's medical history and current state of health. The application provides an extensive health report, including an American Society of Anesthesiologists physical status (ASA-PS) classification and a recommendation for either consultation by an anesthesiologist at the preoperative clinic or approval for screening on the day of surgery.
MEASUREMENTS
The recommendation of the electronic screening system was compared with the regular preoperative assessment using measures of diagnostic accuracy and agreement. Secondary outcomes included ASA-PS classification, patient satisfaction, and the anesthesiologists' opinion on the completeness and quality of the screening report.
RESULTS
Sensitivity to detect patients who needed additional consultation was 97.5% (95%CI 91.2-99.7) and the negative likelihood ratio was 0.08 (95%CI 0.02-0.32). 407 (29.2%) patients were approved for surgery by both electronic screening and anesthesiologist. In 909 (65.2%) cases, the electronic screening system recommended further consultation while the anesthesiologist approved the patient (specificity 30.9% (95%CI 28.4-33.5); poor level of agreement (ĸ = 0.04)). Agreement regarding ASA-PS classification scores was weak (ĸ = 0.48). The majority of patients (78.0%) felt positive about electronic screening replacing the regular preoperative assessment.
CONCLUSIONS
Electronic screening can reliably identify patients who can have their first contact with an anesthesiologist on the day of surgery, potentially allowing a major proportion of patients to safely bypass the preoperative clinic.
Topics: Adult; Anesthesiologists; Electronics; Humans; Preoperative Care; Prospective Studies; Surveys and Questionnaires
PubMed: 35939972
DOI: 10.1016/j.jclinane.2022.110941 -
Anaesthesia Jun 2022
Topics: Humans; Postoperative Complications; Postoperative Period; Preoperative Care; Preoperative Exercise
PubMed: 34793598
DOI: 10.1111/anae.15622