Prehabilitation to Enhance Perioperative Care

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Key points

  • Despite advances in surgical care, there remain patients with suboptimal recovery; elderly patients, especially those with cancer and limited protein reserve are at highest risk for negative postsurgical outcomes.

  • Although more traditional approaches have targeted the postoperative period for rehabilitation, it has been shown that the preoperative period is most effective for intervention.

  • Surgical prehabilitation is an emerging concept, deriving from the realization that effective perioperative

The stress of surgery and trajectory of recovery

Tissue trauma, physical inactivity, quasi-starvation and psychological distress represent major stresses to the body. In turn, immediate systemic changes are initiated, resulting in both short- and long-term effects on the capacity to perform activities of daily living and on overall quality of life.

Despite advances in surgical technology, anesthesia and perioperative care, which have made surgery safer and more accessible to a variety of patients potentially at risk, there remains a group of

Surgical prehabilitation and the published evidence

The process of enhancing functional capacity of the individual to enable them to withstand an incoming stressor has been termed prehabilitation.5 Although several programs have attempted to prepare patients for the postoperative recovery through education and positive reinforcement, little has been developed to systematically enhance functional capacity before surgery.

The theory of prehabilitation was initially supported in animal models. To investigate the effect of voluntary exercise on the

Increasing physiologic reserve with physical exercise: how does exercise benefit?

The participation in an acute bout of strenuous exercise is met with the need for the body to compensate for potentially major systemic perturbations. For example, blood volume can be quickly recruited and flow redirected to active muscle groups from less metabolically active tissue. Depending on the intensity and duration of exercise performed, cardiac output and systolic blood pressure increase to adequately perfuse blood to the working tissue. Breathing rate and the depth of each breath also

Exercise: what to do?

Current recommendations include a combination of moderate and vigorous exercise, if deemed appropriate for the individual (see Box 1). What does moderate and vigorous represent for the patient? On a scale of 1 to 10 (1 representing a resting activity with no effort and 10 representing all-out, exhaustive exercise), moderate activity can be thought of as being a 5 to 6. Vigorous exercise falls within the range of 7 to 8. This scale, otherwise known as Rating of Perceived Exertion (RPE) or Borg

Optimizing nutrition for prehabilitation

The nutritional status of patients scheduled for abdominal surgery is directly influenced by the presence of cancer or other chronic conditions, such as inflammatory bowel disease, which have an impact on all aspects of intermediary (protein, carbohydrate, lipid, trace element, vitamin) metabolism, and by other factors, such as age, adjuvant cancer therapy, and stage of the disease. In addition, a patient who is undernourished before surgery has a greater risk of morbidity and mortality.37 The

Strategies to minimize the emotional burden of surgery

The physical burden of surgery is closely linked to the emotional one. Increased levels of psychosocial distress seen in patients undergoing abdominal surgery are related to the diagnosis (eg, cancer), the treatment (chemotherapy), and most often to the disability (stoma siting). Several studies have identified that anxiety and depression can affect postoperative outcome (eg, those who were more stressed on the third day after surgery stayed longer in hospital, and those who were more

Who benefits from prehabilitation?

Because people are living well in their late 70s, they are more likely to undergo surgery. Morbidity and mortality associated with surgery increase with advancing age once individuals are older than 75 years. There is a large heterogeneity in this population, with frail and cognitively impaired on one side and highly functional and robust on the other side. There has also been a shift in the comorbidity of this population, with an increase in cancer, obesity, diabetes, cognitive impairment, and

Recovery and evaluation of prehabilitation

Traditionally, successful recovery from surgery has been identified with the patient leaving the hospital and without complications during the first 30 postoperative days. However, length of hospital stay may be affected by external elements, such as socioeconomic, cultural, and institutional factors, and complications and mortality are uncommon and often inconsistently measured.64 These measures are important to clinicians and administrators but may not be relevant to the patient, who wants to

Summary

Surgical prehabilitation is an emerging concept that derives from the realization that perioperative care must include, beside clinical and pharmacologic preparation of the surgical patient, preoperative physical, nutritional, and mental optimization. As the population ages and mortality decreases, additional concerns in patients who undergo surgery and other treatment include quality of life, community reintegration, and physical and mental performance after surgery and cancer treatment.

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