Irene Lie

Patients’ experiences with symptoms and needs in the early rehabilitation phase after coronary artery bypass grafting

Background: The first month after discharge for Coronary artery bypass graft (CABG) is particularly challenging for the patients. A larger interview study is warranted to elicit CABG patients’ detailed experiences, and give direction for future clinical practice. Aim: To explore the CABG patients’ symptoms and needs in the early rehabilitation phase. Methods: A qualitative, mixed method design integrating qualitative and quantitative approaches was used. Ninety-three CABG patients aged 39-77, participated in interviews at home after 2 and 4 weeks. The semi-structured interview guide covered: experiences of relief of angina pectoris after surgery, experiences with prescribed discharge medications, psychological experiences: anxiety, depression, sexuality, health professional contact persons, and patient defined experiences. Results: Two weeks after CABG the patients symptoms and needs were characterised by a substantial amount of uncertainty and worries related to what to expect and what was normal for postoperative pain, assessment and sensation of surgical site, different experiences with physical activity/exercise, uncertainty about medications, difficulties with sleep pattern, irritability, postoperative complications,uncertainty about return to work, and insufficient information at discharge. Four weeks after surgerythe patients’ symptom level was decreased, and they experienced life beginning to return back to normal. Patency with grafts after CABG, decision to drive a car, impotence (erectile dysfunction), and a missing link to the hospital remained challenges. Conclusion: CABG patients’ experiences indicate a need to extend the hospital’s discharge care to the first month after surgery for specific themes to promote rehabilitation outcomes.

Pain characteristics and analgesic intake before and following cardiac surgery

Background: Cardiac surgery is a common intervention that involves several pain-sensitive structures, and intense postoperative pain is a predictor of persistent pain. Aims: To describe pain characteristics (i.e. intensity, location, interference, relief) and analgesic intake preoperatively and across postoperative days 1 to 4 after cardiac surgery, and to explore associations between postoperative pain and demographic and clinical characteristics. Methods: Four hundred and sixteen patients (24% women) undergoing elective coronary artery bypass grafting and/or valve surgery were enrolled in a randomized controlled trial. Data were collected using standardized measures including the Brief Pain Inventory-short form. A linear mixed model analysis estimated the impact of sex, age, body mass index, analgesic intake and preoperative pain on postoperative worst pain ratings in the previous 24 hours from postoperative days 1 to 4 prior to discharge Results: Thirty-eight per cent of the cardiac surgery patients reported preoperative pain. Postoperative worst pain remained in the moderate to severe range for the majority of patients across day 1 (85%) to day 4 (57%), mainly around the chest incision area for the majority (70%). Mean oral morphine intake was 17 mg/24 h (day 1: 27mg; day 4: 10mg). Lower age, female sex, preoperative pain and analgesic intake had a statistically significant association with higher postoperative worst pain ratings. Conclusion: Study findings demonstrated a high prevalence of moderate to severe pain after cardiac surgery and insufficient analgesic administration. Results indicated that patients were discharged from hospital with unrelieved pain and a potential risk for further postoperative complications.

The impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery.

Background: Relevant discharge information about the use of analgesic medication and other strategies may help patients to manage their pain more effectively and prevent postoperative persistent pain. Aims: To examine patients’ pain characteristics, analgesic intake and the impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery. Concerns about pain and pain medication prior to surgery will also be described. Methods: From March 2012 to September 2013, 416 participants (23% women) were consecutively enrolled in a randomized controlled trial. The intervention group received usual care plus an educational booklet at discharge with supportive telephone follow-up on postoperative day 10, and the control group received only usual care. The primary outcome was worst pain intensity (The Brief Pain Inventory – Short Form). Data about pain characteristics and analgesic use were collected at 2 weeks and at 1, 3, 6 and 12 months post-surgery. General linear mixed models were used to determine between-group differences over time. Results: Twenty-nine percent of participants reported surgically related pain at rest and 9% reported moderate to severe pain at 12 months post-surgery. Many participants had concerns about pain and pain medication, and analgesic intake was insufficient post-discharge. No statistically significant differences between the groups were observed in terms of the outcome measures following surgery. Conclusion: Postoperative pain and inadequate analgesic use were problems for many participants regardless of group allocation, and the current intervention did not reduce worst pain intensity compared with control. Further examination of supportive follow-up monitoring and/or self-management strategies post-discharge is required.

Changes in Symptom Occurrence and Severity Before and After Lung Cancer Surgery.

Background: Patients need information about the course of recovery after surgery for lung cancer, but knowledge about symptoms in this period is limited. Objective: The purpose of this study was to assess for changes in symptom occurrence rates and severity scores from the preoperative period to 1 month after surgery. Methods: Patients (n = 228) completed questionnaires before and at 1 month after surgery. McNemar tests were used to evaluate for changes over time in symptom occurrence rates and paired t tests for changes in symptom severity scores. General linear model was used to determine if select demographic and clinical characteristics were associated with the number of symptoms after surgery. Results: The total number of symptoms increased significantly from the preoperative (mean, 9.4) to the postoperative (mean, 13.1) assessment. Of the 11 symptoms that occurred in 50% or more of the patients 1 month after surgery, 8 increased significantly in both occurrence and severity. Four symptoms were experienced by more than 80% of the patients 1 month after surgery: shortness of breath (85.5%), lack of energy (83.8%), pain (83.8%), and feeling drowsy (82.5%). Conclusions: Patients experienced a high number of symptoms after lung cancer surgery. The only characteristic that was associated with a higher number of symptoms 1 month after surgery was the number of symptoms reported preoperatively. Implications for Practice: These findings can be used to educate patients about the normal course of postoperative recovery. Clinicians need to assess for these symptoms and develop effective interventions to improve symptom management for these patients.

Association between self-perceived pain sensitivity and pain intensity after cardiac surgery

Background and purpose Cardiac surgical pain remains a clinical challenge affecting about 40% of individuals in the first six months post-cardiac surgery, and continues up to two years after surgery for about 15–20%. Self-perceived sensitivity to pain may help to identify individuals at risk for persistent cardiac surgical pain to optimize health care responses. The purpose of this study was to assess the relationship between self-perceived pain sensitivity assessed by the Pain Sensitivity Questionnaire (PSQ) and postoperative worst pain intensity up to 12 months after cardiac surgery. Sex differences in baseline characteristics and the PSQ scores were also assessed. Methods This study was performed among 416 individuals (23% women) scheduled for elective coronary artery bypass graft and/or valve surgery between March 2012 and September 2013. A secondary data-analysis was utilized to explore the relationship between preoperative PSQ scores and worst pain intensity rated preoperatively, across postoperative Days 1–4, at 2 weeks, and at 1, 3, 6, and 12 months post-surgery. Linear mixed model analyses were performed to estimate changes in pain intensity during 1-year follow-up. Results The mean (±standard deviation) PSQ-total score was 3.3±1.4, with similar scores in men and women. The PSQ-total score was significantly associated with higher worst pain intensity ratings adjusted for participant characteristics (p=0.001). Conclusion Use of the PSQ before surgery may predict cardiac surgical pain intensity. However, previous evidence is limited and not consistent, and more research is needed to substantiate our results.

Thirty-day readmissions in surgical and transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND The 30-day all-cause readmission rate after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) vary substantially. We conducted a systematic review and meta-analysis to examine the overall incidence, causes, and risk factors of 30-day all-cause readmission rate after SAVR and TAVR. METHODS Eight medical research databases were searched; Cochrane, Medline, Embase, UpToDate, PROSPERO, National Guideline Clearinghouse, SweMed and Oria. We followed The Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) for this study. RESULTS Thirty-three articles were included in the systematic review, 32 of which were appropriate for the meta-analysis. Overall, 17% (95% CI: 16-18%) of patients in the SAVR group, and 16% (95% CI: 15-18%) in the TAVR groups were readmitted within 30 days. Heart failure, arrhythmia, infection, and respiratory problems were the most frequent causes of all-cause readmission after SAVR and TAVR. Most frequent reported prior risk factors for all-cause readmission following TAVR were diabetes, chronic lung disease/chronic obstructive pulmonary disease, atrial fibrillation, kidney problems, and transapical approach/nonfemoral access. For SAVR, no risk factors for 30-day all-cause readmission were reported in the literature to date. CONCLUSION In conclusion, the overall proportion of 30-day all-cause readmission after SAVR and TAVR are high. Interventions to prevent avoidable readmissions ought to be developed and implemented.