An open letter to my preoperative patient(s)

Why you will benefit from becoming more engaged in your treatment plan before going for elective surgery

Dear patient,

Most people are filled with dread at the mere thought of going for surgery. It is quite normal to be anxious about an upcoming operation, even if the procedure is small. Some are of the opinion there is no such thing as a small operation or a small anesthetic, but there is a difference between going for a toenail extraction, an appendectomy or a lung resection and everything in between.

Whether you are young, fit and healthy, or older, frailer and less fit, the principles involved of preparing better are applicable to all age groups.

Be assured that every physician involved in your care, from your family doctor (if you’re fortunate to have one), to the surgeon and the anesthesiologist, has one desire and goal: for you to do well with the surgery and recover and heal optimally. Exactly how to achieve the latter, is the source of some debate.

Physician OR open letter

It stands to reason that surviving the surgery and anesthesia should be a given, a non-negotiable. Chances that you will die are negligibly small. Modern surgical and anesthesia procedures and technology has made it possible to perform previously impossible operations and also operate on the very frail, the very sick and on the extremes of ages; most with good outcomes.

However, a certain sup-population of patients will have a stormy perioperative period. They will survive everything, but their intra-operative period and recovery, both in the short and the long term, is troublesome and protracted. They don’t do great.

The good news is, much can be done about this. Clinical practice has shown, and studies confirm: when individuals prepare better for a stressful event, they will tolerate and withstand it better.

Two everyday-life examples of preparing for stressful situations are:

  • The bolstering of soldiers, such as the Navy SEALs, who are toughened up on physical, mental and emotional levels. They are prepared and trained to survive incredible odds
  • Professional athletes—individuals who cannot afford to be off to long with an injury. Injured athletes are optimized, bolstered, and undergo corrective surgery or treatment and will be back in action within weeks.

 

Over the centuries the military has applied the principle of optimally preparing its men and woman going to war, with great success. Unfortunately, these same principles (of pre-stress bolstering), are not applied consistently in medicine.

There is still widespread reluctance to optimize patients’ prior to the trauma of surgery.

Why is that?

There is no simple or single answer. It has never been deemed necessary in the past.  Physicians are trained to diagnose and treat disease, once it’s present. Physicians, who specialize in surgery and anesthesia and internal medicine today, are intensively trained; they are exceptionally high functional and capable individuals—able to perform complex and intricate procedures on the most unlikely of patients, and pull them through. Many are also clinician-scientists and do extensive research. They are able to transplant hearts and lungs, re-attach limbs, operate on unborn fetuses intra-uterine, and cure or resect vicious cancers.

And yet, most medical doctors are not trained in the basics of kinesiology, culinary medicine or psychological bolstering techniques. Most are not trained to optimize patients in the weeks prior to surgery or neo-adjuvant cancer treatment. They are not trained to intervene by optimizing their patients’ functional fitness, nutritional status and psychological robustness: also known as prehabilitation.

The way physicians are remunerated also plays an important role in this conundrum. They are remunerated to perform procedures, do operations and prescribe medications. They are not remunerated to perform lifestyle interventions, give proper guidance or assist with lifestyle modifications.

This does not make them bad or incompetent doctors, to the contrary. Especially when their patients survive intricate surgery. Why should they change anything?

Because it costs too much if we don’t.

Embedded in the comfort of medical tradition is the clinging to dogma, and a reluctance to shift focus in how we train medical students and residents, how we apply the evidence from medical research, or apply sound judgment.

Traditional preoperative preparation today consists of these four steps:

  1. Clinical preparation: the patient is referred by the family physician to the specialist: the surgeon, internist and anesthesiologist.
  2. Pharmaceutical preparation: prescription medications verified and optimized.
  3. Educational preparation: teaching by nursing staff and rest of the team
  4. Extensive assessments. In high-risk patients: special non-invasive tests, scans and ultra sounds to help with risk stratification.

 

Based on the findings of these steps, an extensive operative and anesthesia plan will be put into place. The focus remains on the moment the patient walks through the hospital doors, two to three hours prior to elective surgery. Effectively, from the moment of surgery, all the bells and whistles are put into place (as it should), to minimize risk and guide the patient safely through the surgery and anesthesia, as well as the immediate post-operative period.

 

However, the ever-increasing sub-population of preoperative patients who are:

  • Deconditioned
  • Functionally unfit (has poor exercise tolerance)
  • Frail
  • Emotionally unprepared,

Will perform less well than desirable, when only the four traditional steps are followed.

 

These patients have increased complications during and after surgery, their rehabilitation is prolonged, they are re-admitted more often, their long-term quality of life is diminished and their medical cost escalates.

It is more costly to play catch-up following the stressful event than intervening before the trauma of surgery.

A growing body of evidence is recommending that in addition to the four traditional steps, deconditioned individuals, will benefit from a 3 – 4 week prehabilitation program, prior to surgery.

The three-step prehabilitation program aims to optimize:

  1. Functional fitness (exercise tolerance)
  2. Nutritional status
  3. Psychological robustness

A hospital-based prehabilitation program usually makes use of the services of a kinesiologist, a dietitian and psychologist.

What should you know about interventions that have to be implemented during the 3 – 4 week period before the surgery (or adjuvant cancer treatment) to optimize your health status?

Even if you are in excellent health, you will still benefit from becoming engaged and following the steps listed here. If you are deconditioned (in poor physical and mental state), functionally unfit (has a poor exercise tolerance), have a poor diet and have unresolved psychological concerns, please follow these steps.

You will benefit greatly if you:

  1. Arm yourself with knowledge. Become informed. Become involved in your own treatment plan. It is an empowering experience. Remember: your health is a shared responsibility between yourself, your doctor and the health care team.
  2. Become fitter. The fitter and stronger you are, the better you will do (irrespective of age.)
  3. Don’t panic. Three to four weeks is enough time to have a positive impact on your fitness, strength and robustness.
  4. Start with an aerobic activity, such as: walking, cycling, swimming or dancing. Start for e.g. with walking 15 minutes, 5x/week. Increase to 30 min. 5x/week.
  5. Add strength exercises (resistance exercises.) Yes, it’s essential for everybody, whether you’re female or 90 years old. An effective and inexpensive tool is the resistance band or tubing. It cost between $2 and $20, and comes in different colors. Ideal for initial strengthening, on and a round a chair. Perform 3x/week.
  6. Improve your nutritional status. Take a whey protein supplement within 30 min. of the exercises done in # 3 and # 4. (One scoop—30 g—shaken up in water will suffice) Eat more healthful: Higher protein, healthy fats, complex carbs, unlimited greens and colored vegetables, lots of water.
  7. Use the 3 – 4 weeks to quit smoking. (Short burst exercises/learn about habit loops/consider medications to assist) Smoking is associated with increased respiratory, cardiovascular and wound related complications, as well as an increased 30-day mortality after surgery.
  8. Use the 3 – 4 weeks to cut back on alcohol intake. No alcohol is better, but at least cut down. Max of 1 beer/day, ½ glass wine/day, 1 shot/day.
  9. Get better control over anxiety and depression. Regular strenuous exercise has been proven to be effective. It is an empowering experience. It will bolster you mentally to be better prepared for surgery, feeling more in control. You will be more likely to require less pain medication and will recover faster.

 

Why should you bother with utilizing the time between the day you saw the surgeon, and the actual date of your elective surgery?

  1. It makes medical sense. Use the wait time effectively! (Prepare like a soldier for battle. The bigger your surgery—the bigger the similarity and the need.)
  2. It will empower you. You become involved and engaged in your treatment plan. It will give you some sense of control in your situation.
  3. It will lessen your dread, anxiety and depression
  4. It will prepare you physically and physiologically for the trauma of surgery
  5. It will decrease your complications during and after the procedure
  6. It will improve your mental and cognitive function (before the surgery, but also afterwards.) This is especially true if you’re older and frailer
  7. It can help you establish a lifelong healthier lifestyle
  8. You will recover faster and heal better
  9. You will be able to return to work faster, or reach your previous functional level sooner
  10. In can enable you (if you’re older and frailer), to continue living independently
  11. You can continue getting stronger and fitter over time, after the surgery, as you continue applying the principles learned during this prehabilitation period.

 

What do you need to perform your “own” prehabilitation?

  1. Make the decision. Gather your information and start. (As discussed in this open letter.) Discuss it with your family doctor/surgeon/anesthesiologist. If they don’t offer a pre-surgery prehab-program, do your own
  2. Invest a resistance band or tubing ($2 – $ 20)
  3. Invest in a container of whey protein ($ 40—enough if one scoop/day x 15: 5x/week x 3)
  4. You can do it “alone” at home
  5. Depending on several factors, I often recommend that you join a gym or fitness facility. Many facilities have special 8-12 week short-membership specials. You will enjoy a multitude of added benefits, of which social interaction and support is crucial.
  6. Involve an exercise buddy/partner
  7. Emotional bolstering: if you work hard these 3-4 weeks prior to the surgery as described above and become fitter and stronger, it will improve your mental wellbeing. If the services of a lifestyle-intervention psychologist is available, it will add value.

 

Why should we bother?

Because it makes sense, and we’re talking about the one life you have.

But remember: each individual is different; each patient’s needs are different. There is often no one model fits all.

It is 2016; it is no longer acceptable to merely survive the surgery. We want you to do well, especially in the long term. By becoming actively engaged in your treatment plan and by following this fairly basic, straightforward (and inexpensive) preoperative optimization program, you can have a dramatic impact on the success of your surgery and treatment.

You will immediately feel better, you will recover faster following the surgery, heal better, and positively impact your future wellbeing.

A practical example of patient engagement is the remarkable story of cancer survivor, e-Patient Dave (Dave deBronkart.)

Most important, if you follow these recommendations, you will be able to go into surgery, being (indeed) optimally prepared and empowered, and have more peace of mind.

As always,

Sincerely yours.

 

Danie Botha

(Your Anesthesiologist.)

 

References:

  1. Turan A, Mascha EJ et al. Smoking and perioperative outcomes. Anaesthesiology. 2011; 114: 837-46.
  2. West MA et al. Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients. 114 (2): 244-51 (2015)
  3. Carli F, Scheede-Bergdahl C. Prehabilitation to Enhance Perioperative Care. Anesthesiology Clin 33 (2015) 17 -33
  4. Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS, Carli F. Prehabilitation versus Rehabilitation. Anesthesiology 2014; 121: 937-47

Please note: I reserve the right to delete comments that are offensive or off-topic.

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