Pre-operative exercise and pyrexia as modifying factors in malignant hyperthermia (MH).

Malignant hyperthermia (MH) is a life-threatening reaction triggered by volatile anesthetics and succinylcholine. MH is caused by mutations in the skeletal muscle ryanodine receptor (RYR1) gene, as is rhabdomyolysis triggered by exertion and/or pyrexia. The discrepancy between the prevalence of risk genotypes and actual MH incidence remains unexplained. We investigated the role of pre-operative exercise and pyrexia as potential MH modifying factors. We included cases from 5 MH referral centers with 1) clinical features suggestive of MH, 2) confirmation of MH susceptibility on Contracture Testing (IVCT or CHCT) and/or RYR1 genetic testing, and a history of 3) strenuous exercise within 72 h and/or pyrexia >37.5 °C prior to the triggering anesthetic. Characteristics of MH-triggering agents, surgery and succinylcholine use were collected. We identified 41 cases with general anesthesias resulting in an MH event (GA+MH, n = 41) within 72 h of strenuous exercise and/or pyrexia. We also identified previous general anesthesias without MH events (GA-MH, n = 51) in the index cases and their MH susceptible relatives. Apart from pre-operative exercise and/or pyrexia, trauma and acute abdomen as surgery indications, emergency surgery and succinylcholine use were also more common with GA+MH events. These observations suggest a link between pre-operative exercise, pyrexia and MH.

Prehabilitation, enhanced recovery after surgery, or both? A narrative review.

This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.

Impacts of the perioperative fast track surgery concept on the physical and psychological rehabilitation of total hip arthroplasty: A prospective cohort study of 348 patients.

ABSTRACT: Studies have shown that rapid rehabilitation surgery has a positive effect on recovery after major orthopedic surgery. However, very few studies have examined the impact of fast track surgery on physical and psychological rehabilitation in patients who have undergone total hip replacement.This study aimed to investigate the value of the rapid rehabilitation surgical model for patients undergoing total hip arthroplasty during the perioperative period.We conducted a prospective cohort study that included patients who underwent total hip arthroplasty at our hospital from January 2015 to December 2018. We divided the patients into 2 groups - the rapid rehabilitation group and the conventional rehabilitation group - and compared their length of hospital stay, time to off-bed activity, pain score, Self-Rating Anxiety Scale scores, Self-Rating Depression Scale scores, complication rate, and rate of satisfaction during hospitalization.A total of 348 patients were included in the study. Of these, 180 received rapid rehabilitation nursing and 168 patients received conventional nursing. Compared with the patients in the conventional rehabilitation group, those in the rapid rehabilitation group had shorter hospital stays (11.5 ±â€Š1.2 day vs 15.5 ±â€Š2.3 day, P = .021), resumed off-bed activities sooner (20.5 ±â€Š3.4 hours vs 61.8 ±â€Š4.7 hours, P = .001, had less postoperative pain (4.0 ±â€Š1.2 vs 6.5 ±â€Š1.1, P < .001), and lower anxiety and depression scores (anxiety score: 24.4 ±â€Š2.1 vs 47.9 ±â€Š2.9; depression score: 25.8 ±â€Š1.8 vs 43.7 ±â€Š1.7, P < .001).The application of rapid rehabilitation surgery in total hip arthroplasty can accelerate patients' postoperative recovery, relieve anxiety and depression, and increase the patient's satisfaction with the treatment.

On All Accounts: Cost-Effectiveness Analysis of Limited Preoperative Optimization Efforts Before Colon Cancer Surgery.

BACKGROUND: Reports suggest that preoperative optimization of a patient's serious comorbidities is associated with a reduction in postoperative complications. OBJECTIVE: The purpose of this study was to assess the cost and benefits of preoperative optimization, accounting for total costs associated with postoperative morbidity. DESIGN: This study is a decision tree cost-effectiveness analysis with probabilistic sensitivity analysis (10,000 iterations). SETTING: This is a hypothetical scenario of stage II colon cancer surgery. PATIENT: The simulated 65-year-old patient has left-sided, stage II colon cancer. INTERVENTION: Focused preoperative optimization targets high-risk comorbidities. OUTCOMES: Total discounted (3%) economic costs (US $2018), effectiveness (quality-adjusted life-years), incremental cost-effectiveness ratio (incremental cost-effectiveness ratio, cost/quality-adjusted life-years gained), and net monetary benefit. RESULTS: We calculated the per individual expected health care sector total cost of preoperative optimization and sequelae to be $12,395 versus $15,638 in those not optimized (net monetary benefit: $1.04 million versus $1.05 million). A nonoptimized patient attained an average 0.02 quality-adjusted life-years less than one optimized. Thus, preoperative optimization was the dominant strategy (lower total costs; higher quality-adjusted life-years). Probabilistic sensitivity analysis demonstrated 100% of simulations favoring preoperative optimization. The breakeven cost of optimization to remain cost-effective was $6421 per patient. LIMITATIONS: Generalizability must account for the lack of standardization among existing preoperative optimization efforts, and decision analysis methodology provides guidance for the average patient or general population, and is not patient-specific. CONCLUSIONS: Although currently not comprehensively reimbursed, focused preoperative optimization may reduce total costs of care while also reducing complications from colon cancer surgery. See Video Abstract at http://links.lww.com/DCR/B494. EN TODO CASO ANLISIS DE RENTABILIDAD DE LOS ESFUERZOS LIMITADOS DE OPTIMIZACIN PREOPERATORIA ANTES DE LA CIRUGA DE CNCER DE COLON: ANTECEDENTES:Los informes sugieren que la optimización preoperatoria de las comorbilidades graves de un paciente se asocia con una reducción de las complicaciones postoperatorias.OBJETIVO:El propósito de este estudio fue evaluar el costo y los beneficios de la optimización preoperatoria, teniendo en cuenta los costos totales asociados con la morbilidad postoperatoria.DISEÑO:Análisis de costo-efectividad de árbol de decisión con análisis de sensibilidad probabilístico (10,000 iteraciones).AJUSTE ENTORNO CLINICO:Escenario hipotético Cirugía de cáncer de colon en estadio II.PACIENTE:Paciente simulado de 65 años con cáncer de colon en estadio II del lado izquierdo.INTERVENCIÓN:Optimización preoperatoria enfocada dirigida a comorbilidades de alto riesgo.RESULTADOS:Costos económicos totales descontados (3%) (US $ 2018), efectividad (años de vida ajustados por calidad [AVAC]), relación costo-efectividad incremental (ICER, costo / AVAC ganado) y beneficio monetario neto (NMB).RESULTADOS:Calculamos que el costo total esperado por sector de atención médica individual de la optimización preoperatoria y las secuelas es de $ 12,395 versus $ 15,638 en aquellos no optimizados (NMB: $ 1.04 millones versus $ 1.05 millones, respectivamente). Un paciente no optimizado alcanzó un promedio de 0.02 AVAC menos que uno optimizado. Por lo tanto, la optimización preoperatoria fue la estrategia dominante (menores costos totales; mayores AVAC). El análisis de sensibilidad probabilístico demostró que el 100% de las simulaciones favorecían la optimización preoperatoria. El costo de equilibrio de la optimización para seguir siendo rentable fue de $ 6,421 por paciente.LIMITACIONES:La generalización debe tener en cuenta la falta de estandarización entre los esfuerzos de optimización preoperatorios existentes y esa metodología de análisis de decisiones proporciona una guía para el paciente promedio o la población general, no específica del paciente.CONCLUSIONES:Si bien actualmente no se reembolsa de manera integral, la optimización preoperatoria enfocada puede reducir los costos totales de la atención y al mismo tiempo reducir las complicaciones de la cirugía de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B494.

Effectiveness of an exercise-based prehabilitation program for patients awaiting surgery for lumbar spinal stenosis: a randomized clinical trial.

Lumbar spinal stenosis is the most common reason for spine surgery in older adults, but the effects of prehabilitation on perioperative outcomes among these patients have not been investigated. This study aims to evaluate the effectiveness of a preoperative exercise-based intervention program compared with usual care on the improvement of clinical status, physical capacities and postoperative recovery of patients awaiting surgery for lumbar spinal stenosis. Sixty-eight participants were randomised to receive either a 6-week supervised exercise-based prehabilitation program or hospital usual care. The outcomes included both clinical and physical measures. Data collection occurred at post-intervention, and 6 weeks, 3- and 6-months post-surgery. Significant but small improvements were found in favour of the experimental group at the post-intervention assessment for pain intensity, lumbar spinal stenosis-related disability, lumbar strength in flexion, low back extensor muscles endurance, total ambulation time, and sit to stand performance. A significant difference in favor of the intervention group was found starting at the 3-month postoperative follow-up for low back-related disability. No adverse events were reported. Exercise-based prehabilitation did not improve short-term postoperative recovery in patients with lumbar spinal stenosis.

Role of Cachexia and Fragility in the Patient Candidate for Cardiac Surgery.

Frailty is the major expression of accelerated aging and describes a decreased resistance to stressors, and consequently an increased vulnerability to additional diseases in elderly people. The vascular aging related to frail phenotype reflects the high susceptibility for cardiovascular diseases and negative postoperative outcomes after cardiac surgery. Sarcopenia can be considered a biological substrate of physical frailty. Malnutrition and physical inactivity play a key role in the pathogenesis of sarcopenia. We searched on Medline (PubMed) and Scopus for relevant literature published over the last 10 years and analyzed the strong correlation between frailty, sarcopenia and cardiovascular diseases in elderly patient. In our opinion, a right food intake and moderate intensity resistance exercise are mandatory in order to better prepare patients undergoing cardiac operation.

Determinants of Cardiorespiratory Fitness After Bariatric Surgery: Insights From a Randomised Controlled Trial of a Supervised Training Program.

BACKGROUND: Severely obese patients have decreased cardiorespiratory fitness (CRF) and poor functional capacity. Bariatric surgery-induced weight loss improves CRF, but the determinants of this improvement are not well known. We aimed to assess the determinants of CRF before and after bariatric surgery and the impact of an exercise training program on CRF after bariatric surgery. METHODS: Fifty-eight severely obese patients (46.1 ± 6.1 kg/m2, 78% women) were randomly assigned to either an exercise group (n = 39) or usual care (n = 19). Exercise training was conducted from the 3rd to the 6th months after surgery. Anthropometric measurements, abdominal and mid-thigh computed tomographic scans, resting echocardiography, and maximal cardiopulmonary exercise testing was performed before bariatric surgery and 3 and 6 months after surgery. RESULTS: Weight, fat mass, and fat-free mass were reduced significantly at 3 and 6 months, without any additive impact of exercise training in the exercise group. From 3 to 6 months, peak aerobic power (V̇O2peak) increased significantly (P < 0.0001) in both groups but more importantly in the exercise group (exercise group: from 18.6 ± 4.2 to 23.2 ± 5.7 mL/kg/min; control group: from 17.4 ± 2.3 to 19.7 ± 2.4 mL/kg/min; P value, group × time = 0.01). In the exercise group, determinants of absolute V̇O2peak (L/min) were peak exercise ventilation, oxygen pulse, and heart rate reserve (r2 = 0.92; P < 0.0001), whereas determinants of V̇O2peak indexed to body mass (mL/kg/min) were peak exercise ventilation and early-to-late filling velocity ratio (r2 = 0.70; P < 0.0001). CONCLUSIONS: A 12-week supervised training program has an additive benefit on cardiorespiratory fitness for patients who undergo bariatric surgery.

High-intensity interval training in the prehabilitation of cancer patients-a systematic review and meta-analysis.

PURPOSE: To evaluate the impact of high-intensity interval training (HIIT) on health-related outcome parameters in the prehabilitation of patients diagnosed with cancer. METHODS: A systematic review and meta-analysis of comparative studies on HIIT in cancer prehabilitation conducted by screening standard databases from their inception to March 30, 2020. Outcomes of interest included cardiorespiratory fitness, feasibility, safety, clinical, and patient-reported outcomes. RESULTS: Of the 855 identified studies, 8 articles met the inclusion criteria (7 randomized, 1 non-randomized controlled trial) with a total of 896 patients. The study protocols were heterogeneous, but the methodological quality ranged from good to high according to PEDro scale. Meta-analysis revealed a significant improvement of peak oxygen consumption (VO2peak) achieved with HIIT compared to usual care. Furthermore, HIIT was feasible and safe, showing low risk of adverse events and positive effects on health-related outcomes in prehabilitative settings. CONCLUSION: In the phase of prehabilitation, HIIT has potential health benefits in patients diagnosed with cancer and is feasible and safe to perform. Nonetheless, larger randomized controlled trials focusing on long-term effects (such as cancer recurrence or survival rates) are missing, to underline the potential relevance of HIIT for cancer patients.

Patient acceptance of prehabilitation for major surgery: an exploratory survey.

PURPOSE: Prehabilitation programs are effective in optimising patient's functional reserve prior to surgery and increasingly associated with reduced postoperative complications. However, acceptability of programs among patients is largely unknown. This study set out to explore the acceptability of prehabilitation from the perspective of patients awaiting major cancer surgery. METHODS: Adult patients awaiting major gastrointestinal and urological cancer surgeries were surveyed. Patients were excluded if they were unable to complete the survey due to language, intellectual impairment and/or visual/hearing deficit. The survey was designed to explore categories related to patient demographics, level of physical activity and perceived enablers and barriers to prehabilitation. RESULTS: One hundred and three participants presenting to a pre-anaesthesia clinic completed the survey over a 5-month period, with 83% response rate. Approximately, half of the respondents were female (55%) and were currently physically active (53%). Fewer than one third (30%) felt they completed 'enough exercise'. The majority of participants (83%) were unfamiliar with the concept of prehabilitation but two thirds (68%) were interested in such a program after explanation. The majority of participants (72%) indicated a strong preference to exercise in a home-based environment. Medical recommendation increased willingness to participate (p < 0.001), while program costs (p = 0.01) were potential barriers to participation. CONCLUSION: Patients are willing to participate in prehabilitation prior to major cancer surgery but practical barriers and facilitators should be considered when designing prehabilitation programs to maximise patient commitment to facilitate improved postoperative outcomes.

[Approaches to the pre-operative functional assessment of patients with lung cancer and preoperative rehabilitation]. / Bilan fonctionnel préopératoire du cancer bronchique et réhabilitation préopératoire.

Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.

Prehabilitation program for African sub-Saharan surgical patients is an unmet need.

Approximately 4.2 million people worldwide die within 30 days of surgery each year. Half of these deaths occur in low- and middle-income countries. Postoperative deaths account for 7.7% of all deaths globally, making it the third-highest contributor to deaths, after heart disease and stroke. In sub-Saharan Africa, there is a higher rate of mortality following postoperative complications compared to high-income countries. The WHO has tools to help countries provide safer surgery. However, implementation remains poor in most African countries. Interventions focused on intraoperative or postoperative measures to improve perioperative prognosis may be too late for high-risk patients. Poor preoperative cardiorespiratory functional capacity, poor management of pre-existing comorbidities and risk factors and no assessment of the patient´s surgical risk is associated with adverse postoperative outcomes, including mortality, complications, slower recovery, longer intensive care stay, extended hospital length of stay and reduced postoperative quality of life. To significantly decrease morbidity and mortality following surgery in Africa, we propose the implementation of a comprehensive preoperative intervention, that must include: i) risk assessment of surgical patients to identify those at greater risk of postoperative complications for elective surgery; ii) increase the preoperative functional reserve of these high-risk patients, to enhance their tolerance to surgical stress and improve postoperative recovery; iii) anticipate postoperative care needs and organize tools, resources and establish simple workflows to manage postoperative complications. We believe this approach is simple, feasible and will significantly reduce postoperative burden for both patients, hospitals and society.

The Feasibility and Impact of a Presurgical Exercise Intervention Program (Prehabilitation) for Patients Undergoing Cystectomy for Bladder Cancer.

OBJECTIVE: To assess the feasibility of a prehabilitation program for cystectomy patients and to determine the effectiveness of the program in improving strength and functional capacity in the peri-operative period. MATERIALS AND METHODS: This phase I/II study accrued patients ≥60 years old from January 2013 to October 2017 with biopsy-proven bladder cancer, Karnofsky performance score ≥70 and a sedentary baseline lifestyle to participate in a 4-week supervised preoperative exercise training program. Primary outcomes were feasibility and safety; secondary outcomes included changes in fitness, patient-reported QOL, peri-operative complications and readmissions. Student's ttests and Wilcoxon signed-rank test were performed. RESULTS: Fifty-four patients enrolled in the program. Successful completion, defined as patients who began the program and adhered to >70% of the sessions, was attained by 41 of 51 patients (80.4%, 90% CI [71%-90%]). There were no adverse events. Fitness and patient-reported QOL improved postintervention, with sustained improvements in general and mental health 90-days postsurgery. The primary limitation is no control group. CONCLUSION: Prehabilitation prior to cystectomy is feasible, safe, and results in improvements in patient strength, endurance and sustained improvements in patient-reported QOL from baseline. Efforts to further evaluate the impact of prehabilitation in this population in an expanded and randomized fashion are warranted.

Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes.

Important elements of the preoperative assessment that should be addressed for the older adult population include frailty, comorbidities, nutritional status, cognition, and medications. Frailty has emerged as a plausible predictor of adverse outcomes after surgery. It is present in older patients and is characterized by multisystem physiologic decline, increased vulnerability to stressors, and adverse clinical outcomes. Preoperative preparation may include a prehabilitation program, which aims to address nutritional insufficiencies, modify chronic polypharmacy, and enhance physical and respiratory conditions prior to hospital admission. Special considerations are taken for particularly high-risk patients, where the approach to prehabilitation can address specific, individual risk factors. Identifying patients who are nutritionally deficient allows practitioners to intervene preoperatively to optimize their nutritional status, and different strategies are available, such as immunonutrition. Previous studies have shown an association between increased frailty and the risk of postoperative complications, morbidity, hospital length of stay, and 30-day and long-term mortality following general surgical procedures. Evidence from numerous studies suggests a potential benefit of including a standard assessment of frailty as part of the preoperative workup of older adult patients. Studies addressing validated frailty assessments and the quantification of their predictive capabilities in various surgeries are warranted.

A single-center prospective observational study on the effect of trimodal prehabilitation in colorectal surgery. / Estudio observacional prospectivo unicéntrico sobre el efecto de la prehabilitación trimodal en cirugía colorrectal.

INTRODUCTION: A trimodal prehabilitation protocol was designed with the aim to evaluate whether it contributes to reducing postoperative morbidity, to evaluate the effect of prehabilitation on overall hospital stay, and to analyze the evolution of functional capacity before and after surgery. METHODS: A single-center observational study of patients with colorectal cancer who underwent surgery with curative intent after a trimodal prehabilitation protocol. We collected data for postoperative morbidity according to the Comprehensive Complication Index and hospital stay, which were compared with a historical matrix. Functional capacity data were also collected before and after the application of the prehabilitation protocol. RESULTS: Compared to the historical population, the overall Comprehensive Complication Index was reduced from 13.2 to 11.5, which was statistically significant. Analyzed by morbidity type, all decreased in percentage, although without achieving significance (surgical site infection from 11.7% to 8.4%, nosocomial infection 15.8 to 10% and medical morbidity 8.6% to 4.2%). The overall hospital stay went from 6 to 4 days, and the decrease in the percentage of patients who prepared at home was statistically significant in both cases. CONCLUSIONS: Trimodal prehabilitation can contribute to lowering the postoperative morbidity and overall hospital stay of patients undergoing colorectal cancer surgery.

Prehabilitation: metabolic considerations.

PURPOSE OF REVIEW: The major components of ERAS attenuate the inflammatory response and modulate metabolism in direction of sparing body protein and preserving function. However, these perioperative interventions might have limited effectiveness on postoperative outcomes if preoperative risk factors are not addressed and optimized. RECENT FINDINGS: The preoperative metabolic perturbations characterized by insulin resistance and sarcopenia might predispose patients to a higher degree of postoperative catabolism. High-risk populations for such metabolic disturbances include elderly and frail patients, and patients with metabolic syndrome. Research on the effect of prehabilitation on perioperative metabolism is limited, but recent findings suggest that interventions designed to improve insulin sensitivity prior to surgery might represent a promising therapeutic target to minimize surgical complications. SUMMARY: The present paper will discuss the metabolic implications of modulating preoperative risk factors with elements of multimodal prehabilitation, such as exercise training and nutrition.

Cognitive rehabilitation and prehabilitation in people with epilepsy.

Epilepsy is now recognized as a network disorder of the brain that can impact cognition beyond the periictal disturbance associated with seizures. While there is a large literature on the assessment of cognitive functions, particularly memory, in people with epilepsy, there are far fewer studies looking at the efficacy of treatments for cognitive dysfunction in this population. Reviews of the cognitive rehabilitation literature in epilepsy have begun to outnumber original studies. This paper examines the possible reasons for this unsatisfactory ratio in the literature and examines the unique challenges and opportunities for cognitive rehabilitation in this population, with a particular focus on epilepsy surgical candidates. The concept of prehabilitation in this population is described. While traditional cognitive rehabilitation is implemented after a patient has developed a neuropsychological deficit, in surgical candidates, prehabilitation uses intact functions before they are lost to establish compensatory strategies and routines prior to surgery in preparation for postoperative changes. The likely postoperative neuropsychological profile for individual patients can now be modeled using preoperative data. These predictions can guide and inform the prehabilitation process. Rather than concluding with a generic call for more research, the paper presents a framework for a rehabilitation program with practical solutions to address cognitive difficulties in both surgical and nonsurgical populations of people with epilepsy.

High-intensity interval training produces a significant improvement in fitness in less than 31 days before surgery for urological cancer: a randomised control trial.

OBJECTIVES: To assess the efficacy of high-intensity interval training (HIIT) for improving cardiorespiratory fitness (CRF) in patients awaiting resection for urological malignancy within four weeks. SUBJECTS/PATIENTS AND METHODS: A randomised control trial of consecutive patients aged (>65 years) scheduled for major urological surgery in a large secondary referral centre in a UK hospital. The primary outcome is change in anaerobic threshold (VO2AT) following HIIT vs. standard care. RESULTS: Forty patients were recruited (mean age 72 years, male (39): female (1)) with 34 completing the protocol. Intention to treat analysis showed significant improvements in anaerobic threshold (VO2AT; mean difference (MD) 2.26 ml/kg/min (95% CI 1.25-3.26)) following HIIT. Blood pressure (BP) also significantly reduced in following: HIIT (SBP: -8.2 mmHg (95% CI -16.09 to -0.29) and DBP: -6.47 mmHg (95% CI -12.56 to -0.38)). No reportable adverse safety events occurred during HIIT and all participants achieved >85% predicted maximum heart rate during sessions, with protocol adherence of 84%. CONCLUSIONS: HIIT can improve CRF and cardiovascular health, representing clinically meaningful and achievable pre-operative improvements. Larger randomised trials are required to investigate the efficacy of prehabilitation HIIT upon different cancer types, post-operative complications, socio-economic impact and long-term survival.