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Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial.

ABSTRACT: BACKGROUND:Although early ambulation (EA) is associated with improved outcomes in post-operative patients, implementation of EA in elderly patients is still a challenge. In this study, we aimed to design and assess a precision early ambulation program for cardiac rehabilitation. METHODS:We conducted a single-center, randomized and controlled clinical trial in elderly patients aged over 60?years after off-pump coronary artery bypass graft (OPCABG) surgery. Patients were randomly assigned to a precision early ambulation (PEA) group or a routine ambulation (Control) group. Age-predicted maximal heart rate (APMHR) and maximal oxygen uptake (VO2max) were used as a reference to formulate and monitor the PEA regimen. The primary end-point was the postoperative length of stay in hospital (PLOS). The secondary end-points included 90-day mortality, incidence of early discharge, laboratory tests, length of ICU stay, the incidence of multiple organ complications and post-traumatic stress disorder (PTSD). Ambulation outcomes were also recorded. RESULTS:In total, 178 patients were enrolled (n?=?89 per group). In the intent-to-treat analysis, PLOS in the PEA group was shorter than that in the Control group (9.04?±?3.08 versus 10.09?±?3.32?days, respectively. Mean difference 1.045?days; 95% confidence interval [CI] 0.098-1.992; P?=?0.031 in the unadjusted model; mean difference 0.957?days; CI 0.007-1.907; P?=?0.048 in adjusted model). The incidence of early discharge differed significantly between the PEA and control groups (41[46.1%] versus 24[27.0%] patients, respectively. Odds ratio [OR] 0.432; CI 0.231-0.809; P?=?0.009 in unadjusted model; OR 0.466; CI 0.244-0.889, P?=?0.02 in adjusted model). The time of first bowel movement, partial pressure O2 and post-traumatic stress disorder score in the PEA group were better than those in the Control group. Participants walked much longer distances on day 3 in the PEA group than those in the Control group (76.12?±?29.02 versus 56.80?±?24.40?m, respectively, P < 0.001). CONCLUSION:APMHR and VO2max are valuable for implementation of PEA according to an established security threshold. PEA after OPCAPG surgery is safe and reliable for elderly patients, not only reducing the hospital stay, but also improving their physiological and psychological symptoms. TRIAL REGISTRATION:This study is a component of a protocol retrospectively registered: Application of ERAS in cardiovascular surgery. TRIAL REGISTRATION NUMBER:ChiCTR1800018167 . Date of registration: 3rd September, 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx.

SUBMITTER: Cui Z

PROVIDER: S-EPMC7560239 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial.

Cui Zhaomei Z Li Na N Gao Chaonan C Fan Yiou Y Zhuang Xin X Liu Jing J Zhang Jie J Tan Qi Q

BMC geriatrics 20201014 1

<h4>Background</h4>Although early ambulation (EA) is associated with improved outcomes in post-operative patients, implementation of EA in elderly patients is still a challenge. In this study, we aimed to design and assess a precision early ambulation program for cardiac rehabilitation.<h4>Methods</h4>We conducted a single-center, randomized and controlled clinical trial in elderly patients aged over 60 years after off-pump coronary artery bypass graft (OPCABG) surgery. Patients were randomly as ...[more]

PMID: 33054724

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Project description:BackgroundMyocardial inflammation and injury occur during coronary artery bypass graft (CABG) surgery. We aimed to characterise these processes during routine CABG surgery to inform the diagnosis of type 5 myocardial infarction.MethodsWe assessed 87 patients with stable coronary artery disease who underwent elective CABG surgery. Myocardial inflammation, injury and infarction were assessed using plasma inflammatory biomarkers, high-sensitivity cardiac troponin I (hs-cTnI) and cardiac magnetic resonance imaging (CMR) using both late gadolinium enhancement (LGE) and ultrasmall superparamagnetic particles of iron oxide (USPIO).ResultsSystemic humoral inflammatory biomarkers (myeloperoxidase, interleukin-6, interleukin-8 and c-reactive protein) increased in the post-operative period with C-reactive protein concentrations plateauing by 48 h (median area under the curve (AUC) 7530 [interquartile range (IQR) 6088 to 9027] mg/L/48 h). USPIO-defined cellular myocardial inflammation ranged from normal to those associated with type 1 myocardial infarction (median 80.2 [IQR 67.4 to 104.8] /s). Plasma hs-cTnI concentrations rose by ?50-fold from baseline and exceeded 10-fold the upper limit of normal in all patients. Two distinct patterns of peak cTnI release were observed at 6 and 24 h. After CABG surgery, new LGE was seen in 20% (n?=?18) of patients although clinical peri-operative type 5 myocardial infarction was diagnosed in only 9% (n?=?8). LGE was associated with the delayed 24-h peak in hs-cTnI and its magnitude correlated with AUC plasma hs-cTnI concentrations (r?=?0.33, p?<?0.01) but not systemic inflammation, myocardial inflammation or bypass time.ConclusionPatients undergoing CABG surgery invariably have plasma hs-cTnI concentrations >10-fold the 99th centile upper limit of normal that is not attributable to inflammatory or ischemic injury alone. Peri-operative type 5 myocardial infarction is often unrecognised and is associated with a delayed 24-h peak in plasma hs-cTnI concentrations.

Project description:PurposeMyocardial injury due to on-pump coronary artery bypass grafting (CABG) in patients with low ejection fraction (EF) is associated with poor outcomes. This study determines whether intravenous glutamine could protect the myocardium during on-pump CABG in patients with low EF.Materials and methodsThis was a double-blind, randomized controlled trial to assess glutamine as a myocardial protector during on-pump CABG in patients with left ventricle EF of 31-50%, conducted from January to October 2021. Patients in the glutamine group (n = 30) received 0.5 g/kg of 20% glutamine solution diluted with 0.9% NaCl up to 500 mL in total volume over a period of 24 hours. Patients in the control group (n = 30) received 0.9% NaCl over the same period. The primary outcomes were plasma troponin I and plasma glutamine levels. Secondary outcomes included α-ketoglutarate (α-KG) levels and histopathology scoring of the right atrial appendage tissue, plasma lactate levels, hemodynamic measurement, and morbidity.ResultsTwenty-nine patients from each group (58 in total) were included in the analysis. Plasma troponin I levels at 6 and 24 hours after cardiopulmonary bypass (CPB) were significantly lower in the glutamine than the control group (mean 3.43 ± 1.51 ng/mL vs mean 4.41 ± 1.89 ng/mL; p = 0.034; median 3.08 ng/mL [min-max: 1.30-6.59] vs median 3.77 ng/mL [min-max: 0.00-36.53]; p = 0.038, respectively). Plasma glutamine levels at 24 hours after CPB were significantly higher in the glutamine than the control group (mean 935.42 ± 319.10 μmol/L vs mean 634.79 ± 243.89 μmol/L, p = 0.001). Plasma lactate levels at 6 and 24 hours after CPB were significantly lower in the glutamine than the control group (median 5.30 mmol/L [min-max: 1.20-9.50] vs median 5.70 mmol/L [min-max: 2.80-11.30], p = 0.042; mean 2.08 ± 0.67 mmol/L vs mean 2.46 ± 0.69 mmol/L, p = 0.044, respectively). Myocardial injury score was significantly lower in the glutamine than the control group (mean 1.30 ± 0.24 vs mean 1.48 ± 0.26, p = 0.011).ConclusionPerioperative administration of 0.5 g/kg intravenous glutamine solution over the period of 24 hours has myocardial protection effect in patients with low EF who undergo elective on-pump CABG.

Dataset Information

Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial.

Publications

Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial.

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