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Ripollés-Melchor J, Monge García MI, Ruiz-Escobar A, Sáez-Ruiz E, Algar-Yañez B, Abad-Motos A, Abad-Gurumeta A. Validity of estimated aortic pulse wave velocity measured during the 6-min walk test to predict anaerobic fitness before major non-cardiac surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00126-4. [PMID: 39245143 DOI: 10.1016/j.redare.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/04/2024] [Accepted: 04/09/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND This study aimed to assess the efficacy of estimated preoperative aortic pulse wave velocity (AoPWV) to discriminate between low and high 6 min walk test (6MWT) distance in patients awaiting major non-cardiac surgery. METHODS Prospective observational study in 133 patients undergoing non cardiac surgery. AoPWV and the distance walked during a 6MWT were assessed. Receiver operating characteristic (ROC) curve analysis was used to determine two different AoPWV cut-points for predicting a distance of 427 m in the 6MWT. We also calculated lower and upper AoPWV cut-points (probability ≥ 0.75) for predicting a distance of < 427 m, ≥427 m, and also 563 m in the 6MWT. RESULTS The ROC curve analysis for the < 427 m distance revealed an area under the curve (AUC) of 0.68 (95% confidence interval 0.56-0.79) and an AUC of 0.72 (95% confidence interval 0.61-0.83) for >563 m. Patients with AoPWV > 10.97 m/s should be considered high risk, while those with <9.42 m/s can be considered low risk. CONCLUSIONS AoPWV is a simple, non-invasive, useful clinical tool for identifying and stratifying patients awaiting major non-cardiac surgery. In situations of clinical uncertainty, additional measures should be taken to assess the risk.
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Affiliation(s)
- J Ripollés-Melchor
- Hospital Universitario Infanta Leonor, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain; Spanish Perioperative Audit and Research Network (REDGERM), Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain.
| | - M I Monge García
- Departamento de Cuidados Intensivos, Hospital Universitario SAS de Jerez, Jerez de la Frontera, Cádiz, Spain
| | - A Ruiz-Escobar
- Hospital Universitario Infanta Leonor, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - E Sáez-Ruiz
- Hospital Universitario Infanta Leonor, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - B Algar-Yañez
- Hospital Universitario Infanta Leonor, Madrid, Spain
| | - A Abad-Motos
- Hospital Universitario Infanta Leonor, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain; Spanish Perioperative Audit and Research Network (REDGERM), Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain
| | - A Abad-Gurumeta
- Hospital Universitario Infanta Leonor, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain; Spanish Perioperative Audit and Research Network (REDGERM), Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain
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Sebio-Garcia R, Montané-Muntané M, González-Colom R, Tena B, Dana F, Sisó M, Peláez A, Campero B, Diéguez-Porto I, Capitán D, Borda D, Martínez-Pallí G. Association between the 6MWT and other measurements of physical functioning in patients with cancer awaiting major surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108510. [PMID: 38945057 DOI: 10.1016/j.ejso.2024.108510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/26/2024] [Accepted: 06/23/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The Six Minute Walk Test (6MWT) is a widely used measure of functional capacity in (p)rehabilitation of cancer patients, but it is time-consuming and requires specific space conditions. In this study we explore the association between the 6MWT with other measurements of physical functioning and their predictive value in classifying patients according to their estimated functional capacity. DESIGN This prospective study included cancer patients referred to a prehabilitation programme prior to major surgery. For each patient, data on different measurements of physical functioning including the Duke Activity Status Index (DASI), the handgrip strength, the 30" Sit-to-Stand Test and self-reported physical activity levels were collected. Bivariate associations were performed to determine the association between the 6MWT and other variables. Multivariate analyses were performed to identify potential predictive factors of 6MWT in this population. A subsequent algorithm was developed to classify patients based on their functional capacity (good performance - 6MWT>400 m or poor performance 6MWT<400 m) RESULTS: Between mid-2018 to mid 2022, 692 patients were assessed of whom the 6MWT was performed in 524 (75.7 %) (mean age 72.5 ± 11.8 years; 57.1 % men). Moderate-to-strong correlations were found between 6MWT and 30" Sit-To-Stand Test (r = 0.54, p < 0.001), DASI (r = 0.68; p < 0.001) and handgrip strength (r = 0.5; p < 0.001). Multivariate analyses confirmed that a combination of six variables were able to classify 80 % of patients in good (>400 m) or poor (<400 m) performance in the 6MWT. CONCLUSION The 6MWT was moderately associated with several variables of physical functioning, a combination of which can be used to predict performance in the 6MWT.
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Affiliation(s)
- Raquel Sebio-Garcia
- Department of Physical Medicine and Rehabilitation, Hospital Clínic de Barcelona, Barcelona, Spain; Institut D'Investigacions Biomèdiques Agustí Pi I Sunyer, Universitat de Barcelona, Barcelona, Spain.
| | - Mar Montané-Muntané
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Rubèn González-Colom
- Institut D'Investigacions Biomèdiques Agustí Pi I Sunyer, Universitat de Barcelona, Barcelona, Spain.
| | - Beatriz Tena
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Fernando Dana
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Marina Sisó
- Department of Endocrinology and Metabolic Diseases, Hospital Clinic de Barcelona, Barcelona, Spain.
| | - Amaia Peláez
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Betina Campero
- Department of Endocrinology and Metabolic Diseases, Hospital Clinic de Barcelona, Barcelona, Spain.
| | - Iago Diéguez-Porto
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - David Capitán
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Daniel Borda
- Department of Physical Medicine and Rehabilitation, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Graciela Martínez-Pallí
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain; Institut D'Investigacions Biomèdiques Agustí Pi I Sunyer, Universitat de Barcelona, Barcelona, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid, Spain.
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López-Hernández A, Gimeno-Santos E, Navarro-Ripoll R, Arguis MJ, Romano-Andrioni B, López-Baamonde M, Teres S, Sanz-de la Garza M, Martinez-Palli G. Differential response to preoperative exercise training in patients candidates to cardiac valve replacement. BMC Anesthesiol 2024; 24:280. [PMID: 39123146 PMCID: PMC11311913 DOI: 10.1186/s12871-024-02671-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND There is lack of evidence regarding safety, effectiveness and applicability of prehabilitation on cardiac surgery population, particularly in patients candidates to cardiac valve replacement. The aim of the study is to assess and compare the effect of a multimodal prehabilitation program on functional capacity in patients with severe aortic stenosis (AoS) and severe mitral regurgitation (MR) proposed for valve replacement surgery. METHODS Secondary analysis from a randomised controlled trial whose main objective was to analyze the efficacy of a 4-6 weeks multimodal prehabilitation program in cardiac surgery on reducing postoperative complications. For this secondary analysis, only candidates for valve replacement surgery were selected. The primary outcome was the change in endurance time (ET) from baseline to preoperative assessment measured by a cycling constant work-rate cardiopulmonary exercise test. RESULTS 68 patients were included in this secondary analysis, 34 (20 AoS and 14 MR) were allocated to the prehabilitation group and 34 (20 AoS and 14 MR) to control group. At baseline, patients with AoS had better left systolic ventricular function and lower prevalence of atrial fibrillation compared to MR (p = 0.022 and p = 0.035 respectively). After prehabilitation program, patients with MR showed greater improvement in ET than AoS patients (101% vs. 66% increase from baseline). No adverse events related to the prehabilitation program were observed. CONCLUSIONS A 4-6 week exercise training program is safe and overall improves functional capacity in patients with severe AoS and MR. However, exercise response is different according to the cardiac valve type disfunction, and further studies are needed to know the factors that predispose some patients to have better training response. TRIAL REGISTRATION The study has been registered on the Registry of National Institutes of Health ClinicalTrials.gov (NCT03466606) (05/03/2018).
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Affiliation(s)
- Antonio López-Hernández
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elena Gimeno-Santos
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Barcelona of Global Health Institute (ISGlobal) - Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Ricard Navarro-Ripoll
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - María José Arguis
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Bárbara Romano-Andrioni
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Nutrition and Clinical Dietetics, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Manuel López-Baamonde
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Silvia Teres
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - María Sanz-de la Garza
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Cardiovascular Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Graciela Martinez-Palli
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain.
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
- CIBER de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain.
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Ubré M, Montané-Muntané M, Diéguez I, Martínez-Pallí G. 10 years of prehabilitation: From theory to clinical practice. Cir Esp 2024; 102:451-458. [PMID: 38718979 DOI: 10.1016/j.cireng.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/04/2024] [Indexed: 08/06/2024]
Abstract
In recent years, prehabilitation has generated high expectations as an innovative preoperative strategy to enhance clinical outcomes following surgery. Several studies have demonstrated that multimodal programs are effective in improving patients' health status and cardiopulmonary reserve, allowing them to undergo surgery in better conditions and, consequently, reducing the incidence of postoperative complications. Most publications describe proof-of-concept studies, and literature about their implementation is more limited. The implementation of these programs requires new resources and significant organizational effort. In this paper, we share our experience implementing a multimodal prehabilitation program as a mainstream service at a tertiary hospital. Although there are still many unknowns regarding the optimal selection of patients, as well as the duration and components of the program, this article describes our journey in this field, aiming to provide insight for teams interested in developing a similar project.
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Affiliation(s)
- Marta Ubré
- Department of Anesthesiology, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Mar Montané-Muntané
- Department of Anesthesiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Iago Diéguez
- Department of Anesthesiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Graciela Martínez-Pallí
- Department of Anesthesiology, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain; Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
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Fiorindi C, Giudici F, Testa GD, Foti L, Romanazzo S, Tognozzi C, Mansueto G, Scaringi S, Cuffaro F, Nannoni A, Soop M, Baldini G. Multimodal Prehabilitation for Patients with Crohn's Disease Scheduled for Major Surgery: A Narrative Review. Nutrients 2024; 16:1783. [PMID: 38892714 PMCID: PMC11174506 DOI: 10.3390/nu16111783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/25/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
Approximately 15-50% of patients with Crohn's disease (CD) will require surgery within ten years following the diagnosis. The management of modifiable risk factors before surgery is essential to reduce postoperative complications and to promote a better postoperative recovery. Preoperative malnutrition reduced functional capacity, sarcopenia, immunosuppressive medications, anemia, and psychological distress are frequently present in CD patients. Multimodal prehabilitation consists of nutritional, functional, medical, and psychological interventions implemented before surgery, aiming at optimizing preoperative status and improve postoperative recovery. Currently, studies evaluating the effect of multimodal prehabilitation on postoperative outcomes specifically in CD are lacking. Some studies have investigated the effect of a single prehabilitation intervention, of which nutritional optimization is the most investigated. The aim of this narrative review is to present the physiologic rationale supporting multimodal surgical prehabilitation in CD patients waiting for surgery, and to describe its main components to facilitate their adoption in the preoperative standard of care.
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Affiliation(s)
- Camilla Fiorindi
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Francesco Giudici
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 6, 50135 Florence, Italy; (F.G.); (S.S.)
| | - Giuseppe Dario Testa
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Division of Geriatric and Intensive Care Medicine, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | - Lorenzo Foti
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Section of Anesthesiology and Intensive Care, University of Florence, Largo Brambilla 3, 50139 Florence, Italy
| | - Sara Romanazzo
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Cristina Tognozzi
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Giovanni Mansueto
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
| | - Stefano Scaringi
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla 6, 50135 Florence, Italy; (F.G.); (S.S.)
| | - Francesca Cuffaro
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
| | - Anita Nannoni
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
| | - Mattias Soop
- Department for IBD and Intestinal Failure Surgery, Karolinska University Hospital, SE 177 76 Stockholm, Sweden;
| | - Gabriele Baldini
- Department of Health Science, University of Firenze, Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy; (S.R.); (C.T.); (G.M.); (F.C.); (A.N.); (G.B.)
- Multimodal Prehabilitation Center, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla 6, 50135 Florence, Italy; (G.D.T.); (L.F.)
- Section of Anesthesiology and Intensive Care, University of Florence, Largo Brambilla 3, 50139 Florence, Italy
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Bingül ES, Şentürk NM, Kaynar AM. Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection. Front Med (Lausanne) 2023; 10:1196981. [PMID: 37849492 PMCID: PMC10577193 DOI: 10.3389/fmed.2023.1196981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.
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Affiliation(s)
- Emre Sertaç Bingül
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Nüzhet Mert Şentürk
- Department of Anesthesiology, Acibadem University School of Medicine, Istanbul, Türkiye
| | - Ata Murat Kaynar
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- The Center for Innovation in Pain Care (CIPC), University of Pittsburgh, Pittsburgh, PA, United States
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA, United States
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Ladha KS, Lu J, McIsaac DI, van Vlymen JM, Lebovic G, Ehtesham S, Pazmino-Canizares J, Clarke H, Parotto M, Lorello GR, Wijeysundera DN. Peri-Operative Wearables in Elder Recover after Surgery (POWERS) study: a protocol for a multicentre, prospective cohort study to evaluate perioperative activity with postoperative disability in older adults after non-cardiac surgery. BMJ Open 2023; 13:e073612. [PMID: 37770257 PMCID: PMC10546154 DOI: 10.1136/bmjopen-2023-073612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/31/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION The ageing population has led to an increasing proportion of surgical patients with greater frailty and comorbidity. Complications and mortality within 30 days of a surgical procedure are often used to evaluate success in the perioperative period however these measures can potentially underestimate a substantial level of morbidity associated with surgery. Personal wearable technologies are now readily available and can offer detailed information on activity intensity, sedentary behaviour and sleeping patterns. These devices may provide important information perioperatively by acting as a non-invasive, and cost-efficient means to risk stratify patients. METHODS AND ANALYSIS The Peri-Operative Wearables in Elder Recover After Surgery (POWERS) study is a multicentre observational study of 200 older adults (≥65 years) having major elective non-cardiac surgery. The objectives are to characterise the association between preoperative and postoperative activity monitor measurements with postoperative disability and recovery, as well as characterise trajectories of activity and sleep in the perioperative period. Activity will be monitored with the ActiGraph GT3X device and measured for 7-day increments, preoperatively, and at 1 week, 1 month and 3 months postoperatively. Disability will be assessed using the WHO Disability Assessment Schedule 2.0 assessed at 1 week, 1 month and 3 months postoperatively. ETHICS AND DISSEMINATION The POWERS study received research ethics board approval at all participating sites on 1 August 2019 (REB # 19-121 (CTO 1849)). Renewal was granted on 19 May 2022.
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Affiliation(s)
- Karim S Ladha
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justin Lu
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Janet M van Vlymen
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sahar Ehtesham
- Applied Health Research Centre, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Pain Research Unit, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Gianni R Lorello
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
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Clifford K, Woodfield JC, Tait W, Campbell HA, Baldi JC. Association of Preoperative High-Intensity Interval Training With Cardiorespiratory Fitness and Postoperative Outcomes Among Adults Undergoing Major Surgery: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2320527. [PMID: 37389875 PMCID: PMC10314310 DOI: 10.1001/jamanetworkopen.2023.20527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/12/2023] [Indexed: 07/01/2023] Open
Abstract
Importance Preoperative high-intensity interval training (HIIT) is associated with improved cardiorespiratory fitness (CRF) and may improve surgical outcomes. Objective To summarize data from studies comparing the association of preoperative HIIT vs standard hospital care with preoperative CRF and postoperative outcomes. Data Sources Data sources included Medline, Embase, Cochrane Central Register of Controlled Trials Library, and Scopus databases with no language constraints, including abstracts and articles published before May 2023. Study Selection The databases were searched for randomized clinical trials and prospective cohort studies with HIIT protocols in adult patients undergoing major surgery. Thirty-four of 589 screened studies met initial selection criteria. Data Extraction and Synthesis A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model. Main Outcomes and Measures The primary outcome was change in CRF, as measured by either peak oxygen consumption (V̇o2 peak) or 6-Minute Walk Test (6MWT) distance. Secondary outcomes included postoperative complications; hospital length of stay (LOS); and changes in quality of life, anaerobic threshold, and peak power output. Results Twelve eligible studies including 832 patients were identified. Pooled results indicated several positive associations for HIIT when compared with standard care either on CRF (V̇o2 peak, 6MWT, anaerobic threshold, or peak power output) or postoperative outcomes (complications, LOS, quality of life), although there was significant heterogeneity in study results. In 8 studies including 627 patients, there was moderate-quality evidence of significant improvement in V̇o2 peak (cumulative mean difference, 2.59 mL/kg/min; 95% CI, 1.52-3.65 mL/kg/min; P < .001). In 8 studies including 770 patients, there was moderate-quality evidence of a significant reduction in complications (odds ratio, 0.44; 95% CI, 0.32-0.60; P < .001). There was no evidence that HIIT differed from standard care in hospital LOS (cumulative mean difference, -3.06 days; 95% CI, -6.41 to 0.29 days; P = .07). The analysis showed a high degree of heterogeneity in study outcomes and an overall low risk of bias. Conclusions and Relevance The results of this meta-analysis suggest that preoperative HIIT may be beneficial for surgical populations through the improvement of exercise capacity and reduced postoperative complications. These findings support including HIIT in prehabilitation programs before major surgery. The high degree of heterogeneity in both exercise protocols and study results supports the need for further prospective, well-designed studies.
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Affiliation(s)
- Kari Clifford
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
- Surgical Outcomes Research Centre (SOuRCe), Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - John C. Woodfield
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
- Surgical Outcomes Research Centre (SOuRCe), Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - William Tait
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Holly A. Campbell
- Department of Surgical Sciences, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - James Chris Baldi
- Department of Medicine, Otago Medical School, University of Otago, Dunedin, New Zealand
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Zhou H, Wang Y, Li W, Yang L, Liao Y, Xu M, Zhang C, Ma H. Usefulness of the Duke Activity Status Index to Assess Exercise Capacity and Predict Risk Stratification in Patients with Pulmonary Arterial Hypertension. J Clin Med 2023; 12:jcm12082761. [PMID: 37109099 PMCID: PMC10142524 DOI: 10.3390/jcm12082761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/19/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Exercise capacity is an important component of risk assessment for pulmonary arterial hypertension (PAH). We investigated the association of the Duke Activity Status Index (DASI) with peak oxygen consumption (peakVO2) and explored whether the DASI can discriminate the high-risk individuals in patients with PAH, according to peakVO2 < 11 mL/min/kg. A total of 89 patients were evaluated using cardiopulmonary exercise testing (CPET) and DASI. The correlation between the DASI and peakVO2 was measured by univariate analysis, and a receiver operating characteristic (ROC) curve analysis was conducted. The DASI was correlated with peakVO2 in the univariate analysis. The ROC curve analysis revealed that the DASI had a discriminative value for identifying the individuals with a high risk in PAH patients (p < 0.001), with an area under ROC curve (AUC) of 0.79 (95% CI: 0.67-0.92). Similar results were observed in patients with PAH associated with congenital heart disease (CHD-PAH), (p = 0.001), with an AUC of 0.80 (95% CI: 0.658-0.947). Therefore, DASI reflects exercise capacity in patients with PAH and has good ability to discriminate patients with a low risk and a high risk, and it may be included in the risk assessment of PAH.
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Affiliation(s)
- Haofeng Zhou
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510000, China
| | - Yu Wang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510000, China
| | - Weiya Li
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510000, China
| | - Lifang Yang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510000, China
| | - Yingxue Liao
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510000, China
| | - Mingyu Xu
- School of Medicine, South China University of Technology, Guangzhou 510000, China
| | - Caojin Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510000, China
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou 510000, China
| | - Huan Ma
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510000, China
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou 510000, China
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Dodds N, Angell J, Lewis SL, Pyke M, White P, Darweish-Medniuk A, Mitchell DC, Tolchard S. Characterising recovery following abdominal aortic aneurysm repair using cardiopulmonary exercise testing and patient reported outcome measures. Disabil Rehabil 2023; 45:1178-1184. [PMID: 35348405 DOI: 10.1080/09638288.2022.2055162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Surgery is associated with a post-operative stress response, changes in cardiopulmonary reserve, and metabolic demand. Here recovery after abdominal aortic aneurysm repair is investigated using cardiopulmonary exercise testing and patient-reported questionnaires. MATERIALS AND METHODS Patients undergoing open (n = 21) or endovascular (n = 21) repair undertook cardiopulmonary exercise tests, activity, and health score questionnaires pre-operatively and, 8 and 16 weeks, post-operatively. Oxygen uptake and ventilatory parameters were measured, and routine blood tests were undertaken. RESULTS Recovery was characterised by falls in anaerobic threshold, peak oxygen uptake, and oxygen pulse at 8 weeks which appeared to be associated with operative severity; the fall in peak oxygen uptake was greater following open vs. endovascular repair (3.5 vs. 1.6 ml.kg-1.min-1) and anaerobic threshold showed a similar tendency (3.1 vs. 1.7 ml.kg-1.min-1). In the smaller number of patients re-tested these changes resolved by 16 weeks. Reported health and activity did not change. CONCLUSIONS Aortic repair is associated with falls in the anaerobic threshold, peak oxygen uptake, and oxygen pulse of a magnitude that reflects operative severity and appears to resolve by 16 weeks. Thus, post-operatively patients may be at higher risk of further metabolic insult e.g. infection. This further characterises physiological recovery from aortic surgery and may assist in defining post-operative shielding time.IMPLICATIONS FOR REHABILITATIONAbdominal aortic aneurysm repair is a life-saving operation, the outcome from which is influenced by pre-operative cardiopulmonary reserve; individuals with poor reserve being at greater risk of peri-operative complications and death. However, for this operation, the physiological impact of surgery has not been studied.In a relatively small sample, this study suggests that AAA repair is associated with a significant decline in cardiopulmonary reserve when measured 8 weeks post-operatively and appears to recover by 16 weeks. Moreover, the impact may be greater in endovascular vs. open repair.
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Affiliation(s)
- N Dodds
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - J Angell
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - S L Lewis
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - M Pyke
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - P White
- Applied Statistics Group, Department of Mathematics and Statistics, University of the West of England, Bristol, UK
| | - A Darweish-Medniuk
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D C Mitchell
- Department of Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - S Tolchard
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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11
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Feasibility and effects of prehabilitation in cardiac surgery. Preliminary study. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:218-223. [PMID: 36842687 DOI: 10.1016/j.redare.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/18/2022] [Indexed: 02/26/2023]
Abstract
Prehabilitation programs that combine exercise training, nutritional support, and emotional reinforcement have demonstrated efficacy as a strategy for preoperative optimization in abdominal surgery. The experience in cardiac surgery, one of those associated with greater morbidity and mortality, is anecdotal. OBJECTIVE evaluation of the feasibility of a multimodal prehabilitation program and its effect on functional capacity in patients candidates for elective cardiac surgery. METHODS Pilot study conducted from July 2017 to June 2018 in patients candidates to myocardial revascularization and/or valve replacement. The program consisted of: 1) supervised exercise training program, 2) breathing incentive exercises, 3) nutritional support, and 4) mindfulness training. An evaluation was carried out prior to the start of the program and at the end of it (preoperatively). RESULTS All patients except one who refused surgery, completed the program, which lasted an average of 45 days. No patients presented complications related to the program. The program induced a significantly increase in functional capacity measured by the six-minute walking test (510.7 + 62 m vs 534.3 + 71 m, p = 0.007) and the chair test (13.2 + 4, 7 vs 16.4 + 7 repetitions, p = 0.02), as well as an increase in the level of physical activity measured by the Yale physical activity questionnaire (37.6 + 20 vs 54.2 + 27; p = 00029). CONCLUSIONS Multimodal prehabilitation in patients candidates for elective cardiac surgery is feasible and it increases functional capacity preoperatively without being associated with complications. The presumed beneficial impact of this improvement on the incidence of postoperative complications and hospital stay, requires further investigation.
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12
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Louyot C, Portran P, Schweizer R, Glerant JC, Thivolet S, Brassart O, Mewton N, Jacquet-Lagreze M, Fellahi JL. Elaboration of a French version of the Duke Activity Status Index questionnaire and performance to predict functional capacity. Anaesth Crit Care Pain Med 2023; 42:101199. [PMID: 36706990 DOI: 10.1016/j.accpm.2023.101199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Guidelines recommend detecting poor functional capacity (VO2max < 14 ml.kg-1.min-1) to assess preoperative cardiac risk. This screening is performed via a cardiopulmonary exercise test (CPET), the self-reported inability to climb two flights of stairs, or the use of the Duke Activity Status Index (DASI) questionnaire, which has shown a significant correlation with VO2max and postoperative outcomes. The objectives of the present study were: 1) to create a French version of the DASI questionnaire (FDASI); 2) to assess its diagnostic performance in predicting functional capacity. METHODS Consecutive adult patients undergoing CPET for medical or preoperative evaluation were prospectively included between May 2020 and March 2021. All patients were asked to complete FDASI as a self-questionnaire and report their inability to climb two flights of stairs. RESULTS 122 patients were included. Test-retest reliability was 0.88 and 23 (19%) patients experienced a VO2max < 14 ml.kg-1.min-1. There was a significant positive relationship between FDASI and VO2max: r2 = 0.32; p < 0.001. ROCAUC was 0.81 [95%CI: 0.73-0.89]. The best FDASI score threshold was 36 points, leading to sensitivity and specificity values of 87% [74-100] and 68% [56-79], respectively. Besides, sensitivity and specificity were 35% [17-56] and 92% [86-97] for the self-reported inability to climb two flights of stairs. CONCLUSION A FDASI score of 36 represents a reliable threshold the clinicians could routinely use to identify patients with a VO2max < 14 ml.kg-1.min-1. FDASI could advantageously replace the self-reported inability to climb two flights of stairs.
