Physical performance following acute high-risk abdominal surgery: a prospective cohort study

Line Rokkedal Jønsson, Lina Holm Ingelsrud, Line Toft Tengberg, Thomas Bandholm, Nicolai Bang Foss, Morten Tange Kristensen, Line Rokkedal Jønsson, Lina Holm Ingelsrud, Line Toft Tengberg, Thomas Bandholm, Nicolai Bang Foss, Morten Tange Kristensen

Abstract

Background: Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical performance and barriers to independent mobilization among patients who received AHA surgery (postoperative days [POD] 1-7).

Methods: Patients undergoing AHA surgery were consecutively enrolled from a university hospital in Denmark. In the first postoperative week, all patients were evaluated daily with regards to physical performance, using the Cumulated Ambulation Score (CAS; 0-6 points) to assess basic mobility and the activPAL monitor to assess the 24-hour physical activity level. We recorded barriers to independent mobilization.

Results: Fifty patients undergoing AHA surgery (mean age 61.4 ± 17.2 years) were included. Seven patients died within the first postoperative week, and 15 of 43 (35%) patients were still not independently mobilized (CAS < 6) on POD-7, which was associated with pulmonary complications developing (53% v. 14% in those with CAS = 6, p = 0.012). The patients lay or sat for a median of 23.4 hours daily during the first week after AHA surgery, and the main barriers to independent mobilization were fatigue and abdominal pain.

Conclusion: Patients who receive AHA surgery have very limited physical performance in the first postoperative week. Barriers to independent mobilization are primarily fatigue and abdominal pain. Further studies investigating strategies for early mobilization and barriers to mobilization in the immediate postoperative period after AHA surgery are needed.

Conflict of interest statement

Competing interests: None declared.

Figures

Fig. 1
Fig. 1
Flow of patients through the study. POD = postoperative day.

