The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery.
Prehabilitation, ...including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients.
This was a randomized blinded controlled trial. Eligible candidates accepting to participate were blindly randomized (1:1 ratio) to control (standard care) or intervention (standard care + prehabilitation) groups. Inclusion criteria were: i) age >70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Prehabilitation covered 3 actions: i) motivational interview; ii) high-intensity endurance training; and promotion of physical activity. The main study outcome was the proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise.
We randomized 71 patients to the control arm and 73 to intervention. After excluding 19 patients because of changes in the surgical plan, 63 controls and 62 intervention patients were included in the intention-to-treat analysis. The intervention group enhanced aerobic capacity ΔET 135 (218) %; P < 0.001), reduced the number of patients with postoperative complications by 51% (relative risk 0.5; 95% confidence interval, 0.3-0.8; P = 0.001) and the rate of complications 1.4 (1.6) and 0.5 (1.0) (P = 0.001) as compared with controls.
Prehabilitation enhanced postoperative clinical outcomes in high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity.
Background
Pain is a clinical feature of COVID‐19, however, data about persistent pain after hospital discharge, especially among ICU survivors is scarce. The aim of this study was to explore the ...incidence and characteristics of new‐onset pain and its impact on Health‐Related Quality of Life (HRQoL), and to quantify the presence of mood disorders in critically ill COVID‐19 survivors.
Methods
This is a preliminary report of PAIN‐COVID trial (NCT04394169) presenting a descriptive analysis in critically ill COVID‐19 survivors, following in person interview 1 month after hospital discharge. Pain was assessed using the Brief Pain Inventory, the Douleur Neuropathique 4 questionnaire and the Pain Catastrophizing Scale. HRQoL was evaluated with the EQ 5D/5L, and mood disorders with the Hospital Anxiety and Depression Scale (HADS).
Results
From 27 May to 19 July 2020, 203 patients were consecutively screened for eligibility, and 65 were included in this analysis. Of these, 50.8% patients reported new‐onset pain; 38.5% clinically significant pain (numerical rating score ≥3 for average pain intensity); 16.9% neuropathic pain; 4.6% pain catastrophizing thoughts, 44.6% pain in ≥2 body sites and 7.7% widespread pain. Patients with new‐onset pain had a worse EQ‐VAS and EQ index value (p < 0.001). Pain intensity was negatively correlated to both the former (Spearman ρ: −0.546, p < 0.001) and the latter (Spearman ρ: −0.387, p = 0.001). HADS anxiety and depression values equal or above eight were obtained in 10.8% and 7.7% of patients, respectively.
Conclusion
New‐onset pain in critically ill COVID‐19 survivors is frequent, and it is associated with a lower HRQoL.
Trial registration No.: NCT04394169. Registered 19 May 2020. https://clinicaltrials.gov/ct2/show/NCT04394169.
Significance
A substantial proportion of severe COVID‐19 survivors may develop clinically significant persistent pain, post‐intensive care syndrome and chronic ICU‐related pain. Given the number of infections worldwide and the unprecedented size of the population of critical illness survivors, providing information about the incidence of new‐onset pain, its characteristics, and its influence on the patients’ quality of life might help establish and improve pain management strategies.
Prehabilitation has shown its potential for most intra-cavity surgery patients on enhancing preoperative functional capacity and postoperative outcomes. However, its large-scale implementation is ...limited by several constrictions, such as: i) unsolved practicalities of the service workflow, ii) challenges associated to change management in collaborative care; iii) insufficient access to prehabilitation; iv) relevant percentage of program drop-outs; v) need for program personalization; and, vi) economical sustainability. Transferability of prehabilitation programs from the hospital setting to the community would potentially provide a new scenario with greater accessibility, as well as offer an opportunity to effectively address the aforementioned issues and, thus, optimize healthcare value generation. A core aspect to take into account for an optimal management of prehabilitation programs is to use proper technological tools enabling: i) customizable and interoperable integrated care pathways facilitating personalization of the service and effective engagement among stakeholders; ii) remote monitoring (i.e. physical activity, physiological signs and patient-reported outcomes and experience measures) to support patient adherence to the program and empowerment for self-management; and, iii) use of health risk assessment supporting decision making for personalized service selection. The current manuscript details a proposal to bring digital innovation to community-based prehabilitation programs. Moreover, this approach has the potential to be adopted by programs supporting long-term management of cancer patients, chronic patients and prevention of multimorbidity in subjects at risk.
