Review
Preadmission interventions to prevent postoperative complications in older cardiac surgery patients: A systematic review

https://doi.org/10.1016/j.ijnurstu.2013.05.011Get rights and content

Abstract

Objective(s)

The literature on postoperative complications in cardiac surgery patients shows high incidences of postoperative complications such as delirium, depression, pressure ulcer, infection, pulmonary complications and atrial fibrillation. These complications are associated with functional and cognitive decline and a decrease in the quality of life after discharge. Several studies attempted to prevent one or more postoperative complications by preoperative interventions. Here we provide a comprehensive overview of both single and multiple component preadmission interventions designed to prevent postoperative complications.

Methods

We systematically reviewed the literature following the PRISMA statement guidelines.

Results

Of 1335 initial citations, 31 were subjected to critical appraisal. Finally, 23 studies were included, of which we derived a list of interventions that can be applied in the preadmission period to effectively reduce postoperative depression, infection, pulmonary complications, atrial fibrillation, prolonged intensive care unit stay and hospital stay in older elective cardiac surgery patients. No high quality studies were found describing effective interventions to prevent postoperative delirium. We did not find studies specifically targeting the prevention of pressure ulcers in this patient population.

Conclusions

Multi-component approaches that include different single interventions have the strongest effect in preventing postoperative depression, pulmonary complications, prolonged intensive care unit stay and hospital stay. Postoperative infection can be best prevented by disinfection with chlorhexidine combined with immune-enhancing nutritional supplements. Atrial fibrillation might be prevented by ingestion of N-3 polyunsaturated fatty acids. High quality studies are urgently needed to evaluate preadmission preventive strategies to reduce postoperative delirium or pressure ulcers in older elective cardiac surgery patients.

Introduction

Over the recent decades, the patient population undergoing cardiac surgery has become older, sicker and higher-risk (Bacchetta et al., 2003, Litovski et al., 2008, Northrup et al., 2004). Patients of 65 years and older account for almost 60% of cardiac surgeries (Northrup et al., 2004) and show substantial heterogeneity in postoperative outcomes (Ettema et al., 2011). Whereas some older people have little increased risk of adverse events compared to the general population (Ettema et al., 2011, Zangrillo et al., 2004), vulnerable older patients (who are susceptible to physical or emotional injury) are more likely to experience adverse intra- and postoperative events (Norkiene et al., 2007, Scott et al., 2005).

The reported incidence of postoperative complications after cardiac surgery patients is high: ranging from 17% to 43.1% for delirium (Gamberini et al., 2009, Rudolph et al., 2010); from 17.5% to 28.7% for depression (Hata et al., 2006, Krannich et al., 2007); from 14.3% to 18% for pressure ulcer (Feuchtinger et al., 2006, Gomez et al., 2009); from 10.6% to 54.5% for hospital infection (DeRiso et al., 1996, Segers et al., 2008, Tepaske et al., 2001, Tepaske et al., 2007); from 10.6% to 12.1% for postoperative pulmonary complications (Al-Sarraf et al., 2009, Hulzebos et al., 2006, Zarbock et al., 2009) and from 15.2% to 33.3% for atrial fibrillation (Calò et al., 2005). These complications are associated with functional and cognitive decline and a decrease in quality of life and well-being after discharge (Hoogerduijn et al., 2007, Rudolph et al., 2010).

Already in the nineties, Recker (1994) concluded that preoperative teaching might facilitate admission of the cardiac surgical patient on the day of surgery, which could shorten the length of hospital stay. Other attempts have been made to prepare patients for cardiac surgery in the preadmission period (Cupples, 1991, Boyer et al., 2000, Lamarche et al., 1998, Watt-Watson et al., 2004) in order to prevent adverse events in the postoperative period. Many common and comorbid health problems, particularly in older persons, are multifactorial in etiology. These multifactorial syndromes are health conditions in which more than one risk factor is related to the outcome (Allore et al., 2005, Milisen et al., 2005). A good example of a multifactorial geriatric syndrome is delirium, which results from a complex and dynamic interplay between the various risk factors in a vulnerable patient. An effective intervention should therefore properly address this multifactorial origin (Milisen et al., 2005). Also, due to the multifactorial origin of syndromes more postoperative complications can occur at the same time in one vulnerable patient and risk factors are often related to more complications (Allore et al., 2005). However, in the literature several interventions that showed evidence of effectiveness aimed at preventing a single adverse outcome (Calò et al., 2005, DeRiso et al., 1996, Hulzebos et al., 2006, Segers et al., 2008, Tepaske et al., 2001), while others reported effectiveness of a combined multifactorial approach targeted at preventing multiple adverse outcomes simultaneously (Allore et al., 2005, Furze et al., 2009, Milisen et al., 2005, Shuldham et al., 2002). As a consequence, it is still unclear how older cardiac surgery patients can best be prepared for their cardiac surgery. Therefore, the purpose of the present systematic review is to provide an overview of both single and multi-component preadmission interventions designed to prevent single and multiple postoperative complications in older elective cardiac surgery patients.

Section snippets

Methods

We used the PRISMA statement recommendations in the design, literature search, analysis, and reporting of our systematic review (Moher et al., 2009).

Results

After removing the duplicates, the database searches and the additional snowball search resulted in 1335 citations. In screening on domain and inclusion criteria, 1304 articles were excluded. In 689 studies, also patients who underwent other surgery were included and no distinction was made to cardiac surgery patients only and in 214 studies the main intervention was not in cardiac surgery patients. In 175 studies patients with a mean age younger than 60 years were included and in 162 studies

Discussion

In this systematic review we identified a series of single and multi-component preadmission interventions that have been shown with a sufficient level of evidence to reduce single and multiple postoperative complications in older patients undergoing elective cardiac surgery. The susceptibility for these complications is related to the vulnerability of older cardiac surgery patients due to multifactorial geriatric syndromes (Allore et al., 2005, Milisen et al., 2005).

Only one of the 23 studies

Conclusion

In general, good quality studies found that multi-component interventions have an effect on preventing postoperative complications in older cardiac surgery patients. The current review indicates that there are several interventions that can decrease the occurrence of postoperative depression, pulmonary complications (both multi component interventions), atrial fibrillation (N-3 polyunsaturated fatty acids) and infection (combined disinfection and immune-enhancing nutritional supplements) in

Conflicts of Interest

None declared

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