Nurses' knowledge of and attitude toward postoperative patient-controlled analgesia (PCA) and the associated factors.

BACKGROUND: Postoperative pain control is pivotal for surgical care; it facilitates patient recovery. Although patient-controlled analgesia (PCA) has been available for decades, inadequate pain control remains. Nurses' knowledge of and attitude toward PCA may influence the efficacy on clinic application. PURPOSE: The purpose of this study is to evaluate nurses' knowledge of and attitude toward postoperative PCA and investigate the associated factors. METHODS: This is a cross-sectional study. We enrolled registered nurses from a 2200-bed medical center in northern Taiwan within one year. The participants completed an anonymous self-reported PCA knowledge inventory and PCA attitude inventory. Data were analyzed descriptively and associated were tested using logistic regression. RESULTS: With 303 participants enrolled, we discovered that nurses had limited knowledge of and a negative attitude toward PCA. Under half of the participants know how to set up a bolus dose and lockout intervals. The majority held misconceptions regarding side effect management for opioids. The minority agree to increase the dose when a patient experienced persistent pain or suggested the use of PCA. Surprisingly, participants with a bachelor's or master's degree had lower knowledge scores than those with a junior college degree. Those with 6-10 years of work experience also are lower than those with under 5 years of experience. However, the participants with experience of using PCA for patient care had higher knowledge scores and a more positive attitude. CONCLUSIONS: Although postoperative PCA has been available for decades and education programs are routinely provided, nurses had limited knowledge of and a negative attitude toward PCA. A higher education level and longer work experience were not associated with more knowledge. The current education programs on PCA should be revised to enhance their efficacy in delivering up-to-date knowledge and situation training which may convey supportive attitude toward clinical application of PCA.

Effects of a swallowing and oral-care program on resuming oral feeding and reducing pneumonia in patients following endotracheal extubation: a randomized, open-label, controlled trial.

BACKGROUND: The resumption of oral feeding and free from pneumonia are important therapeutic goals for critically ill patients who have been successfully extubated after prolonged (≥ 48 h) endotracheal intubation. We aimed to examine whether a swallowing and oral-care (SOC) program provided to critically ill patients extubated from prolonged mechanical ventilation improves their oral-feeding resumption and reduces 30-day pneumonia incidence. METHODS: In this randomized, open-label, controlled trial, participants were consecutively enrolled and randomized to receive the SOC program or usual care. The interventions comprised three protocols: oral-motor exercise, sensory stimulation and lubrication, and safe-swallowing education. Beginning on the day following patient extubation, an SOC nurse provided the three-protocol care for seven consecutive days or until death or hospital discharge. With independent outcome assessors, oral-feeding resumption (yes, no) corresponded to level 6 or level 7 on the Functional Oral Intake Scale (censored seven days postextubation) along with radiographically documented pneumonia (yes, no; censored 30 days postextubation), abstracted from participants' electronic medical records were coded. RESULTS: We analyzed 145 randomized participants (SOC group = 72, control group = 73). The SOC group received, on average, 6.2 days of intervention (14.8 min daily) with no reported adverse events. By day 7, 37/72 (51.4%) of the SOC participants had resumed oral feeding vs. 24/73 (32.9%) of the control participants. Pneumonia occurred in 11/72 (15.3%) of the SOC participants and in 26/73 (35.6%) of the control participants. Independent of age and intubation longer than 6 days, SOC participants were likelier than their control counterparts to resume oral feeding (adjusted hazard ratio, 2.35; 95% CI 1.38-4.01) and had lower odds of developing pneumonia (adjusted odds ratio, 0.28; 95% CI 0.12-0.65). CONCLUSIONS: The SOC program effectively improved patients' odds that oral feeding would resume and the 30-day pneumonia incidence would decline. The program might advance dysphagia care provided to critically ill patients extubated from prolonged mechanical ventilation. TRIAL REGISTRATION: NCT03284892, registered on September 15, 2017.

Predicting hospital mortality and length of stay: A prospective cohort study comparing the Intensive Care Delirium Screening Checklist versus Confusion Assessment Method for the Intensive Care Unit.

OBJECTIVE: The objective of this study was to compare two tools, the Intensive Care Delirium Screening Checklist (ICDSC) and Confusion Assessment Method for the intensive care unit (ICU) (CAM-ICU), for their predictive validity for outcomes related to delirium, hospital mortality, and length of stay (LOS). METHODS: The prospective study conducted in six medical ICUs at a tertiary care hospital in Taiwan enrolled consecutive patients (≥20 years) without delirium at ICU admission. Delirium was screened daily using the ICDSC and CAM-ICU in random order. Arousal was assessed by the Richmond Agitation-Sedation Scale (RASS). Participants with any one positive result were classified as ICDSC- or CAM-ICU-delirium groups. RESULTS: Delirium incidence evaluated by the ICDSC and CAM-ICU were 69.1% (67/97) and 50.5% (49/97), respectively. Although the ICDSC identified 18 more cases as delirious, substantial concordance (κ = 0.63; p < 0.001) was found between tools. Independent of age, Acute Physiology and Chronic Health Evaluation II score, and Charlson Comorbidity Index, both ICDSC- and CAM-ICU-rated delirium significantly predicted hospital mortality (adjusted odds ratio: 4.93; 95% confidence interval [CI]:1.56 to 15.63 vs. 2.79; 95% CI: 1.12 to 6.97, respectively), and only the ICDSC significantly predicted hospital LOS with a mean of 17.59 additional days compared with the no-delirium group. Irrespective of delirium status, a sensitivity analysis of normal-to-increased arousal (RASS≥0) test results did not alter the predictive ability of ICDSC- or CAM-ICU-delirium for hospital mortality (adjusted odds ratio: 2.97; 95% CI: 1.06 to 8.37 vs. 3.82; 95% CI: 1.35 to 10.82, respectively). With reduced arousal (RASS<0), neither tool significantly predicted mortality or LOS. CONCLUSIONS: The ICDSC identified more delirium cases and may have higher predictive validity for mortality and LOS than the CAM-ICU. However, arousal substantially affected performance. Future studies may want to consider patients' arousal when deciding which tool to use to maximise the effects of delirium identification on patient mortality.

Association of Incident Delirium With Short-term Mortality in Adults With Critical Illness Receiving Mechanical Ventilation.

Importance: Intensive care unit (ICU)-acquired delirium and/or coma have consequences for patient outcomes. However, contradictory findings exist, especially when considering short-term (ie, in-hospital) mortality and length of stay (LOS). Objective: To assess whether incident delirium, days of delirium, days of coma, and delirium- and coma-free days (DCFDs) are associated with 14-day mortality, in-hospital mortality, and hospital LOS among patients with critical illness receiving mechanical ventilation. Design, Setting, and Participants: This single-center prospective cohort study was conducted in 6 ICUs of a university-affiliated tertiary hospital in Taiwan. A total of 267 delirium-free patients (aged ≥20 years) with critical illness receiving mechanical ventilation were consecutively enrolled from August 14, 2018, to October 1, 2020. Exposures: Participants were assessed daily for the development of delirium and coma status over 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. Main Outcomes and Measures: Mortality rates (14-day and in-hospital) and hospital LOS using electronic health records. Results: Of 267 participants (median [IQR] age, 65.9 [57.4-75.1] years; 171 men [64.0%]; all of Taiwanese ethnicity), 149 patients (55.8%) developed delirium for a median (IQR) of 3.0 (1.0-5.0) days at some point during their first 14 days of ICU stay, and 105 patients (39.3%) had coma episodes also lasting for a median (IQR) of 3.0 (1.0-5.0) days. The 14-day and in-hospital mortality rates were 18.0% (48 patients) and 42.1% (112 of 266 patients [1 patient withdrew from the study]), respectively. The incidence and days of delirium were not associated with either 14-day mortality (incident delirium: adjusted hazard ratio [aHR], 1.37; 95% CI, 0.69-2.72; delirium by day: aHR, 1.00; 95% CI, 0.91-1.10) or in-hospital mortality (incident delirium: aHR, 1.00; 95% CI, 0.64-1.55; delirium by day: aHR, 1.02; 95% CI, 0.97-1.07), whereas days spent in coma were associated with an increased hazard of dying during a given 14-day period (aHR, 1.16; 95% CI, 1.10-1.22) and during hospitalization (aHR, 1.10; 95% CI, 1.06-1.14). The number of DCFDs was a protective factor; for each additional DCFD, the risk of dying during the 14-day period was reduced by 11% (aHR, 0.89; 95% CI, 0.84-0.94), and the risk of dying during hospitalization was reduced by 7% (aHR, 0.93; 95% CI, 0.90-0.97). Incident delirium was associated with longer hospital stays (adjusted ß = 10.80; 95% CI, 0.53-21.08) when compared with no incident delirium. Conclusions and Relevance: In this study, despite prolonged LOS, ICU delirium was not associated with short-term mortality. However, DCFDs were associated with a lower risk of dying, suggesting that future research and intervention implementation should refocus on maximizing DCFDs to potentially improve the survival of patients receiving mechanical ventilation.

