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Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 8  |  Issue : 2  |  Page : 156-161  

Clinical strategies to accelerate recovery after surgery orthopedic femur in elderly patients


1 Department of Anesthesiology, Faculty of Medicine, Nova Esperança; Institute for Regional Anesthesia, João Pessoa, PB, Brazil
2 Nutritionist Specializing in Public Health; Head of Nutrition Complexo Hospitalar Mangabeira, João Pessoa, PB, Brazil
3 Nurse with Specialization in the Intensive Care Unit; Nurse Surgical Center Complexo Hospitalar Mangabeira, João Pessoa, PB, Brazil
4 UFPB; Statistician of the Complexo Hospitalar Mangabeira, João Pessoa, PB, Brazil
5 Technical Nursing from the School of Nursing Santa Emilia de Rodat; Technical Nursing Center Surgical Complexo Hospitalar Mangabeira, João Pessoa, PB, Brazil

Date of Web Publication16-Jun-2014

Correspondence Address:
Luiz Eduardo Imbelloni
Rua Francisco Diomedes Cantalice, 21/802, Cabo Branco, 58045-210, João Pessoa, PB
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0259-1162.134490

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   Abstract 

Background: The prevalence of hip fracture is increasing with the continued aging of the population. The aim of this study was to compare the results after implementing the project accelerated post-operative recovery after surgery femur in patients aged over 60 years.
Methods: Patients were observed during two distinct periods: Before implantation and after the implementation of the project Acerto. Patients underwent spinal anesthesia with post-operative analgesia by lumbar plexus block. Data evaluation was carried out in four stages of the study in both groups: Before arrival to the operating room during surgery, post-anesthesia care unit and on the ward in the morning of day 1 post-operatively.
Results: The project implementation significantly reduces the length of stay, the number of suspension of surgery, duration of fasting, the incidence of hunger and thirst and the reintroduction of oral feeding. Oral feeding 2-4 h before surgery with dextrinomaltose not attended with nausea and vomiting. All patients were able to discharge on day 1 post-operatively.
Conclusions : The use of clinical measures of accelerating patient recovery decreased length of stay, the number of suspensions of surgery, the time of fasting, the time of oral food reintroduction, high earlier and faster return to family life, working as humanization of treatment to the elderly.

Keywords: Fasting, fast-track surgery, orthopedic, perioperative care, spinal anesthesia, surgery


How to cite this article:
Imbelloni LE, Gomes D, Braga RL, de Morais Filho GB, da Silva A. Clinical strategies to accelerate recovery after surgery orthopedic femur in elderly patients. Anesth Essays Res 2014;8:156-61

How to cite this URL:
Imbelloni LE, Gomes D, Braga RL, de Morais Filho GB, da Silva A. Clinical strategies to accelerate recovery after surgery orthopedic femur in elderly patients. Anesth Essays Res [serial online] 2014 [cited 2017 May 28];8:156-61. Available from: http://www.aeronline.org/text.asp?2014/8/2/156/134490


   Introduction Top


The hip fracture refers to a fracture of the femur in the area of bone immediately distal to the articular cartilage of the hip, about 2 inches below the bottom edge of the lesser trochanter. [1] The majorities of people with hip fracture are elderly and are treated surgically, which requires anesthesia. [2] The surgery to correct the fracture can be performed under general anesthesia, epidural, spinal anesthesia or a combination of these techniques.

Surgical injury is followed by pain, stress-induced catabolism, impairment of organ function and a risk of thromboembolism and impaired cognitive function. [3] These events may contribute to complications, a need for prolonged hospitalization, post-operative fatigue, delayed convalescence and the need for rehabilitation. [3] Optimization of the individual care components in perioperative care (the fast-track methodology) reduces the need for hospitalization, morbidity and prolonged convalescence, with subsequent economic savings. [4]

Early mobilization after surgery is essential for rapid functional recovery and is considered critical to the acceleration of recovery including analgesia without opioid oral nutrition, optimization of therapy, intravenous (IV) fluids and early ambulation. [4] Pain relief is a prerequisite for the success of rapid recovery and this can be achieved with continuous peripheral nerve blockade is currently the most effective analgesic technique. [5],[6]

Nutritional status, result of the balance between intake and nutrient requirements, it is important to properly maintain the composition and functions of the body. [7] The elderly population is particularly prone to nutritional problems due to several factors. [8] In recent study, the prevalence of malnutrition was high in hospitalized patients in Brazil. [9]

In the era of evidence based medicine however, there are no scientific reasons to keep a patient in prolonged pre-operative fasting. This routine was questioned and shown to be unnecessary for most patients. As a result, many anesthesia societies have changed their guidelines and currently recommend intake of clear fluids up until 2 h before surgery and anesthesia. [10] The benefits of fasting 6-8 h to prevent gastric aspiration have been questioned and this practice is considered obsolete. [11],[12] Current guidelines recommend clear fluids (water, tea and juices without waste) up to 2 h before surgery. [11],[12]

The surgery of hip fractures in elderly patients (over 60 years) are only performed in the hospital (SUS) (Brazilian public health care system), with patients in the use of urinary catheters with opioid analgesia and referred to the intensive care unit (ICU). The implementation of these protocols with quality control in elderly patients with hip fractures do not appear to be easy, but is necessary because the specialty requires interaction with several areas of medicine, involving the services of anesthesiology, orthopedics, nutrition and nursing and different hospital departments. The aim of this study was to compare outcomes after project implementation accelerated full recovery after surgery in orthopedics in a hospital with service to public patients over the age of 60 and hip fracture, with the primary objective to assess the time hospitalization, the number of suspensions of surgery, length of pre-operative fasting and the ability to receive net Carbohydrates (CHO) so complete motor block in the post-anesthesia care unit (PACU), time to reintroduce oral food compared with the data before implementation.


   Methods Top


In May 2012, we initiated a longitudinal prospective study at a hospital covered by the Brazilian public health system (SUS) in a patients undergoing corrective femur fracture over the age of 60 years. The protocol was registered in Brazil platform. The Ethics Research Committee approved the study protocol and all patients were informed and agreed to participate in the study. Inclusion criteria were: Normal blood volume, no pre-existing neurological disease, no coagulation disorders, without infection at the puncture site, which did not present agitation, mental confusion and/or delirium, which did not make use of bladder indwelling catheters, with hemoglobin level >10 g% and that was not in the ICU.

This is a study of the case-control. The hospital performs around 700 surgeries/month, being 250 femoral fractures. Assuming a significance level of 10% and a power of 80%, we obtained the required number of 83 patients in each group. From May to August 2001, 83 subjects 60 years and older admitted consecutively with a femoral neck or intertrochanteric fracture attributable to a conventional conduct (Group Pre-Acerto) and from September to December 2012, 85 subjects with the same type of fracture undergoing new protocol of perioperative care (Group Post-Acerto) [Table 1].
Table 1: Anesthetic approaches in orthopedic surgery of femur before and after implementation of the project

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Premedication was not used. Monitoring consisted to electrocardiogram, of non-invasive blood pressure, heart rate (HR) and pulse oximetry. After venous cannulation with 18G catheter in the hand or forearm, infusion of Ringer's lactate in parallel with 6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride injection was started. Administered cefazolin 2 g and dexamethasone 10 mg IV.

After sedation with IV ketamine (0.1 μg/kg) and midazolam (1 mg), skin cleansing with chlorhexidine and excess removal, spinal puncture was performed with the patient in sitting position, through the median interspace L 2 -L 3 or L 3 -L 4 , using a 26G or 27G Quincke needle (B. Braun Melsungen). After observing cerebrospinal fluid confirming the correct position of the needle, 15 mg of 0.5% isobaric bupivacaine were administered in the group before implantation and 7.5-10 mg after project implementation at a rate of 1 mL/15 s. Patients were immediately placed in supine position for surgery. The sensorial blockade and motor blockade were evaluated at 10 min after injection.

Cardiorespiratory parameters were measured every 5 min. Hypotension (a reduction in systolic blood pressure > 30% when compared to the pressure in the regular ward) was treated with ethylephrine (2 mg IV), while bradycardia (HR < 45 bpm) was treated with atropine (0.50 mg IV). At the end of surgery, patients received tenoxicam 40 mg and dipyrone 40 mg/kg in 50 mL of Ringer's lactate.

The post-operative analgesia was performed through the anterior lumbar plexus block (inguinal) or posterior (psoas compartment) with a neuroestimulator. Obtained the desired contraction, were injected 40 mL bupivacaine 0.25%.

The patient was transferred to the ward and received IV tenoxicam 20 mg 12/12 h, dipyrone 1 g and cefazolin 1 g every 6 h. Data evaluation was carried out in four stages of the study in both groups: Before arrival to the operating room during surgery, PACU and on the ward in the morning of day 1 post-operatively.

Statistical analysis

The tests used for data analysis were all non-parametric and the Wilcoxon-Mann-Whitney used the variables described in [Table 2] and [Table 3], the Chi-square test with Monte Carlo simulation: The variable used cephalad spread of analgesia in [Table 4] and Fisher's exact test used in [Table 5].
Table 2: Demographics dates (mean±SD)

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Table 3: Days of hospitalization, number of suspension of surgery, time fasting, incidence of hunger and thirst

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Table 4: Cephalad spread of analgesia

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Table 5: Duration of surgery, use of drains, blocking duration, time to feeding dextrinomaltose in PACU, duration of stay in the PACU, time of oral food reintroduction on the ward and duration of analgesia (mean±SD)

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   Results Top


There is no significant difference between the groups with regard to demographic characteristics. The data show that 67.2% of patients were female [Table 2]. All patients were sedated with intermittent doses of midazolam and ketamine.

The average hospital stay until the day of surgery was significantly shorter after implementation of the project [Table 3]. There was significant difference in number of surgery suspension [Table 3]. 76 patients (89.4%) of patients in the post-acerto had not one cancelation, compared with 27 patients (32.5%) pre-project [Table 3]. The mean fasting time was significantly shorter after implementation of the project, lowering of 13:38 h to < 3 h [Table 3]. This reflected that no patient complained of thirst or hunger to reach the operating room.

All patients were submitted to spinal anesthesia and there was no need of general anesthesia. All pre-implantation patients received a fixed dose of 15 mg of 0.5% isobaric bupivacaine. In the post-implantation group, 61 patients received 10 mg and 24 patients 7.5 mg of the same drug. In the 15 mg group cephalad dispersion varied between T 10 and T 6 , while those that received 10 or 7.5 mg remained between T 12 and T 10 , with a significant difference [Table 4]. The difference reflected in a mode of two segments lower (T 11 × T 9 ), with significance. All patients presented full motor block in the lower limbs.

There were not a significant difference (P = 0.012) in relation to the Ringer with Lactate) received infusion (1.182 ± 247 mL vs. 1.089 ± 173 mL). All patients received 500 mL of 6% hidroxyetilamido a 6%. There was not a significant difference (P = 0.836) as to the necessity of blood transfusion (14 vs. 13). The use of a drain (16 vs. 0) in the surgical site was statistically significant [Table 5].

Bradycardia occurred in tree patients before Acerto implantation against one after the implantation, without significance. Arterial hypotension occurred in 15 patients pre-implantation while in only three patients after the implantation, with a significant difference (P = 0.020). All hypotension were easily treated with only one dose of etylefrina.

There was no significant difference in relation to the duration of the surgery. The duration of the spinal block was significantly longer before the implantations of the project. This reflected in longer time in the PACU. The time for the use of dextrinomaltose in the post-implantation group in the PACU remained in 1:18 h. The moment to reintroduce normal meals was longer in the pre-project era. There was not a significant difference in relation to the time of analgesia with the lumbar plexus [Table 5].

In the pre-implantation time, four male patients needed a catheterization to void. No patient in the study group went to the ICU. In the first pain observation evaluation, no patient presented mental confusion. No nausea or vomiting occurred in the study group. All 85 patients after the implantation of the project were ready for discharge in the first post-operative day.


   Discussion Top


The elderly represent the fastest-growing population in the World. The concept of fast-track surgery, also called enhanced recovery after surgery or multimodal surgery involves using various strategies to facilitate better conditions for surgery and recovery in an effort to achieve faster discharge from hospital and more rapid resumption of normal activities after both major and minor surgical procedures, without an increase in complications or readmissions. The implantation of the project reduced the time spent in Hospital before the surgery, the time of pre-operative fasting, the number of canceled surgeries, the time spent in the PACU and the reintroduction of their meals in the infirmary. The time of fasting before surgery, the time spent in the PACU and the reintroduction of their meals in the infirmary. The quality of analgesia, immediate return to their meals with dextrinomaltose in 1 h in the PACU and a free diet in 6 h after surgery contributed for the chances in the protocol formerly used in the Hospital. All 85 patients had conditions for discharge in the first morning after surgery.

Because they were all elderly, well over 60 years, the pre-anesthetic interview took place in the 1 st day, in the presence of their relatives who received detailed explanation of the project, to reduce the anxiety of them all. Due to the number of cancelation before the establishment of the project, this question was the most important for all familiars: Will the surgery be postponed? Preparing for the surgery, the patient brings with him/her a great deal of expectations and doubts with respect to what will happen. All his worries concern his/her surgery and fear its cancelation. [3],[13],[14] The cancelation rate in a University Hospital devoted to secondary assistance was 19.91%. [13] In this study, in the pre-implantation time, only 27 (32.5%) had their surgery done. The implantation of the project raised this number to 76 (89.4%) patients, almost 3 times the previous number. The other way, the number of canceled surgery reduced drastically.

The surgical trauma generates a variety of problems in the elderly, contributing to increase the number of complication and the stay in hospital. [3] The optimization of the perioperative components of individual care result in economy or cost reduction. [4] The improvement in the perioperative period reduced the length of hospital stay after total hip replacement (THR) and total knee arthroplasty, with a stay of 3 days in various departments. [3] It is well-known that patients with a hip fracture and stay in bed develop infection, deteriorate their nutritional state and develop chronic pain. The implantation of this project in a SUS Hospital reduced a stay of 24 days to <½ time, before the surgery.

The majority of the Anesthesiologist Societies recommend a fasting time of clear liquids of 2 h and 6 h for a light meal. [11] Unfortunately, anesthesiologists demand a fasting time of over 8 h. Another aspect is the lengthening of the fasting time due to delayed surgeries in the afternoon schedule or because of lack of material. One important aspect of this study is the mean time of fasting found among patients before implantation of the project around 14 h that was a bit shorter than the 16 h in the General Surgery Department. [10] During implantation of the Project, this mean time was six fold reduced (2:48 h). The reduction of the fasting time erased the sensation of hungry at the door of the operating room. No patient referred to hunger or thirst after dextrinomaltose before surgery, whereas 62 patients referred hunger and 72 referred thirst in the old system of fasting from 8:00 pm the night before. The fasting time reduction did not cause nausea or vomit during the surgery after implantation of the protocol.

All patients from the pre-implantation period were submitted to spinal anesthesia with a fixed dose of 15 mg of 0.5% isobaric bupivacaine The knowledge of the orthopedic team of only experienced professionals was very important for the decision to reduce the total dose of isobaric 0.5% bupivacaine. With the adherence of some orthopedics to the project it was possible to reduce the bupivacaine dose to 10 or 7.5 mg of isobaric bupivacaine, providing a lesser incidence of hypotension, shorter duration of the block, shorter stay in the PACU.

The incidence of arterial hypotension was 18% with 15 mg, reducing to 3.5% with the new doses of 10 and 7.5 mg. Furthermore bradicardia reduced its appearance with smaller dose. The use of colloid (6% hydroxyethylamide) during the whole procedure contributed for the reduction in the incidence of arterial hypotension, even in cases of THR. [16] Another important fact: With the rigorous inclusion criteria, there were 14 patients (16.1%) that needed blood transfusion before implantation. Post-implantation of the protocol, similar result to the 17% in THR. [15]

The dose of 15 mg of 0.5% isobaric bupivacaine provided a mean time of block of 3:35 h. The reduction of the dose to 10 and then to 7.5 mg of the same solution decreased this mean time to 2:30 h, a reduction of 32% in the blocking time. This way, the time for feeding with dextrinomaltose in the PACU shortened to the mean time of 1:18 h. This fact also resulted in a 36% decrease in length of stay in the PACU.

Utilization of dextrinomaltose in the PACU at the resolution of the block in the group post-implantation did not cause nausea or vomit and allowed the introduction of a free diet about 6:22 h after block. A recent metaanalysis demonstrated that early feeding in gastrointestinal surgery can be conducted with lesser risk with potential benefits to the patients, such as early discharge, lesser incidence of infectious complication and reduced cost. [16] This study showed that in orthopedics, when all gastrointestinal tracts tends to be normal, early feeding generates greater satisfaction to patients and family members and does not cause an increase of nausea and vomit. [17]

The efficacious relief of the post-operative pain is a pre-requisite to a better recovery and a fundamental part to the success in the implantation of a project of acceleration of Hospital discharge. [3],[4],[10] Due to this, a protocol of regional anesthesia must be developed and applied, not only for surgery but also for post-operative analgesia, to reduce intrathecal opioids. Regional anesthesia provides surgical anesthesia as much post-operative analgesia, reducing intrathecal opioids that can cause nausea/vomits, respiratory depression, vomit and pruritus. In this project, spinal anesthesia was employed for the surgical procedure and analgesia was provided with a lumbar plexus block (inguinal or lumbar) with bupivacaine. The mean duration of analgesia was 22 h in both groups. With the dose employed, all patients presented residual analgesia next day to the surgery, although no one presented a motor block. The mean duration was 22 h in both groups. The better pain control allow patients to return to their activities such as eat, drink, take a bath or dress themselves, as also return to social life as soon as possible. Patients were given food and drink around 6 h after surgery, since in the presence of their families in the ward, after removal of the IV hydration.

Urinary retention increase with ageing, being 2.4 times in patients above 50 years, being 4.7% in men when compared to 2.9% in women. [18] The incidence varies with the type of surgery and transoperative hydration. [19] Urinary retention frequently occurs in patients when spinal morphine is administered and there is not a difference between doses and necessity of catheterization. [19] The Acerto Project did not utilize opioids in spinal anesthesia to avoid catheterization, what was a routine in this type of Hospital before implantation of this project. The same way, during the surgical procedure there was also a restrictive hydration. Only four patients that received a larger dose presented a necessity to catheterize the bladder in the post-operative period. Smaller doses did present urinary retention.

In a recent meta-analysis showed that the closed suction drainage increases the transfusion requirements after elective arthroplasty of the hip and knee and drainage has not great benefits. [20] Furthermore, the drains can act as a source of contamination and prevent natural buffering effect when the wounds are closed by suture. [21] Part of the project not to use any type of drainage in the operative field. Thus, we used drains in 16 patients (19.2%) pre-deployment and no patient post-deployment.

Confusion and delirium post-operatively are common in elderly patients after surgical repair of fractures of the femur and hip and is associated with increased mortality. [22] In this study, there was no confusion and delirium in the assessment on the 1 st day post-operatively.

The totality of our patients was admitted to the emergency room and they were hospitalized for a long time in the hospital with an average of 24 days before surgery, before the implementation of the project. After the project the average hospital stay has dropped to 11 days before surgery. For problems inherent in the design some patients remained in the hospital for another day or two.

The concept of "fast-track" or accelerated recovery from surgery has evolved considerably in recent times. The implementation of a new project to accelerate the recovery in orthopedics showed evidence of its benefits. However, there was the widespread implementation of this approach by the medical staff. The difficulties of implementation of this project may be due to lack of knowledge or a reluctance to introduce concepts based on evidence.

The Brazilian Public Health System project has as objective the humanization of any medical treatment. In conclusion, the use of clinical strategies improved length of stay before surgery, the number of suspensions of surgery, the time of fasting, the time of oral food reintroduction, high earlier in elderly patients with hip fracture and return more early to family life, working as a humane treatment to the elderly.

 
   References Top

1.Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev 2001;4:CD000521.  Back to cited text no. 1
    
2.Aharonoff GB, Koval KJ, Skovron ML, Zuckerman JD. Hip fractures in the elderly: Predictors of one year mortality. J Orthop Trauma 1997;11:162-5.  Back to cited text no. 2
    
3.Kehlet H, Søballe K. Fast-track hip and knee replacement - What are the issues? Acta Orthop 2010;81:271-2.  Back to cited text no. 3
    
4.Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189-98.  Back to cited text no. 4
    
5.Ilfeld BM, Ball ST, Gearen PF, Le LT, Mariano ER, Vandenborne K, et al. Ambulatory continuous posterior lumbar plexus nerve blocks after hip arthroplasty: A dual-center, randomized, triple-masked, placebo-controlled trial. Anesthesiology 2008;109:491-501.  Back to cited text no. 5
    
6.Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: A randomized, triple-masked, placebo-controlled study. Anesthesiology 2008;108:703-13.  Back to cited text no. 6
    
7.Jeejeebhoy KN, Detsky AS, Baker JP. Assessment of nutritional status. JPEN J Parenter Enteral Nutr 1990;14:193S-6.  Back to cited text no. 7
    
8.Acuña K, Cruz T. Nutritional assessment of adults and elderly and the nutritional status of the Brazilian population. Arq Bras Endocrinol Metabol 2004;48:345-61.  Back to cited text no. 8
    
9.Waitzberg DL, Caiaffa WT, Correia MI. Hospital malnutrition: The Brazilian national survey (IBRANUTRI): A study of 4000 patients. Nutrition 2001;17:573-80.  Back to cited text no. 9
    
10.Aguilar-Nascimento JE, Bicudo-Salomão A, Caporossi C, et al. Acerto Project: Outcome evaluation after the implementation of a multidisciplinary protocol of peri-operative care in general surgery. Rev Col Bras Cir 2006;33:181-8.  Back to cited text no. 10
    
11.American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011;114:495-511.  Back to cited text no. 11
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12.Nascimento JE, Campos AC, Borges A, Correia MI, Tavares GM. Terapia Nutritional therapy perioperatively. Design Guidelines; Medical Association And Brazilian Federal Council of Medicine, August 19, 2011.  Back to cited text no. 12
    
13.Perroca MG, Jericó Mde C, Facundin SD. Monitoring cancellations of surgical procedures: An indicator of organizational performance. Rev Esc Enferm USP 2007;41:113-9.  Back to cited text no. 13
    
14.Pascoal MLH, Gatto MAF. Cancellation rate of surgery in a university hospital and the reasons for absenteeism patient scheduled for surgery. 2006;14:48-53.  Back to cited text no. 14
    
15.Hamaji A, Hajjar L, Caiero M, Almeida J, Nakamura RE, Osawa EA, et al. Volume replacement therapy during hip arthroplasty using hydroxyethyl starch (130/0.4) compared to lactated Ringer decreases allogeneic blood transfusion and postoperative infection. Rev Bras Anestesiol 2013;63:27-35.  Back to cited text no. 15
    
16.Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: Systematic review and meta-analysis of controlled trials. BMJ 2001;323:773-6.  Back to cited text no. 16
    
17.Imbelloni LE, Pombo IAN, Morais Filho GB. The decrease in fasting time improves comfort and satisfaction with anesthesia in elderly patients with hip fracture. Rev Bras Anestesiol 2014: [In press].  Back to cited text no. 17
    
18.Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: Anesthetic and perioperative considerations. Anesthesiology 2009;110:1139-57.  Back to cited text no. 18
    
19.Jacobson L, Chabal C, Brody MC. A dose-response study of intrathecal morphine: Efficacy, duration, optimal dose, and side effects. Anesth Analg 1988;67:1082-8.  Back to cited text no. 19
    
20.Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2004;86-A: 1146-52.  Back to cited text no. 20
    
21.Raves JJ, Slifkin M, Diamond DL. A bacteriologic study comparing closed suction and simple conduit drainage. Am J Surg 1984;148:618-20.  Back to cited text no. 21
[PUBMED]    
22.McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med 2002;162:457-63.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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