Multimodal preoperative prehabilitation has been shown to be effective in improving the functional capacity of cancer patients, reducing postoperative complications and the length of hospital and ICU ...stay after surgery. The availability of prehabilitation units that gather all the professionals involved in patient care facilitates the development of integrated and patient-centered multimodal prehabilitation programs, as well as patient adherence. This article describes the process of creating a prehabilitation unit in our center and the role of perioperative nursing. Initially, the project was launched with the performance of a research study on prehabilitation for gastrointestinal cancer surgery. The results of this study encouraged us to continue the implementation of the unit. Progressively, multimodal prehabilitation programs focusing on each type of patient and surgery were developed. Currently, our prehabilitation unit is a care unit that has its own gym, which allows supervised training of cancer patients prior to surgery. Likewise, the evolution of perioperative nursing in the unit is described: from collaboration and assistance in the integral evaluation of the patient at the beginning to current work as a case manager; a task that has proven extremely important for the comprehensive and continuous care of the patient.
Introduction: The efficacy-effectiveness gap constitutes a well-known limitation for adoption of digitally enabled integrated care services. The current report describes the co-creation process ...undertaken (2016–2021) to deploy a prehabilitation service at Hospital Clínic de Barcelona with the final aim of achieving sustainable adoption and facilitate site transferability. Methods: An implementation research approach with a population-based orientation, combining experience-based co-design and quality improvement methodologies, was applied. We undertook several design-thinking sessions (Oct-Nov 2017, June 2021 and December 2021) to generate and follow-up a work plan fostering service scalability. The implementation process was assessed using the Comprehensive Framework for Implementation Research, leading to the identification of key performance indicators. Discussion: Personalization and modularity of the intervention according to patients’ surgical risk were identified as core traits to enhance patients’ adherence and value generation. A digitally enabled service workflow, with an adaptive and collaborative case management approach, should combine face-to-face and remotely supervised sessions with intelligent systems for patients’ and professionals’ decision support. The business model envisages operational costs financed by savings generated by the service. Conclusions: Evidence-based co-creation, combining appropriate methodologies and a structured evaluation framework, was key to address challenges associated with sustainable prehabilitation service adoption, scalability and transferability. Resum Introducció: La bretxa eficàcia-efectivitat limita l’adopció de serveis d’atenció integrada amb suport digital. L’estudi descriu el procés de co-creació efectuat (2016–2021) per desplegar, a l’Hospital Clínic de Barcelona, un servei de prehabilitació de pacients de risc per a procediments quirúrgics, amb l’objectiu d’aconseguir una adopció sostenible del servei i facilitar-ne la transferibilitat. Mètodes: Es van aplicar eines de recerca d’implementació amb una orientació poblacional, combinant metodologies de codisseny basades en l’experiència i de millora de la qualitat. Es van realitzar diverses sessions de design-thinking (Octubre-Novembre de 2017, Juny de 2021 i Desembre de 2021) per generar, i fer el seguiment, d’un pla de treball concebut per assolir escalabilitat del servei. El procés d’implementació es va avaluar utilitzant el Consolidated Framework for Implementation Research (CFIR), que va conduir a la identificació d’indicadors clau de rendiment. Discussió: La personalització i la modularitat de la intervenció segons el risc quirúrgic dels pacients es van identificar com a trets bàsics per millorar l’adherència i la generació de valor. La organització de la prehabilitació, amb un enfocament adaptatiu i col·laboratiu de gestió de casos, hauria de combinar sessions presencials i supervisades remotament amb sistemes intel·ligents de suport a la decisió per a pacients i professionals. El model de negoci preveu que els costos operatius de la prehabilitació siguin finançats per l’estalvi generat. Conclusions: El procés de co-creació, combinant metodologies adequades i un marc d’avaluació estructurat, va esser clau per abordar els reptes associats a l’adopció sostenible del servei, així com la seva escalabilitat i transferibilitat. Paraules clau: Activitat física; Atenció continuada; Co-creació; mHealth; Optimització nutricional; Prehabilitació
Purpose
To define the impact of the COVID-19 outbreak on hospital surgical activity and assess the incidence of perioperative COVID-19 within two protocolized screening pathways for elective and ...non-elective surgery.
