The Daily Dose • Thursday, June 10, 2021

Prehabilitation for the Marathon of Surgery

Christian S. Guay, MD

Prehabilitation is an emerging field in perioperative medicine aiming to improve patient-centered outcomes. From frailty and nutrition to brain health, this panel, “Prehabilitation and Medical Optimization in High-Risk Surgical Patients,” held May 15 at the IARS 2021 Annual Meeting, explored ways to assess and optimize our highest risk patients.

Prehabilitation has recently emerged as a promising strategy to optimize patients for surgery while also having a lasting impact on their postoperative trajectories. Matthew McEvoy, MD, from Vanderbilt University Medical Center, started by introducing the panel members with diverse expertise and then wrapped up the session with some practical guidance on how to implement an effective preoperative infrastructure.

Kimberly Rengel, MD, from Vanderbilt University Medical Center, began with a discussion of prehabilitation for elderly patients who have two major goals in mind: live independently and return to activity. Identifying patients at risk of not achieving these goals has been a major research question and the biological syndrome of frailty has emerged to describe these patients. Although multiple screening tools exist, frailty is broadly defined as a biologic syndrome of decreased reserve and resistance to external stressors resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes. Frailty has been associated with higher cost of care, increased length of stay, greater functional decline and a higher rate of 30-day readmissions. In an effort to improve postoperative outcomes for these patients, various prehabilitation programs have been developed, usually integrating a combination of aerobic conditioning, resistance training, nutrition and mindfulness. Although some programs have shown promising early results, this literature is still in its infancy and the questions of optimal dosing and timing remain unanswered.

A deep dive into perioperative nutrition followed, presented by Paul Wischmeyer, MD, EDIC, FASPEN, FCCM, from Duke University School of Medicine. The take-home point: “No malnourished patient should ever have elective surgery without nutritional optimization.” Using marathons as a metaphor, Dr. Wischmeyer convincingly presented data suggesting that we are not adequately preparing our patients for the tremendous stress of surgery. Two-thirds of patients presenting for gastrointestinal surgery are malnourished which has been associated with increased mortality and complications, yet only 20% of hospitals have a formal nutrition screening process in place and only one in five patients receives any preoperative nutrition intervention. With this in mind, he headed a group in POQI 2 that published guidelines in Anesthesia & Analgesia with the following six key points:

  1. nutrition screening is essential,
  2. protein is more important than calories,
  3. feeding should only stop shortly before surgery and resume early postoperatively,
  4. oral nutrition supplements are important for all patients,
  5. oral nutrition is superior to enteral which is superior to parenteral, and
  6. nutrition management is a team game.

A discussion of the Duke PONS score followed, which classifies patients into either high or low risk. Importantly, all patients receive a nutrition intervention, with the higher risk patients being assigned a registered dietician and a program that emphasizes protein nutrition (> 1.2 g/kg/day for at least 7 days preoperatively). He also made a point of debunking the myth that contemporary TPN increases the risk of infection and that preoperative protein interventions in fact decrease the risk of infection. From a practical and administrative perspective, nutrition interventions have been shown to be very cost effective, saving hospitals an average of $52.63 for every dollar spent.

Deborah Culley, MD, from Brigham and Women’s Hospital, wrapped up the panel discussion with the emerging field of cognitive prehabilitation. It is well established that cognitive impairment exhibits a high prevalence in the geriatric community, which is also reflected in the elderly surgical population. Multiple brief cognitive screening tools have been developed to help identify these patients who are at increased risk of postoperative delirium, persistent postoperative neurocognitive disorders, and other nonneurological complications. Despite advances in defining the prevalence and trajectories of these vulnerable patients, it is still premature to say whether preoperative cognitive training can improve postoperative outcomes, with conflicting results from early trials.

Anesthesiology is expanding its scope further into the pre- and postoperative phases of care, and prehabilitation is emerging as a promising strategy to improve patient-centered outcomes beyond their hospitalization. Next time you meet a patient in preoperative clinic, ask yourself: “Is this patient frail, malnourished, or cognitively impaired?” If the answer is yes, how can you improve their chances of surmounting the marathon of surgery?