Predicting feeding-tube dependence in patients following endotracheal extubation: a two-item swallowing screen.

BACKGROUND: To meet the surging demands for intubation and invasive ventilation as more COVID-19 patients begin their recovery, clinicians are challenged to find an ultra-brief and minimally invasive screen for postextubation dysphagia predicting feeding-tube dependence persisting for 72 h after extubation. METHODS: This study examined the predictive validity of a two-item swallowing screen on feeding-tube dependence over 72 h in patients following endotracheal extubation. Intensive-care-unit (ICU) patients (≥ 20 years) successfully extubated after ≥ 48 h endotracheal intubation were screened by trained nurses using the swallowing screen (comprising oral stereognosis and cough-reflex tests) 24 h postextubation. Feeding-tube dependence persisting for 72 h postextubation was abstracted from the medical record by an independent rater. To verify the results and cross-check whether the screen predicted penetration and/or aspiration during fiberoptic endoscopic evaluation of swallowing (FEES), participants agreeing to receive FEES were analyzed within 30 min of screening. RESULTS: The results showed that 95/123 participants (77.2%) failed the screen, which predicted ICU patients' prolonged (> 72 h) feeding-tube dependence, yielding sensitivity of 0.83, specificity of 0.35, and accuracy of 0.68. Failed-screen participants had 2.96-fold higher odds of feeding-tube dependence (95% CI, 1.13-7.76). For the 38 participants receiving FEES, the swallowing screen had 0.89 sensitivity to detect feeding-tube dependence and 0.86 sensitivity to predict penetration/aspiration, although specificity had room for improvement (0.36 and 0.21, respectively). CONCLUSION: This ultra-brief swallowing screen is sufficiently sensitive to identify high-risk patients for feeding-tube dependence persisting over 72 h after extubation. Once identified, a further assessment and care are indicated to ensure the prompt return of patients' oral feeding. TRIAL REGISTRATION: NCT03284892, registered on September 15, 2017.

Effects of Slowness, Frailty, Insufficient Intake, and Delirium in Patients Following Cardiac Surgery: A Cohort Study.