Methods
We conducted a prospective cohort study of adults undergoing surgery during the COVID-19 outbreak. The elective pathway included telephone surveys and a quantitative polymerase-chain-reaction test (RT-PCR) only for patients who were asymptomatic and at low risk of infection. Only patients with negative screening underwent surgery. In the non-elective pathway, preoperative screening was performed during the hospital admission.
Results
Among 835 patients considered for the elective pathway, 725 had negative RT-PCR results and underwent surgery. This reflects an 83% reduction in surgical activity from 2019. Moreover, 596 patients underwent non-elective surgery, representing a 28% reduction. Preoperatively, 39 patients (6.5%) tested positive for SARS-CoV-2 and underwent surgery through the non-elective pathway, vs. none in the elective pathway (
p
< 0.001). Postoperatively, 1.4% of elective surgery patients and 2.2% of non-elective surgery patients tested positive (
p
> 0.05). Mortality was higher in non-elective surgery (0.6% vs. 2.9%,
p
< 0.001) and in patients with COVID-19 (0% vs. 14%,
p
< 0.001).
Conclusions
The low incidence of COVID-19 in elective surgeries during the outbreak demonstrates the importance and effectiveness of preoperative screening, combining surveys and RT-PCR.
Chronic diseases are generating a major health and societal burden worldwide. Healthy lifestyles, including physical activity (PA), have proven efficacy in the prevention and treatment of many ...chronic conditions. But, so far, national PA surveillance systems, as well as strategies for promotion of PA, have shown low impact. We hypothesize that personalized modular PA services, aligned with healthcare, addressing the needs of a broad spectrum of individual profiles may show cost-effectiveness and sustainability.
The current manuscript describes the protocol for regional implementation of collaborative self-management services to promote PA in Catalonia (7.5 M habitants) during the period 2017-2019. The protocols of three implementation studies encompassing a broad spectrum of individual needs are reported. They have a quasi-experimental design. That is, a non-randomized intervention group is compared to a control group (usual care) using propensity score methods wherein age, gender and population-based health risk assessment are main matching variables. The principal innovations of the PA program are: i) Implementation of well-structured modular interventions promoting PA; ii) Information and communication technologies (ICT) to facilitate patient accessibility, support collaborative management of individual care plans and reduce costs; and iii) Assessment strategies based on the Triple Aim approach during and beyond the program deployment.
The manuscript reports a precise roadmap for large scale deployment of community-based ICT-supported integrated care services to promote healthy lifestyles with high potential for comparability and transferability to other sites.
This study protocol has been registered at ClinicalTrials.org ( NCT02976064 ). Registered November 24th, 2016.
(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This ...single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s,
< 0.001) and quality-of-life (Minnesota score 58 vs. 47,
0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31,
0.033), lower mechanical ventilation time (37 vs. 20 h,
0.032), ICU stay (7 vs. 5 days,
0.01), total hospitalization stay (23 vs. 18 days,
0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%,
0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.
The mechanism of orthodeoxia (OD), or decreased partial pressure of arterial oxygen (PaO2) from supine to upright, a characteristic feature of hepatopulmonary syndrome (HPS), has never been ...comprehensively elucidated. We therefore investigated the intrapulmonary (shunt and ventilation‐perfusion V̇A/Q̇ mismatching) and extrapulmonary factors governing PaO2 in 20 patients with mild to severe HPS (14 males, 6 females; 50 ± 3 years old SE) at upright and supine, in random order. We set out a cutoff value for OD, namely a PaO2 decrease ≥5% or ≥4 mm Hg (area under the receiver operating characteristic curve, 0.96 each). Compared to supine, 5 patients showed OD (PaO2 change, −11% ± 2%, −7 ± 1 mm Hg, P < .05) with further V̇A/Q̇ worsening (shunt + low V̇A/Q̇ mode increased from 19% ± 7% to 21% ± 7% of cardiac output Q̇T, P < .05), as opposed to 15 patients who did not (+2% ± 2%, +1± 1 mm Hg) with V̇A/Q̇ improvement (from 20% ± 4% to 16% ± 4% of Q̇T, P < .01). Cardiac output was significantly lower in OD patients in both positions. Changes in extrapulmonary factors at upright, such as increased minute ventilation and decreased Q̇T, were of similar magnitude in both subsets of patients. In conclusion, our data suggest that gas exchange response to OD in HPS points to a more altered pulmonary vascular tone inducing heterogeneous blood flow redistribution to lung zones with prominent intrapulmonary vascular dilatations. (HEPATOLOGY 2004;40:660–666.)
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