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Canadian Journal of Cardiology

“NEW” Prehabilitation: A 3-Way Approach to Improve Postoperative Survival and Health-Related Quality of Life in Cardiac Surgery Patients

      Abstract

      With advances in health care practices and delivery, the overall life expectancy of the Western population has increased. For those practitioners involved in the care of the patient with advanced cardiac disease, there has been a resultant higher prevalence of increasingly frail and older patients undergoing complex cardiac procedures. The higher rates of comorbid-associated higher vulnerability, with associated deconditioning, predisposes older, frail patients to poorer postoperative outcomes and a complicated recovery process after cardiac surgery. In addition, such patients experience inferior quality of life as a result of reduced ability to independently perform activities of daily living. During the preoperative waiting period, the cardiac symptoms and anxiety induces inactivity that in turn compounds the physical and mental deconditioning. To improve functional capacity and enhance postoperative recovery, prehabilitation, a component of the enhanced recovery after surgery model, might be of particular importance. In some studies, the preoperative improvement of the baseline physical, nutritional, and mental status has been reported to improve postoperative outcomes and enhance recovery after cardiac surgery. To address these domains, a 3-way approach to prehabilitation that is targeted toward improving nutritional status (N), exercise capacity (E) and worry reduction (W) (nutrition, exercise, and worry; “NEW” approach) might facilitate the perioperative management by ameliorating the postoperative outcomes and alleviating the surgical stress-related health deconditioning. In this review, the NEW approach and its potential benefits on postoperative outcomes as well as an implementation model (Promoting Action on Research Implementation in Health Services [PARiHS] framework) to aid institutional level implementation is described.

      Résumé

      Grâce aux avancées en matière de pratiques et de prestations de soins de santé, l’espérance de vie générale de la population occidentale a augmenté. Pour les praticiens qui prodiguent des soins aux patients atteints de cardiopathies à un stade avancé, une conséquence de cette augmentation a été l’accroissement de la prévalence des patients de plus en plus faibles et âgés subissant des interventions cardiaques complexes. Les taux plus élevés de vulnérabilité associée à la comorbidité et le déconditionnement qui en découle prédisposent les patients fragiles et plus âgés à une issue moins favorable de la chirurgie cardiaque et à un processus de convalescence plus compliqué après une telle intervention. De plus, ces patients ont une qualité de vie inférieure en raison de leur capacité réduite à s’adonner de façon autonome aux activités de leur vie quotidienne. Pendant la période d’attente préopératoire, les symptômes cardiaques et l’anxiété poussent à l’inactivité, ce qui ajoute encore au déconditionnement physique et mental. Pour améliorer la capacité fonctionnelle et favoriser la récupération postopératoire, la préadaptation, qui est un volet du modèle d’amélioration de la récupération post-chirurgie, pourrait jouer un rôle majeur. Dans certaines études, il a été rapporté que l’amélioration préopératoire de la forme physique, de la nutrition et de l’état mental a une incidence positive sur les résultats postopératoires et accroît la récupération après une chirurgie cardiaque. Pour approfondir ces questions, nous avons examiné si une approche de la préadaptation sur 3 niveaux s’attaquant à l’amélioration du statut nutritionnel et de la forme physique et à la réduction de l’inquiétude (ou approche « NEW » en anglais pour « Nutrition, Exercise and Worry ») pouvait faciliter la prise en charge périopératoire en améliorant les résultats postopératoires et en atténuant le déconditionnement physique lié à l’anxiété de l’intervention chirurgicale. Dans cette étude, nous décrivons l’approche NEW et ses effets bénéfiques possibles sur les résultats postopératoires, ainsi qu’un modèle de mise en œuvre (cadre Promoting Action on Research Implementation in Health Services [PARiHS]) visant à faciliter sa mise en application au niveau des établissements.
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