The impact of delayed mobilization on post-discharge outcomes after emergency abdominal surgery: A prospective cohort study in older patients

Prevalence and associated factors of postoperative orthostatic intolerance at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022: cross sectional study

BACKGROUND

Postoperative orthostatic intolerance is an inability to maintain an upright position because of symptoms of cerebral hypoperfusion. It is a common problem in the early postoperative period and hinders early mobilization, however, there is limited information about factors associated with it. Thus, the main aim of this study was to determine the prevalence and identify factors associated with postoperative orthostatic intolerance.

METHOD

Hospital based cross-sectional study was conducted from April 08 to July 20, 2022, at University of Gondar comprehensive Specialized Hospital. A semi-structured questionnaire containing sociodemographic variables and perioperative factors related to anesthesia and surgery was used for data collection. The presence of postoperative orthostatic intolerance during the first ambulation was evaluated with a standardized symptom checklist which contains symptoms of orthostatic intolerance. Binary logistic regression analysis was performed to assess factors associated with postoperative orthostatic intolerance. In multivariable regression, variables with P-value < 0.05 were considered statistically significant.

RESULT

A total of 420 patients were included in this study with a response rate of 99.06%. Postoperative orthostatic intolerance was experienced in 254 (60.5%) participants. Being female (AOR = 2.27; 95% CI = 1.06-4.86), low BMI (AOR = 0.79; 95% CI = 0.71-0.95), ASA II and above (AOR = 3.34; 95% CI = 1.34-8.28), low diastolic blood pressure (AOR = 0.82; 95% CI = 0.88-0.99), general anesthesia (AOR = 3.26, 95% CI = 1.31-8.12), high intraoperative blood lose (AOR = 0.93, 95% CI = 0.88-0.99), high postoperative fluid intake (AOR = 2.09, 95% CI = 1.23-3.55), pain before ambulation (AOR = 1.99, 95% CI = 1.28-3.11) and pain during ambulation (AOR = 1.82, 95% CI = 1.23-2.69) were the significant factors associated with orthostatic intolerance.

CONCLUSION

Our study revealed that postoperative orthostatic intolerance was experienced in nearly two-thirds of participants. During the time of ambulation, assessing patients for the presence of orthostatic intolerance is necessary to reduce the adverse effects of postoperative OI. In addition, maintaining preoperative normotension, reducing intraoperative blood loss and optimizing postoperative pain control is recommended to reduce the risk of postoperative orthostatic intolerance.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients

INTRODUCTION

Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC).

MATERIALS AND METHODS

We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations.

RESULTS

We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations.

CONCLUSIONS

Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Preoperative physiotherapy education for patients undergoing colorectal cancer resection

BACKGROUND

Surgical resection is a common treatment for patients with colorectal cancer. Patients undergoing surgery are at risk of functional deterioration as a response to surgical stress. Furthermore, patients with cancer often present with systemic problems as well as a functional decline. The study aimed to create a framework for preoperative education for patients undergoing colorectal cancer resection.

METHODS

Five databases were utilised to find intervention-based studies describing the content, mode, setting and timing of delivery of preoperative education for patients undergoing abdominal surgery. Physiotherapists were purposively sampled to participate in a focus group session using a seven-step nominal group technique (NGT) with the goal to reach consensus on the proposed content of a preoperative patient education programme.

RESULTS

Seventeen studies were reviewed. Results indicate that the mode and timing of the education provided are heterogenous. Content included in the education programs described were breathing exercises, coughing techniques, verbal advice, physical exercises, surgical information, postoperative pain management, nutritional support, relaxation techniques and information about postoperative complications. Six physiotherapists participated in the focus group discussion. Ideas generated in the focus group were similar to those described in the literature.

CONCLUSION

Results from both the narrative review and the focus group session assisted the authors to develop a framework for the content, timing, setting and mode of delivery of physiotherapy preoperative education for patients undergoing surgical resection for colorectal cancer.Contribution: The framework can be used to inform a physiotherapy preoperative education programme for patients undergoing surgery for colorectal cancer.

Impact of early mobilization on the duration of delirium in elderly hospitalized patients: A retrospective cohort pilot study

Development of delirium during hospitalization impairs the activities of daily living in elderly hospitalized patients. In clinical practice, early mobilization from bed is recommended to reduce delirium incidence and hospitalization stay. However, the effects of early mobilization on elderly inpatients with delirium have not been established yet. The aim of this study was to investigate the association between early mobilization and the duration of delirium in elderly inpatients with delirium. This retrospective cohort pilot study examined 45 participants (23 males, 22 females; mean age: 84.5 ± 6.6 years), who developed delirium during hospitalization. Of the participants, 28 were surgically treated and 17 were non-surgically treated. We classified early or delayed mobilization based on the median number of days until the start of mobilization and compared after propensity score matching to adjust for baseline characteristics. Additionally, we examined the correlation between the number of days until the start of mobilization and the duration of delirium. The duration of delirium was significantly shorter in the early mobilization group, particularly in terms of sitting on the bed and wheelchair use than that in the delayed mobilization group {median: 4.0 [interquartile range (IQR): 2.0-6.0] vs 8.0 [IQR: 7.0-14.5] days, P = .013; median: 3.0 [IQR: 2.0-5.5] vs 11.0 [IQR: 7.5-14.5] days, P = .004, respectively}. Moreover, the duration of delirium significantly positively moderate correlated with the time until the start of sitting on the bed and wheelchair use (Spearman r = 0.527; P = .012, Spearman r = 0.630; P = .002, respectively). The results of this study suggest that early mobilization from sitting on the bed or wheelchair use after hospitalization or surgery may shorten the duration of delirium. Because the sample size of this pilot study is small, careful interpretation is needed, and further research is warranted.

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial

BACKGROUND

Postoperative pneumonia and delayed physical recovery are significant problems after emergency laparotomy. No randomized controlled trial has assessed the feasibility, safety, or effectiveness of intensive postoperative physical therapy in this high-risk acute population.

METHODS

The internal pilot phase of the Incidence of Complications after Emergency Abdominal Surgery: Get Exercising (ICEAGE) trial was a prospective, randomized controlled trial that evaluated the feasibility, safety, and clinical trial processes of providing intensive physical therapy immediately following emergency laparotomy. Fifty consecutive patients were recruited at the principal participating hospital and randomly assigned to standard-care or intensive physical therapy of twice daily coached breathing exercises for 2 days and 30 minutes of daily supervised rehabilitation over the first 5 postoperative days.

RESULTS

Interventions were provided exactly as per protocol in 35% (78 of 221 patients) of planned treatment sessions. Main barriers to protocol delivery were physical therapist unavailability on weekends (59 of 221 patients [27%]), awaiting patient consent (18 of 99 patients [18%]), and patient fatigue (26 of 221 patients [12%]). Despite inhibitors to treatment delivery, the intervention group still received twice as many breathing exercise sessions and four times the amount of physical therapy over the first 5 postoperative days (23 minutes [interquartile range, 12-29 minutes] vs. 86 minutes [interquartile range, 53-121 minutes]; p < 0.001). One adverse event was reported from 78 rehabilitation sessions (1.3%), which resolved fully on cessation of activity without escalation of medical care.

CONCLUSION

Intensive postoperative physical therapy can be delivered safely and successfully to patients in the first week after emergency laparotomy. The ICEAGE trial protocol resulted in intervention group participants receiving more coached breathing exercises and spending significantly more time physically active over the first 5 days after surgery compared with standard care. It was therefore recommended to progress into the multicenter phase of ICEAGE to definitively test the effect of intensive physical therapy to prevent pneumonia and improve physical recovery after emergency laparotomy.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review

Purpose of Review

The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes.

Recent Findings

Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function.

Summary

This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.

Implementation of a Frailty Assessment and Targeted Care Interventions and Its Association with Reduced Postoperative Complications in Elderly Surgical Patients

BACKGROUND

Older patients with frailty syndrome have a greater risk of poor postoperative outcomes. In this study, we used a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to implement an assessment tool to identify frail patients and targeted interventions to improve their outcomes.

STUDY DESIGN

We implemented a 5-question frailty assessment tool for patients 65 years and older admitted to the general and vascular surgery services from January 1, 2018 to December 31, 2019. Identified frail patients received evidence-based clinical orders and nursing care plan interventions tailored to optimize recovery. A RE-AIM framework was used to assess implementation effectiveness through provider and nurse surveys, floor audits, and chart review.

RESULTS

Of 1,158 patients included in this study, 696 (60.1%) were assessed for frailty. Among these, 611 patients (87.8%) scored as frail or intermediately frail. After implementation, there were significant increases in the completion rates of frailty-specific care orders for frail patients, including delirium precautions (52.1% vs 30.7%; p < 0.001), aspiration precautions (50.0% vs 26.9%; p < 0.001), and avoidance of overnight vitals (32.5% vs 0%). Floor audits, however, showed high variability in completion of care plan components by nursing staff. Multivariate analysis showed significant decreases in 30-day complication rates (odds ratio 0.532; p < 0.001) after implementation.

CONCLUSIONS

A frailty assessment was able to identify elderly patients for provision of targeted, evidence-based frailty care. Despite limited uptake of the assessment by providers and completion of care plan components by nursing staff, implementation of the assessment and care interventions was associated with substantial decreases in complications among elderly surgical patients.

The effect of mobilization protocol on mobilization start time and patient care outcomes in patients undergoing abdominal surgery

AIM

To evaluate the effect of mobilization protocol on mobilization start time, maintenance of mobilization and patient care outcomes in patients who underwent major abdominal open surgery.