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Affiliation(s)
- Claire Louyot
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France.
| | - Philippe Portran
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France.
| | - Rémi Schweizer
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Jean-Charles Glerant
- Service d'Explorations Fonctionnelles Respiratoires, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Sophie Thivolet
- Service d'Explorations Fonctionnelles Cardiovasculaires, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Océane Brassart
- Direction de la Recherche Clinique et de l'Innovation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France
| | - Nathan Mewton
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, France
| | - Matthias Jacquet-Lagreze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677 Bron Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, France
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13
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Dana F, Sebio-García R, Tena B, Sisó M, Vega F, Peláez A, Capitán D, Ubré M, Costas-Carrera A, Martínez-Pallí G. Perioperative Nursing as the Guiding Thread of a Prehabilitation Program. Cancers (Basel) 2022; 14:5376. [PMID: 36358794 PMCID: PMC9653559 DOI: 10.3390/cancers14215376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 09/19/2023] Open
Abstract
Multimodal preoperative prehabilitation has been shown to be effective in improving the functional capacity of cancer patients, reducing postoperative complications and the length of hospital and ICU stay after surgery. The availability of prehabilitation units that gather all the professionals involved in patient care facilitates the development of integrated and patient-centered multimodal prehabilitation programs, as well as patient adherence. This article describes the process of creating a prehabilitation unit in our center and the role of perioperative nursing. Initially, the project was launched with the performance of a research study on prehabilitation for gastrointestinal cancer surgery. The results of this study encouraged us to continue the implementation of the unit. Progressively, multimodal prehabilitation programs focusing on each type of patient and surgery were developed. Currently, our prehabilitation unit is a care unit that has its own gym, which allows supervised training of cancer patients prior to surgery. Likewise, the evolution of perioperative nursing in the unit is described: from collaboration and assistance in the integral evaluation of the patient at the beginning to current work as a case manager; a task that has proven extremely important for the comprehensive and continuous care of the patient.
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Affiliation(s)
- Fernando Dana
- Anesthesiology Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, 08007 Barcelona, Spain
| | - Raquel Sebio-García
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, 08007 Barcelona, Spain
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Beatriz Tena
- Anesthesiology Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Marina Sisó
- Department of Endocrinology and Metabolic Diseases, Hospital Clinic de Barcelona, 08036 Barcelona, Spain
| | - Francisco Vega
- Anesthesiology Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Amaia Peláez
- Anesthesiology Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - David Capitán
- Anesthesiology Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Marta Ubré
- Anesthesiology Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Ana Costas-Carrera
- Psychiatry Service, Hospital Universitari Central de Asturias, 33011 Oviedo, Spain
| | - Graciela Martínez-Pallí
- Anesthesiology Department, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, 08007 Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), 28029 Madrid, Spain
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14
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Silvapulle E, Darvall J. Objective methods for preoperative assessment of functional capacity. BJA Educ 2022; 22:312-320. [PMID: 36097575 PMCID: PMC9463693 DOI: 10.1016/j.bjae.2022.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- E. Silvapulle
- The Royal Melbourne Hospital, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
| | - J. Darvall
- The Royal Melbourne Hospital, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
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15
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Subjective methods for preoperative assessment of functional capacity. BJA Educ 2022; 22:249-257. [PMID: 35754857 PMCID: PMC9214434 DOI: 10.1016/j.bjae.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 01/09/2023] Open
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16
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Matthews L, Levett DZH, Grocott MPW. Perioperative Risk Stratification and Modification. Anesthesiol Clin 2022; 40:e1-e23. [PMID: 35595387 DOI: 10.1016/j.anclin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.
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Affiliation(s)
- Lewis Matthews
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom.
| | - Denny Z H Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Perissiou M, Bailey TG, Saynor ZL, Shepherd A, Harwood AE, Askew CD. The physiological and clinical importance of cardiorespiratory fitness in people with abdominal aortic aneurysm. Exp Physiol 2022; 107:283-298. [PMID: 35224790 PMCID: PMC9311837 DOI: 10.1113/ep089710] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/21/2022] [Indexed: 12/01/2022]
Abstract
New Findings What is the topic of this review? This review focuses on the physiological impact of abdominal aortic aneurysm (AAA) on cardiorespiratory fitness and the negative consequences of low fitness on clinical outcomes in AAA. We also discuss the efficacy of exercise training for improving cardiorespiratory fitness in AAA. What advances does it highlight? We demonstrate the negative impact of low fitness on disease progression and clinical outcomes in AAA. We highlight potential mechanistic determinants of low fitness in AAA and present evidence that exercise training can be an effective treatment strategy for improving cardiorespiratory fitness, postoperative mortality and disease progression.
Abstract An abdominal aortic aneurysm (AAA) is an abnormal enlargement of the aorta, below the level of the renal arteries, where the aorta diameter increases by >50%. As an aneurysm increases in size, there is a progressive increase in the risk of rupture, which ranges from 25 to 40% for aneurysms >5.5 cm in diameter. People with AAA are also at a heightened risk of cardiovascular events and associated mortality. Cardiorespiratory fitness is impaired in people with AAA and is associated with poor (postoperative) clinical outcomes, including increased length of hospital stay and postoperative mortality after open surgical or endovascular AAA repair. Although cardiorespiratory fitness is a well‐recognized prognostic marker of cardiovascular health and mortality, it is not assessed routinely, nor is it included in current clinical practice guidelines for the management of people with AAA. In this review, we discuss the physiological impact of AAA on cardiorespiratory fitness, in addition to the consequences of low cardiorespiratory fitness on clinical outcomes in people with AAA. Finally, we summarize current evidence for the effect of exercise training interventions on cardiorespiratory fitness in people with AAA, including the associated improvements in postoperative mortality, AAA growth and cardiovascular risk. Based on this review, we propose that cardiorespiratory fitness should be considered as part of the routine risk assessment and monitoring of people with AAA and that targeting improvements in cardiorespiratory fitness with exercise training might represent a viable adjunct treatment strategy for reducing postoperative mortality and disease progression.
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Affiliation(s)
- Maria Perissiou
- Physical Activity Health and Rehabilitation Thematic Research Group School of Sport Health and Exercise Science Faculty of Science and Health University of Portsmouth Portsmouth UK
| | - Tom G. Bailey
- Physiology and ultrasound Laboratory in Science and Exercise Centre for Research on Exercise Physical Activity and Health School of Human Movement and Nutrition Sciences University of Queensland Brisbane Australia
- School of Nursing Midwifery and Social Work University of Queensland Brisbane Australia
| | - Zoe L. Saynor
- Physical Activity Health and Rehabilitation Thematic Research Group School of Sport Health and Exercise Science Faculty of Science and Health University of Portsmouth Portsmouth UK
| | - Anthony Shepherd
- Physical Activity Health and Rehabilitation Thematic Research Group School of Sport Health and Exercise Science Faculty of Science and Health University of Portsmouth Portsmouth UK
| | - Amy E. Harwood
- Centre for Sport Exercise & Life Sciences Institute of Health and Wellbeing Coventry University Coventry UK
| | - Christopher D. Askew
- VasoActive Research Group School of Health and Behavioural Sciences University of the Sunshine Coast Sippy Downs Queensland Australia
- Sunshine Cost Health Institute Sunshine Coast Hospital and Health Service Birtinya Queensland Australia
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18
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Ferguson M, Shulman M. Cardiopulmonary Exercise Testing and Other Tests of Functional Capacity. CURRENT ANESTHESIOLOGY REPORTS 2021; 12:26-33. [PMID: 34840532 PMCID: PMC8605465 DOI: 10.1007/s40140-021-00499-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review Assessment of functional capacity is a cornerstone of preoperative risk assessment. While subjective clinician assessment of functional capacity is poorly predictive of postoperative outcomes, other objective functional assessment measures may provide more useful information. Recent Findings Cardiopulmonary exercise testing (CPET) is generally accepted as the gold standard for functional capacity assessment. However, CPET is resource-intensive and not universally available. Simpler objective tests of functional capacity such as the Duke Activity Status Index (DASI) and the 6-min walk test (6MWT) are cheap and efficient. In addition, they predict important postoperative outcomes including death, disability, and myocardial infarction. Summary Simple preoperative tests such as the DASI may be useful for routine preoperative assessment. CPET may be helpful to investigate further patients with functional status limitation, and to guide prehabilitation and perioperative shared decision-making in high-risk patients.
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Affiliation(s)
| | - Mark Shulman
- Austin Hospital, 145 Studley Rd, Heidelberg, VIC Australia
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19
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Tous-Espelosin M, Ruiz de Azua S, Iriarte-Yoller N, Sanchez PM, Elizagarate E, Sampedro A, Maldonado-Martín S. Cross-Validation of Predictive Equation for Cardiorespiratory Fitness by Modified Shuttle Walk Test in Adults with Schizophrenia: A Secondary Analysis of the CORTEX-SP Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111390. [PMID: 34769904 PMCID: PMC8582746 DOI: 10.3390/ijerph182111390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 11/24/2022]
Abstract
Cardiorespiratory fitness (CRF) can be direct or estimated from different field tests. The Modified Shuttle Walk Test (MSWT) is suitable for all levels of function, allowing a peak response to be elicited. Therefore, we aimed (1) to validate the equation presented in the original study by Singh et al. for evaluating the relationship between MSWT with peak oxygen uptake (VO2peak) in adults with schizophrenia (SZ), (2) to develop a new equation for the MSWT to predict VO2peak, and (3) to validate the new equation. Participants (N = 144, 41.3 ± 10.2 years old) with SZ performed a direct measurement of VO2peak through a cardiopulmonary exercise test and the MSWT. A new equation incorporating resting heart rate, body mass index, and distance from MSWT (R2 = 0.617; adjusted R2 = 0.60; p < 0.001) performs better than the Singh et al. equation (R2 = 0.57; adjusted R2 = 0.57; p < 0.001) to estimate VO2peak for the studied population. The posteriori cross-validation method confirmed the model’s stability (R2 = 0.617 vs. 0.626). The findings of the current study support the validity of the new regression equation incorporating resting heart rate, body mass index, and distance from MSWT to predict VO2peak for assessment of CRF in people with SZ.
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Affiliation(s)
- Mikel Tous-Espelosin
- GIzartea, Kirola eta Ariketa Fisikoa Ikerkuntza Taldea (GIKAFIT), Society, Sports and Physical Exercise Research Group, Department of Physical Education and Sport, Faculty of Education and Sport-Physical Activity and Sport Sciences Section, University of the Basque Country (UPV/EHU), 01007 Vitoria-Gasteiz, Spain;
- Physical Activity, Exercise and Health Group, Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain
| | - Sonia Ruiz de Azua
- Cibersam, Department of Neuroscience, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain;
| | - Nagore Iriarte-Yoller
- Refractory Psychosis Unit, Psychiatric Hospital of Alava, 01007 Vitoria-Gasteiz, Spain; (N.I.-Y.); (P.M.S.); (E.E.)
| | - Pedro M. Sanchez
- Refractory Psychosis Unit, Psychiatric Hospital of Alava, 01007 Vitoria-Gasteiz, Spain; (N.I.-Y.); (P.M.S.); (E.E.)
- Faculty of Medicine, University of Deusto, 48007 Bilbao, Spain
| | - Edorta Elizagarate
- Refractory Psychosis Unit, Psychiatric Hospital of Alava, 01007 Vitoria-Gasteiz, Spain; (N.I.-Y.); (P.M.S.); (E.E.)
| | - Agurne Sampedro
- Department of Psychology, Faculty of Health Sciences, University of Deusto, 48007 Bilbao, Spain;
| | - Sara Maldonado-Martín
- GIzartea, Kirola eta Ariketa Fisikoa Ikerkuntza Taldea (GIKAFIT), Society, Sports and Physical Exercise Research Group, Department of Physical Education and Sport, Faculty of Education and Sport-Physical Activity and Sport Sciences Section, University of the Basque Country (UPV/EHU), 01007 Vitoria-Gasteiz, Spain;
- Physical Activity, Exercise and Health Group, Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain
- Correspondence: ; Tel.: +34-945013534; Fax: +34-945013501
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20
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Quantification of metabolic equivalents (METs) by the MET-REPAIR questionnaire: A validation study in patients with a high cardiovascular burden. J Clin Anesth 2021; 76:110559. [PMID: 34687977 DOI: 10.1016/j.jclinane.2021.110559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Quantifying functional capacity is a core component of preoperative cardiovascular risk assessment. Lower metabolic equivalents (METs) are associated with higher morbidity/mortality in non-surgical and surgical populations. However, actually measuring METs preoperatively is rare. We sought to determine the correlation of self-reported METs using the questionnaire of the MET: REevaluation for Perioperative cArdIac Risk (MET-REPAIR) study and objectively measured METs by gold-standard cardiopulmonary exercise testing (CPET). DESIGN Single-center prospective validation study. SETTING University hospital. PATIENTS We enrolled adult patients aged ≥45 undergoing out-patient cardiac rehabilitation. INTERVENTION Patients completed the MET-REPAIR Questionnaire and the Duke Activity Status Index (DASI), had blood samples drawn, and underwent undergoing routine CPET. MEASUREMENTS We compared measured METs by CPET to 1) self-reported METs (the MET-REPAIR Questionnaire), 2) the DASI score, 3) stand-alone questions, and 4) N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations. MAIN RESULTS 140 patients were recruited. Measured METs by CPET correlated with 1) self-reported METs by the MET-REPAIR Questionnaire (ρ = 0.489, "fair"), 2) self-reported physical activity by the DASI (ρ = 0.487, "fair"), 3) the self-reported continual stair climbing ability (one of the stand-alone questions; ρ = 0.587, "fair") and 4) NT-proBNP concentrations (ρ = -0.353, "poor"). The area under the receiver operating characteristic curve (AUROC) for the ability to perform more than 4 METs were: highest for flights of stairs (0.841 [95%CI 0.735-0.948], p < 0.05 to rest, optimum: 3 flights), not significantly different between MET-REPAIR Questionnaire and DASI (0.666 [95%CI 0.551-0.781], optimum: 6 METs vs. 0.704 [95%CI 0.578-0.829], optimum: 32.2 points or 6.7 METs, p = 0.405), and not significant for NT-proBNP: (0.623 [95%CI 0.483-0.763]). CONCLUSIONS The MET-REPAIR Questionnaire correlates with measured METs; all utilized forms of self-reported physical activity overestimate measured METs. NT-proBNP correlates poorly with measured METs.
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Abstract
PURPOSE OF REVIEW This review examines how functional capacity informs preoperative risk stratification, as well as strengths and limitations of options for estimating functional capacity. RECENT FINDINGS Functional capacity (or cardiopulmonary fitness) overlaps with other important characteristics, including muscular strength, balance, and frailty. Poor functional capacity is associated with postoperative morbidity, especially noncardiovascular complications. Both patient interviews and exercise tests are used to assess functional capacity. The usual approach of an unstructured patient interview does not predict outcomes. Structured interviews that incorporate validated questionnaires (Duke Activity Status Index) or standardized questions about physical activity (ability to climb stairs) do predict moderate-or-severe complications and cardiovascular complications. Among exercise tests, cardiopulmonary exercise testing (CPET) has shown the most consistent association with risks of complications. Other tests (6-min walk test, incremental shuttle walk test, stair climbing) might predict complications, but still require further high-quality evaluation. SUMMARY A straightforward way to better assess functional capacity is a structured interview with validated questionnaires or standardized questions about physical activities. Functional capacity can also be assessed by exercise tests, with the strongest evidence supporting CPET. Although some simpler exercise tests have shown promise, more research remains needed to better define their role in preoperative evaluation.
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Minnella EM, Baldini G, Quang ATL, Bessissow A, Spicer J, Carli F. Prehabilitation in Thoracic Cancer Surgery: From Research to Standard of Care. J Cardiothorac Vasc Anesth 2021; 35:3255-3264. [PMID: 33752968 DOI: 10.1053/j.jvca.2021.02.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether personalized, stepped prehabilitation care is a feasible, safe, and effective implementation strategy. DESIGN Quality improvement project. Data collected prospectively from August 2018 to December 2019 were analyzed retrospectively to describe the clinical implementation of a prehabilitation care program for elective lung cancer surgery. SETTING Single center, tertiary university hospital. PARTICIPANTS Eighty-one consecutive adult patients living in the metropolitan area of Montreal were included if an elective resection of suspected or confirmed lung cancer was planned. INTERVENTIONS At the earliest contemplation of surgery, the whole cohort was screened for impaired physical, nutritional, and/or psychological status. Patients screened at higher risk received dedicated assessment and personalized prehabilitation care upon specific needs. MEASUREMENTS AND MAIN RESULTS Patients' specific needs and their access and flow through the different services were described. Prehabilitation effectiveness was evaluated using walking and exercise tests, and adverse events were monitored. Eighty-one patients were screened for functional impairments. Forty patients showed reduction of physical function, seven of them refused the specific assessment, one refused in-hospital exercise; 48 patients showed nutritional risk, eight of them refused or did not comply with nutritional therapy. Overall, 45 high-risk patients received a one-month personalized prehabilitation program: 16 partook in a trimodal program (exercise, nutrition, and psychological), and 22 received a program with both nutrition and exercise. No adverse events occurred during the study period. After prehabilitation, six-minute waking distance improved by 29.9 meters (standard deviation 47.3 m) (n = 35; p = 0.001) and the oxygen uptake at the anaerobic threshold improved by 1.6 (1.7) mL/kg/min (n = 13; p = 0.004). Length of hospital stay was two (interquartile range one-four) days in prehabilitated patients versus three (two-seven) days in the usual care group (p = 0.101). CONCLUSIONS A personalized, stepped prehabilitation program targeting high-risk patients undergoing elective lung cancer surgery was feasible, safe, and effective.
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Affiliation(s)
- Enrico Maria Minnella
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Anh Thy Le Quang
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Amal Bessissow
- Department of Medicine, Division of Internal Medicine, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Surgery, Division of Thoracic Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
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Coca-Martinez M, Lopez-Hernandez A, Montane-Muntane M, Arguis MJ, Gimeno-Santos E, Navarro-Ripoll R, Perdomo J, Lopez-Baamonde M, Rios J, Moises J, Sanz de la Garza M, Sandoval E, Romano B, Sebio R, Dana F, Martinez-Palli G. Multimodal prehabilitation as strategy for reduction of postoperative complications after cardiac surgery: a randomised controlled trial protocol. BMJ Open 2020; 10:e039885. [PMID: 33371022 PMCID: PMC7757458 DOI: 10.1136/bmjopen-2020-039885] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Prehabilitation programmes that combine exercise training, nutritional support and emotional reinforcement (multimodal prehabilitation) have demonstrated efficacy reducing postoperative complications in the context of abdominal surgery. However, such programmes have seldom been studied in cardiac surgery, one of the surgeries associated with higher postoperative morbidity and mortality. This trial will assess the feasibility and efficacy in terms of reduction of postoperative complications and cost-effectiveness of a multimodal prehabilitation programme comparing to the standard of care in cardiac surgical patients. METHODS AND ANALYSIS This is a single-centre, randomised, open-label, controlled trial with a 1:1 ratio. Consecutive 160 elective valve replacement and/or coronary revascularisation surgical patients will be randomised to either standard of care or 4-6 weeks of multimodal prehabilitation that will consist in (1) two times/week supervised endurance and strength exercise training sessions, (2) promotion of physical activity and healthy lifestyle, (3) respiratory physiotherapy, (4) nutrition counselling and supplementation if needed, and (5) weekly mindfulness sessions. Baseline, preoperative and 3-month postoperative data will be collected by an independent blinded evaluator. The primary outcome of this study will be the incidence of postoperative complications. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of Clinical investigation of Hospital Clinic de Barcelona (HCB/2017/0708). The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT03466606.
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Affiliation(s)
- Miquel Coca-Martinez
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Antonio Lopez-Hernandez
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Mar Montane-Muntane
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Maria Jose Arguis
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
| | - Elena Gimeno-Santos
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
- Prehabilitation Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Ricard Navarro-Ripoll
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Juan Perdomo
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Manuel Lopez-Baamonde
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jose Rios
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
- Biostatistics Unit, Universitat Autonoma de Barcelona Facultat de Medicina, Bellaterra, Catalunya, Spain
| | - Jorge Moises
- Respiratory Medicine, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Maria Sanz de la Garza
- Department of Cardiology, Cardiovascular Institute, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Elena Sandoval
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Barbara Romano
- Nutrition and Clinical Dietetics, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Raquel Sebio
- Prehabilitation Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Fernando Dana
- Prehabilitation Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Graciela Martinez-Palli
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalunya, Spain
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Davies SJ, Minto G. Occam's razor at the sharp end: simplified preoperative risk assessment. Br J Anaesth 2020; 126:27-30. [PMID: 33097181 DOI: 10.1016/j.bja.2020.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/04/2020] [Accepted: 09/12/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Simon J Davies
- Department of Anaesthesia, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Gary Minto
- Department of Anaesthesia, University Hospitals Plymouth NHS Trust, Plymouth, UK.
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A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study. Br J Anaesth 2020; 126:181-190. [PMID: 32690247 DOI: 10.1016/j.bja.2020.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/13/2020] [Accepted: 06/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. METHODS In this secondary cross-sectional analysis of the international, multicentre Measurement of Exercise Tolerance before Surgery (METS) study, we assessed cardiopulmonary exercise testing and DASI data from 1455 participants. Multivariable regression analyses were used to revise the DASI model in predicting an anaerobic threshold (AT) >11 ml kg-1 min-1 and peak oxygen consumption (VO2 peak) >16 ml kg-1 min-1, cut-points that represent a reduced risk of postoperative complications. RESULTS Five questions were identified to have dominance in predicting AT>11 ml kg-1 min-1 and VO2 peak>16 ml.kg-1min-1. These items were included in the M-DASI-5Q and retained utility in predicting AT>11 ml.kg-1.min-1 (area under the receiver-operating-characteristic [AUROC]-AT: M-DASI-5Q=0.67 vs original 12-question DASI=0.66) and VO2 peak (AUROC-VO2 peak: M-DASI-5Q 0.73 vs original 12-question DASI 0.71). Conversely, in a sensitivity analysis we removed one potentially sensitive question related to the ability to have sexual relations, and the ability of the remaining four questions (M-DASI-4Q) to predict an adequate functional threshold remained no worse than the original 12-question DASI model. Adding a dynamic component to the M-DASI-4Q by assessing the chronotropic response to exercise improved its ability to discriminate between those with VO2 peak>16 ml.kg-1.min-1 and VO2 peak<16 ml.kg-1.min-1. CONCLUSIONS The M-DASI provides a simple screening tool for further preoperative evaluation, including with cardiopulmonary exercise testing, to guide perioperative management.
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Carli F, Baldini G. From preoperative assessment to preoperative optimization of frail older patiens. Eur J Surg Oncol 2020; 47:519-523. [PMID: 32753116 DOI: 10.1016/j.ejso.2020.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022] Open
Abstract
Physiological and mental reserve decreases with age and the ability to mount a response to a stress like surgery can represent a burden to the frail and sarcopenic patient. It is necessary to evaluate the cardiorespiratory capacity and muscle strength before surgery in the older persons and prepare adequately to the same extent the marathon runner prepares before a full marathon. Assessment and stratification of risk are necessary for decision-making, but also for planning interventions aimed at improving the functional and emotional status in anticipation of surgery. Prehabilitation can improve the physiological reserve by optimizing cardiorespiratory capacity, muscle strength, and mental resiliency. Patients with low reserve and chronic medical conditions at high risk can benefit.
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Affiliation(s)
- Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Room D10.165, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Room D10.165, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada
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Sivakumar J, Sivakumar H, Read M, Sinclair RCF, Snowden CP, Hii MW. The Role of Cardiopulmonary Exercise Testing as a Risk Assessment Tool in Patients Undergoing Oesophagectomy: A Systematic Review and Meta-analysis. Ann Surg Oncol 2020; 27:3783-3796. [DOI: 10.1245/s10434-020-08638-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 02/06/2023]
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Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study. Br J Anaesth 2020; 124:261-270. [DOI: 10.1016/j.bja.2019.11.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/28/2019] [Accepted: 11/23/2019] [Indexed: 11/18/2022] Open
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Marsman M, van Waes JAR, Grobben RB, Weersink CSA, van Klei WA. Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury. Eur J Prev Cardiol 2020; 28:262-269. [PMID: 33891688 DOI: 10.1177/2047487320906918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/27/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality. DESIGN An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital. METHODS Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity. RESULTS A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5-2.0; P < 0.001), postoperative myocardial infarction (RR 2.9, 95% CI 1.9-4.2; P < 0.001) and one year mortality (RR 1.7, 95% CI 1.4-2.0; P < 0.001). After adjustment for other predictors, functional capacity was still a significant predictor for myocardial injury (odds ratio (OR) 1.3, 95% CI 1.0-1.7; P = 0.023), postoperative myocardial infarction (OR 2.0, 95% CI 1.3-3.0; P = 0.002) and one year mortality (OR 1.4, 95% CI 1.1-1.8; P = 0.003), but had no added value on top of other predictors. CONCLUSIONS Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors.
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Affiliation(s)
- Marije Marsman
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Corien S A Weersink
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
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Stubbs DJ, Grimes LA, Ercole A. Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review. PLoS One 2020; 15:e0226480. [PMID: 32012165 PMCID: PMC6996804 DOI: 10.1371/journal.pone.0226480] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance. METHODS After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables. RESULTS We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the association of Peak VO2 (sensitivity 85.7-100%, PPV 2.7-5.9%) and VE/VCO2 (Sensitivity 27.8%-100%, PPV 3.4-7.1%) with mortality. CONCLUSIONS In general CPET's 'rule-out' capability appears better than its ability to 'rule-in' complications. Poor PPV may reflect the frequency of complications in studied populations. Our calculated estimates of classifier performance suggest the need for a balanced interpretation of the pros and cons of CPET guided pre-operative risk stratification.
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Affiliation(s)
- Daniel J. Stubbs
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Lisa A. Grimes
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Ari Ercole
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
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Angell J, Dodds N, Darweish-Mednuik AM, Lewis S, Pyke M, Mitchell DC, Hamilton K, White P, Tolchard S. Characterising recovery from renal transplantation and live-related donation using cardiopulmonary exercise testing. Disabil Rehabil 2019; 43:1692-1698. [PMID: 31600094 DOI: 10.1080/09638288.2019.1674387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND An association between end-stage renal failure and exercise intolerance exists. Whether live kidney donation impacts on exercise tolerance is unknown. Here recovery post renal transplant and donation using cardiopulmonary exercise testing is investigated. METHODS Renal donors (n = 28) and recipients (n = 24) undertook a cardiopulmonary exercise test, Duke activity score index and patient reported health score questionnaires pre-operatively and in the 7th and 14th week post-operatively. Anaerobic threshold, peak oxygen uptake and ventilatory equivalents were measured in relation to activity and reported health scores. Haemoglobin and renal function was recorded. RESULTS Recipients showed impaired cardiopulmonary function compared to donors with lower anaerobic threshold (10.5 vs. 14.4 ml/kg/min) and peak oxygen uptake (18.5 vs 23.0 ml/kg/min). Post-operatively the anaerobic threshold of recipients improved and normalised by the 14th week, whereas that in donors fell by ∼20% by the 7th (mean 11.4 ml/kg/min), recovering by the 14th (mean 15.6 ml/kg/min). Reported health but not activity scores showed similar changes. CONCLUSIONS Recovery following renal transplantation and donation differ. Transplantation improves renal function resulting in an increase in anaerobic threshold and peak oxygen uptake which essentially normalise by the 14th week post-operatively. Donors suffer a 20% reduction in cardiopulmonary reserve post-operatively, which recovers by the 14th week, suggesting no associated chronic exercise intolerance.IMPLICATIONS FOR REHABILITATIONCardiopulmonary exercise testing is a real-time predictor of functional capacity and thus is used as a pre-operative tool to measure physiological fitness and predict outcomes.Renal failure is associated with exercise intolerance and transplantation is transformational in terms of quality of life, longevity and healthcare cost.Live - related renal donation is increasingly available but whether donation itself carries a long-term health burden has not been previously well established.This study suggests that renal donation is not associated with long-term cardiopulmonary compromise and patients who donate their kidneys recover their previous fitness within 14 weeks.
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Affiliation(s)
- Johanna Angell
- ASCC Division, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Nicholas Dodds
- ASCC Division, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Simon Lewis
- ASCC Division, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Mark Pyke
- ASCC Division, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - David C Mitchell
- ASCC Division, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Kay Hamilton
- ASCC Division, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | - Stephen Tolchard
- ASCC Division, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Barberan-Garcia A, Ubre M, Pascual-Argente N, Risco R, Faner J, Balust J, Lacy A, Puig-Junoy J, Roca J, Martinez-Palli G. Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial. Br J Anaesth 2019; 123:450-456. [DOI: 10.1016/j.bja.2019.05.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/29/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022] Open
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Dhir S, Dhir A. The Global Perspective of Cardiovascular Assessment for Noncardiac Surgery: Comparisons from Around the World. J Cardiothorac Vasc Anesth 2019; 33:2287-2295. [DOI: 10.1053/j.jvca.2019.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 01/09/2023]
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A cross-sectional survey of Australian anesthetists’ and surgeons’ perceptions of preoperative risk stratification and prehabilitation. Can J Anaesth 2019; 66:388-405. [DOI: 10.1007/s12630-019-01297-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 11/17/2018] [Accepted: 12/03/2018] [Indexed: 12/17/2022] Open
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Re-evaluation of peri-operative cardiac risk (the MET REPAIR study): Study protocol of a prospective, multicentre cohort study sponsored by the European Society of Anaesthesiology. Eur J Anaesthesiol 2018; 34:709-712. [PMID: 28984795 DOI: 10.1097/eja.0000000000000697] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wijeysundera DN, Pearse RM, Shulman MA, Abbott TEF, Torres E, Ambosta A, Croal BL, Granton JT, Thorpe KE, Grocott MPW, Farrington C, Myles PS, Cuthbertson BH. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018; 391:2631-2640. [PMID: 30070222 DOI: 10.1016/s0140-6736(18)31131-0] [Citation(s) in RCA: 250] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/04/2018] [Accepted: 05/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery. METHODS We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (<4), moderate (4-10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification. FINDINGS Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2-25) and 94·7% specificity (93·2-95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83-0·99; p=0·03). INTERPRETATION Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
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Affiliation(s)
- Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Mark A Shulman
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | | | - Elizabeth Torres
- Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Althea Ambosta
- Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada
| | | | - John T Granton
- Department of Medicine, University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Kevin E Thorpe
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Michael P W Grocott
- University Hospital Southampton, Southampton, UK; University of Southampton, Southampton, UK
| | - Catherine Farrington
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Paul S Myles
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Brian H Cuthbertson
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Comparison of Duke Activity Status Index with cardiopulmonary exercise testing in cancer patients. J Anesth 2018; 32:576-584. [DOI: 10.1007/s00540-018-2516-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/23/2018] [Indexed: 02/07/2023]
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Abstract
The surgical patient population is increasingly elderly and comorbid and poses challenges to perioperative physicians. Accurate preoperative risk stratification is important to direct perioperative care. Reduced aerobic fitness is associated with increased postoperative morbidity and mortality. Cardiopulmonary exercise testing is an integrated and dynamic test that gives an objective measure of aerobic fitness or functional capacity and identifies the cause of exercise intolerance. Cardiopulmonary exercise testing provides an individualized estimate of patient risk that can be used to predict postoperative morbidity and mortality. This technology can therefore be used to inform collaborative decision-making and patient consent, to triage the patient to an appropriate perioperative care environment, to diagnose unexpected comorbidity, to optimize medical comorbidities preoperatively, and to direct individualized preoperative exercise programs. Functional capacity, evaluated as the anaerobic threshold and peak oxygen uptake ([Formula: see text]o2peak) predicts postoperative morbidity and mortality in the majority of surgical cohort studies. The ventilatory equivalents for carbon dioxide (an index of gas exchange efficiency), is predictive of surgical outcome in some cohorts. Prospective cohort studies are needed to improve the precision of risk estimates for different patient groups and to clarify the best combination of variables to predict outcome. Early data suggest that preoperative exercise training improves fitness, reduces the debilitating effects of neoadjuvant chemotherapy, and may improve clinical outcomes. Further research is required to identify the most effective type of training and the minimum duration required for a positive effect.
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Whibley J, Peters CJ, Halliday LJ, Chaudry AM, Allum WH. Poor performance in incremental shuttle walk and cardiopulmonary exercise testing predicts poor overall survival for patients undergoing esophago-gastric resection. Eur J Surg Oncol 2018; 44:594-599. [PMID: 29459017 DOI: 10.1016/j.ejso.2018.01.242] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 11/27/2017] [Accepted: 01/30/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Esophageal and gastric cancer have a poor prognosis and surgical intervention is associated with considerable morbidity, highlighting the need for careful preoperative assessment. The Incremental Shuttle Walk Test (ISWT) and Cardiopulmonary exercise testing (CPET) can assess preoperative fitness. This study aims to investigate their correlation with both postoperative respiratory complications and overall survival. PATIENTS AND METHODS Patients were identified who underwent esophageal or gastric resections for cancer between 2010 and 2014 and had ISWT and/or CPET assessments. Tumor differentiation, stage, postoperative respiratory complications, and outcome were documented and then correlated with the results of the preoperative fitness assessments. RESULTS Neither the ISWT result, anaerobic threshold (AT) nor VO2 Max correlated well with perioperative complications. However, ISWT (p < 0.001), AT (p < 0.001) and VO2 Max (p < 0.001) all correlated strongly with overall survival. No patient with a score of less than 350 m on ISWT survived beyond 3 years. In a subset of patients with ISWT results both pre and post chemotherapy (n = 49), those that had an improvement in result had a 19% incidence of post-operative respiratory complications compared to 45% where the result did not change or declined, though due to small numbers this only approached significance (p = 0.08). CONCLUSION ISWT and CPET can be useful preoperative tools to predict overall survival for patients undergoing esophago-gastric resection. Furthermore, patients that improve their functional status during chemotherapy seem to do better than those where it remains static or declines.
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Affiliation(s)
- Jessica Whibley
- Department of Physiotherapy, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK.
| | - Christopher J Peters
- Department of Surgery & Cancer, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, UK.
| | - Laura J Halliday
- Department of Surgery & Cancer, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, UK.
| | - Asif M Chaudry
- Academic Department of Surgery, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK.
| | - William H Allum
- Academic Department of Surgery, The Royal Marsden Hospital, Fulham Rd, London, SW3 6JJ, UK.
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Williams FR, Vallance A, Faulkner T, Towey J, Kyte D, Durman S, Johnson J, Holt A, Perera MT, Ferguson J, Armstrong MJ. Home-based exercise therapy in patients awaiting liver transplantation: protocol for an observational feasibility trial. BMJ Open 2018; 8:e019298. [PMID: 29358444 PMCID: PMC5781094 DOI: 10.1136/bmjopen-2017-019298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Liver disease is the third most common cause of premature mortality in the UK. Liver failure accelerates frailty, resulting in skeletal muscle atrophy, functional decline and an associated risk of liver transplant waiting list mortality. However, there is limited research investigating the impact of exercise on patient outcomes pre and post liver transplantation. The waitlist period for patients listed for liver transplantation provides a unique opportunity to provide and assess interventions such as prehabilitation. METHODS AND ANALYSIS This study is a phase I observational study evaluating the feasibility of conducting a randomised control trial (RCT) investigating the use of a home-based exercise programme (HBEP) in the management of patients awaiting liver transplantation. Twenty eligible patients will be randomly selected from the Queen Elizabeth University Hospital Birmingham liver transplant waiting list. Participants will be provided with an individually tailored 12-week HBEP, including step targets and resistance exercises. Activity trackers and patient diaries will be provided to support data collection. For the initial 6 weeks, telephone support will be given to discuss compliance with the study intervention, achievement of weekly targets, and to address any queries or concerns regarding the intervention. During weeks 6-12, participants will continue the intervention without telephone support to evaluate longer term adherence to the study intervention. On completing the intervention, all participants will be invited to engage in a focus group to discuss their experiences and the feasibility of an RCT. ETHICS AND DISSEMINATION The protocol is approved by the National Research Ethics Service Committee North West - Greater Manchester East and Health Research Authority (REC reference: 17/NW/0120). Recruitment into the study started in April 2017 and ended in July 2017. Follow-up of participants is ongoing and due to finish by the end of 2017. The findings of this study will be disseminated through peer-reviewed publications and international presentations. In addition, the protocol will be placed on the British Liver Trust website for public access. TRIAL REGISTRATION NUMBER NCT02949505; Pre-results.
