Mobilization Started Within 2 Hours After Abdominal Surgery Improves Peripheral and Arterial Oxygenation: A Single-Center Randomized Controlled Trial

Physical function and activity of patients after open abdominal surgery: a prospective cohort study comparing the clinimetric properties of two outcome measures

OBJECTIVES

To measure and compare the clinimetric properties of the Chelsea Critical Care Physical Assessment (CPAx) and Physical Function in Intensive Care Test-scored (PFIT-s) for assessment of physical function and activity.

DESIGN

Prospective cohort design using crossover-randomisation of the sequence in which participants were assessed with CPAx and PFIT-s.

SETTING

Surgical and transplant intensive care units (ICU) in an academic hospital.

PARTICIPANTS

Adults who underwent elective open abdominal surgery. Consecutive sampling was used to enrol 69 participants.

INTERVENTIONS

Physical function and activity were assessed on ICU days one, three, five and at ICU discharge using the CPAx and PFIT-s in random order.

MAIN OUTCOME MEASURES

Responsiveness to change, minimal clinically important difference (MCID), floor and ceiling effect, and convergent validity.

RESULTS

CPAx demonstrated a large responsiveness (effect size index (ESI)= 0.83) and PFIT-s moderate responsiveness (ESI=0.73) to change in scores. MCID for CPAx was 2.1 (standard error of measurement (SEM) 1.1) and for PFIT-s 0.6 (SEM=0.3). CPAx had no floor effect and a small ceiling effect (9%, n = 6) at ICU discharge compared to 2% (n = 1) floor and 48% (n = 32) ceiling effects of PFIT-s. Moderate convergent validity was found for both tools at ICU admission (n = 67, r = 0.62, p < 0.001) and discharge (n = 67, r = 0.51, p < 0.001).

CONCLUSION

CPAx is most responsive to changes in physical function and activity scores, has no floor and limited ceiling effects and moderate convergent validity, and is recommended for similar cohorts. CONTRIBUTION OF THE PAPER.

Immediate mobilization in post-anesthesia care unit does not increase overall postoperative physical activity after elective colorectal surgery: A randomized, double-blinded controlled trial within an enhanced recovery protocol

BACKGROUND

The level of post-operative mobilization according to Enhanced Recovery After Surgery (ERAS) guidelines is not always achieved. We investigated whether immediate mobilization increases postoperative physical activity. The objective was to evaluate the effects of immediate postoperative mobilization in the post-anesthesia care unit (PACU) compared to standard care.

METHODS

This randomized controlled trial, involved 144 patients, age ≥18 years, undergoing elective colorectal surgery. Patients were randomized to mobilization starting 30 min after arrival in the PACU, or to standard care. Standard care consisted of mobilization a few hours later at the ward according to ERAS guidelines. The primary outcome was physical activity, in terms of number of steps, measured with an accelerometer during postoperative days (PODs) 1-3. Secondary outcomes were physical capacity, functional mobility, time to readiness for discharge, complications, compliance with the ERAS protocol, and physical activity 1 month after surgery.

RESULTS

With the intention-to-treat analysis of 144 participants (median age 71, 58% female) 47% underwent laparoscopic-or robotic-assisted surgery. No differences in physical activity during hospital stay were found between the participants in the intervention group compared to the standard care group (adjusted mean ratio 0.97 on POD 1 [95% CI, 0.75-1.27], p = 0.84; 0.89 on POD 2 [95% CI, 0.68-1.16], p = 0.39, and 0.90 on POD 3 [95% CI, 0.69-1.17], p = 0.44); no differences were found in any of the other outcome measures.

CONCLUSIONS

Addition of the intervention of immediate mobilization to standard care did not make the patients more physically active during their hospital stay.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NTC 03357497.

First mobilisation after abdominal and cardiothoracic surgery: when is it actually performed? A national, multicentre, cross-sectional study

OBJECTIVES

Knowledge of clinical practice regarding mobilisation after surgery is lacking. This study therefore aimed to reveal current mobilisation routines after abdominal and cardiothoracic surgery and to identify factors associated with mobilisation within 6 hours postoperatively.

DESIGN

A prospective observational national multicentre study.

SETTING

18 different hospitals in Sweden.

PARTICIPANTS

1492 adult patients undergoing abdominal and cardiothoracic surgery with duration of anaesthesia>2 hours.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was time to first postoperative mobilisation. Secondary outcomes were the type and duration of the first mobilisation. Data were analysed using multivariate logistic regression and general structural equation modelling, and data are presented as ORs with 95% CIs.

RESULTS

Among the included patients, 52% were mobilised to at least sitting on the edge of the bed within 6 hours, 70% within 12 hours and 96% within 24 hours. Besides sitting on the edge of the bed, 76% stood up by the bed and 22% were walking away from the bedside the first time they were mobilised. Patients undergoing major upper abdominal surgery required the longest time before mobilisation with an average time of 11 hours post surgery. Factors associated with increased likelihood of mobilisation within 6 hours of surgery were daytime arrival at the postoperative recovery unit (OR: 5.13, 95% CI: 2.16 to 12.18), anaesthesia <4 hours (OR: 1.68, 95% CI: 1.17 to 2.40) and American Society of Anaesthesiologists (ASA) classification 1-2, (OR: 1.63, 95% CI: 1.13 to 2.36).

CONCLUSIONS

In total, 96% if the patients were mobilised within 24 hours after surgery and 52% within 6 hours. Daytime arrival at the postoperative recovery unit, low ASA classification and shorter duration of anaesthesia were associated with a shorter time to mobilisation.

TRIAL REGISTRATION NUMBER

FoU, Forskning och Utveckling in VGR, Vastra Gotaland Region (Id:275357) and Clinical Trials (NCT04729634).

Transversus abdominis plane block improves postoperative recovery following cesarean delivery under general anesthesia: A propensity score matched retrospective cohort study

OBJECTIVE

To evaluate the effects of transversus abdominis plane (TAP) block on postoperative recovery 24 h after cesarean delivery under general anesthesia.

METHODS

A propensity-score-matched, retrospective cohort study was used. A total of 173 pregnancies resulting in elective cesarean delivery under general anesthesia between March 2021 and March 2022 were analyzed retrospectively. Patients receiving TAP block were compared with those receiving only intravenous analgesia. The Quality of Recovery 15 (QoR-15) score, assessed 24 h postoperatively using a 15-item questionnaire, was the primary outcome. Secondary outcomes included time to first ambulation, time to first flatus postoperatively, ability to tolerate ambulation, visual analog scale (VAS) score, hospitalization cost, and postoperative nausea and/or vomiting.

RESULTS

The total QoR-15 score 24 h postoperatively in the TAP group was significantly higher than in the Control group (P < 0.001). Patients in the TAP group had higher Bruggemann comfort scale scores (P < 0.001), could better tolerate early postoperative ambulation (P < 0.001), and had shorter time to first ambulation (P < 0.001) and flatus (P < 0.001). Correlation analysis demonstrated an inverse relationship between the cumulative VAS pain scores, time to first postoperative ambulation, time to first flatus, and total QoR-15 score 24 h postoperatively.

CONCLUSIONS

Following cesarean delivery under general anesthesia, TAP block combined with intravenous analgesia can improve postoperative recovery and shorten the time to postoperative ambulation and recovery of intestinal function.

Factors influencing early mobilisation for patients undergoing pancreatic surgery from multiple perspectives: a qualitative descriptive study

OBJECTIVES

Despite early mobilisation as a key component of enhanced recovery after surgery pathways for pancreatic surgery, the implementation of early mobilisation remains unsatisfactory. What factors influence the implementation of early mobilisation from the lens of all stakeholders is unclear. The aim of this study was to identify the influencing factors of early mobilisation in pancreatic surgery from the perspective of patients, family members and health professionals.

DESIGN

A qualitative descriptive design using individual interviews and focus groups.

SETTING AND PARTICIPANTS

Twenty-two patients undergoing pancreatic surgery, 10 family members and 10 healthcare professionals from a large university teaching hospital in China.

METHODS

We collected data on participants' views on factors influencing early mobilisation after pancreatic surgery. Two researchers independently reviewed the transcripts and emergent coding. The data were analysed using qualitative content analysis.

RESULTS

Three main categories that influenced the implementation of early mobilisation in pancreatic surgery were identified: (1) attitude towards early postoperative mobilisation (eg, perceived advantages or disadvantages of early mobilisation), (2) subjective norm (eg, impact from health professionals, family members and fellow patients) and (3) perceived behavioural control (eg, knowledge, abilities, resources and environment).

CONCLUSION

Factors influencing early mobilisation are diverse and multidimensional. The successful implementation of early mobilisation requires the dedication of both patients and healthcare professionals.

Effects of early postoperative mobilization following gastrointestinal surgery: systematic review and meta-analysis

BACKGROUND

Early postoperative mobilization is considered a key element of enhanced recovery after surgery protocols. The aim of this study was to summarize the effect of early postoperative mobilization following gastrointestinal operations on patient recovery, mobility, the morbidity rate and duration of hospital stay.

METHODS

A systematic literature search was conducted in December, 2022, using PubMed, Web of Science and the Cochrane Central Register of Controlled Trials. Controlled trials reporting the effects of early postoperative mobilization after gastrointestinal surgery were included. The risk of bias was assessed using a modified Downs and Black tool and the Cochrane Collaboration tool for randomized trials. The outcomes of interest were gastrointestinal recovery (defined passage of first flatus or bowel movements), mobility (step count on postoperative day 3), the morbidity rate and duration of hospital stay.

RESULTS

After elimination of duplicates, 3678 records were identified, and 71 full-text articles were screened. Finally, 15 studies (eight RCTs) reporting on 3538 patients were included. Most trials evaluated early postoperative mobilization after different gastrointestinal operations, including upper gastrointestinal (n = 8 studies), hepatopancreatobiliary (n = 10 studies) and colorectal resections (n = 10 studies). The investigated early postoperative mobilization protocols, operative techniques (minimally invasive or open) and outcome parameters were heterogeneous between the studies. Early postoperative mobilization seemed to significantly accelerate clinical gastrointestinal recovery (mean difference, hours: -11.53 (-22.08, -0.97), P = 0.03). However, early postoperative mobilization did not significantly improve the morbidity rate (risk ratio: 0.93 (0.70, 1.23), P = 0.59), postoperative mobility of patients (step count mean difference: 1009 (-803, 2821), P = 0.28) or shorten the duration of hospital stay (mean difference, days: -0.25 (-0.99,0.43), P = 0.47) in randomized trials.

CONCLUSION

There is a large heterogeneity among the study cohorts, operations and interventions. The available evidence currently does not support specific early postoperative mobilization protocols as an isolated element to further reduce the morbidity rate and duration of hospital stay. Further well-designed trials are required to identify effective early postoperative mobilization protocols.

Application of the Perme Score to assess mobility in patients with COVID-19 in inpatient units

Objective

To evaluate the ability of the Perme Score to detect changes in the level of mobility of patients with COVID-19 outside the intensive care unit.

Method

A retrospective cohort study was conducted in inpatient units of a private hospital. Patients older than 18, diagnosed with COVID-19, who were discharged from the intensive care unit and remained in the inpatient units were included. The variables collected included demographic characterization data, length of hospital stay, respiratory support, Perme Score values at admission to the inpatient unit and at hospital discharge and the mobilization phases performed during physical therapy.

Result

A total of 69 patients were included, 80% male and with a mean age of 61.9 years (SD=12.5 years). The comparison of the Perme Score between the times of admission to the inpatient unit and at hospital discharge shows significant variation, with a mean increase of 7.3 points (95%CI:5.7-8.8; p<0.001), with estimated mean values of Perme Score at admission of 17.5 (15.8; 19.3) and hospital discharge of 24.8 (23.3; 26.3). There was no association between Perme Score values and length of hospital stay (measure of effect and 95%CI 0.929 (0.861; 1.002; p=0.058)).

Conclusion

The Perme Score proved effective for assessing mobility in patients diagnosed with COVID-19 with prolonged hospitalization outside the intensive care setting. In addition, we demonstrated by the value of the Perme Score that the level of mobility increases significantly from the time of admission to inpatient units until hospital discharge. There was no association between the Perme Score value and length of hospital stay.

Intestinal Obstruction for Anisakiasis: Surgical and Physical Therapy Treatment

Anisakiasis, a zoonotic disease that can lead to small intestine obstruction, has seen a significant rise in Spain. The country has become the first in Europe with an annual incidence of 8000 cases, primarily due to the popularity of consuming exotic dishes of undercooked or raw fish and the impact of climate change. The clinical presentation of anisakiasis can mimic symptoms of acute appendicitis or intestinal obstruction, leading to potential misdiagnosis. This case report describes a 37-year-old patient with no significant medical history who presented abdominal distension and intense pain in the right lower quadrant. The patient underwent surgery and received physiotherapy treatment, including therapeutic exercises and pulsed-pressure myofascial vacuum therapy, to facilitate functional recovery. The increasing incidence of anisakiasis in Spain underscores the need to consider it in the differential diagnosis of digestive diseases, given the high consumption of poorly prepared or raw fish in the region.

Early mobilization after esophageal cancer surgery: a retrospective cohort study

A key component of the Enhanced Recovery After Surgery pathway for esophagectomy is early mobilization. Evidence on a specific protocol of early and structured mobilization is scarce, which explains variation in clinical practice. This study aims to describe and evaluate the early mobilization practice after esophagectomy for cancer in a tertiary referral center in the Netherlands. This retrospective cohort study included data from a prospectively maintained database of patients who underwent an esophagectomy between 1 January 2015 and 1 January 2020. Early mobilization entailed increase in activity with the first target of ambulating 100 meters. Primary outcomes were the number of postoperative days (PODs) until achieving this target and reasons for not achieving this target. Secondary outcomes were the relationship between preoperative factors (e.g. sex, BMI) and achieving the target on POD1, and the relationship between achieving the target on POD1 and postoperative outcomes (i.e. length of stay, readmissions). In total, 384 patients were included. The median POD of achieving the target was 2 (IQR 1-3), with 173 (45.1%) patients achieving this on POD1. Main reason for not achieving this target was due to hemodynamic instability (22.7%). Male sex was associated with achieving the target on POD1 (OR = 1.997, 95%CI 1.172-3.403, P = 0.011); achieving this target was not associated with postoperative outcomes. Ambulation up to 100 m on POD1 is achievable in patients after esophagectomy, with higher odds for men to achieve this target. ERAS pathways for post esophagectomy care are encouraged to incorporate 100 m ambulation on POD1 in their guideline as the first postoperative target.

Postoperative Respiratory Failure and Advanced Ventilator Settings

Postoperative respiratory failure has a multifactorial etiology, of which atelectasis is the most common mechanism. Its injurious effects are magnified by surgical inflammation, high driving pressures, and postoperative pain. Chest physiotherapy and noninvasive ventilation are good options to prevent progression of respiratory failure. Acute respiratory disease syndrome is a late and severe finding, which is associated with high morbidity and mortality. If present, proning is a safe, effective, and underutilized therapy. Extracorporeal membrane oxygenation is an option only when traditional supportive measures have failed.

Pulmonary function and complication prevention: A randomized controlled trial on lung expansion modalities of older adults undergoing upper abdominal surgery

Postoperative pulmonary complications (PPCs) are a major catastrophic consequence of upper abdominal surgery, resulting in morbidity and mortality. Therefore, the study aims to assess the effect of lung expansion modalities (LEMs) on older adults' pulmonary function and the incidence of pulmonary complications. The study randomly allocated 80 older adults (40 cases and 40 controls). Pulmonary function testing revealed a significant improvement in the study group's forced expiratory volume in one second, sixth second, and oxygen saturation on the fifth postoperative day (POD) compared to the first day [55.23%, 38.41%, and 2.87%; P0.001]. The reported PPCs incidence of the intervention group was less than the control group (15% and 30% on the third POD; 15% and 37.5% on the fifth POD). In conclusion, LEMs provide practical enhancement for the postoperative care of older adults by reducing PPCs by restoring measured pulmonary volumes.

Interdisciplinary and cross-sectoral perioperative care model in cardiac surgery: implementation in the setting of minimally invasive heart valve surgery (INCREASE)-study protocol for a randomized controlled trial

Background

Valvular heart diseases are frequent and increasing in prevalence. Minimally invasive heart valve surgery embedded in an interdisciplinary enhanced recovery after surgery (ERAS) program may have potential benefits with regard to reduced length of stay and improved patient reported outcomes. However, no prospective randomized data exist regarding the superiority of ERAS program for the patients’ outcome.

Methods

We aim to randomize (1:1) a total of 186 eligible patients with minimally invasive heart valve surgery to an ERAS program vs. standard treatment at two centers including the University Medical Center Hamburg-Eppendorf, Germany, and the University Hospital Augsburg, Germany. The intervention is composed out of pre-, peri-, and postoperative components. The preoperative protocol aims at better preparation for the operation with regard to physical activity, nutrition, and psychological preparedness. Intraoperative anesthesiologic and surgical management are trimmed to enable an early extubation. Patients will be transferred to a specialized postoperative anesthesia care unit, where first mobilization occurs 3 h after surgery. Transfer to low care ward will be at the next day and discharge at the fifth day. Participants in the control group will receive treatment as usual. Primary endpoints include functional discharge at discharge and duration of in-hospital care during the first 12 months after index surgery. Secondary outcomes include health-related quality of life, health literacy, and level of physical activity.

Discussion

This is the first randomized controlled trial evaluating the effectiveness of an ERAS process after minimally invasive heart valve surgery. Interprofessional approach is the key factor of the ERAS process and includes in particular surgical, anesthesiological, physiotherapeutic, advanced nursing, and psychosocial components. A clinical implication guideline will be developed facilitating the adoption of ERAS model in other heart teams.

Trial registration

The study has been registered in ClinicalTrials.gov (NCT04977362 assigned July 27, 2021).

Supervised Immediate Postoperative Mobilization After Elective Colorectal Surgery: A Feasibility Study

BACKGROUND

Early mobilization is a significant part of the ERAS^® Society guidelines, in which patients are recommended to spend 2 h out of bed on the day of surgery. However, it is not yet known how early patients can safely be mobilized after completion of colorectal surgery. The aim of this study was to evaluate the feasibility, and safety of providing almost immediate structured supervised mobilization starting 30 min post-surgery at the postoperative anesthesia care unit (PACU), and to describe reactions to this approach.

METHODS

This feasibility study includes 42 patients aged ≥18 years who received elective colorectal surgery at Örebro University Hospital. They underwent a structured mobilization performed by a specialized physiotherapist using a modified Surgical ICU Optimal Mobilization Score (SOMS). SOMS determines the level of mobilization at four levels from no activity to ambulating. Mobilization was considered successful at SOMS ≥ 2, corresponding to sitting on the edge of the bed as a proxy of sitting in a chair due to lack of space.

RESULTS

In all, 71% (n = 30) of the patients reached their highest level of mobilization between the second and third hour of arrival in the PACU. Before discharge to the ward, 43% (n = 18) could stand at the edge of the bed and 38% (n = 16) could ambulate. Symptoms that delayed advancement of mobilization were pain, somnolence, hypotension, nausea, and patient refusal. No serious adverse events occurred.

CONCLUSIONS

Supervised mobilization is feasible and can safely be initiated in the immediate postoperative care after colorectal surgery. Trial registration Clinical trials.gov identifier: NTC03357497.