Post-op Periods Research Articles

Towards an objective longitudinal assessment of oncogeriatric outpatients

of completing the Brief Geriatric Assessment on patient’s age 70 and older undergoing thoracic surgery and the secondary objective is to measure decline and recovery of IADLs after surgery. The use of the BGA will be considered “feasible” if 70% of participants are able to complete all components of the assessment and patients will be considered recovered if scores return to 90% of baseline to satisfy the two main objectives. Methods: This is a mostly self-administered questionnaire that requires an average of 25 minutes to complete. During the preoperative time period only, the patients will also answer a 10 minute serious of questions asked by a trained health care professional. These questions include a mini memory test and a walking test called the “timed up and go”. The BGA is administered at the pre-operative time period and again within two weeks of surgery, and repeated at 6 weeks and 4 months after surgery. Postoperative responses will be compared to preoperative responses to judge how surgery has affected mood, social support, and independent function. Results: To date, 51 patients have been accrued. Of those participants, 46 have completed the initial assessment. The preoperative BGA is proving to be a feasible method of collecting meaningful data in 90% of participants. The average time required for individual patients to complete the entire BGA in our outpatient clinic has been 25 minutes in the first 46 patients. Furthermore, our new preliminary data strongly support the utility of the BGA for assessing post-surgical functional decline and recovery from baseline, in our sample of 14 patients tested to date at the 6 week post-hospitalization mark. Scores were calculated for the patient’s ability to perform activities of daily living at the pre-op, 1 week post-op and 6 week post-op time periods. Of those 14 patients, the median decline of their preoperative score to the nadir was 46%. Also, the scores of the same group were on average %170 of their baseline scores at the 6 week mark. There was only one significant outlier whodid not recover from surgery and had complications leading to death. Image:

Reduction in the incidence of shivering with perioperative dexmedetomidine: A randomized prospective study

Background and Aims:Shivering is distressing to the patient and discomforting to the attending anesthesiologist, with a varying degree of success. Various drugs and regimens have been employed to abolish the occurrence of shivering. The present study aims to explore the effectiveness of dexmedetomidine in suppressing the postanesthetic shivering in patients undergoing general anesthesia.Materials and Methods:The present study was carried out on 80 patients, in American Society of Anesthesiologists I and II, aged 22–59 years, who underwent general anesthesia for laparoscopic surgical procedures. Patients were allocated randomly into two groups: group N (n = 40) and group D (n = 40). Group D were administered 1 μg/kg of dexmedetomidine intravenously, while group N received similar volume of saline during peri-op period. Cardiorespiratory parameters were observed and recorded during the preop, intraop, and postop periods. Any incidence of postop shivering was observed and recorded as per 4 point scale. Side effects were also observed, recorded, and treated symptomatically. Statistical analysis was carried out using statistical package for social sciences (SPSS) version 15.0 for windows and employing ANOVA and chi-square test with post-hoc comparisons with Bonferroni's correction.Results:The two groups were comparable regarding demographic profile (P > 0.05). Incidence of shivering in group N was 42.5%, which was statistically highly significant (P = 0.014). Heart rate and mean arterial pressure also showed significant variation clinically and statistically in group D patients during the postop period (P = 0.008 and 0.012). A high incidence of sedation (P = 0.000) and dry mouth (P = 0.000) was observed in group D, whereas the incidence of nausea and vomiting was higher in group N (P = 0.011 and 0.034).Conclusions:Dexmedetomidine seems to possess antishivering properties and was found to reduce the occurrence of shivering in patients undergoing general anesthesia.

772 FACTORS PREDICTING EARLY AND LATE RENAL FUNCTION AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: We prospectively assessed the impact of multiple factors affecting early, intermediate and late renal function after LPN. METHODS: Between 2004–2009, sixty-eight patients with 2 functioning renal units undergoing LPN were prospectively analysed. MDRD and Cockcroft Gault-calculated glomerular filtration rates (GFR), MAG-3 renograms with GFR and differential function were obtained at 1) preoperatively 2) immediately post-op ( 3 days) 3) intermediate post-op (6–12wks) and late post-op (one year). The impact of patient demographics, tumour characteristics and surgical factors on functional renal outcomes were assessed. Correlation analysis was first performed using Spearman correlation to elucidate factors correlated with GFR decline. Subsequent multivariate analysis was performed at each of the postop periods. Paired t-test was used to compare baseline GFR and renograms to these outcomes at each of the postoperative time periods. RESULTS: Spearman correlation determined that age, weight, pre-operative GFR, piece size and warm ischemia time (WIT) were correlated with early decline in GFR. However, multivariate analysis showed that in the immediate time period, only tumor weight and WIT were predictive of decreased renal function (p 0.01). As well, in the late post-op period, only the degree of early/intermediate reduction in renal function was predictive of persistent impaired renal function (p 0.00001). Paired t-test analysis showed that there was significant decline in renal function in the immediate and intermediate time points (p 0.001); this decline did not persist at one year, indicating capacity for late renal recovery (p NS). However, paired t-test using nuclear renogram studies showed that there was persistent dysfunction of the affected kidney at one year postop (41.7% vs 49.4% preop; p 0.001). Taken together, this indicates that late renal recovery may occur as a result of compensation from the contralateral renal unit. CONCLUSIONS: This study confirms the negative impact of warm ishemic time upon early renal function post-LPN. Importantly, this is the first study to show that the degree of initial renal functional loss is a key determinant to renal recovery at one year. Additionally, the function of the affected kidney remains compromised at one year, and recovery of renal function is primarily by compensation from the contralateral kidney.

Are we use of chemotherapy for elderly stage III colon cancer patients? An analysis from the Cancer Care Outcomes & Research Surveillance Consortium (CanCORS)

6500 Background: Multiple studies have documented lower rates of use of adjuvant therapy for colorectal cancer with increasing patient age despite evidence from RCTs that older patients (pts) experience similar benefits from treatment. This suggests the concern that pts treated on those trials may not be representative of the typical elderly colorectal cancer patient. We therefore examined the outcomes of adjuvant therapy for colorectal cancer in a nationally representative sample of pts treated in the routine care setting. Methods: As part of the CanCORS observational cohort study, we assessed important clinical morbid events (CME) recorded in the medical records (e.g., sepsis, myocardial infarction) for a population-based sample of 705 patients with incident colon cancer from multiple U.S. regions. We used Poisson models with propensity score to calculate adjusted mean number of CME events summed, from colectomy to 15 months post- diagnosis, by age. We adjusted for demographics, site, survey type, comorbidity, pre-dx health status, clinical complications during the pre- and post-op periods prior to chemo use; and then for 1st 5FU dose and route, chemo dose reduction, and chemo duration. Results: Overall, of 705 stage III pts, the prevalence of CME was none for 67%, one for 22%, and ≥two for 11% with a mean of 0.49 (SD 0.91) CME following surgery to the end of study. The adjusted mean number of CME are not worse for older pts, even after adjustment for 1st chemo dose and route, dose reduction and chemo duration. Conclusions: Although elderly patients are much less likely than younger patients to receive adjuvant chemotherapy for stage III colon cancer, those who receive chemotherapy, experience similar rates of clinical morbid events. Age Categories (years) Adjusted Mean Number of Clinical Morbid Events (n=705) Pts Receiving Chemo (N=517) No Chemo (n=188) Without adjustment for chemo dose After adjustment for chemo dose 21–55 (n=79) 0.71 (n=8) 0.46 0.45 56–65 (n=153) 0.40 (n=19) 0.54 0.53 66–75 (n=180) 0.48 (n=38) 0.49 0.51 >75 (n=293) 0.38 (n=123) 0.47 0.48 Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Expert Testimony Other Remuneration National Cancer Institute

Effects of pudendal nerve injury in the female rat.

To test a neurogenic hypothesis for external urethral sphincter (EUS) dysfunction associated with urinary incontinence, the proximal pudendal nerve was crushed in anesthetized retired breeder female rats (n = 5) and compared with a sham lesion group (n = 4). Outcome measures included concentric needle electromyograms (EMGs) from the target EUS, voiding patterns during a 2-hour dark period, and micturition data over a 24-hour period. Fast Blue (FB) was introduced to the crush site at the time of injury and Diamidino Yellow (DY) to the EUS at the time the rats were killed (3 months post-operative), when histological analysis of the nerve and urethra was also performed. EMG records indicated the EUS motor units undergo typical denervation changes followed by regeneration and recovery. Voiding patterns from the crush group show a significant increase of small urine marks in the front third of the cage. At 1-2 weeks post-op, the frequency of voids was significantly increased in the crush group compared to pre-op and late post-op time periods. The mean volume voided in the light phase at the early post-op time was significantly increased in the sham group. Light and electron microscopic patterns seen in nerve and muscle suggest the regenerating motor units maintain a structural integrity. Motoneurons in the lower lumbar cord were labeled with either DY (14. 5 +/- 6.8), FB (31.7 +/- 23.7), or both (35.0 +/- 17.5) tracers, indicating approximately 54% of the crushed pudendal neurons regenerated to the EUS. In conclusion, several measures suggest this reversible crush lesion induces mild urinary incontinence. This animal model is promising for further development of hypotheses regarding neural injury, the pathogenesis of incontinence, and strategies aimed at prevention and treatment. Neurourol. Urodynam. 19:53-69, 2000.

Analysis of perioperative ventricular arrhythmias in valvular heart diseases by holter ECG recording.

Seventy-one consecutive patients undergoing cardiac surgery for acquired valvular diseases were analyzed to determine the incidence of and the predisposing factors to postoperative ventricular arrhythmias. We recorded the Holter ECGs before (pre-op), and within 24h (op-day) and 4 to 10 weeks after operation (post-op) and determined the frequency of ventricular arrhythmias and the degree according to the Lown grade. The relationship between the op-day ventricular arrhythmias and clinical, hemodynamic, operative or postoperative variables was examined. The operation included mitral valve replacement or open mitral commissurotomy (49 patients, group M), aortic valve replacement (12 patients, group A) and a combined mitral and aortic operation (10 patients, group A + M). In all groups, the frequency and the degree of ventricular arrhythmias increased at the op-day and decreased at the post-op period approximately to the pre-op level. The frequency and Lown grade of the 3 groups were similar in each of the pre-op, the op-day and the post-op periods. The frequency and Lown grade of the op-day ventricular arrhythmias increased with increases in the arrhythmia frequency and Lown grade at the pre-op period, and in patients with left ventricular (LV) dysfunction at the post-op period, as evidence by an increased LV volume and decreased ejection fraction on echocardiograms. Furthermore, the frequency of ventricular premature contractions in the op-day was significantly less when a cardioplegia solution containing magnesium was used than in the case of a cardioplegia solution without magnesium. The op-day ventricular arrhythmias showed no significant relation to extracorporeal circulation time, aortic cross-clamping time, the antiarrhythmic drugs used and the op-day serum levels of K and CK-MB.