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Affiliation(s)
- Felicity Rhian Williams
- Department of Physiotherapy, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Alice Vallance
- Department of Physiotherapy, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthesia, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jennifer Towey
- Department of Dietetics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Derek Kyte
- Centre for Patient-Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Jill Johnson
- Department of Dietetics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Andrew Holt
- Liver Transplant and Hepatobiliary Pancreatic Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - M Thamara Perera
- Liver Transplant and Hepatobiliary Pancreatic Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - James Ferguson
- Liver Transplant and Hepatobiliary Pancreatic Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Matthew James Armstrong
- Liver Transplant and Hepatobiliary Pancreatic Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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De Silva S. High risk endovascular aneurysm repair: a case report. J Perioper Pract 2018; 27:234-235. [PMID: 29328848 DOI: 10.1177/175045891702701006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/26/2016] [Indexed: 11/16/2022]
Abstract
Mr AB is a 66-year old gentleman who presented for elective endovascular aneurysm repair (EVAR) following a routine screening scan identifying a 5.5cm abdominal aortic aneurysm (AAA). He had a past history of chronic obstructive pulmonary disease (COPD) with FEV1/FVC ratio of 48% on pre-assessment. He was hypertensive with a history of ischaemic heart disease (IHD), which has remained asymptomatic following coronary artery bypass grafting (CABG) eight years prior to this presentation.
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Barberan-Garcia A, Ubré M, Roca J, Lacy AM, Burgos F, Risco R, Momblán D, Balust J, Blanco I, Martínez-Pallí G. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery. Ann Surg 2018; 267:50-56. [DOI: 10.1097/sla.0000000000002293] [Citation(s) in RCA: 401] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Dana F, Capitán D, Ubré M, Hervás A, Risco R, Martínez-Pallí G. Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:5-12. [PMID: 28559045 DOI: 10.1016/j.redar.2017.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/14/2017] [Accepted: 04/14/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. OBJECTIVE To characterize surgical population in a university hospital. METHODS All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. RESULTS One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. CONCLUSIONS The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.
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Affiliation(s)
- F Dana
- Área Quirúrgica, Hospital Clínic de Barcelona, Barcelona, España.
| | - D Capitán
- Área Quirúrgica, Hospital Clínic de Barcelona, Barcelona, España
| | - M Ubré
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - A Hervás
- Institut Clínic de Malalties Digestives, Hospital Clínic de Barcelona, Barcelona, España
| | - R Risco
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - G Martínez-Pallí
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
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Cui HW, Kirby GS, Surmacz K, Hargrove C, Griffiths J, Turney BW. The association of pre-operative home accelerometry with cardiopulmonary exercise variables. Anaesthesia 2017; 73:738-745. [DOI: 10.1111/anae.14181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 12/19/2022]
Affiliation(s)
- H. W. Cui
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - G. S. Kirby
- Nuffield Department of Anaesthetics; University of Oxford; Oxford UK
| | - K. Surmacz
- Nuffield Department of Anaesthetics; University of Oxford; Oxford UK
| | - C. Hargrove
- Nuffield Department of Anaesthetics; University of Oxford; Oxford UK
| | | | - B. W. Turney
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
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Heldens AFJM, Bongers BC, Lenssen AF, Stassen LPS, Buhre WF, van Meeteren NLU. The association between performance parameters of physical fitness and postoperative outcomes in patients undergoing colorectal surgery: An evaluation of care data. Eur J Surg Oncol 2017; 43:2084-2092. [PMID: 28943177 DOI: 10.1016/j.ejso.2017.08.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/11/2017] [Accepted: 08/21/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Preoperative cardiorespiratory fitness, as measured by cardiopulmonary testing or estimated using the less sophisticated incremental shuttle walk test, timed up-and-go test or stair climb test is known to be associated with postoperative outcome. This study aimed to evaluate whether parameters of physical fitness are associated with postoperative outcome in patients with colorectal cancer scheduled for elective resection. PATIENTS AND METHODS Perioperative data of patients who underwent colorectal resection at Maastricht University Medical Center were retrospectively analyzed. Preoperative variables (e.g., age, body mass index, comorbidities, physical fitness, tumour characteristics, neoadjuvant treatment, American Society of Anesthesiologists score, level of perceived fatigue and nutritional status) were compared with postoperative outcomes. RESULTS Out of 80 consecutive cases, 75 (93.8%) were available for analysis (57.3% male, median ± interquartile range age 69.2 ± 11.7 years). A higher Charlson comorbidity index (odds ratio (OR) of 1.604, 95% confidence interval (CI) 1.120-2.296), worse functional exercise capacity (in meters, OR of 0.995, 95% CI 0.991-1.000), a lower physical activity level (in min/day, OR of 0.994, 95% CI 0.988-1.000), and a higher level of perceived fatigue (OR of 1.047, 95% CI 1.016-1.078), were associated with a slower time to recovery of physical functioning. A better functional exercise capacity was associated with a lower OR (OR of 0.995, 95% CI 0.991-1.000) for non-surgical complications. CONCLUSION There is an association between preoperative parameters and postoperative outcomes in patients with colorectal cancer scheduled for resection. Patients benefit from an optimal preoperative physical fitness level. Specific interventions can target this physical fitness level.
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Affiliation(s)
- A F J M Heldens
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Physical Therapy, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - B C Bongers
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | - A F Lenssen
- Department of Physical Therapy, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - L P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - W F Buhre
- Department of Anesthesiology and Pain Therapy, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - N L U van Meeteren
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Top Sector Life Sciences and Health (Health∼Holland), The Hague, The Netherlands.
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Kanakaraj M, Yates DR, Wilson RJT, Baroni ML, Davies SJ. Prognostic Markers of Outcome in Patients Undergoing Infra-inguinal Revascularisation: A Prospective Observational Pilot Study. Eur J Vasc Endovasc Surg 2017. [PMID: 28625356 DOI: 10.1016/j.ejvs.2017.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim was to investigate whether cardiopulmonary exercise testing (CPET) variables derived from cycle and arm ergonometry correlate, and whether CPET variables and pre-operative N-terminal pro-brain natriuretic peptide (NT-proBNP) have prognostic significance and if the combination of the two has incremental value. METHODS A prospective observational pilot study was conducted; 70 patients who underwent infra-inguinal bypass surgery were recruited. Pre-operatively subjects underwent CPET with both arm and leg ergonometry, to measure peak oxygen consumption, anaerobic threshold (AT), and ventilatory equivalents. In addition pre-operative serum samples of NT-proBNP were obtained. The primary endpoint was 1 year all-cause mortality; in addition, data were collected on complications, morbidity, length of stay, and major adverse cardiac events (MACE). RESULTS The 1 year mortality rate was 6%, the overall complications rate was 23%, and the combined incidence of MACE and 1 year mortality was 10%. Cycle ergonometry peak VO2 14 mL/kg/min (RR 5.5, 95% CI 1.4-22.4, p = .007) and AT < 10mL/kg/min (RR 3.0, 95% CI 1.1-7.0, p = .03) were predictors of post-operative complications. Pre-operative NT-proBNP > 320 ng/L (RR 18, 95% CI 2.5-140 p = .0003) was the sole predictor of 1 year mortality or MACE. CONCLUSION The measurement of pre-operative NT-proBNP in peripheral vascular disease patients undergoing infra-inguinal bypass can predict 1 year mortality and MACE. CPET variables from cycle ergonometry are predictors of post-operative complications in this patient group.
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Affiliation(s)
- M Kanakaraj
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - D R Yates
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - R J T Wilson
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - M L Baroni
- Department of Vascular Surgery, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - S J Davies
- Department of Anaesthesia and Intensive Care, York Teaching Hospitals NHS Foundation Trust, York, UK.
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Cascella M. Preoperative cardiac evaluation and anesthetic considerations for cancer patients who underwent chemotherapy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Jurio-Iriarte B, Gorostegi-Anduaga I, Aispuru GR, Pérez-Asenjo J, Brubaker PH, Maldonado-Martín S. Association between Modified Shuttle Walk Test and cardiorespiratory fitness in overweight/obese adults with primary hypertension: EXERDIET-HTA study. ACTA ACUST UNITED AC 2017; 11:186-195. [DOI: 10.1016/j.jash.2017.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 01/16/2017] [Accepted: 01/27/2017] [Indexed: 12/20/2022]
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