Clinical Evidence

Ongoing research using questionnaire

1. The Effect of Abdominal Support on Functional Outcomes in Patients Following Major Abdominal Surgery: A Randomized Controlled Trial. Physiotherapy Can. 2010; 62:242–25 Oren Cheifetz, S. Deborah Lucy, Tom J. Overend, Jean Crowe

ABSTRACT

Purpose: Immobility and pain are modifiable risk factors for development of venous thromboembolism and pulmonary morbidity after major abdominal surgery (MAS). The purpose of this study was to investigate the effect of abdominal incision support with an elasticized abdominal binder on postoperative walk performance (mobility), perceived distress, pain, and pulmonary function in patients following MAS.

Methods: Seventy-five patients scheduled to undergo MAS via laparotomy were randomized to experimental (binder) or control (no binder) groups. Sixty (33 male, 27 female; mean age 58e14.9 years) completed the study. Preoperative measurements of 6-minute walk test (6MWT) distance, perceived distress, pain, and pulmonary function were repeated 1, 3, and 5 days after surgery.

Results: Surgery was associated with marked postoperative reductions (p < 0.001) in walk distance (P75–78%, day 3) and forced vital capacity (35%, all days) for both groups. Improved 6MWT distance by day 5 was greater (p < 0.05) for patients wearing a binder (80%) than for the control group (48%). Pain and symptom-associated distress remained unchanged following surgery with binder usage, increasing significantly (p < 0.05) only in the no binder group.

Conclusion: Elasticized abdominal binders provide a non-invasive intervention for enhancing recovery of walk performance, controlling pain and distress, and improving patients’ experience following MAS. 

2. Kroenke K, Lawrence VA, Theroux JF, Tuley MR, Hilsenbeck S. Postoperative complications after thoracic and major abdominal surgery in patients with and without obstructive lung disease. Chest. 1993;104:1445–51. doi:10.1378/chest.104.5.1445

ABSTRACT

To determine the risk of thoracic and major abdominal surgery in patients with chronic obstructive pulmonary disease (COPD).Retrospective cohort study with controls.
A 692-bed teaching hospital.

A cohort of 26 patients with severe COPD (FEV1 < 50 percent predicted) undergoing thoracic and major abdominal surgery was matched by age and type of operation to 52 patients with mild-moderate COPD and 52 patients with no COPD.

The 26 patients with severe COPD had rates of cardiac, vascular, and minor pulmonary complications similar to patients with mild-moderate COPD and without COPD, but experienced higher rates of serious pulmonary complications (23 percent vs 10 percent vs 4 percent, p = 0.03) and death (19 percent vs 4 percent vs 2 percent, p = 0.02). All deaths and instances of ventilatory failure in the patients with severe COPD occurred in the subset undergoing coronary artery bypass surgery. Logistic regression revealed that increased age, higher American Society of Anesthesiologists class, an abnormal chest radiograph, and perioperative bronchodilator administration were associated with higher cardiac or serious pulmonary complication rates. Spirometry was not an independent predictor of postoperative complications.

Clinical variables appear better than preoperative spirometry in predicting postoperative cardiopulmonary complications. The utility of preoperative spirometry as well as the benefits of perioperative bronchodilators in patients in stable condition remain to be determined

3. Basse L, Raskov HH, Jakobsen DH, Sonne E, Billesbølle P, Hendel HW, et al. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Brit J Surg. 2002;89:446–53.

ABSTRACT

Background: Postoperative organ dysfunction contributes to morbidity, hospital stay and convalescence. Multimodal rehabilitation with epidural analgesia, early oral feeding, mobilization and laxative use after colonic resection has reduced ileus and hospital stay.

Method: Fourteen patients receiving conventional care (group 1) and 14 patients who had multimodal rehabilitation (group 2) were studied before and 8 days after colonic resection. Outcome measures included postoperative mobilization, body composition by whole-body dual X-ray absorptiometry, cardiovascular response to treadmill exercise, pulmonary function and nocturnal oxygen saturation.

Results: Defaecation occurred earlier (median day 1 versus day 4) and hospital stay was shorter (median 2 versus 12 days) in patients who had multimodal treatment. Lean body and fat mass decreased in group 1 but not in group 2. Exercise performance decreased by 44 per cent in group 1 but was unchanged in group 2. A postoperative increase in heart rate (HR) response to exercise was avoided in group 2. Pulmonary function decreased in group 1 but not in group 2. There was less nocturnal postoperative hypoxaemia in group 2. Cardiac demand–supply (HR/oxygen saturation ratio) increased in group 1 but not in group 2.

Conclusion: Multimodal rehabilitation prevents reduction in lean body mass, pulmonary function, oxygenation and cardiovascular response to exercise after colonic surgery. © 2002 British Journal of Surgery Society Ltd.

4. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA, et al. Prevention of venous thromboembolism. Chest. 2001;119:132S–75S.

ABSTRACT

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients’ values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S–187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [≤ 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).

5. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism E. O. Pearse, MA, FRCS(Orth), Specialist Registrar in Orthopaedics, Clinical Knee Fellow1; B. F. Caldwell, FRACS(Orth), Orthopaedic Surgeon; R. J. Lockwood, BHlth Sc(Nursing), RN Surgical Nursing Unit Manager and J. Hollard, BMed(Hons), FANZCA, Consultant Anaesthetist © 2007 British Editorial Society of Bone and Joint Surgery

ABSTRACT

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement.

Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively.

In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors.