Delirium After Cardiac Surgery and Cumulative Fluid Balance: A Case-Control Cohort Study.

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Delirium After Cardiac Surgery and Cumulative Fluid Balance: A Case-Control Cohort Study.

J Cardiothorac Vasc Anesth. 2018 Aug 16;:

Authors: Mailhot T, Cossette S, Lambert J, Beaubien-Souligny W, Cournoyer A, O'Meara E, Maheu-Cadotte MA, Fontaine G, Bouchard J, Lamarche Y, Benkreira A, Rochon A, Denault A

Abstract
OBJECTIVE: To assess a novel hypothesis to explain delirium after cardiac surgery through the relationship between cumulative fluid balance and delirium. This hypothesis involved an inflammatory process combined with a hypervolemic state, which could lead to venous congestion reaching the brain.
DESIGN: Retrospective case-control (1:1) cohort study.
SETTING: University-affiliated tertiary cardiology center.
PARTICIPANTS: Cardiac surgery intensive care unit (ICU) patients.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Cumulative fluid balance was evaluated at 3 times: (1) upon arrival at the ICU after surgery, (2) 24 hours post-ICU arrival, and (3) 48 hours post-ICU arrival. A generalized estimated equation was used to model the association between cumulative fluid balance and delirium occurrence 24 hours later. Covariates were selected based on the statistical differences between cases and controls on delirium risk factors and clinical characteristics. The cohort included 346 patients, of which 39 (11%), 104 (30%), and 142 patients (41%) presented delirium at 24, 48, and 72 hours post-ICU arrival, respectively. The effect of time had an odds ratio (OR) of 2.14, 95% confidence interval (CI) 1.603 to 2.851, and a p value < 0.001. The cumulative fluid balance was associated with delirium occurrence (OR 1.20, 95% CI: 1.066-1.355, p = .003). History of neurological disorder, having both hearing and visual impairment, type of procedure, perioperative cerebral oximetry, mean pulmonary artery pressure pre-cardiopulmonary bypass (CPB), and mean arterial pressure post-CPB also contributed to delirium in the model.
CONCLUSION: Delirium is associated with a cumulative fluid balance, but the extent through which this plays an etiologic role remains to be determined.

PMID: 30122614 [PubMed - as supplied by publisher]

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Delirium After Cardiac Surgery and Cumulative Fluid Balance: A Case-Control Cohort Study.

Related Articles

Delirium After Cardiac Surgery and Cumulative Fluid Balance: A Case-Control Cohort Study.

J Cardiothorac Vasc Anesth. 2018 Aug 16;:

Authors: Mailhot T, Cossette S, Lambert J, Beaubien-Souligny W, Cournoyer A, O'Meara E, Maheu-Cadotte MA, Fontaine G, Bouchard J, Lamarche Y, Benkreira A, Rochon A, Denault A

Abstract
OBJECTIVE: To assess a novel hypothesis to explain delirium after cardiac surgery through the relationship between cumulative fluid balance and delirium. This hypothesis involved an inflammatory process combined with a hypervolemic state, which could lead to venous congestion reaching the brain.
DESIGN: Retrospective case-control (1:1) cohort study.
SETTING: University-affiliated tertiary cardiology center.
PARTICIPANTS: Cardiac surgery intensive care unit (ICU) patients.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Cumulative fluid balance was evaluated at 3 times: (1) upon arrival at the ICU after surgery, (2) 24 hours post-ICU arrival, and (3) 48 hours post-ICU arrival. A generalized estimated equation was used to model the association between cumulative fluid balance and delirium occurrence 24 hours later. Covariates were selected based on the statistical differences between cases and controls on delirium risk factors and clinical characteristics. The cohort included 346 patients, of which 39 (11%), 104 (30%), and 142 patients (41%) presented delirium at 24, 48, and 72 hours post-ICU arrival, respectively. The effect of time had an odds ratio (OR) of 2.14, 95% confidence interval (CI) 1.603 to 2.851, and a p value < 0.001. The cumulative fluid balance was associated with delirium occurrence (OR 1.20, 95% CI: 1.066-1.355, p = .003). History of neurological disorder, having both hearing and visual impairment, type of procedure, perioperative cerebral oximetry, mean pulmonary artery pressure pre-cardiopulmonary bypass (CPB), and mean arterial pressure post-CPB also contributed to delirium in the model.
CONCLUSION: Delirium is associated with a cumulative fluid balance, but the extent through which this plays an etiologic role remains to be determined.

PMID: 30122614 [PubMed - as supplied by publisher]

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Contributors to knee loading deficits during gait in individuals following anterior cruciate ligament reconstruction

Publication date: Available online 20 August 2018

Source: Gait & Posture

Author(s): Paige E. Lin, Susan M. Sigward

Abstract

Background

Altered gait mechanics following anterior cruciate ligament reconstruction (ACLr) are commonly reported in the surgical limb 2-3 months post-surgery when normalization of gait is expected clinically. Specifically, deficits in knee extensor moment during loading response of gait are found to persist long-term; however, the mechanisms by which individuals reduce sagittal plane knee loading during gait are not well understood.

Research question: This study investigated between limb asymmetries in knee flexion range of motion, shank angular velocity, and ground reaction forces to determine the strongest predictor of knee extensor moment asymmetries during gait.

Methods

Thirty individuals 108 ± 17 days post-ACLr performed walking gait at a self-selected speed and peak knee extensor moment, peak vertical and posterior ground reaction force, and peak anterior shank angular velocity were identified during loading response. Paired t-tests compared limbs; Pearson's correlations determined associations between variables in surgical and non-surgical limbs; and stepwise linear regression determined the best predictor of knee extensor moment asymmetries during gait.

Results

Reduced vertical and posterior ground reaction forces and shank angular velocity were strongly associated with reduced knee extensor moment in both limbs (r = 0.499-0.917, p < 0.005). Less knee flexion range of motion was associated with reduced knee moment in the surgical limb (r = 0.358, p < 0.05). Additionally, asymmetries in posterior ground reaction force and knee flexion range of motion predicted asymmetries in knee extensor moment (R2 = 0.473, p < 0.001).Significance: Modulation of kinetics and kinematics contribute to decreases in knee extensor moments during gait and provide direction for targeted interventions to restore gait mechanics.

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Is in-toing gait physiological in children? - Results of a large cohort study in 5910 healthy (pre-) school children

Publication date: Available online 20 August 2018

Source: Gait & Posture

Author(s): Ronald Verch, Anja Hirschmüller, Juliane Müller, Heiner Baur, Frank Mayer, Steffen Müller

Abstract

Background

In-toeing is a major concern of many parents presenting their children to pediatric orthopedists. Foot progression angle (FPA) quantifies the rotation of the foot’s longitudinal axis during gait, with negative values describing in-toeing and positive values describing out-toeing. Although it has been shown that the FPA changes over the course of a child’s development, reference values for the normal FPA-range are lacking.

Research question

This study aimed to establish reference values in 1-14 year old healthy children and to implement FPA-percentile curves for daily clinical use.

Methods

5910 healthy children performed at least 3 repetitions of barefoot walking over an instrumented walkway using a pressure measurement platform. The FPA [°] was extracted and analyzed by age and gender (mean ± standard deviation; median with percentiles, MANOVA (age, gender) and Wilcoxon-Signed-Rank test for intra-individual side differences (α = 0.05).

Results

FPA maximum was observed in 2-year-old children and diminished significant until the age of 4 to moderate out-toeing. For ages 5-14, no statistically significant differences in FPA values were present (p > 0.05). MANOVA confirmed age (p < 0.001) and gender (p < 0.001) as significant FPA influencing factors, without combined effect (p > 0.05). In every age group, right feet showed significantly greater out-toeing (p < 0.05).

Significance

Percentile values indicate a wide FPA range in children. FPA development in young children shows a spontaneous shift towards moderate external rotation (age 2-4), whereby in-toeing ≤ 1-5° can be present, but can return to normal. Bilateral in-toeing after the age of four and unilateral in-toeing after the age of seven should be monitored.

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Test-retest reliability of an instrumented electronic walkway system (GAITRite) for the measurement of spatio-temporal gait parameters in young patients with Friedreich’s ataxia

Publication date: Available online 20 August 2018

Source: Gait & Posture

Author(s): Bastien Roche, Anne-Laure Simon, Sophie Guilmin-Crépon, Priscilla Boizeau, Béatrice Andriss, Corinne Alberti, Ana Presedo, Brice Ilharreborde, Isabelle Husson

Abstract

Background

Friedreich ataxia (FRDA) affects the spatio-temporal parameters (STP) of gait. To our knowledge, proper tools to measure the variability of ataxic gait have not been validated yet. The aims of the present study were: (1) to measure the reproducibility of STP and gait scores in young patients with FRDA and (2) to describe the characteristics of gait parameters in this population.

Methods

Thirty-six patients (18 males, 18 females) with diagnosis of FRDA (mean age 16.4 ± 4.5 years) were asked to walk barefoot at a self-selected pace along the pressure sensitive walkway (GAITRite®). Three trials were recorded for each patient and repeated 48 hours later. Collected data was put into statistical analysis tests to determine reliability and variability of STPs and two other gait scores: The Functional Ambulation Performance score (FAP) and the Gait Variability Index (GVI).

Results

All STPs showed strong or very strong reliability (ICC > 0.7) and a low variability. The two parameters showing the lowest reliability (0.71 and 0.74) were the base of support and the foot progression angle. The FAP score and the GVI showed strong reliability (ICC > 0.8).

Conclusions

The GAITRite system allows feasible and reliable measurements of gait parameters in young patients with FRDA. Lower reliability found for the weakest parameters was attributed to the software automatic errors and the ankle laxity noted in every patient.

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Compensations in lower limb joint work during walking in response to unilateral calf muscle weakness

Publication date: Available online 20 August 2018

Source: Gait & Posture

Author(s): Niels F.J. Waterval, Merel-Anne Brehm, Hilde E. Ploeger, Frans Nollet, Jaap Harlaar

Abstract

Background

Patients with calf muscle weakness due to neuromuscular disorders have a reduced ankle push-off work, which leads to increased energy dissipation at contralateral heel-strike. Consequently, compensatory positive work needs to be generated, which is mechanically less efficient. It is unknown whether neuromuscular disorder patients compensate with their ipsilateral hip and/or contralateral leg; and if such compensatory joint work is related to walking energy cost.

Research question

Do patients with calf muscle weakness compensate for the increase in negative joint work by increasing positive ipsilateral hip work and/or positive contralateral leg work? And is the total mechanical work related with walking energy cost?

Methods

Seventeen patients with unilateral flaccid calf muscle weakness and 10 healthy individuals performed the following two tests: i) a barefoot 3D gait analysis at comfortable speed and matched control speed (i.e. 0.4 non-dimensional) to assess lower limb joint work and ii) a 6-minute walk test at comfortable speed to assess walking energy cost.

Results

Patients had a lower comfortable walking speed compared to healthy individuals (1.05 vs 1.36 m/s, p < 0.001) and did not increase positive lower limb joint work at comfortable speed. At matched speed (1.25 m/s), patients showed increased positive work at their ipsilateral hip (0.38 ± 0.08 vs 0.27 ± 0.07, p = 0.001) and/or contralateral leg (0.99 ± 0.14 vs 0.69 ± 0.14, p < 0.001). Patients with weakest plantar flexors used both strategies. No relation between total positive work and walking energy cost was found (r = 0.43, p = 0.122).

Significance

Patients with unilateral calf muscle weakness compensated for reduced ankle push-off work by lowering their comfortable walking speed or, at matched speed, by generating additional positive joint work at the ipsilateral hip and/or contralateral leg. The additional positive joint work at matched speed did not explain the elevated walking energy cost at comfortable speed, which needs further exploration.

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Contributors to knee loading deficits during gait in individuals following anterior cruciate ligament reconstruction

Publication date: Available online 20 August 2018

Source: Gait & Posture

Author(s): Paige E. Lin, Susan M. Sigward

Abstract

Background

Altered gait mechanics following anterior cruciate ligament reconstruction (ACLr) are commonly reported in the surgical limb 2-3 months post-surgery when normalization of gait is expected clinically. Specifically, deficits in knee extensor moment during loading response of gait are found to persist long-term; however, the mechanisms by which individuals reduce sagittal plane knee loading during gait are not well understood.

Research question: This study investigated between limb asymmetries in knee flexion range of motion, shank angular velocity, and ground reaction forces to determine the strongest predictor of knee extensor moment asymmetries during gait.

Methods

Thirty individuals 108 ± 17 days post-ACLr performed walking gait at a self-selected speed and peak knee extensor moment, peak vertical and posterior ground reaction force, and peak anterior shank angular velocity were identified during loading response. Paired t-tests compared limbs; Pearson's correlations determined associations between variables in surgical and non-surgical limbs; and stepwise linear regression determined the best predictor of knee extensor moment asymmetries during gait.

Results

Reduced vertical and posterior ground reaction forces and shank angular velocity were strongly associated with reduced knee extensor moment in both limbs (r = 0.499-0.917, p < 0.005). Less knee flexion range of motion was associated with reduced knee moment in the surgical limb (r = 0.358, p < 0.05). Additionally, asymmetries in posterior ground reaction force and knee flexion range of motion predicted asymmetries in knee extensor moment (R2 = 0.473, p < 0.001).Significance: Modulation of kinetics and kinematics contribute to decreases in knee extensor moments during gait and provide direction for targeted interventions to restore gait mechanics.

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