Postoperative complications and mobilisation following major abdominal surgery with vs. without fitness tracker-based feedback (EXPELLIARMUS): study protocol for a student-led multicentre randomised controlled trial (CHIR-Net SIGMA study group).

BACKGROUND: Postoperative complications following major abdominal surgery are frequent despite progress in surgical technique and perioperative care. Early and enhanced postoperative mobilisation has been advocated to reduce postoperative complications, but it is still unknown whether it can independently improve outcomes after major surgery. Fitness trackers (FTs) are a promising tool to improve postoperative mobilisation, but their effect on postoperative complications and recovery has not been investigated in clinical trials. METHODS: This is a multicentre randomised controlled trial with two parallel study groups evaluating the efficacy of an enhanced and early mobilisation protocol in combination with FT-based feedback in patients undergoing elective major abdominal surgery. Participants are randomly assigned (1:1) to either the experimental group, which receives daily step goals and a FT giving feedback about daily steps, or the control group, which is mobilised according to hospital standards. The control group also receives a FT, however with a blackened screen; thus no FT-based feedback is possible. Randomisation will be stratified by type of surgery (laparoscopic vs. open). The primary endpoint of the study is postoperative morbidity within 30 days measured via the Comprehensive Complication Index. Secondary endpoints include number of steps as well as a set of functional, morbidity and safety parameters. A total of 348 patients will be recruited in 15 German centres. The study will be conducted and organised by the student-led German Clinical Trial Network SIGMA. DISCUSSION: Our study aims at investigating whether the implementation of a simple mobilisation protocol in combination with FT-based feedback can reduce postoperative morbidity in patients undergoing major abdominal surgery. If so, FTs would offer a cost-effective intervention to enhance postoperative mobilisation and improve patient outcomes. TRIAL REGISTRATION: Deutsches Register Klinischer Studien (DRKS, German Clinical Trials Register): DRKS00016755, UTN U1111-1228-3320. Registered on 06.03.2019.

Comparison of Automated Activity Recognition to Provider Observations of Patient Mobility in the ICU.

OBJECTIVES: To compare noninvasive mobility sensor patient motion signature to direct observations by physicians and nurses. DESIGN: Prospective, observational study. SETTING: Academic hospital surgical ICU. PATIENTS AND MEASUREMENTS: A total of 2,426 1-minute clips from six ICU patients (development dataset) and 4,824 1-minute clips from five patients (test dataset). INTERVENTIONS: None. MAIN RESULTS: Noninvasive mobility sensor achieved a minute-level accuracy of 94.2% (2,138/2,272) and an hour-level accuracy of 81.4% (70/86). CONCLUSIONS: The automated noninvasive mobility sensor system represents a significant departure from current manual measurement and reporting used in clinical care, lowering the burden of measurement and documentation on caregivers.

Wearable-Based Mobile Health App in Gastric Cancer Patients for Postoperative Physical Activity Monitoring: Focus Group Study.

BACKGROUND: Surgical cancer patients often have deteriorated physical activity (PA), which in turn, contributes to poor outcomes and early recurrence of cancer. Mobile health (mHealth) platforms are progressively used for monitoring clinical conditions in medical subjects. Despite prevalent enthusiasm for the use of mHealth, limited studies have applied these platforms to surgical patients who are in much need of care because of acutely significant loss of physical function during the postoperative period. OBJECTIVE: The aim of our study was to determine the feasibility and clinical value of using 1 wearable device connected with the mHealth platform to record PA among patients with gastric cancer (GC) who had undergone gastrectomy. METHODS: We enrolled surgical GC patients during their inpatient stay and trained them to use the app and wearable device, enabling them to automatically monitor their walking steps. The patients continued to transmit data until postoperative day 28. The primary aim of this study was to validate the feasibility of this system, which was defined as the proportion of participants using each element of the system (wearing the device and uploading step counts) for at least 70% of the 28-day study. "Definitely feasible," "possibly feasible," and "not feasible" were defined as ≥70%, 50%-69%, and <50% of participants meeting the criteria, respectively. Moreover, the secondary aim was to evaluate the clinical value of measuring walking steps by examining whether they were associated with early discharge (length of hospital stay <9 days). RESULTS: We enrolled 43 GC inpatients for the analysis. The weekly submission rate at the first, second, third, and fourth week was 100%, 93%, 91%, and 86%, respectively. The overall daily submission rate was 95.5% (1150 days, with 43 subjects submitting data for 28 days). These data showed that this system met the definition of "definitely feasible." Of the 54 missed transmission days, 6 occurred in week 2, 12 occurred in week 3, and 36 occurred in week 4. The primary reason for not sending data was that patients or caregivers forgot to charge the wearable devices (>90%). Furthermore, we used a multivariable-adjusted model to predict early discharge, which demonstrated that every 1000-step increment of walking on postoperative day 5 was associated with early discharge (odds ratio 2.72, 95% CI 1.17-6.32; P=.02). CONCLUSIONS: Incorporating the use of mobile phone apps with wearable devices to record PA in patients of postoperative GC was feasible in patients undergoing gastrectomy in this study. With the support of the mHealth platform, this app offers seamless tracing of patients' recovery with a little extra burden and turns subjective PA into an objective, measurable parameter.

Association of Wearable Activity Monitors With Assessment of Daily Ambulation and Length of Stay Among Patients Undergoing Major Surgery.

Importance: Early postoperative ambulation is vital to minimizing length of stay (LOS), but few hospitals objectively measure ambulation to predict outcomes. Wearable activity monitors have the potential to transform assessment of postoperative ambulation, but key implementation data, including whether digitally monitored step count can identify patients at risk for poor efficiency outcomes, are lacking. Objectives: To define the distribution of digitally measured daily step counts after major inpatient surgical procedures, to assess the accuracy of physician assessment and ordering of ambulation, and to quantify the association of digitally measured step count with LOS. Design, Setting, and Participants: Prospective cohort study at Cedars-Sinai Medical Center, an urban tertiary referral center. Participants were patients undergoing 8 inpatient operations (lung lobectomy, gastric bypass, hip replacement, robotic cystectomy, open colectomy, abdominal hysterectomy, sleeve gastrectomy, and laparoscopic colectomy) from July 11, 2016, to August 30, 2017. Interventions: Use of activity monitors to measure daily postoperative step count. Main Outcomes and Measures: Operation-specific daily step count, daily step count by physician orders and assessment, and a prolonged LOS (>70th percentile for each operation). Results: Among 100 patients (53% female), the mean (SD) age was 53 (18) years, and the median LOS was 4 days (interquartile range, 3-6 days). There was a statistically significant increase in daily step count with successive postoperative days in aggregate (r = 0.55; 95% bootstrapped CI, 0.47-0.62; P < .001) and across individual operations. Ninety-five percent (356 of 373) of daily ambulation orders were "ambulate with assistance," although daily step counts ranged from 0 to 7698 steps (0-5.5 km) under this order. Physician estimation of ambulation was predictive of the median step count (r = 0.66; 95% bootstrapped CI, 0.59-0.72; P < .001), although there was substantial variation within each assessment category. For example, daily step counts ranged from 0 to 1803 steps (0-1.3 km) in the "out of bed to chair" category. Higher step count on postoperative day 1 was associated with lower odds of prolonged LOS from 0 to 1000 steps (odds ratio [OR], 0.63; 95% CI, 0.45-0.84; P = .003), with no further decrease in odds after 1000 steps (OR, 0.99; 95% CI, 0.75-1.30; P = .80). Conclusions and Relevance: In this study, digitally measured step count up to 1000 steps on postoperative day 1 was associated with lower probability of a prolonged LOS. Wearable activity monitors improved the accuracy of assessment of daily step count over the current standard of care, providing an opportunity to identify patients at risk for poor efficiency outcomes.

Joint distraction and early mobilization using a new dynamic external finger fixator for the treatment of fracture-dislocations of the proximal interphalangeal joint.

BACKGROUND: Dynamic external fixation is a useful treatment option for unstable fracture-dislocations of the proximal interphalangeal (PIP) joint, because it simultaneously reduces axial pressure load on the joint surface, maintains congruent joint reduction, and permits early joint motion. However, most current devices are large, hindering finger movement, and unstable. To address these problems, we developed a dynamic external finger fixator, named the Micro Ortho Fixator®. The purpose of this study was to review the results of using the new external finger fixator to treat unstable fracture-dislocations of the PIP joint. MATERIALS AND METHODS: Nine patients who sustained unstable fracture-dislocation injuries of the PIP joint were treated with the Micro Ortho Fixator®. Seven fractures were accompanied by depressed bony fragments at the base of the middle phalanx. All patients were evaluated for pain and range of PIP motion at the final follow-up. Radiographs of the affected fingers were evaluated for PIP congruity and reduction. The mean follow-up duration was 11.1 months (range: 6-33 months). RESULTS: At the final follow-up, pain averaged 0.3 (range: 0-2) on the Numeric Pain Rating Scale, and the total arc of motion at the PIP joint averaged 91.2° (range: 50-110°). All fractures had healed, and the intra-articular step-off improved from 1.9 mm (SD: 1.0) before surgery to 0.2 mm (SD: 0.4) at the final follow-up. The patients who sustained sports injuries returned to competition after an average of 3.5 months (range: 2.5-4 months). CONCLUSION: The external fixator is compact and facilitates range-of-motion (ROM) exercises, has high stability, and achieves good joint congruity and an ROM equivalent to the healthy joint of the patient. STUDY DESIGN/LEVEL OF EVIDENCE: Therapeutic/IV.

The effect of different ankle and knee supports on balance in early ambulation of post-stroke hemiplegic patients.

The purpose of this study was to compare the effects of different ankle and knee supports on balance in early ambulation of post-stroke hemiplegic patients. This is a randomized experimental study. The study sample included 20 hemiplegic patients who were able to stand with support and who had been diagnosed with a cerebrovascular accident within the last month. A knee immobilization brace (KIB) was first placed on each individual (first application), followed by placement of knee immobilizer brace and Foot Lifter Orthosis ® (FLO) (second application), and lastly, placement of KIB and rigid taping (RT) (third application). The balance parameters of the patients were evaluated using the Korebalance system. The mean age of the patients was 65.1 ± 4.7 years, and the mean number of days that had passed since stroke occurred was 14.6 ± 4.97. In calculating the front/left balance scores of the applications, statistically significant differences were observed in the comparisons of all three supports and first-second applications performed (p = 0.041 and p = 0.021, respectively). Regarding the total scores between the applications, statistically significant differences were determined in balance in the comparisons on all three supports, in comparisons between the first and second applications, and in the comparisons between the second and third applications (p = 0.004, p = 0.007, and p = 0.001, respectively). Based on the findings from this study, it is recommended that the use of a knee immobilizer brace in combination with a foot lifter orthosis for post-stroke hemiplegic patients in early ambulation can lead to considerably improved standing balance.

Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage.

BACKGROUND: Recent trials have challenged the notion that very early mobility benefits patients with acute stroke. It is unclear how cerebral autoregulatory impairments, prevalent in this population, could be affected by mobilization. The safety of mobilizing patients who have external ventricular drainage (EVD) devices for cerebrospinal fluid diversion and intracranial pressure (ICP) monitoring is another concern due to risk of device dislodgment and potential elevation in ICP. We report hemodynamic and ICP responses during progressive, device-assisted mobility interventions performed in a critically ill patient with intracerebral hemorrhage (ICH) requiring two EVDs. METHODS: A 55-year-old man was admitted to the Neuroscience Critical Care Unit with an acute thalamic ICH and complex intraventricular hemorrhage requiring placement of two EVDs. Progressive mobilization was achieved using mobility technology devices. Range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using a tilt table. Physiological parameters were recorded before and after the interventions. RESULTS: All mobility interventions were completed without any adverse event or clinically detectable change in the patient's neurological state. Physiological parameters including hemodynamic variables and ICP remained within prescribed goals throughout. CONCLUSION: Progressive, device-assisted early mobilization was feasible and safe in this critically ill patient with hemorrhagic stroke when titrated by an interdisciplinary team of skilled healthcare professionals. Studies are needed to gain insight into the hemodynamic and neurophysiological responses associated with early mobility in acute stroke to identify subsets of patients who are most likely to benefit from this intervention.

Early or delayed provision of an ankle-foot orthosis in patients with acute and subacute stroke: a randomized controlled trial.

OBJECTIVE: (1) To study the effects of providing ankle-foot orthoses in subjects with (sub)acute stroke; and (2) to study whether the point in time at which an ankle-foot orthosis is provided post-stroke (early or delayed) influences these effects. DESIGN: Randomized controlled trial. SETTING: Rehabilitation centre. SUBJECTS: Unilateral hemiparetic stroke subjects with indication for use of an ankle-foot orthosis and maximal six weeks post-stroke. INTERVENTIONS: Subjects were randomly assigned to: early provision (at inclusion; Week 1) or delayed provision (eight weeks later; Week 9). OUTCOME MEASURES: 10-metre walk test, 6-minute walk test, Timed Up and Go Test, stairs test, Functional Ambulation Categories, Berg Balance Scale, Rivermead Mobility Index and Barthel Index; assessed in Weeks 1, 3, 9 and 11. RESULTS: A total of 33 subjects were randomized (16 early, 17 delayed). Positive effects of ankle-foot orthoses were found two weeks after provision, both when provided early (significant effects on all outcomes) or delayed (Berg Balance Scale p = 0.011, Functional Ambulation Categories p = 0.008, 6-minute walk test p = 0.005, Timed Up and Go Test p = 0.028). Comparing effects after early and delayed provision showed that early provision resulted in increased levels of improvement on Berg Balance Scale (+5.1 points, p = 0.002), Barthel Index (+1.9 points, p = 0.002) and non-significant improvements on 10-metre walk test (+0.14 m/s, p = 0.093) and Timed Up and Go Test (-5.4 seconds, p = 0.087), compared with delayed provision. CONCLUSIONS: We found positive effects of providing ankle-foot orthoses in (sub)acute stroke subjects that had not used these orthoses before.

The Sara Combilizer® as an early mobilisation aid for critically ill patients: A prospective before and after study.

BACKGROUND: Early mobility within the ICU is associated with a number of positive outcomes including reductions in ICU and hospital length of stay and better functional recovery. The exact definition of 'early' mobility is still not defined, with the actual ability to mobilise limited by a number of perceived factors. The Sara Combilizer® is a combined tilt table and stretcher chair, which allows passive transfer of patients out of bed. This study aimed to assess whether the introduction of the Sara Combilizer® reduced time taken to first mobilise for patients mechanically ventilated for at least five days and at risk of ICU acquired weakness. METHODS: Patients admitted to a large UK critical care unit during the trial period and ventilated for ≥5days were included in the study. Baseline data was collected prospectively for a period of four months. The Sara Combilizer® was then introduced for a one month training and familiarisation period, followed by a further four months prospective data collection. The primary outcome was time to first mobilisation, defined as a Manchester Mobility Score ≥2. RESULTS: Following the introduction of the Sara Combilizer®, time taken to mobilise reduced significantly from 13.6 to 10.6days (p=0.028). SOFA scores were significantly higher at the point of first mobilisation in the Combilizer group (mean: 2.9±0.5 vs. 5.1±2.4; p=0.005). There was no statistical difference in therapy time between the groups, or ICU or hospital length of stay. CONCLUSIONS: The introduction of the Sara Combilizer® was associated with a significant reduction in time to mobilise patients ventilated for ≥5days, and patients were mobilised with a higher degree of organ failure. This was achieved without any increase in therapy time. The Sara Combilizer® may be a useful adjunct to an early mobility protocol within the ICU.

PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children.

OBJECTIVE: To determine the safety and feasibility of an early mobilization program in a PICU. DESIGN: Observational, pre-post design. SETTING: PICU in a tertiary academic hospital in the United States. PATIENTS: Critically ill pediatric patients admitted to the PICU. INTERVENTION: This quality improvement project involved a usual-care baseline phase, followed by a quality improvement phase that implemented a multicomponent, interdisciplinary, and tiered activity plan to promote early mobilization of critically ill children. MEASUREMENTS AND MAIN RESULTS: Data were collected and analyzed from July to August 2014 (preimplementation phase) and July to August 2015 (postimplementation). The study sample included 200 children 1 day through 17 years old who were admitted to the PICU and had a length of stay of at least 3 days. PICU Up! implementation led to an increase in occupational therapy consultations (44% vs 59%; p = 0.034) and physical therapy consultations (54% vs 66%; p = 0.08) by PICU day 3. The median number of mobilizations per patient by PICU day 3 increased from 3 to 6 (p < 0.001). More children engaged in mobilization activities after the PICU Up! intervention by PICU day 3, including active bed positioning (p < 0.001), and ambulation (p = 0.04). No adverse events occurred as a result of early mobilization activities. The most commonly reported barriers to early mobilization after PICU Up! implementation was availability of appropriate equipment. The program was positively received by PICU staff. CONCLUSIONS: Implementation of a structured and stratified early mobilization program in the PICU was feasible and resulted in no adverse events. PICU Up! increased physical therapy and occupational therapy involvement in the children's care and increased early mobilization activities, including ambulation. A bundled intervention to create a healing environment in the PICU with structured activity may have benefits for short- and long-term outcomes of critically ill children.

Inpatient ambulation: use of an ambulation platform apparatus.

Ambulation has proven to be an important part of recovery for medical-surgical patients. This study provides original research on the use of a platform apparatus for ambulation of patients on a medical-surgical unit. Outcomes included number of ambulation attempts, distance of ambulation, length of hospital stay, number of staff necessary to ambulate, and discharge destination. Compared with a control group, patients who had access to the ambulation platform apparatus had a shorter length of stay with fewer nurses and other staff needed to ambulate. Staff rated ambulation with the apparatus as easier than without and noted that patients were more willing to ambulate on their own with the ambulation platform apparatus.

Randomized controlled trial of accelerated rehabilitation versus standard protocol following surgical repair of ruptured Achilles tendon.

BACKGROUND: There is no consensus regarding the optimal management of the acutely ruptured Achilles tendon (TA). Functional bracing alone achieves outcomes similar to those of surgical repair. Surgical repair combined with immediate mobilization may improve the clinical outcome further. The purpose of our study was to determine if an accelerated rehabilitation programme following surgical repair of the ruptured TA could improve clinical outcome, relative to the standard protocol. METHODS: Patients with an acutely ruptured TA were randomly allocated to undergo an accelerated programme (AP) or standard programme (SP), following surgery. Outcome was assessed at 12 months post-surgery using the Achilles tendon Total Rupture Score (ATRS), the heel-raise height and the time taken to return to running. RESULTS: Fifty-one patients completed the study, 25 in the AP group and 26 in the SP group. At 12 months post-surgery, the ATRS results were similar in the two treatment groups (87.46 in AP with standard error (SE) of 0.735 versus 87.12 in SP with SE of 0.75) while the AP group had less lengthening of the TA (0.385 cm, SE 0.166 versus 1.00 cm, SE 0.169) and a more rapid return to running (17.231 weeks, SE 0.401 versus 21.08 weeks, SE 0.409), than the SP group. CONCLUSION: The accelerated rehabilitation programme resulted in less tendon lengthening, more rapid return to running, but similar ATRS relative to the standard rehabilitation. Immobilization following TA repair may prolong recovery.

Equipment used for safe mobilization of the ICU patient.

Mobilizing critically ill patients in the intensive care unit requires careful planning and attention to detail. The risks involved in mobilizing these patients include dislodging equipment, injury to the patient, injury to the caregivers, and physiologic decompensation of the patient. To carry out the activity safely, the therapist and the nurse must identify risks and have contingency plans in place for; physically supporting the patient should they become unstable during the activity, for returning the patient to bed quickly if needed; and for providing increased oxygen/ventilator support if needed. If the activity involves leaving the bedside area, there must be a method to transport monitors, oxygen, and intravenous pumps. There are simple pieces of equipment, already available in the intensive care unit, which can be used to accomplish the mobility goals safely in all patient populations. This article explores how standard hospital equipment can be used to improve patient activity and performance and minimize risk.

Acidente vascular encefálico agudo: reabilitação / Acute encephalic vascular accident: rehabilitation

Este estudo revisou artigos nas bases de dados do MEDLINE (Pub-Med) e demais fontes de pesquisa, sem limite de tempo. Para tanto, adotou-se a estratégia de busca baseada em perguntas estruturadas na forma (P.I.C.O.) das iniciais: "Paciente"; "Intervenção"; "Controle" e "Outcome". Como descritores utilizaram-se: (cerebrovascular disorders OR Stroke) AND acute AND (movement OR physical therapy modalities OR exercise movement techniques); (cerebrovascular disorders OR stroke) AND (Postural Balance OR Musculoskeletal Physiological Phenomena) AND Rehabilitation AND trunk; (cerebrovascular disorders OR Stroke)AND (virtual reality OR user-computer interface OR video games); cerebrovascular disorders AND (home care services, hospital-based); cerebrovascular disorders AND (contractures OR splint OR orthotic devices); cerebrovascular disorders AND acute AND (rehabilitation OR physical therapy disorders or task performance); cerebrovascular disorders AND (physical therapy modalities OR rehabilitation OR exercise therapy) AND (Home Care Services OR self care); (cerebrovascular disorders OR stroke) AND (electric stimulation OR electric stimulation therapy) AND (muscle tonus OR muscle hypotonia OR muscle hypertonia); cerebrovascular disorders AND (restraint physical OR constraint induced movement therapy OR constraint); (cerebrovascular disordersOR stroke) AND (body weight support OR supported treadmill training OR partial weight bearing); (cerebrovascular disorders OR stroke) AND transcranial magnetic stimulation; (cerebrovascular disorders OR stroke) AND bandages. Com esses descritores efetivaram-se cruzamentos de acordo com o tema proposto em cada tópico das perguntas (P.I.C.O.). Analisado esse material, foram selecionados os artigos relativos às perguntas e, por meio do estudo dos mesmos, estabeleceram-se as evidências que fundamentaram às diretrizes do presente documento.

This study revised articles from the MEDLINE (PubMed) databases and other research sources, with no time limit. To do so, the search strategy adopted was based on (P.I.C.O.) structured questions (from the initials "Patient"; "Intervention"; "Control" and "Outcome". As keywords were used: (cerebrovascular disorders OR Stroke) AND acute AND (movement OR physical therapy modalities OR exercise movement techniques); (cerebrovascular disorders OR stroke) AND (Postural Balance OR Musculoskel et al. Physiological Phenomena) AND Rehabilitation AND trunk; (cerebrovascular disorders OR Stroke) AND (virtual reality OR user-computer interface OR video games); cerebrovascular disorders AND (home care services, hospital-based); cerebrovascular disorders AND (contractures OR splint OR orthotic devices); cerebrovascular disorders AND acute AND (rehabilitation OR physical therapy disorders or task performance); cerebrovascular disorders AND (physical therapy modalities OR rehabilitation OR exercise therapy) AND (Home Care Services OR self care); (cerebrovascular disorders OR stroke) AND (electric stimulation OR electric stimulation therapy) AND (muscle tonus OR muscle hypotonia OR muscle hypertonia); cerebrovascular disorders AND (restraint physical OR constraint induced movement therapy OR constraint); (cerebrovascular disorders OR stroke) AND (body weight support OR supported treadmill training OR partial weight bearing); (cerebrovascular disorders OR stroke) AND transcranial magnetic stimulation; (cerebrovascular disorders OR stroke) AND bandages. With the above keywords crossings were performed according to the proposed theme in each topic of the (P.I.C.O.) questions. After analyzing this material, articles regarding the questions were selected and, by studying those, the evidences that fundamented the directives of this document were established.

Anestesia subaracnoidea hipobárica a dosis bajas para cirugía anorrectal en posición de navaja: comparación entre levobupivacaína-fentanilo y lidocaína-fentanilo / Low-dose hypobaric spinal anesthesia for anorectal surgery in jackknife position: levobupivacaine-fentanyl compared to lidocaine-fentanyl

INTRODUCCIÓN: El objetivo de este estudio fue comparar el porcentaje de pacientes que evitaban su paso (bypass) por la unidad de recuperación postanestésica (URPA) después de una anestesia subaracnoidea selectiva con lidocaína- fentanilo respecto a otra de levobupivacaína-fentanilo, en cirugía anorrectal realizada en pacientes en posición de navaja. MATERIAL YMÉTODOS: Estudio aleatorizado, prospectivo y doble ciego. Se compararon dos grupos de 30 pacientes, ASA I-II. El grupo Lido recibió 18 mg de lidocaína 0,6% más 10 μg fentanilo y el grupo Levo 3 mg de levobupivacaína 0,1% más 10 μg fentanilo. Se monitorizaron las siguientes variables intraoperatorias: tiempo de inicio de la cirugía, nivel máximo de bloqueo sensitivo, necesidad de suplementación analgésica, aparición de eventos hemodinámicos. El nivel sensitivo se registró a los 5, 10 y 15 minutos y al final de la cirugía. Tras la cirugía se registró el grado de bloqueo motor, el nivel de propiocepción, el test de Romberg y si el paciente podía puentear la Unidad de recuperación postanestésica. Los tiempos de deambulación y de alta a domicilio, las complicaciones y la satisfacción postoperatoria también fueron registradas. RESULTADOS: No se observó diferencias significativas entre los grupos en cuanto a variables intraoperatorias. El 100% de los pacientes del estudio fue directamente a la unidad de adaptación al medio sin pasar por la URPA. Los tiempos para la deambulación, el alta a domicilio, así como las complicaciones y la satisfacción global postoperatoria fueron similares en ambos grupos. CONCLUSIONES: Ambas soluciones intratecales producen anestesia selectiva efectiva proporcionando un porcentaje de bypass de la URPA similar en cirugía anorrectal en posición de navaja(AU)

OBJECTIVE: To compare the percentage of patients who were able to bypass the postoperative intensive care recovery unit after selective spinal anesthesia with lidocaine-fentanyl versus levobupivacaine-fentanyl for anorectal surgery in jackknife position. MATERIAL AND METHODS: Randomized double-blind clinical trial comparing 2 groups of 30 patients classified ASA 1-2. One group received 18 mg of 0.6% lidocaine plus 10 μg of fentanyl while the other group received 3 mg of 0.1% levobupivacaine plus 10 μg of fentanyl. Intraoperative variables were time of start of surgery, maximum extension of sensory blockade, requirement for rescue analgesics, and hemodynamic events. The level of sensory blockade was recorded at 5, 10, and 15 minutes after the start of surgery and at the end of the procedure. The degrees of postoperative motor blockade and proprioception were recorded, as were the results of the Romberg test and whether or not the patient was able to bypass the postoperative recovery unit. Also noted were times of start of ambulation and discharge, complications, and postoperative satisfaction. RESULTS: Intraoperative variables did not differ significantly between groups, and all patients in both groups bypassed the postoperative recovery unit. Times until walking and discharge home, complications, and overall satisfaction after surgery were similar in the 2 groups. CONCLUSIONS: Both spinal anesthetic solutions provide effective, selective anesthesia and are associated with similar rates of recovery care unit bypass after anorectal surgery in jackknife position(AU)

A randomized trial of rocking-chair motion on the effect of postoperative ileus duration in patients with cancer recovering from abdominal surgery.

Patients who undergo abdominal surgery experience a phenomenon commonly called postoperative ileus (POI). Standard of care requires patients to get out of bed, sit in a chair, and begin ambulating the first postoperative day. No evidence supports standard care activities reduce POI duration. Rocking-chair motion has shown promise in reducing POI duration. Sixty-six participants were randomized into 2 groups. The experimental group (n = 34) received standard care plus the rocking-chair intervention; the control group (n = 32) received standard care. Participants in the experimental group had shorter duration of POI, no effect on medication use, and time to discharge.

Safety of early ambulation after diagnostic and therapeutic neuroendovascular procedures without use of closure devices.

OBJECTIVE: To evaluate the safety of manual compression and early ambulation after diagnostic and therapeutic neuroendovascular procedures. METHODS: Data were prospectively collected and retrospectively analyzed for consecutive patients undergoing diagnostic or therapeutic neuroendovascular procedures. Manual compression at the femoral access site was applied. The target for early ambulation was 2 hours after compression. RESULTS: Three hundred forty-three patients were enrolled, of whom 295 were eligible for early ambulation. Diagnostic procedures totaled 214 (72.5%); therapeutic procedures, 81 (27.5%). Ambulation occurred at 2 hours for 82 patients who underwent a diagnostic and 11 patients who underwent a therapeutic procedure. Overall, 142 patients (66.4%) after a diagnostic and 21 patients (25.9%) after a therapeutic procedure ambulated within 3 hours; 94% of outpatients ambulated within 2 to 3 hours and were dismissed shortly thereafter. Delayed ambulation was related to nursing staff delays, recovery from general anesthesia, or patient preference. Fourteen patients (4.7%)--9 (4.2%) who had a diagnostic and 5 (6.2%) who had a therapeutic procedure--required delayed ambulation because of local oozing (8 patients), a hematoma of less than 5 cm (3 patients), a pseudoaneurysm (2 patients), or a large hematoma requiring surgical evacuation (1 patient). CONCLUSION: Early ambulation is feasible and safe after diagnostic and therapeutic procedures and manual compression. A longer period of bed rest or the routine use of closure devices is often not required; thereby avoiding the costs associated with bed rest and the complications associated with closure devices.

Continuous local anaesthesia for post-operative mobilization of injured digits.

We have studied the effects of sustained local anaesthesia on postoperative mobilization of the injured hand. Small epidural catheters were placed adjacent to the peripheral nerves providing sensation to the involved part of the hand under direct vision in the distal forearm. Repeated doses of 0.5% bupivacaine were then administered during mobilization therapy to relieve pain. Fourteen out of 24 digits (60%) recorded 30 degrees or more increases in active range of motion after bupivacaine injection. The cases that failed to improve had suffered severe injuries. Complications were few and were easily managed as the catheters were distal, superficial and accessible. This is an effective, specific and safe method of providing sustained postoperative analgesia for mobilization.

Use of a modified tilt table for preambulation strength training as an adjunct to burn rehabilitation: a case series.

Because of the system-wide complications that arise with prolonged bed rest, early mobilization plays a critical role in the recovery process, especially in the patient with significant burn injury. Unfortunately, early mobilization of patients with severe burns can be a difficult and uncontrolled task and often requires several people to lift a patient to a standing position. This article describes the use of a modified tilt table that allows patients to perform a weight-bearing exercise, such as an inclined squat, in a gravity-reduced environment. Use of the modified tilt table may offer a more suitable therapeutic option when treating critically ill patients by providing a safe and controlled transition from bed rest to ambulation. Perhaps most importantly, the table appears to provide psychological benefits by empowering the patient to take more of an active role during the early stage of recovery.