BACKGROUND: Slow gait, frailty, insufficient postoperative caloric intake, and delirium, although seemingly distinct, can appear simultaneously in patients who underwent cardiac surgery. OBJECTIVES: The aim of this study was to evaluate how these 4 factors overlap and how they individually and cumulatively affect cardiac surgery outcomes. METHODS: The effects of slowness (gait speed <0.83 m/s), frailty (≥3/5 Fried criteria), insufficient postoperative intake (<800 kcal/d), and delirium (defined by the Confusion Assessment Method) on hospital length of stay (LOS) and 3-month mortality were analyzed in 308 adult patients. RESULTS: Slowness, frailty, insufficient intake, and delirium affected 27.5%, 29.5%, 31.5%, and 13.3% of participants, respectively; only 42.2% (130/308) were free from these risks. Risk overlap was prevalent, as 26.3% (n = 81) had 2 or more risk factors. The most obvious overlap was in delirium (80% of delirious participants had other risks), suggesting that delirium cannot be managed in isolation. Individually, whereas slowness was associated only with longer LOS, frailty, insufficient intake, and delirium all led to longer LOS and higher mortality. When equally weighting each risk factor to analyze their cumulative effects, LOS increased by 4.4 days (95% confidence interval, 3.0-5.7) and 3-month mortality increased by 2.6-fold (95% confidence interval, 1.4-4.6), with each risk factor added, independent of participants' educational level, body mass index, and risk for cardiac surgery (EuroSCORE II ≥6). CONCLUSIONS: Because a clinical overlap of slowness, frailty, insufficient postoperative intake, and delirium was evident in patients who underwent cardiac surgery, and risk of death and longer hospital stay increased with each factor added, care should be revised to consider these overlapping factors to maximize patient outcomes.

Surviving and Thriving 1 Year After Cardiac Surgery: Frailty and Delirium Matter.

BACKGROUND: We compared 1-year functional outcomes for 4 cardiac surgery patient groups: comparison (without preoperative frailty or postoperative delirium [POD]), frailty only (with preoperative frailty only), POD only (with POD only), and frailty-POD (combined frailty and POD). METHODS: Consecutive cardiac surgery patients (n = 298) at a university hospital were assessed for preoperative frailty using Fried's phenotype, and POD was assessed daily for 10 days after surgery using the Confusion Assessment Method. Functional outcomes (Barthel Index for activities of daily living [ADL]) and all-cause mortality were evaluated 1-year after surgery. RESULTS: Preoperative frailty presented in 85 of participants (28.5%) and POD in 38 (12.8%). Frail participants were at increased risk for POD (odds ratio = 4.9; P < .001). Overall, 1-year mortality was 4.0% (n = 12) and functional change was 0.4 ± 11.0 Barthel points. Controlling for age, cardiac risk, and baseline ADL, frailty-only and comparison participants had comparable 1-year functional outcomes. The POD-only group had greater mortality (adjusted hazard ratio = 23.9; P = .01), whereas the combined frailty-POD group had the greatest ADL decline (ß = -23.7; P = .01) and the highest mortality (adjusted hazard ratio = 30.2; P = .006) compared with the comparison group. CONCLUSIONS: Preoperative frailty alone did not negatively affect cardiac surgery patients' functional outcomes up to 1 year, but coexisting frailty and POD led to substantial loss of independence on 3 to 4 ADLs and a 30.2-fold higher likelihood of dying 1 year after surgery. Because frailty led to a 4.9-fold increase in POD risk, frailty may serve as a presurgical screen to identify patients who would likely benefit from delirium prevention and functional recovery programs to maximize 1-year postsurgical outcomes.

Effects of Apparent Temperature on the Incidence of Ventricular Tachyarrhythmias in Patients With an Implantable Cardioverter-Defibrillator: Differential Association Between Patients With and Without Electrical Storm.

Background: Electrical storm (ES) has profound psychological effects and is associated with a higher mortality in patients with implantable cardioverter-defibrillator (ICD). Assessing the incidence and features of ES, is vital. Previous studies have shown winter peaks for ventricular tachyarrhythmia (VTA) in ICD patients. However, the effects of heat with a high relative humidity remain unclear. Thus, this study aimed to assess the nonlinear and lagged effects of apparent temperature [or heat index (HI)] on VTA among patients with and without ES after ICD implantation. Methods: Of 626 consecutive patients who had ICDs implanted from January 2004 to June 2017 at our hospital, 172 who experienced sustained VTAs in ICD recording were analyzed, and their clinical records were abstracted to assess the association between VTA incidence and HI by time-stratified case-crossover analysis. Cubic splines were used for the nonlinear effect of HI, with adjustment for air pollutant concentrations. Results: A significant seasonal effect for ES patients was noted. Apparent temperature, but not ambient temperature, was associated with VTA occurrences. The low and high HI thresholds for VTA incidence were <15° and >30°C, respectively, with a percentage change in odds ratios of 1.06 and 0.37, respectively, per 1°C. Lagged effects could only be demonstrated in ES patients, which lasted longer for low HI (in the next 4 days) than high HI (in the next 1 day). Conclusion: VTA occurrence in ICD patients was strongly associated with low HI and moderately associated with high HI. Lagged effects of HI on VTA were noted in patients with ES. Furthermore, patients with ES were more vulnerable to heat stress than those without ES. Patients with ICD implantation, particularly in those with ES, should avoid exposure to low and high HI to reduce the risk of VTAs, improve quality of life and possibly reduce mortality.

Effects of a swallowing and oral care intervention for patients following endotracheal extubation: a pre- and post-intervention study.

BACKGROUND: For patients who survive a critical illness and have their oral endotracheal tube removed, dysphagia is highly prevalent, and without intervention, it may persist far beyond hospital discharge. This pre- and post-intervention study with historical controls tested the effects of a swallowing and oral care (SOC) intervention on patients' time to resume oral intake and salivary flow following endotracheal extubation. METHODS: The sample comprised intensive care unit patients (≥ 50 years) successfully extubated after ≥ 48 h endotracheal intubation. Participants who received usual care (controls, n = 117) were recruited before 2015, and those who received usual care plus the intervention (n = 54) were enrolled after 2015. After extubation, all participants were assessed by a blinded nurse for daily intake status (21 days) and whole-mouth unstimulated salivary flow (2, 7, 14 days). The intervention group received the nurse-administered SOC intervention, comprising toothbrushing/salivary gland massage, oral motor exercise, and safe-swallowing education daily for 14 days or until hospital discharge. RESULTS: The intervention group received 8.3 ± 4.2 days of SOC intervention, taking 15.4 min daily with no reported adverse event (coughing, wet voice, or decreased oxygen saturation) during and immediately after intervention. Participants who received the intervention were significantly more likely than controls to resume total oral intake after extubation (aHR 1.77, 95% CI 1.08-2.91). Stratified by age group, older participants (≥ 65 years) in the SOC group were 2.47-fold more likely than their younger counterparts to resume total oral intake (aHR 2.47, 95% CI 1.31-4.67). The SOC group also had significantly higher salivary flows 14 days following extubation (ß = 0.67, 95% CI 0.29-1.06). CONCLUSIONS: The nurse-administered SOC is safe and effective, with greater odds of patients' resuming total oral intake and increased salivary flows 14 days following endotracheal extubation. Age matters with SOC; it more effectively helped participants ≥ 65 years old resume total oral intake postextubation. TRIAL REGISTRATION: NCT02334774, registered on January 08, 2015.

Effects of sarcopenia on functional improvement over the first year after cardiac surgery: a cohort study.

BACKGROUND: Sarcopenia is linked with poor postoperative outcomes. AIMS: To evaluate the effects of sarcopenia on first-year functional changes after cardiac surgery. METHODS: In this prospective cohort study, functional changes (physical activity levels in metabolic equivalent hours/week, 6-minute walking distance in metres, and grip strength in kg) from preoperative baseline to 1, 3, 6 and 12 months postoperatively were compared in adult patients with and without sarcopenia undergoing cardiac surgery at a tertiary medical centre. Presurgical sarcopenia was defined as low muscle mass plus either low strength or poor physical performance (i.e. reduced gait speed). Secondary outcomes (length of hospital stay and 1-year mortality) were compared between sarcopenia and non-sarcopenia groups. RESULTS: Sarcopenia presented in 27.7% ( n=67) of 242 participants. Participants with sarcopenia were significantly older, predominantly women, and had lower body mass index and higher cardiac surgery risk (measured by the EuroSCORE II) than those without sarcopenia. For both groups, physical activity levels, walking distance and grip strength steadily improved over the year following cardiac surgery. Independent of EuroSCORE II, changes in physical activity levels, walking distance and grip strength did not differ significantly between the sarcopenia and non-sarcopenia groups 1, 3, 6 and 12 months after surgery. Nevertheless, the sarcopenia group had a significantly longer length of hospital stay than the non-sarcopenia group (19.4 vs. 15.3 days; ß=2.9, P=0.02) but 1-year mortality (3.4 vs. 3.9% for non-sarcopenia group) was comparable. CONCLUSIONS: Despite a longer length of hospital stay for the sarcopenia group, sarcopenia was not a restriction for cardiac surgery given their comparable functional improvement and mortality 1 year following surgery.

Bedside screen for oral cavity structure, salivary flow, and vocal production over the 14days following endotracheal extubation.

PURPOSE: To describe the sequelae of oral endotracheal intubation by evaluating prevalence rates of structural injury, hyposalivation, and impaired vocal production over 14days following extubation. MATERIALS AND METHODS: Consecutive adults (≥20years, N=114) with prolonged (≥48h) endotracheal intubation were enrolled from medical intensive care units at a university hospital. Participants were assessed by trained nurses at 2, 7, and 14days after extubation, using a standardized bedside screening protocol. RESULTS: Within 48-hour postextubation, structural injuries were common, with 51% having restricted mouth opening. Unstimulated salivary flow was reduced in 43%. For vocal production, 51% had inadequate breathing support for phonation, dysphonia was common (94% had hoarseness and 36% showed reduced efficiency of vocal fold closure), and >40% had impaired articulatory precision. By 14days postextubation, recovery was noted in most conditions, but reduced efficiency of vocal fold closure persisted. Restricted mouth opening (39%) and reduced salivary flow (34%) remained highly prevalent. CONCLUSIONS: After extubation, restricted mouth opening, reduced salivary flow, and dysphonia were common and prolonged in recovery. Reduced efficiency of vocal cord closure persisted at 14days postextubation. The extent and duration of these sequelae remind clinicians to screen for them up to 2weeks after extubation.

Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial.

IMPORTANCE: Older patients undergoing abdominal surgery commonly experience preventable delirium, which extends their hospital length of stay (LOS). OBJECTIVE: To examine whether a modified Hospital Elder Life Program (mHELP) reduces incident delirium and LOS in older patients undergoing abdominal surgery. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized clinical trial of 577 eligible patients enrolled 377 older patients (≥65 years of age) undergoing gastrectomy, pancreaticoduodenectomy, and colectomy at a 2000-bed urban medical center in Taipei, Taiwan, from August 1, 2009, through October 31, 2012. Consecutive older patients scheduled for elective abdominal surgery with expected LOS longer than 6 days were enrolled, with a recruitment rate of 65.3%. Participants were cluster randomized by room to receive the mHELP or usual care. INTERVENTIONS: The intervention (implemented by an mHELP nurse) consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. Intervention group participants received all 3 mHELP protocols postoperatively, in addition to usual care, as soon as they arrived in the inpatient ward and until hospital discharge. Adherence to protocols was tracked daily. MAIN OUTCOMES AND MEASURES: Presence of delirium was assessed daily by 2 trained nurses who were masked to intervention status by using the Confusion Assessment Method. Data on LOS were abstracted from the medical record. RESULTS: Of 577 eligible patients, 377 (65.3%) were enrolled and randomly assigned to the mHELP (n = 197; mean [SD] age, 74.3 [5.8] years; 111 [56.4%] male) or control (n = 180; mean [SD] age, 74.8 [6.0] years; 103 [57.2%] male) group. Postoperative delirium occurred in 13 of 196 (6.6%) mHELP participants vs 27 of 179 (15.1%) control individuals, representing a relative risk of 0.44 in the mHELP group (95% CI, 0.23-0.83; P = .008). Intervention group participants received the mHELP for a median of 7 days (interquartile range, 6-10 days) and had a shorter median LOS (12.0 days) than control participants (14.0 days) (P = .04). CONCLUSIONS AND RELEVANCE: For older patients undergoing abdominal surgery who received the mHELP, the odds of delirium were reduced by 56% and LOS was reduced by 2 days. Our findings support using the mHELP to advance postoperative care for older patients undergoing major abdominal surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01045330.

Swallowing dysfunction following endotracheal intubation: Age matters.

To evaluate postextubation swallowing dysfunction (PSD) 21 days after endotracheal extubation and to examine whether PSD is time-limited and whether age matters.For this prospective cohort study, we evaluated 151 adult critical care patients (≥20 years) who were intubated for at least 48 hours and had no pre-existing neuromuscular disease or swallowing dysfunction. Participants were assessed for time (days) to pass bedside swallow evaluations (swallow 50 mL of water without difficulty) and to resume total oral intake. Outcomes were compared between younger (20-64 years) and older participants (≥65 years).PSD, defined as inability to swallow 50 mL of water within 48 hours after extubation, affected 92 participants (61.7% of our sample). At 21 days postextubation, 17 participants (15.5%) still failed to resume total oral intake and were feeding-tube dependent. We found that older participants had higher PSD rates at 7, 14, and 21 days postextubation, and took significantly longer to pass the bedside swallow evaluations (5.0 vs 3.0 days; P = 0.006) and to resume total oral intake (5.0 vs 3.0 days; P = 0.003) than their younger counterparts. Older participants also had significantly higher rates of subsequent feeding-tube dependence than younger patients (24.1 vs 5.8%; P = 0.008).Excluding patients with pre-existing neuromuscular dysfunction, PSD is common and prolonged. Age matters in the time needed to recover. Swallowing and oral intake should be monitored and interventions made, if needed, in the first 7 to 14 days postextubation, particularly for older patients.

A Walk-and-Eat Intervention Improves Outcomes for Patients With Esophageal Cancer Undergoing Neoadjuvant Chemoradiotherapy.

BACKGROUND: Preserving functional walking capacity and nutritional status is important for patients with esophageal cancer, but no effective intervention is available, particularly during active treatment. METHODS: This pilot randomized controlled trial tested the effects of a walk-and-eat intervention for patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy. Participants with locally advanced esophageal cancer stage IIB or higher (n = 59) were randomly assigned to receive the walk-and-eat intervention (n = 30; nurse-supervised walking three times per week and weekly nutritional advice) or usual care (n = 29; control group) during 4-5 weeks of chemoradiotherapy. Primary endpoints were changes in distance on the 6-minute walk test, hand-grip strength, lean muscle mass, and body weight between initiation and completion of intervention. RESULTS: Participants (mean age: 59.6 years) were mostly male (92.9%) with squamous cell carcinoma (96.4%). During chemoradiotherapy, participants who received the walk-and-eat intervention had 100-m less decline than controls in walk distance (adjusted p = .012), 3-kg less decrease in hand-grip strength (adjusted p = .002), and 2.7-kg less reduction in body weight (adjusted p < .001), regardless of age. The intervention group also had significantly lower rates of need for intravenous nutritional support and wheelchair use. CONCLUSION: The nurse-led walk-and-eat intervention is feasible and effective to preserve functional walking capacity and nutritional status for patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy.

Pre-surgical Geriatric Syndromes, Frailty, and Risks for Postoperative Delirium in Older Patients Undergoing Gastrointestinal Surgery: Prevalence and Red Flags.