BACKGROUND

Early mobilization in the first 24 hours postoperatively is recommended. Early mobilization is one of the evidence-based, effective nursing interventions that improve patient care outcomes.

DESIGN

A quasi-experimental non-randomised design was used in the study.

METHODS

In the study, the groups were followed sequentially and the data of the control group (n = 21) were collected before the intervention group (n = 21). The patients in the control group were mobilised postoperatively by the nurses according to the decision of the nurse and physician in the intensive care unit (ICU) on the day of the operation. There was no standard protocol for mobilization in the ICU. Mobilization training was given to the patients in the intervention group by the researcher nurse the evening before the operation, and a mobilization protocol was applied on the 0th postoperative day. Data on patient care outcomes were collected until the day when the patient was discharged from the hospital. The TREND checklist was followed.

RESULTS

According to the postoperative comparison of the patients in the intervention group to those in the control group, patients in the intervention group started mobilization earlier after admission in intensive care unit (6.22 ± 1.95 hours versus 12.21 ± 3.76 hours), had higher postoperative 0^th -day total mobilization time (128 minutes versus 34 minutes), had a shorter passage of flatus time and length of intensive care unit and hospital stay and had higher sleep quality and satisfaction scores.

CONCLUSIONS

The structured mobilization protocol is effective in the management of early mobilization and improvement of patient care outcomes.

RELEVANCE TO CLINICAL PRACTICE

mobilization protocols ensure that the mobilization process is maintained effectively.

U.S. trends in elective and emergent major abdominal surgical procedures from 2002 to 2014 in older adults

BACKGROUND

The U.S. population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States.

METHODS

We performed a retrospective cohort study using the National Inpatient Sample from 2002 to 2014 with trend analysis using National Cancer Institute's Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in the yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age).

RESULTS

Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4 (15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults aged 65-74 (AAPC: -1.43, -1.75, -1.11, p < 0.0001), 75-84 (AAPC: -2.75, -3.33, -2.16, p < 0.001), and ≥85 (AAPC: -4.07, -4.67, -3.47, p < 0.0001). The AAPC for elective procedures decreased for older adults aged 75-84 (AAPC = -1.65; -2.44, -0.85: p = 0.0001) and >85 (AAPC = -3.53; -4.57, -2.48: p < 0.0001). All age groups showed decreases in emergent procedures in 50-64 (AAPC = -1.76, -2.00, -1.52, p < 0.0001), 65-74 (AAPC = -3.59, -4.03, -3.14, p < 0.0001), 75-84 (AAPC = -3.90, -4.34, -3.46, p < 0.0001), ≥85 (AAPC = -4.58, -4.98, -4.17, p < 0.0001) age groups.

CONCLUSIONS AND RELEVANCE

In this cohort of older adults, the frequency of emergent and elective major abdominal procedures in adults ≥65 years of age decreased with significant variation among individual procedure types. Future studies are needed to identify the generalizability of our findings to other surgical procedures.

Preoperative Frailty Assessment, Operative Severity Score, and Early Postoperative Loss of Independence in Surgical Patients Age 65 Years or Older

BACKGROUND

Preoperative discussions around postoperative discharge planning have been amplified by the COVID pandemic. We wished to determine whether our preoperative frailty screen would predict postoperative loss of independence (LOI).

STUDY DESIGN

This single-institutional study included demographic, procedural, and outcomes data from patients 65 years or older who underwent frailty screening before a surgical procedure. Frailty was assessed using the Edmonton Frail Scale. The Operative Severity Score was used to categorize procedures. The Hierarchical Condition Category risk-adjustment score, as calculated by the Centers for Medicare and Medicaid Services, was included. LOI was defined as an increase in support outside of the home after discharge. Univariable, multivariable logistic regressions, and adjusted postestimation analyses for predictive probabilities of best fit were performed.

RESULTS

Five hundred and thirty-five patients met inclusion criteria and LOI was seen in 38 patients (7%). Patients with LOI were older, had a lower BMI, a higher Edmonton Frail Scale score (7 vs 3.0; p < 0.001), and a higher Hierarchical Condition Category score than patients without LOI. Being frail and undergoing a procedure with an Operative Severity Score of 3 or higher was independently associated with an increased risk of LOI. In addition, social dependency, depression, and limited mobility were associated with an increased risk for LOI. On multivariable modeling, frailty status, undergoing an operation with an Operative Severity Score of 3 or higher, and having a Hierarchical Condition Category score ≥1 were the most predictive of LOI (odds ratio 12.72; 95% CI, 12.04 to 13.44; p < 0.001). In addition, self-reported depression, weight loss, and limited mobility were associated with a nearly 11-fold increased risk of postoperative LOI.

CONCLUSIONS

This study was novel, as it identified clear, generalizable risk factors for LOI. In addition, our findings support the implementation of preoperative assessments to aid in care coordination and provide specific targets for intervention.