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PubMed1999

Prospective evaluation of an algorithm for the functional assessment of lung resection candidates.

Patients with impaired pulmonary function are at increased risk for the development of postoperative complications. Recently exercise testing and predicted postoperative (ppo) function have gained increasing importance in the evaluation of lung resection candidates. We prospectively evaluated an algorithm for the preoperative functional evaluation that was developed at our institution. This algorithm incorporated the cardiac history including an electrocardiogram (ECG), and the three parameters FEV1, diffusing capacity of the lungs for carbon monoxide (DLCO), and maximal oxygen uptake (VO2max), as well as their respective ppo values (FEV1-ppo, DLCO-ppo, and VO2max-ppo) calculated based on radionuclide perfusion scans. A consecutive group of 137 patients (mean age 62 yr; range 23 to 81; 102 males, 35 females) with clinically resectable lesions underwent assessment according to our algorithm. Five patients were deemed functionally inoperable, 132 passed the algorithm and underwent pulmonary resections with standard thoracotomy: 9 segmental or wedge resections, 85 lobectomies (inclusive 3 bilobectomies), and 38 pneumonectomies. All patients were extubated within 24 h. The mean stay in the ICU was 1.4 (+/- 1.8) d, and the mean hospital stay was 14.6 (+/- 5) d. Postoperative complications (within 30 d) occurred in 15 patients (11%), of whom two died (overall mortality rate 1.5%). In comparison to our previous series this meant a 50% reduction in complications whereas the percentage of inoperable patients remained unchanged (4% now, 5% before). We conclude that adherence to our algorithm resulted in a very low complication rate (morbidity and mortality), and excluded more rigorous patient selection as a bias for the improved results.

Aged↗
PubMed1987

[Effect of isoflurane on intracranial pressure].

The influence exercised by isoflurane on intracranial pressure is studied in a total of 22 patients subjected to neurosurgery. Of these, 12 patients had brain tumours, 4 hydrocephalus occlusus (preoperative measurement of the intracranial pressure) and 6 severe craniocerebral trauma (continuous monitoring of intracranial pressure). In the patients suffering from cerebral tumours the intracranial pressure remained generally unchanged under isoflurane or dropped only slightly in accordance with the drop in median arterial pressure. This drop in median arterial pressure was considerable (-20% to -30%). In patients with hydrocephalus occlusus a biphasic course of the intracranial pressure was frequently observed. After a transient rise the pressure dropped again to the starting level. Isoflurane, on the other hand, led to marked increases in intracranial pressure in 5 patients with craniocerebral trauma (+4 to 22 mmHg). If the median arterial pressure also dropped at the same time, critical ranges were occasionally calculated for the cerebral perfusion pressure. The influence of nitrous oxide in respect of the performance of isoflurane in connection with intracranial pressure is discussed. It appears possible that in contrast to halothane isoflurane does not further increase the intracranial pressure if used in low doses and in the presence of nitrous oxide. However, the results presented here point to the need to exercise caution when using isoflurane in patients with markedly limited intracranial compliance.

Anesthesia, General↗
PubMed1994

Does routine stress-thallium cardiac scanning reduce postoperative cardiac complications?

OBJECTIVE: Prophylactic cardiac revascularization in patients with ischemic myocardium could reduce postoperative cardiac complications after aortic reconstruction. However, the effectiveness of this approach has not been documented. SUMMARY BACKGROUND DATA: Stress-thallium scanning can identify patients with ischemic myocardium. Morbidity and mortality after aortic reconstruction appears to be largely caused by co-existent coronary artery disease, and patients who have had recent cardiac revascularization have few postoperative cardiac complications. METHODS: Preoperative stress-thallium scanning was evaluated prospectively in 146 patients undergoing aortic reconstruction. Patients with positive studies underwent coronary arteriography and cardiac revascularization, when appropriate. Postoperative cardiac complications and long-term survival in these patients were compared with results from 172 similar patients undergoing aortic reconstruction without stress-thallium scanning. Results also were analyzed to determine predictors of postoperative cardiac events. RESULTS: Forty-one per cent of patients undergoing stress-thallium testing underwent coronary arteriography, and 11.6% had cardiac revascularization. In contrast, 14.7% of patients treated without stress-thallium testing had coronary arteriography, and 4.1% had revascularization (p < 0.01). Despite this, cardiac mortality, serious cardiac complications, and long-term cardiac mortality were similar in both groups. Only advanced age and intraoperative complications (but not a positive stress-thallium test) predicted postoperative cardiac events. CONCLUSIONS: Preoperative stress-thallium testing confirmed a high incidence of significant coronary artery disease in patients undergoing aortic reconstruction, but prophylactic cardiac intervention does not reduce operative or long-term mortality. Thus, the risk and expense of routine stress-thallium testing and subsequent cardiac revascularization cannot be justified.

Aged↗
PubMed1989

Cast immobilization after total elbow arthroplasty. A safe cost-effective method of initial postoperative care.

Seventeen nonconstrained total elbow replacements were inserted in 12 patients. One patient died prior to the one-year follow-up examination, and two others required revision in the immediate postoperative period. The remaining 14 primary total elbow arthroplasties in 11 patients were included in this study. There were eight women and three men with an average age of 58.1 years. The diagnosis was rheumatoid arthritis in 12 patients and posttraumatic arthritis and juvenile rheumatoid arthritis each in one patient. Postoperatively, patients were immobilized in a long arm cast. The mean hospital stay was 4.3 days. At four weeks, the patients were seen for cast removal. Instructions were given for range of motion (ROM) exercises and patients were encouraged to resume normal daily activities as tolerated. No formal physical therapy was prescribed. The average follow-up period was 32 months. Preoperatively, the mean elbow motions were flexion 124 degrees, extension 34 degrees, pronation 65 degrees, and supination 44 degrees. At the last follow-up examination, ROM had improved significantly in all directions except extension (flexion 141 degrees, extension 36 degrees, pronation 77 degrees, and supination 61 degrees). There was one ulnar nerve palsy that only partially resolved. Another patient's elbow had initially subluxed due to excessive shortening of the humerus; however, he had an excellent ROM and was asymptomatic at 31 months. There were no dislocations or wound healing problems. Cast immobilization provides an effective means of promoting soft-tissue healing, permitting early discharge from the hospital and simplifying the postoperative rehabilitation while achieving satisfactory ROM without formal physical therapy.

Adult↗
PubMed1985

Rest-exercise radionuclide angiographic assessment of left ventricular function in chronic aortic regurgitation: significance of serial studies in medically versus surgically treated groups.

Forty consecutive asymptomatic patients with chronic aortic regurgitation who underwent three serial yearly rest and postexercise radionuclide angiograms were compared with 27 consecutive patients with chronic aortic regurgitation and aortic valve replacement who were studied preoperatively, 3 and 15 months postoperatively. Patients were divided into four subgroups based upon the resting left ventricular ejection fraction and the functional reserve on the initial study. Of the 40 medically treated patients, 19 (47.5%) and 24 (60%) demonstrated a response at least one type lower at 12 months and 24 months, respectively. Initial functional reserve, initial duration of exercise, and the change in exercise duration during the 24 months was not associated with changes in resting or postexercise left ventricular ejection fraction. A seesaw pattern was observed between the resting and the postexercise left ventricular ejection fraction as ventricular function deteriorated. We observed in the surgical groups a reversal of the seesaw interaction between the resting and postexercise ejection fraction seen in the medical patients. In the surgical groups the left ventricular end-diastolic pressure, initial functional reserve, initial duration of exercise, and change in exercise duration postoperatively were not predictors of improvement in left ventricular function at 15 months. Comparing medical and surgical serial data, we suggest yearly radionuclide angiographic determination of rest left ventricular ejection fraction in asymptomatic patients with chronic aortic regurgitation. When the rest ejection fraction is less than 50%, exercise angiography should be performed to determine functional reserve. When functional reserve is also abnormal, surgery should be recommended.

Adolescent↗
PubMed1999

Quantification of Viable Myocardium in Multivessel Coronary Disease: Effects of the Redistribution Time after Reinjection Of Thallium-201 and Comparison with Postrevascularization Defect Size.

Reinjection of 201Tl is used for improved detection of viable myocardium. Prospectively the effect of the redistribution time after injection for the quantification of the definitive perfusion defect size in multivessel coronary heart disease and severely impaired left ventricular function was examined. Thirty patients were included preoperatively before CABG. The study was performed with 80-90 MBq 201Tl-Cl and reinjection (40-50 MBq). Imaging was performed after an exercise test and 3 hours afterwards. Thereafter, the reinjection dose was given and repeated studies were performed 10 minutes, 2 hours, and 20 hours later. Defect sizes were compared with the 3-hour rest-study without reinjection. Imaging studies were repeated postoperatively. The defect size was expressed as % of left ventricular total myocardium. Perfusion defect sizes were as follows: post-stress study (27%), 3 hour rest-study (17%), post-reinjection-10 min (12%), 2 hours (9%), and 20 hours (7%). Compared with the 3 hour rest-study, the perfusion defect was reduced only in 7/30 patients in the study immediately after reinjection. In the delayed studies, defect sizes were markedly smaller (p < 0.05) both in studies 2 hours and 20 hours after reinjection. In 15/30 patients there was a marked reduction of 50% of defect sizes in the study 2 hours post-reinjection vs the 3 hour rest-study. The residual defects at 2 hours after reinjection were identical to the postoperative defect sizes (10%). Further prolongation of the redistribution time to 20 horus caused an additional small reduction in defect size only in two patients compared with the 2-hour post-reinjection images (n.s.). Using a marker as 201Tl with redistribution characteristics, the redistribution time after reinjection is of utmost importance to correctly identify the definitive size of the perfusion defect vs viable myocardium in patients with multivessel disease. A delay of 2 hours for redistribution after the reinjection most correctly corresponds to the postop defect size; a longer redistribution time did not provide additional advantages.

Journal Article↗
PubMed1998

Patients' reactions to attempts to increase passive or active coping with surgery.

It is generally regarded as valuable for patients to exercise control over aspects of their medical treatment. Although psychological and other interventions are commonly used with the aim of increasing patients' ability or willingness to control events, it is not known whether patients experience these procedures in the way assumed. The present study compared responses to (i) a psychological intervention designed to increase patients' readiness to exercise control and cope actively and (ii) a comparable intervention intended to induce acceptance and passive coping. Hip or knee arthroplasty patients were visited preoperatively by a researcher who administered the active (N = 15) or passive (N = 15) intervention in a dialogue with the patient. Patients' verbal responses to the interventions were analyzed qualitatively to identify the range of reactions to each type of intervention. Patients readily accepted the passive message on the grounds of doctors' and nurses' authority and the value of the patients' emotional detachment from their surgery. Few responses to the active message indicated acceptance that patients have control over their care and its outcomes; instead, recipients typically interpreted it in terms of the need for obedience to medical and nursing authority. In conclusion, patients do not automatically accept messages intended to change ways of coping. In particular, the attempt to increase patients' readiness to take control over aspects of care can be perceived by patients in an opposite way to that intended. This and previous studies suggest that patient control over aspects of treatment is a professional and theoretical construction that often means little to patients.

Adaptation, Psychological↗
PubMedDate not supplied

Psychological factors in postoperative fatigue.

OBJECTIVE: To assess whether the fatigue commonly reported by patients following surgery is partly a result of somatization and/or cognitive-behavioral factors. METHODS: One hundred eighty-three patients completed questionnaires before surgery and then 2 days, 3 weeks and 6 months afterward. Multiple regressions were used to assess which of the following factors were important in predicting self-reported postoperative fatigue, controlling for preoperative fatigue and for various demographic and surgical variables: negative mood, history of mood disorder, preoperative expectations of fatigue, preoperative worry or optimism about surgery, preoperative beliefs about the benefits of activity or rest, self-reported postoperative activity, self-reported cardiovascular deconditioning, and availability of social support. RESULTS: Controlling for demographic and surgical variables and preoperative fatigue, postoperative fatigue showed significant associations with negative mood at each stage of follow-up (p < .001) and was significantly predicted by history of mood disorder at 2 days postoperatively (p = .02). Higher fatigue expectations were self-fulfilling at 3 weeks after surgery (p = .02), whereas preoperative belief in physical activity as being beneficial to recovery predicted reduced fatigue at 6 months (p < .001). Finally, self-reported breathlessness after exercise, an indicator of cardiovascular deconditioning, was also significantly associated with greater fatigue at 6 months (p = .02). CONCLUSION: The results indicate that psychological processes may well be relevant in the etiology of postoperative fatigue. In particular, the results relating to mood and expectations suggest that somatization may be particularly important in the first few weeks following surgery, whereas cognitive-behavioral factors and cardiovascular deconditioning may be more important in determining later-stage recovery.

Adolescent↗
PubMedDate not supplied

Gas exchange and exercise capacity affect neurocognitive performance in patients with lung disease.

OBJECTIVE: This study examined the relationship between cognitive functioning and the severity of underlying lung disease in patients awaiting lung transplantation. METHODS: Ninety-four patients with end-stage lung disease completed a test battery to assess cognitive performance in two domains: executive functioning/attention (Trails A and B, COWA, Animal Naming, Stroop Color-Word Test, Digit Symbol, and the 2 & 7 Test) and verbal memory (Digit Span-Backward and Forward, WMS-R Logical Memory and Paired Verbal Associates). RESULTS: Thirty-seven percent of the patients demonstrated moderate to severe cognitive impairment data on two or more tests. Adjusting for age and education, there were no statistically significant differences on executive functioning or verbal memory as a function of specific lung disease diagnosis. Lower PCO2 values were associated with better cognitive performance on latent measures of executive functioning and attention (p = .006) and verbal memory (p = .009), whereas higher PO2 values tended to be associated with better performance on the executive functioning/attention measure (p = .064). Distance walked in 6 minutes was positively related to verbal memory (p < .023). CONCLUSIONS: Impaired neurocognitive functioning may be relatively common in patients awaiting lung transplantation and is associated with ineffective pulmonary gas exchange and reduced exercise tolerance.

Adult↗
PubMed1993

Predictive value of manual ECG-monitored exercise test before abdominal aortic or peripheral vascular surgery.

The value of manual ECG-monitored exercise test was studied in 58 patients (39 men and 19 women) with intermittent claudication scheduled for abdominal or peripheral vascular surgery. There was a high incidence of well-known risk factors (hypercholesterolemia, smoking, and hypertension) in men and women. History of coronary artery disease (CAD) was present in 29.3% of the patients. No correlation was found between patients with single or multiple stenoses in lower extremity arteries (angiography) and CAD. Ischemic response (ECG) to manual exercise testing was positive in 14 patients (24.1%), of whom 2 (14.3%) had major cardiovascular postoperative complications. Both died of acute myocardial infarction within fourteen days. They had slow recovery (thirty to sixty minutes) of the ST segment (0.3-0.6 mV). The authors conclude that manual exercise testing might reveal serious CAD in patients with severe occlusive peripheral arterial disease of the lower extremities. In cases with slow recovery of ischemic response to exercise, coronary bypass or angioplasty could be advantageous before major vascular surgery.

Adult↗
PubMed2003

Clinical and exercise test determinants of survival after cardiac transplantation.

BACKGROUND: Cardiac transplantation (CTX) is now a viable option for patients with end-stage heart failure, but there remains a paucity of available donor hearts relative to the demand for them. Establishing prognosis after CTX can help direct this resource to patients most likely to benefit, as well as to help guide therapy for CTX recipients. Clinical, exercise, and hemodynamic factors associated with survival after CTX have not been well established. METHODS: One hundred seventy-four randomly selected patients who underwent heart transplantation between 1983 and 1999 at Rikshospitalet University Hospital were included in the study. Data were collected as a part of routine posttransplantation management a mean of 3.5 +/- 2.1 years (+/- SD) after CTX. Clinical, cardiopulmonary exercise testing, and hemodynamic measures were performed, including measures of peak oxygen uptake (O(2)), ejection fraction, cardiac index, pulmonary capillary wedge pressure (PCWP), pulmonary artery pressure, creatinine, and the presence of coronary artery disease. Patients were followed up for a mean of 7.1 +/- 2.1 years; all-cause mortality was used as the end point for survival analysis. RESULTS: During the follow-up period, 39 patients died; the average annual mortality was 3.6%. Peak O(2) was 19.6 +/- 5.6 mL/kg/min, representing 70.5 +/- 6.7% of the age-predicted value. Only right atrial pressure and PCWP differed between those who survived and those who died; both were slightly higher among those who died. By Cox proportional hazard analysis, there were no age-adjusted univariate or multivariate predictors of survival among continuous variables. Exploring various cut points revealed that serum creatinine > 118 micromol/L, PCWP > 12 mm Hg, and mean pulmonary artery pressure > 25 mm Hg were significant univariate predictors of mortality. These cut points for PCWP and pulmonary artery pressure generated hazard ratios of 2.3 and 2.9, respectively. CONCLUSION: Long-term survival after CTX was comparatively high in our cohort, with 5-year survival > 80%. Standard clinical, hemodynamic, and cardiopulmonary exercise test variables were not strong predictors of mortality in CTX patients a mean of 7 years after CTX. The association between elevated hemodynamic pressures and mortality, although weak, suggests that ventricular compliance, pulmonary vascular resistance, or both, may predict long-term survival after CTX.

Blood Pressure↗
PubMed2000

Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder.

BACKGROUND: Neer and Foster previously described the inferior capsular shift procedure for treating multidirectional instability of the shoulder and reported preliminary results that were quite satisfactory. The purpose of our study was to perform a longer-term follow-up evaluation of the efficacy of the inferior capsular shift procedure for treating multidirectional instability of the shoulder. METHODS: An inferior capsular shift procedure was used to treat multidirectional instability of the shoulder in forty-nine patients (fifty-two shoulders). All patients had failed to respond to an exercise program. In this series, the operative approach (anterior or posterior) was based on the major direction of the instability, as determined by the preoperative history and physical examination and as verified by examination with the patient under anesthesia. In all of the patients, the inferior capsular shift was the primary attempt at operative stabilization. The repair consisted of a lateral-side (or humeral-side) shift of the capsule to reduce capsular redundancy and, when necessary, a reattachment of the avulsed labrum to the anteroinferior aspect of the glenoid. RESULTS: A redundant capsular pouch was seen in all of the shoulders in this series. In addition, detachment of the anteroinferior aspect of the labrum was found in ten shoulders and an anterior fracture of the glenoid rim was seen in two shoulders. At an average of sixty-one months (range, twenty-four to 132 months), results were available for forty-nine shoulders (forty-six patients). Thirty shoulders (61 percent) had an excellent overall result, sixteen (33 percent) had a good result, one (2 percent) had a fair result, and two (4 percent) had a poor result. Forty-seven (96 percent) of the forty-nine shoulders remained stable at the time of follow-up. Two of the thirty-four shoulders that had been repaired through an anterior approach began to subluxate anteroinferiorly again. None of the fifteen shoulders that had been repaired through a posterior approach had recurrent instability. Full function, including the ability to perform strenuous manual tasks, was restored to forty-five shoulders (92 percent). A return to sports was possible after thirty-one (86 percent) of the thirty-six procedures done in athletes; however, a return to the premorbid level of participation was possible after only twenty-five (69 percent) of the thirty-six procedures. CONCLUSIONS: The results in this series demonstrate the efficacy and the durability of the results of the inferior capsular shift procedure for the treatment of shoulders with multidirectional instability. The procedure directly addresses the major pathological feature - a redundant joint capsule. Similar results were seen with either an anterior or a posterior approach, and we continue to approach shoulders with multidirectional instability on the side of greatest instability. A postoperative brace was reserved for patients in whom a posterior approach had been used or in whom an anterior approach had involved extensive posterior capsular dissection (ten of the thirty-four shoulders treated with the anterior approach).

Adolescent↗
PubMed1990

Hemispherectomy--a radical solution.

1. Hemispherectomy, a procedure where half of the brain is removed, is one of the most radical surgeries performed. One of the few medical conditions to warrant such a procedure is intractable seizures in infantile hemiplegia. 2. Children on whom hemispherectomies are performed present with one or more of the following symptoms: hemiplegia, persistent focal seizures, mental deterioration, and hemianopia. Mental deterioration is usually present to some degree but can be exacerbated by the persistent seizures. 3. Nursing implications include extensive preoperative teaching as to pathology, surgical procedure, and expected outcomes. Postoperative instruction involves training parents to assist their child with passive range of motion exercises or ambulation and the action and side effects of medications.

Brain↗
PubMed1974

Bunion surgery.

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Adolescent↗