OBJECTIVE: We sought to identify and evaluate red flags for pre-surgical geriatric conditions (geriatric syndromes, frailty, and risks for postoperative delirium) in older patients undergoing gastrointestinal surgery. METHODS: Older individuals (≥65 years) undergoing major elective gastrointestinal surgery from 2009 to 2012 were enrolled and assessed preoperatively. RESULTS: Participants (N=379; mean age=74.5 ± 5.9 years) primarily underwent colorectal (54.3 %), gastric (21.9 %), and pancreatobiliary (12.6 %) surgery. Overall, 30.9 % had existing geriatric syndromes, 26.7 % were frail, and 22.8 % had >3 risk factors for postoperative delirium. The largest proportion (45.7 %) presented with at least one geriatric condition. Patients with or without geriatric conditions were discriminated with adequate sensitivity (67 %), specificity (84 %), and positive predictive value (77 %) by eight red flags: age ≥75 years (OR, 2.86; P<0.001), eating soft food (OR, 3.63; P=0.001), reported hypertension (OR, 2.8; P=0.001), weight loss >3 kg (OR, 4.79; P<0.001), fair-to-weak grip strength (OR, 2.53; P=0.001), sleeplessness (OR, 2.57; P=0.001), no-better-than-peer perceived health (OR, 1.88; P=0.022), and short-term inability to recall two of three common words (OR, 1.81; P=0.025). CONCLUSIONS: Eight red flags covered as part of history and physical examination are well suited to screen patients for geriatric conditions indicating the need for preoperative geriatric assessments and optimization.

Tongue weakness and somatosensory disturbance following oral endotracheal extubation.

The tongue plays important roles in mastication, swallowing, and speech, but its sensorimotor function might be affected by endotracheal intubation. The objective of this pilot study was to describe disturbances in the sensorimotor functions of the tongue over 14 days following oral endotracheal extubation. We examined 30 post-extubated patients who had prolonged (≥48 h) oral endotracheal intubation from six medical intensive care units. Another 36 patients were recruited and examined from dental and geriatric outpatient clinics served as a comparison group. Tongue strength was measured by the Iowa Oral Performance Instrument. Sensory disturbance of the tongue was measured by evaluating light touch sensation, oral stereognosis, and two-point discrimination with standardized protocols. Measurements were taken at three time points (within 48 h, and 7 and 14 days post-extubation) for patients with oral intubation but only once for the comparison group. The results show that independent of age, gender, tobacco used, and comorbidities, tongue strength was lower and its sensory functions were more impaired in patients who had oral intubation than in the comparison group. Sensory disturbances of the tongue gradually recovered, taking 14 days to be comparable with the comparison group, while weakness of the tongue persisted. In conclusion, patients with oral endotracheal intubation had weakness and somatosensory disturbances of the tongue lasting at least 14 days from extubation but whether is caused by intubation and whether is contributed to postextubation dysphagia should be further investigated.

Delirium, subsyndromal delirium, and cognitive changes in individuals undergoing elective coronary artery bypass graft surgery.

BACKGROUND: The course of incident delirium and subsyndromal delirium (SSD) after cardiac surgery is not well studied. OBJECTIVE: The aim of this study was to evaluate the course of incident delirium and SSD, their risk factors, and impact on patients' cognitive function after elective coronary artery bypass graft (CABG) surgery. METHODS: Consecutive patients scheduled for an isolated CABG at a tertiary medical center in Taiwan were enrolled if they had no preoperative delirium symptoms. Delirium was assessed daily for 1 week after surgery using the Confusion Assessment Method. Subsyndromal delirium was defined as presenting with any core symptom below the diagnostic threshold for delirium. Cognitive function was assessed by the Mini-mental State Examination. RESULTS: Of 38 participants, 7 had incident (first-time) delirium (18.4% incidence) and 13 had incident SSD (34.2% incidence). Whereas SSD usually lasted 1 day, delirium changed gradually to SSD to recovery and its symptomatology lasted longer. We identified 6 delirium risk factors: older age, more comorbidities, cardiac pulmonary bypass, blood transfusion, larger transfusion volume, and longer duration of intraoperative blood pressure less than 60 mm Hg. The frequencies of these risk factors for SSD were often intermediate between those of risk factors in groups with and without delirium. By hospital discharge, participants with delirium had the longest hospital stays and lowest cognitive scores, those with SSD had intermediate stays and scores, and those without delirium had the lowest stays and scores. CONCLUSION: Delirium and SSD after CABG are common. Greater number and severity of risk factors for delirium may predict increasingly poor outcomes, with the dose-response relationship between risk factors and outcomes for SSD intermediate between that for no symptoms and full delirium. Intervention trials are indicated, particularly for patients with a greater number and severity of predisposing and precipitating risk factors.