Resources  |  Structured Prehabilitation For High Risk Surgery: Getting the surgeons on board

Structured Prehabilitation For High Risk Surgery: Getting the surgeons on board

 D. Cottam   T. Rampal   R. Laza-Cagigas   M. Shah 

Prehabilitation may improve outcomes and hasten return to pre-operative functional levels following major surgery.

Due to contradictory evidence, surgeons may desire local trials to encourage referral for prehabilitation. Medway Maritime Hospital is a 588-bed district general hospital where high risk patients are reviewed by consultant anaesthetists and undergo cardiopulmonary exercise testing (CPET); however, no formalised process existed for patients who may benefit from intervention to increase surgical fitness. We describe the implementation of a prehabiliation programme, assessing the impact on predicted perioperative mortality and aiming to promote surgical engagement.

CPET/training bike set upCPET/training bike set up

Methods

An 81-year-old male with a background of cerebrovascular disease, pulmonary embolism and bladder transitional cell carcinoma was referred to the prehabilitation unit following CPET assessing fitness for cystectomy.

We provided nutritional information, home-based respiratory muscle training instructions, and supervised cycle ergometer interval training (twenty-four 30- minute sessions over eight weeks), and assessed the impact on CPET, laboratory tests and 30-day post-operative mortality estimation.

Presentation of case data along with CPET demonstrations to surgeons and Trust wide educational presentation, we have established links with Surgical schedulers to increase the potential benefit to all major surgical patients.

We continue to invite surgeons and GPs to Patient education evenings and regular promotions in social media and newsletters.

Results

The intervention was well tolerated by the patient. Pre- and post-intervention spirometry, CPET and laboratory data are summarised in table 1. BMI reduced from 30.9 to 29.7 with 3 kg of weight loss. Spirometry values improved post-intervention with increases in FVC, FEV1 and PEF, while CPET demonstrated increases in VO2 Max, minute ventilation and maximum load. Serum creatinine reduced, while albumin and haemoglobin increased post-intervention. The patient’s predicted 30-day mortality fell from 11.5% to 6.14% within 8 weeks.

Conclusion

A structured prehabilitation programme may have the potential to reduce perioperative risk in high risk patients in a hospital with no pre-existing set-up. Following the presentation of the initial proof of concept and collaborative educational sessions for surgeons, we have increased the referral rate into our programme. We have enrolled further patients and continue to review the impact on perioperative mortality.

References

  • Gillis C, et al. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology 2014; 358:937-47;
  • Li C, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc 2013; 358:1072-82;
  • Cabilan CJ, et al. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review. JBI Database System Rev Implement Re; 13:146-87, 2015;
  • J. B. Carlisle; Assessing fitness, predicting outcome, and the missing axis, BJA: British Journal of Anaesthesia, Volume 109, Issue 1, 1 July 2012, Pages 35–39

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