References

    1. Pearse RM, Harrison DA, James P, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care. 2006;10:1–6.
    1. Arenal JJ, Bengoechea-Beeby M. Mortality with emergency abdominal surgery in the elderly. Can J Surg. 2003;46:111–6.
    1. Svenningsen P, Manoharan T, Foss NB, et al. Increased mortality in the elderly after emergency abdominal surgery. Dan Med J. 2014;61:5–8.
    1. Saunders DI, Murray D, Pichel AC, et al. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth. 2012;109:368–75.
    1. Vester-Andersen M, Lundstrøm LH, Møller MH, et al. Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study. Br J Anaesth. 2014;112:860–70.
    1. Barrow E, Anderson ID, Varley S, et al. Current UK practice in emergency laparotomy. Ann R Coll Surg Engl. 2013;95:599–603.
    1. Tengberg LT, Bay-Nielsen M, Bisgaard T, et al. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. Br J Surg. 2017;104:463–71.
    1. Møller MH, Adamsen S, Thomsen RW, et al. Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation. Br J Surg. 2011;98:802–10.
    1. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248:189–98.
    1. Kehlet H, Mythen M. Why is the surgical high-risk patient still at risk? Br J Anaesth. 2011;106:289–91.
    1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630–41.
    1. Adamina M, Kehlet H, Tomlinson GA, et al. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149:830–40.
    1. Dorcaratto D, Grande L, Pera M. Enhanced recovery in gastrointestinal surgery: upper gastrointestinal surgery. Dig Surg. 2013;30:70–8.
    1. Peden C, Scott MJ. Anesthesia for emergency abdominal surgery. Anesthesiol Clin. 2015;33:209–21.
    1. Jakobsen DH, Sonne E, Andreasen J, et al. Convalescence after colonic surgery with fast-track vs conventional care. Color Dis. 2006;8:683–7.
    1. Castelino T, Fiore JF, Niculiseanu P, et al. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review. Surgery. 2016;159:991–1003.
    1. Lawrence VA, Hilsenbeck SG, Mulrow CD, et al. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med. 1995;10:671–8.
    1. Suetta C, Magnusson SP, Beyer N, et al. Effect of strength training on muscle function in elderly hospitalized patients. Scand J Med Sci Sports. 2007;17:464–72.
    1. Haines KJ, Skinner EH, Berney S. Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy. 2013;99:119–25.
    1. Bautmans I, Njemini R, De Backer J, et al. Surgery-induced inflammation in relation to age, muscle endurance, and self-perceived fatigue. J Gerontol A Biol Sci Med Sci. 2010;65:266–73.
    1. Münter KH, Clemmesen CG, Foss NB, et al. Fatigue and pain limit independent mobility and physiotherapy after hip fracture surgery. Disabil Rehabil. 2017 Apr;17:1–9. doi: 10.1080/09638288.20171314556. [Epub ahead of print]
    1. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications. Ann Surg. 2009;250:187–96.
    1. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;29:530–8.
    1. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–55.
    1. Owens WD, Felts JA, Spitznagel EL. ASA physical status clssifications: a study of consistency of ratings. Aneshesiology. 1978;49:239–43.
    1. Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J Bone Jt Surg [Br] 1993;755:797–8.
    1. Kristensen MT, Kehlet H. Most patients regain prefracture basic mobility after hip fracture surgery in a fast-track programme. Dan Med J. 2012;59:A4447.
    1. Kristensen MT, Bandholm T, Foss NB, et al. High inter-tester reliability of the new mobility score in patients with hip fracture. J Rehabil Med. 2008;40:589–91.
    1. von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12:1495–9.
    1. Foss NB, Kristensen MT, Kehlet H. Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score. Clin Rehabil. 2006;20:701–8.
    1. Kristensen MT, Jakobsen TL, Nielsen JW, et al. Cumulated Ambulation Score to evaluate mobility is feasible in geriatric patients and in patients with hip fracture. Dan Med J. 2012;59:A4464.
    1. Kristensen MT, Andersen L, Bech-Jensen R, et al. High intertester reliability of the Cumulated Ambulation Score for the evaluation of basic mobility in patients with hip fracture. Clin Rehabil. 2009;23:1116–23.
    1. Kristensen MT, Foss NB, Ekdahl C, et al. Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery. Acta Orthop. 2010;81:296–302.
    1. Ryan CG, Grant PM, Tigbe WW, et al. The validation of a novel activity monitor in the measurement of posture and motion during everyday activities. Br J Sports Med. 2006;40:992–7.
    1. Sellers C, Dall P, Grant M, et al. Gait & posture validity and reliability of the activPAL3 for measuring posture and stepping in adults and young people. Gait Posture. 2016;43:42–7.
    1. Taraldsen K, Askim T, Sletvold O, et al. Evaluation of a body-worn sensor system to measure physical activity in older people with impaired function. Phys Ther. 2011;91:277–85.
    1. Grant PM, Granat MH, Thow M, et al. Analyzing free-living physical activity of older adults in different environments using body-worn activity monitors. J Aging Phys Act. 2010;18:171–84.
    1. Huskisson EC. Measurement of pain. Lancet. 1974;7:1127–31.
    1. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14:798–804.
    1. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. JAGS. 2003;51:451–8.
    1. Gill TM, Allore HG, Zhenchao G. Restricted activity and functional decline among community-living older persons. Arch Intern Med. 2003;163:1317–22.
    1. Roubenoff R. Sarcopenia: effects on body composition and function. J Gerontol. 2003;58:1012–7.
    1. Hirvensalo M, Rantanen T, Heikkinen E. Mobility difficulties and physical activity as predictors of mortality and loss of independence in the community-living older population. J Am Geriatr Soc. 2000;48:493–8.
    1. Roubenoff R. Physical activity, inflammation, and muscle loss. Nutr Rev. 2007;65:208–13.
    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. Bailey JG, Davis PJB, Levy AR, et al. The impact of adverse events on the health care costs for older adults undergoing nonelective abdominal surgery. Can J Surg. 2016;59:172–9.
    1. Gill TM, Allore HG, Holford TR, et al. Hospitalization, restricted activity, and the development of disability among older persons. JAMA. 2004;292:2115–24.
    1. Gill TM, Allore HG, Gahbauer EA, et al. Change in disability after hospitalization or restricted activity in older persons. JAMA. 2010;304:1919–28.
    1. Lees MC, Merani S, Tauh K, et al. Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis. Can J Surg. 2015;58:312–7.
    1. Khuri SF, Henderson WG, Depalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326–43.
    1. Shea RA, Brooks JA, Dayhoff NE, et al. Pain intensity and postoperative pulmonary complications among the alderly after abdominal surgery. Heart Lung. 2002;31:440–9.
    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. 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;144:581–95.
    1. Mackay MR, Ellis E, Johnston C. Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Aust J Physiother. 2005;51:151–9.
    1. Nielsen KG, Holte K, Kehlet H. Effects of posture on postoperative pulmonary function. Acta Anaesthesiol Scand. 2003;47:1270–6.
    1. Havey R, Herriman E, O’Brien DO. Guarding the gut — early mobility after abdominal surgery. Crit Care Nurs Q. 2013;36:63–72.
    1. Galvin E, Boesjes H, Hol J, et al. Modafinil reduces patient-reported tiredness after sedation/analgesia but does not improve patient psychomotor skills. Acta Anaesthesiol Scand. 2010;54:154–61.
    1. de la Motte L, Kehlet H, Vogt K, et al. Preoperative methylprednisolone enhances recovery after endovascular aortic repair. Ann Surg. 2014;260:540–9.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren