Research Article
Fast Track Pathways: Early Ambulation after Open Aortic Surgery in Elderly Patients Is Not Only Safe but Recommendable
Piero Brustia1*, Renato Cassatella1, Alessandra Renghi2, Luca Gramaglia2, Michele Aronici1 and Francesco Casella1
1Department of Vascular Surgery, University Hospital “Maggiore della Carità”, Italy
2Department of Anaesthesia, University Hospital “Maggiore della Carità”, Italy
*Corresponding author: Piero Brustia, Department of Vascular Surgery, University Hospital “Maggiore della Carità”, 18 Corso Mazzini, Novara 28100, Italy
Published: 20 Apr, 2017
Cite this article as: Brustia P, Cassatella R, Renghi A,
Gramaglia L, Aronici M, Casella F. Fast
Track Pathways: Early Ambulation after
Open Aortic Surgery in Elderly Patients
Is Not Only Safe but Recommendable.
Clin Surg. 2017; 2: 1407.
Abstract
Introduction: Bed rest has always been an integral part of traditional perioperative care, but there
is no evidence that it has any significant beneficial effect, especially in elderly patients. Conversely,
the immediate recovery of ambulation improves outcomes after complex surgical procedures. We
devised a multidisciplinary programme to achieve early ambulation after abdominal aortic surgery
in elderly patients.
Methods: We carried out a prospective study of patients older than 70 years who were scheduled
for abdominal aortic surgery from January 2009 to December 2011. All patients were treated with
minilaparotomy, light general anaesthesia and thoracic epidural anaesthesia. The postoperative
programme consisted of continuous epidural analgesia and early mobilisation.
Results: We enrolled 130 patients. The mean age was 76.1 years (95% CI=75.33-76.79). The patients
began walking at a mean time of 175.2 (95% CI=145.3-205.2) min after the surgery. On the day of
surgery, the mean ambulation time was 33.7 (95% CI=27.3-40.1) min, and the patients covered an
average distance of 172.3 (95% CI=124.3-220.3). On the day after surgery the mean ambulation time
was 157.7 (95% CI=146.8-168.6) min, and the patients covered an average distance of 1130.3 (95%
CI=884.7-1375.9) metres. The perioperative mortality was 0.8% and the global morbidity was 12.3%.
The patients had no pulmonary complications. We observed no side effects in connection with the
early ambulation. The average time for the discharge to home was day 4 after surgery (range 2-24).
Conclusion: In elderly patients, a multidisciplinary approach with mininvasive surgery, pain control
and postoperative intensive rehabilitation allowed the rapid and safe recovery of ambulation after
abdominal aortic surgery thereby contributing to an improved postoperative outcome.
Keywords: Aortic surgery; Elderly patients; Prolonged bed rest; Postoperative pain; Functional
decline; Perioperative care; Fast Track pathways
Introduction
Pain, ileus, fatigue and postoperative morbidity significantly affect the resumption of daily life
after major abdominal vascular surgery. The enhanced recovery after surgery pathway suggests a
multidisciplinary approach to improve outcomes after complex elective surgical procedures [1,2].
This approach includes stress-free anaesthesia, mininvasive surgical techniques and postoperative
enforced rehabilitation, such as early feeding and ambulation. Early ambulation has always been
a controversial point in medical procedures, including surgery [3,4]. However, early ambulation
is possible thanks to a programme of accelerated recovery, and it represents a fundamental step
towards improving postoperative outcomes [5,6]. As proof, bed rest causes a functional decline in
elderly patients [7] and, during the postoperative period, leads to a decrease in whole-body protein
synthesis, is responsible for postoperative fatigue and impairs pulmonary and cardiovascular
functions [8,9].
Since April 2000, in our Vascular Unit, we have introduced a multidisciplinary protocol for
abdominal aortic surgery based on left sub costal minilaparotomy, thoracic epidural anaesthesia and
analgesia and aggressive postoperative rehabilitation, including early mobilisation and feeding [2].
In this paper, we evaluate the clinical impact of early mobilisation and ambulation after abdominal
aortic surgery in elderly patients.
Materials and Methods
We performed a prospective study of consecutive patients older
than 70 years of age who were scheduled for elective abdominal aortic
surgery for aneurysm or obstructive disease from January 2009 to
December 2011.
All patients were treated by the same surgical team. To promote
their full cooperation, the patients were assessed in the preoperative
clinic, and a written perioperative programme was explained to them
and their relatives by a team of surgeons, anaesthesiologists and
nurses. The premedication, protocolled for all patients, consisted of
0.1 mg/kg subcutaneous morphine two hours before surgery. An
epidural catheter was placed at the T6-T7 interspace, and 15-25 ml
of 0.5% levobupivacaine was administered to achieve sensory block
(pin prick) between the T4 and L5 dermatomes. The induction of
light general anaesthesia was achieved with 1 mg/kg propofol. A
laryngeal mask was inserted, without need of curare and spontaneous
ventilation was maintained with 80% oxygen. The anaesthesia was
continued with the infusion of sevoflurane to obtain a minimum
alveolar concentration (MAC) of 0.8%. Curare was not administered.
An epidural infusion of 0.5% levobupivacaine at a rate of 4-5 ml/h
was ensured throughout surgery. Absence of curare, associated with
continous infusion of intratecal anaesthetic, performing a trasversal
mininvasive access, with previous study and skills by anaesthsiological
and surgical team, doesn't give major troubles to perform the
operation. A great advantage for patient is manteining a spontaneus
breathing in laryngeal mask, with capacity of acid omeosthasis and no
need of prolonged tracheal intubation at end of surgery.
The aortic bypass was performed via transperitoneal access. A left
subcostal incision, parallel to the costal edge and, 10-15 cm long, was
performed on the supine patient. Once the aortic graft was inserted,
the abdominal wall was sutured without the use of surgical drains.
A nasogastric tube was not placed. At the end of the surgery, the
laryngeal mask was removed, and the patient was transferred to the
surgical ward, where skilled nurses assisted by the anaesthesiologist
started monitoring the patient.
Postoperative analgesia was achieved with a continuous epidural
infusion of 0.25% levobupivacaine at a rate of 3-6 ml/h for 48 hours,
supplemented by 600 mg oral ibuprofen every eight hours. For the
additional demand for analgesia 100 mg intravenous ketoprofen was
scheduled. Opioids were not used. As soon as the general conditions
were stable, the patients were encouraged to take sugared drinks, and
a semisolid diet was offered two to six hours after surgery. The patients
were forced to perform breathing exercises. An oxygen mask was
provided during the first two postoperative nights. Shortly after the
surgery, the patients started bed exercise and foot pumps. The patients
were forced to ambulate with assistance in the absence of motor block
and in the presence of stable haemodynamic parameters. The bladder
catheter was removed on the afternoon of the day of surgery as soon
as an ice test check showed that there was no sacral-nerve block.
Every two hours, the clinical parameters were recorded: non-invasive
arterial pressure, heart rate, oxygen peripheral saturation using a
pulse oximeter, urine output, pain intensity using the visual analogue
scale (VAS), and the evaluation of the motor block. All parameters
were recorded before and after ambulation on day of surgery (DAY
0). The minutes and metres of each ambulation were also recorded.
The readiness to discharge the patients from the hospital to
home was determined according to standard criteria (tolerance of
solid food, passage of stool, absence of infection and ambulation
without assistance). A consultation with the medical team was
scheduled 6 days after surgery. For up to thirty days following the
hospital discharge, the medical team kept a record of the medical
and surgical complications, and the rate of readmission. The primary
outcome measurements were related to the postoperative recovery
of ambulation. The following data were recording: demographic
characteristics, ASA (American Society of Anaesthesiologists) class,
Goldman Cardiac Risk Index, Goldman et al. [10], NYHA (New York
Heart Association) class, type of surgery, intraoperative variables,
postoperative motor block using the Bromage test (on a scale where
a total motor block was 1 and the absence of a motor block was 4),
postoperative recovery parameters of ambulation (defining time zero
as the end of surgery), the visual analogue score (VAS) on a scale 0 to
100 (where 0 represents no pain and 100 the worst imaginable pain)
at rest and upon moving and postoperative complications.
Nominal variables were described by relative and absolute
frequencies. Ordinal variables were described as medians with range.
Variables considered to be continuous were described as the means
and 95% CI (confidence interval). The data were analysed using Epi
Info (CDC, Atlanta, GA, USA). The statistical analysis was performed
using two-tailed Student’s t-test for independent variables that are
normally distributed. A p value of less than 0.05 was considered
significant.
Table 1
Results
From January 2009 to December 2011, we studied 130 patients,
including 122 men and 8 women. Their ages ranged from 70 to 89
years (median 75.5, mean 76.1 with 95%CI=75.33-76.79): 76 patients
(58.5%) were older than 75 years.
The average body mass index was 25.1 (95%CI=24.61-25.57).
The patient characteristics and the anaesthetic and surgical data are
shown in (Table 1). A large number were high-risk patients: 85.4%
had an ASA score of 3-4.
In all patients, the abdominal surgical approach was a left
subcostal mininvasive incision. Only 3 (2.3%) patients required an
enlargement in the bilateral subcostal incision because of anatomical
difficulties. The mean duration of surgery was 145.4 minutes (95%CI
136.2-154.7). The mean blood loss was 796.9 ml (95%CI=705.1-
888.6). In all patients, we used the cell saver, with an average of 430.7
ml (95%CI=375.8-485.5) of autologous blood transfusion; 18 patients
received a homologous transfusion with 2 units of blood each, and 4
patients needed a plasma transfusion for intraoperative coagulation
disorders, solved before the end of surgery.
At the end of the surgery, all patients were transferred to
the surgical ward, where a skilled team of nurses assisted by an
anaesthesiologist take care immediately of the patient. During the
postoperative period, the pain control at rest and on walking was
optimal (Figure 1).
A pain peak was observed at 8 am on the day after the surgical
intervention. Only 24 patients (18.5%) needed a rescue dose of
ketoprofen, which had a beneficial effect.
The postoperative sensory block (determined using the ice test)
had an average extension from T3 (range: C3-T8) to L1 (range:
T4-S4). Two hours after surgery, the motor block was minimal.
As a consequence of the epidural blockade, there was a reduction
of the mean arterial pressure of less than 30%, compared with the
preoperative values. The haemodynamic parameters are shown in
(Figure 2).
In the afternoon of the day of surgery 128 patients (98.5%) were
able to ambulate; only 2 patients (1.5%) were unable to perform the
protocol and ambulated the day after. The characteristics of the first
ambulation are shown in (Table 2).
The haemodynamic parameters were stable; furthermore, a
significant increase in the oxygen peripheral saturation was observed
after the patients first got up. A first get-up failure affected six
patients: four cases were caused by hypotension and two cases by
lower limb weakness. In four patients, a return to bed and epidural
infusion optimisation solved these symptoms, and a successful getup
was achieved after two hours. Persistent weakness did not allow
two patients to ambulate until the morning after the surgery. The
ambulation data are shown in (Table 3).
With a programme of enforced mobilisation, the patients were
able to ambulate more than 1 kilometre on the day after surgery
without dangerous haemodynamic effects.
Eight patients suffered episodes of vomiting, without affecting the
postoperative programme. We registered the passage of stool a mean
of 40.2 hours (SD 11.5) after surgery.
One patient (0.8%) died after surgery: this patient, suffering
from severe coronary arteries disease, experienced angina two days
after surgery, was transferred to the Intensive Cardiologic Unit and
died twenty days later. The postoperative morbidity was 12.3%.
No patient needed to be transferred to the Intensive Care Unit.
Cardiac complications were investigated using an electrocardiogram
and measurements of the level of plasma troponin I: one patient
(0.8%) experienced an episode of atrial fibrillation, which resolved
spontaneously. No pulmonary complications (investigated with
chest-radiography) were recorded. Six patients (4.6%) exhibited
a transient increase in the creatinine plasmatic level; one patient
required three dialysis sessions. Four embolectomies (3.1%) were
performed due to postoperative lower limb ischaemia (Figure 1).
One patient previously affected by a distonia of colon, presented
a progressive distension of right colon in second day after surgery
and needed a right emicolectomy because of complicated megacolon
disease. Four patients (3.1%) developed inguinal lymphorrhea, only
one needed a new suture in groin side.
All patients were discharged home. The median day of discharge
was day 4 after the surgery (range 2-24), and the mean discharge
time was 4.6 days (95% CI=3.9-5.29). Only two patients (1.5%) were
readmitted within 30 days after discharge: one patient after 11 days
because of inguinal lymphorrhea, and one patient after 20 days
because of surgical abdominal wound dehiscence.
Figure 1
Figure 2
Table 2
Table 3
Discussion
A functional decline in elderly patients occurs after a few days of
hospitalisation [11] and is linked to age, delirium, immobility and bed
rest [7,12]. Bed rest is considered a potentially harmful measure in a
large number of medical conditions [4]. Bed rest can cause several
complications in the immediate and long-term periods: loss of skeletal
muscle mass due to decreased basal protein synthesis, systemic
inflammation, decreased insulin sensitivity, pulmonary atelectasis,
reductions in blood and plasma volume and post-discharge decreased
physical functioning [9,12-14].
Although traditional perioperative care involves bed rest, there is
no evidence that it has any significant beneficial effect when used after
surgery [3]. Conversely, complications often result from prolonged
bed rest, especially in older patients [15]. Bed rest predisposes
individuals to orthostatic intolerance and instability while standing
up [16]. Immobilisation increases the risk of thromboembolism and
atelectasis with pulmonary complications [6,16,17]. Postoperative
hypoxaemia is more pronounced in the supine position with potential
adverse effects on cardiac, cerebral and wound functions [18]. In
surgery patients, changes in protein metabolism are pronounced due
to stress-related hypercortisolaemia and produce a threefold greater
loss of skeletal muscle mass than bed rest alone [8]. Conversely, early
ambulation and mobilisation may contribute to the anticatabolic
effect of epidural analgesia [19]. Moreover, early ambulation may
improve wound healing [5] and contribute to the reduction of “trash
foot” after abdominal aortic surgery [20].
Removing the hazard of hospitalisation requires interdisciplinary
care that involves surgeons, anaesthesiologists and nurses, to improve
the postoperative recovery after complex elective surgical procedures,
particularly in elderly patients [1,6,21]. Enhanced recovery
after surgery (ERAS) strategies includes stress-free anaesthesia,
mininvasive techniques and postoperative enforced rehabilitation,
such as early feeding and ambulation.
Abdominal aortic disease is characteristic of an aging population
and often presents in patients with several cardiac, respiratory
and renal impairments. These comorbidities have a significant
effect on the outcome of subsequent aortic repair, characterised
by perioperative mortality ranging from 4% to 8% and morbidity
ranging from 15% to 30%. Traditional care after open aortic surgery
includes a postoperative stay in the Intensive Care Unit (ICU) and an
average hospital stay of 9 days [22,23].
A fast-tracking multidisciplinary programme reduces
periprocedural complications and permits an immediate
rehabilitation with early mobilisation and ambulation [2,22].
In our experience [25], this aim has been pursued by mininvasive
surgery, optimal pain relief and an accelerated postoperative
recovery programme. A transverse left subcostal minilaparotomy
was performed, which resulted in less wound traction, less pain
and reduced respiratory impairment [24,25]. The patients received
thoracic epidural anaesthesia and analgesia, which minimises motor
blockade and thus facilitates early mobilization [26]. The postoperative
care included an intensive nursing programme of muscular exercises
in bed and encouragement to move round.
In our series, the patients walked for the first time after an average
of three hours. The patients walked an average of 150 metres on the
day of surgery and 1 kilometre the day after. Early mobilisation and
ambulation did not cause problematic haemodynamic alterations.
Only two patients got up later than the day of the surgery.
No variations on the heart rate and mean arterial pressure related
to standing up were recorded. Interestingly, the oxygen peripheral
saturation increased during the postoperative period after the first
ambulation. Early mobilisation proved possible due to optimal pain
relief, the absence of motor block and haemodynamic stability in the
first 48 h after the surgical intervention.
We believe that early mobilisation contributed to the avoidance
of pulmonary complications in these patients. No side effects due to
early ambulation were observed. In contrast the patients enjoyed a
fast resumption of their daily activities and showed a high degree of
compliance. All patients were discharged to home an average of 4
days after surgery, and there were no readmission due to the early
ambulation program.
However, a learning period of one year is required for the medical
and nursing staff to apply this multidisciplinary protocol, which
should be noted.
Conclusion
With a multidisciplinary approach, including mininvasive surgery, stress-free anaesthesia and an intensive nursing programme, early ambulation after abdominal aortic surgery is possible and safe and contributes to improved postoperative outcomes.
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