PREHABILITATION

PREHABILITATION

The functional capacity of a patient can be reduced following major surgery . This can have a significant negative impact on the recovery of patients with poor functional reserve prior to surgery . Prehabilitation is a process of improving the functional capacity of patients prior to major surgery in order to improve postoperative outcomes. The time period between the decision to operate and the surgery date itself is used for prehabilitation. The patient is medically optimised by asking them to, for example, stop smoking, r educe their alcohol intake or lose weight. Anaemia should be treated and blood sugar can be e ff ectively controlled in patients with diabetes during this period. Existing medication should be reviewed and modified if necessary to better control 0  1  2  3 DATE OF BIRTH DATE TIME ≥25 21–24 + A B 18–20 Respirations Breaths/min 15–17 12–14 9–1 1 ≤8 ≥96 94–95 + A B 92–93 SpO Scale 1 2 Oxygen saturation (%) ≤91 on O ≥97 2 † SpO Scale 2 2 Oxygen saturation (%) 95–96 on O 2 Use Scale 2 if target 93–94 on O 2 range is 88–92%, eg in hypercapnic ≥93 on air respiratory failure 88–92 86–87 † ONLY use Scale 2 84–85 under the direction of a qualified clinician ≤83% A=Air Air or oxygen? O L/min 2 Device ≥220 201–219 C 181–200 Blood 161–180 pressure mmHg 141–160 Score uses l systolic BP on y 121–140 111–120 101–110 91–100 81–90 71–80 61–70 51–60 ≤50 ≥131 121–130 C 111–120 Pulse Beats/min 101–110 91–100 81–90 71–80 61–70 51–60 41–50 31–40 ≤30 Alert Confusion D V Consciousness Score for NEW P i onset of confus on i (no score if chron c) U ≥39.1° 38.1–39.0° E 37.1–38.0° Temperature °C 36.1–37.0° 35.1–36.0° ≤35.0° NEWS TOTAL Monitoring frequency Escalation of care Y/N Initials DATE OF ADMISSION DATE TIME 3 3 ≥25 21–24 2 2 18–20 15–17 12–14 9–1 1 1 ≤8 3 ≥96 94–95 1 92–93 2 ≤91 3 on O ≥97 3 2 95–96 on O 2 2 93–94 on O 2 1 ≥93 on air 88–92 86–87 1 84–85 2 ≤83% 3 A=Air O L/min 2 2 Device 3 ≥220 201–219 181–200 161–180 141–160 121–140 111–120 101–110 1 91–100 2 81–90 71–80 61–70 3 51–60 ≤50 ≥131 3 121–130 2 111–120 101–110 1 91–100 81–90 71–80 61–70 51–60 41–50 1 31–40 3 ≤30 Alert Confusion V 3 3 P © Royal College of Physicians 2017 ) U 2 ≥39.1° 1 38.1–39.0° 37.1–38.0° 36.1–37.0° 35.1–36.0° 1 ≤35.0° 3 TOTAL Monitoring Escalation Initials National Early Warning Score 2 (NEWS2

Figure 24.1 An example of an early warning system using patient observations: the National Early Warning System (NEWS) from the Royal College of Physicians. (Reproduced from Royal College of Physicians. of acute-illness severity in the NHS . Updated report of a working party. London: RCP , 2017.) National Early Warning Score (NEWS) 2: Standardising the assessment

hypertension. Functional capacity can be assessed formally using either CPET or the 6-minute walk test. Patients should be encouraged to undertake strength and aerobic exercises in formal programmes or as far as possible to improve their physical fitness. A poor preoperativ e nutritional state leads to poorer outcomes, and correcting nutritional imbalances will help the recovery of the patient. Psychological interventions to reduce anxiety prior to surgery and improve the patient’s motivation to recover after surgery will benefit the patient greatly . Preoperative assessment, including assessment of high-risk surgical patients, has been covered in Chapter 21 . Anaesthesia and pain relief has been covered in Chapter 23 . The postoperativ e phase begins at the end of surgery when the patient is transferred to ‘recovery’ or ‘PACU’. At the end of surgery , a ‘sign out’ is performed as part of the WHO checklist. The thea tre team should then formally hand over the care of the patient to the PACU sta ff . The information provided should include the patient’s name and age, the surgical procedure, the anaesthetic and analgesics given, fluid replacement, blood loss, urine output, any surgical/anaesthetic problems encountered or expected, existing medical problems and allergies. A plan for the management of pain and nausea or vomiting should also be conveyed. PREHABILITATION

The functional capacity of a patient can be reduced following major surgery . This can have a significant negative impact on the recovery of patients with poor functional reserve prior to surgery . Prehabilitation is a process of improving the functional capacity of patients prior to major surgery in order to improve postoperative outcomes. The time period between the decision to operate and the surgery date itself is used for prehabilitation. The patient is medically optimised by asking them to, for example, stop smoking, r educe their alcohol intake or lose weight. Anaemia should be treated and blood sugar can be e ff ectively controlled in patients with diabetes during this period. Existing medication should be reviewed and modified if necessary to better control 0  1  2  3 DATE OF BIRTH DATE TIME ≥25 21–24 + A B 18–20 Respirations Breaths/min 15–17 12–14 9–1 1 ≤8 ≥96 94–95 + A B 92–93 SpO Scale 1 2 Oxygen saturation (%) ≤91 on O ≥97 2 † SpO Scale 2 2 Oxygen saturation (%) 95–96 on O 2 Use Scale 2 if target 93–94 on O 2 range is 88–92%, eg in hypercapnic ≥93 on air respiratory failure 88–92 86–87 † ONLY use Scale 2 84–85 under the direction of a qualified clinician ≤83% A=Air Air or oxygen? O L/min 2 Device ≥220 201–219 C 181–200 Blood 161–180 pressure mmHg 141–160 Score uses l systolic BP on y 121–140 111–120 101–110 91–100 81–90 71–80 61–70 51–60 ≤50 ≥131 121–130 C 111–120 Pulse Beats/min 101–110 91–100 81–90 71–80 61–70 51–60 41–50 31–40 ≤30 Alert Confusion D V Consciousness Score for NEW P i onset of confus on i (no score if chron c) U ≥39.1° 38.1–39.0° E 37.1–38.0° Temperature °C 36.1–37.0° 35.1–36.0° ≤35.0° NEWS TOTAL Monitoring frequency Escalation of care Y/N Initials DATE OF ADMISSION DATE TIME 3 3 ≥25 21–24 2 2 18–20 15–17 12–14 9–1 1 1 ≤8 3 ≥96 94–95 1 92–93 2 ≤91 3 on O ≥97 3 2 95–96 on O 2 2 93–94 on O 2 1 ≥93 on air 88–92 86–87 1 84–85 2 ≤83% 3 A=Air O L/min 2 2 Device 3 ≥220 201–219 181–200 161–180 141–160 121–140 111–120 101–110 1 91–100 2 81–90 71–80 61–70 3 51–60 ≤50 ≥131 3 121–130 2 111–120 101–110 1 91–100 81–90 71–80 61–70 51–60 41–50 1 31–40 3 ≤30 Alert Confusion V 3 3 P © Royal College of Physicians 2017 ) U 2 ≥39.1° 1 38.1–39.0° 37.1–38.0° 36.1–37.0° 35.1–36.0° 1 ≤35.0° 3 TOTAL Monitoring Escalation Initials National Early Warning Score 2 (NEWS2

Figure 24.1 An example of an early warning system using patient observations: the National Early Warning System (NEWS) from the Royal College of Physicians. (Reproduced from Royal College of Physicians. of acute-illness severity in the NHS . Updated report of a working party. London: RCP , 2017.) National Early Warning Score (NEWS) 2: Standardising the assessment

hypertension. Functional capacity can be assessed formally using either CPET or the 6-minute walk test. Patients should be encouraged to undertake strength and aerobic exercises in formal programmes or as far as possible to improve their physical fitness. A poor preoperativ e nutritional state leads to poorer outcomes, and correcting nutritional imbalances will help the recovery of the patient. Psychological interventions to reduce anxiety prior to surgery and improve the patient’s motivation to recover after surgery will benefit the patient greatly . Preoperative assessment, including assessment of high-risk surgical patients, has been covered in Chapter 21 . Anaesthesia and pain relief has been covered in Chapter 23 . The postoperativ e phase begins at the end of surgery when the patient is transferred to ‘recovery’ or ‘PACU’. At the end of surgery , a ‘sign out’ is performed as part of the WHO checklist. The thea tre team should then formally hand over the care of the patient to the PACU sta ff . The information provided should include the patient’s name and age, the surgical procedure, the anaesthetic and analgesics given, fluid replacement, blood loss, urine output, any surgical/anaesthetic problems encountered or expected, existing medical problems and allergies. A plan for the management of pain and nausea or vomiting should also be conveyed.