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

Anna Svensson-Raskh, Anna Regina Schandl, Agneta Ståhle, Malin Nygren-Bonnier, Monika Fagevik Olsén, Anna Svensson-Raskh, Anna Regina Schandl, Agneta Ståhle, Malin Nygren-Bonnier, Monika Fagevik Olsén

Abstract

Objective: The aim of this study was to investigate if mobilization out of bed, within 2 hours after abdominal surgery, improved participants' respiratory function and whether breathing exercises had an additional positive effect.

Methods: Participants were 214 consecutively recruited patients who underwent elective open or robot-assisted laparoscopic gynecological, urological, or endocrinological abdominal surgery with an anesthetic duration of >2 hours. They were recruited to a randomized controlled trial. Immediately after surgery, patients were randomly assigned to 1 of 3 groups: mobilization (to sit in a chair) and standardized breathing exercises (n = 73), mobilization (to sit in a chair) only (n = 76), or control (n = 65). The interventions started within 2 hours after arrival at the postoperative recovery unit and continued for a maximum of 6 hours. The primary outcomes were differences in peripheral oxygen saturation (SpO2, as a percentage) and arterial oxygen pressure (PaO2, measured in kilopascals) between the groups. Secondary outcomes were arterial carbon dioxide pressure, spirometry, respiratory insufficiency, pneumonia, and length of stay.

Results: Based on intention-to-treat analysis (n = 214), patients who received mobilization and breathing exercises had significantly improved SpO2 (mean difference [MD] = 2.5%; 95% CI = 0.4 to 4.6) and PaO2 (MD = 1.40 kPa; 95% CI = 0.64 to 2.17) compared with the controls. For mobilization only, there was an increase in PaO2 (MD = 0.97 kPa; 95% CI = 0.20 to 1.74) compared with the controls. In the per-protocol analysis (n = 201), there were significant improvements in SpO2 and PaO2 for both groups receiving mobilization compared with the controls. Secondary outcome measures did not differ between groups.

Conclusion: Mobilization out of bed, with or without breathing exercises, within 2 hours after elective abdominal surgery improved SpO2 and PaO2.

Impact: The respiratory effect of mobilization (out of bed) immediately after surgery has not been thoroughly evaluated in the literature. This study shows that mobilization out of bed following elective abdominal surgery can improve SpO2 and PaO2.

Lay summary: Mobilization within 2 hours after elective abdominal surgery, with or without breathing exercises, can improve patients' respiratory function.

Trial registration: ClinicalTrials.gov NCT02929446.

Keywords: Early Ambulation; Physiotherapy; Postoperative Care; Postoperative Complications; Respiratory Function.

© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association.

Figures

Figure 1
Figure 1
CONSORT flowchart of the study design. C = control; ITT = intention-to-treat; M = mobilization only; MB = mobilization and breathing exercises; PEP = positive expiratory pressure; PP = per-protocol.
Figure 2
Figure 2
(a and b) Changes in primary outcomes (peripheral oxygen saturation [SpO2], as a percentage, and arterial oxygen pressure [PaO2], in kilopascals) across time points, by treatment groups, at 95% CIs, in the intention-to-treat population (n = 214). Changes in SpO2 (as a percentage) and PaO2 (in kilopascals) across time points, by treatment groups, at 95% CIs, in the per-protocol population (n = 201). Preop = preoperatively (c and d).
Figure 2
Figure 2
(a and b) Changes in primary outcomes (peripheral oxygen saturation [SpO2], as a percentage, and arterial oxygen pressure [PaO2], in kilopascals) across time points, by treatment groups, at 95% CIs, in the intention-to-treat population (n = 214). Changes in SpO2 (as a percentage) and PaO2 (in kilopascals) across time points, by treatment groups, at 95% CIs, in the per-protocol population (n = 201). Preop = preoperatively (c and d).

References

    1. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–298.
    1. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146:571–577.
    1. Castelino T, Fiore JF Jr, Niculiseanu P, Landry T, Augustin B, Feldman LS. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review. Surgery. 2016;159:991–1003.
    1. Porserud A, Aly M, Nygren-Bonnier M, Hagstromer M. Objectively measured mobilisation is enhanced by a new behaviour support tool in patients undergoing abdominal cancer surgery. Eur J Surg Oncol. 2019;45:1847–1853.
    1. Browning L, Denehy L, Scholes RL. The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Aust J Physiother. 2007;53:47–52.
    1. Fiore JF, Castelino T, Pecorelli N, et al. Randomized controlled trial of an intervention to facilitate early mobilization after colorectal surgery: impact on postoperative pulmonary function and complications. Eur Respir J. 2017;50;OA1768.
    1. Fernandez-Bustamante A, Frendl G, Sprung J, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the perioperative research network investigators. JAMA Surg. 2017;152:157–166.
    1. Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118:317–334.
    1. Gallart L, Canet J. Post-operative pulmonary complications: understanding definitions and risk assessment. Best Pract Res Clin Anaesthesiol. 2015;29:315–330.
    1. Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:581–595.
    1. Hedenstierna G. Oxygen and anesthesia: what lung do we deliver to the post-operative ward? Acta Anaesthesiol Scand. 2012;56:675–685.
    1. Craig DB. Postoperative recovery of pulmonary function. Anesth Analg. 1981;60:46–52.
    1. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology. 2005;102:838–854.
    1. Jenkins SC, Soutar SA, Moxham J. The effects of posture on lung volumes in normal subjects and in patients pre-and post-coronary artery surgery. Physiotherapy. 1988;74:492–496.
    1. Hsu HO, Hickey RF. Effect of posture on functional residual capacity postoperatively. Anesthesiology. 1976;44:520–521.
    1. Fagevik Olsen M, Lannefors L, Westerdahl E. Positive expiratory pressure - common clinical applications and physiological effects. Respir Med. 2015;109:297–307.
    1. Mynster T, Jensen LM, Jensen FG, Kehlet H, Rosenberg J. The effect of posture on late postoperative oxygenation. Anaesthesia. 1996;51:225–227.
    1. Nielsen KG, Holte K, Kehlet H. Effects of posture on postoperative pulmonary function. Acta Anaesthesiol Scand. 2003;47:1270–1275.
    1. Ramos Dos Santos PM, Aquaroni Ricci N, Aparecida Bordignon Suster E, Moraes Paisani D, Dias Chiavegato L. Effects of early mobilisation in patients after cardiac surgery: a systematic review. Physiotherapy. 2017;103:1–12.
    1. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS((R))) society recommendations. World J Surg. 2013;37:259–284.
    1. Ricksten SE, Bengtsson A, Soderberg C, Thorden M, Kvist H. Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Chest. 1986;89:774–781.
    1. Silva YR, Li SK, Rickard MJ. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial. Physiotherapy. 2013;99:187–193.
    1. Mackay MR, Ellis E, Johnston C. Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Aust J Physiother. 2005;51:151–159.
    1. Wolk S, Linke S, Bogner A, et al. Use of activity tracking in major visceral surgery-the enhanced perioperative mobilization trial: a randomized controlled trial. J Gastrointest Surg. 2019;23:1218–1226.
    1. Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. Br J Surg. 1997;84:1535–1538.
    1. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005;26:319–338.
    1. Fitz-Henry J. The ASA classification and peri-operative risk. Ann R Coll Surg Engl. 2011;93:185–187.
    1. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14:798–804.
    1. Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol. 2015;32:88–105.
    1. Urell C, Emtner M, Hedenstrom H, Tenling A, Breidenskog M, Westerdahl E. Deep breathing exercises with positive expiratory pressure at a higher rate improve oxygenation in the early period after cardiac surgery--a randomised controlled trial. Eur J Cardiothorac Surg. 2011;40:162–167.
    1. Brown H. Applied Mixed Models In Medicine. 3rd ed. Chichester, UK: Wiley; 2015.
    1. Neto AS, Costa LGV, Hemmes SNT, et al. The LAS VEGAS risk score for prediction of postoperative pulmonary complications: an observational study. Eur J Anaesthesiol. 2018;35:691–701.
    1. Marshall BE, Wyche MQ Jr. Hypoxemia during and after anesthesia. Anesthesiology. 1972;37:178–209.
    1. Moreno F, Lyons HA. Effect of body posture on lung volumes. J Appl Physiol. 1961;16:27–29.
    1. Blair E, Hickam JB. The effect of change in body position on lung volume and intrapulmonary gas mixing in normal subjects. J Clin Invest. 1955;34:383–389.
    1. Lumb AB. Nunn’s Applied Respiratory Physiology. 8th ed. Edinburgh, UK: Elsevier; 2016.
    1. Olsén MF. Chest physical therapy in surgery: a theoretical model about who to treat. Breathe. 2005;1:308–314.
    1. Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:596–608.
    1. Orman J, Westerdahl E. Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review. Acta Anaesthesiol Scand. 2010;54:261–267.
    1. Westerdahl E, Lindmark B, Eriksson T, Friberg O, Hedenstierna G, Tenling A. Deep-breathing exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery. Chest. 2005;128:3482–3488.
    1. Chumillas S, Ponce JL, Delgado F, Viciano V, Mateu M. Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study. Arch Phys Med Rehabil. 1998;79:5–9.
    1. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113:1338–1350.
    1. Lindberg P, Gunnarsson L, Tokics L, et al. Atelectasis and lung function in the postoperative period. Acta Anaesthesiologica Scandinavica. 1992;36:546–553.
    1. Svensson-Raskh A, Schandl A, Holdar U, Fagevik Olsén M, Nygren-Bonnier M. I have everything to win and nothing to lose: patient experiences of mobilization out of bed immediately after abdominal surgery. Phys Ther. 2020;100:2079–2089.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren