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Enhanced recovery after surgery (ERAS) is an evidence-based, multimodal approach to optimising patient outcomes following surgery. The role of physiotherapy within ERAS and intensive care units (ICU) is important. Patients admitted to an ICU following elective major surgery may suffer from physical, psychological and cognitive problems, which can impact their return to function and quality of life. ICU physiotherapists can enable patients to achieve ERAS programme aims throughout their stay in an ICU and this may accelerate the achievement of discharge criteria and subsequent return to function. Functional limitations and persistent weakness may exist long after discharge, and therefore there is a need to increase the awareness and involvement of physiotherapists within the outpatient setting. Establishing a standardised rehabilitation programme, informed by key ERAS principles and delivered by specialist physiotherapists supported by a well-informed ICU team can have longterm benefits to patients post-discharge.
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ICU
MANAGEMENT & PR ACTICE
icu-management.org ICU Management & Practice - part of HealthManagement.org @ICU_Management
VOLUME 17 - ISSUE 3 - AUTUMN 2017
Ultrasound-guided mechanical
ventilation, F. Mojoli & S. Mongodi
Haemodynamic monitoring: stuff
we never talk about, C. Boerma
Animal-assisted activity in the
intensive care unit, M.M. Hosey
et al.
From command and control to
modern approaches to leadership,
T. Dorman
Enabling machine learning in
critical care, T.J. Pollard & L.A. Celi
PLUS
Recovery
The role of autophagy in the metabolism and outcomes after surgery,
J. Gunst et al.
Fast-track surgery: a multidisciplinary collaboration, H. Kehlet
The patient voice in Enhanced Recovery After Surgery, A. Balfour &
R. Alldridge
The role of physiotherapy in Enhanced Recovery after Surgery in the ICU,
T.W. Wainwright et al.
Innovations in monitoring: from smartphones to wearables, F. Michard
Physical rehabilitation in the ICU: understanding the evidence,
C. M. Goodson et al.
Optimising nutrition for recovery after ICU, P.E. Wischmeyer
Outcomes after 1 week of mechanical ventilation for patients and families,
M. Parotto & M.S. Herridge
Continuing rehabilitation after intensive care unit discharge, S. Evans et al.
The hidden faces of sepsis, what do they tell us? I. Nutma-Bade
CSL Behring
Supplement from
Euroanaesthesia
2017 Symposium
ICU Management & Practice 3 - 2017
144
COVER STORY: RecoveRy
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The role of physiotherapy
in Enhanced Recovery
After Surgery in the
intensive care unit
E
nhanced recovery after surgery (ERAS)
is a combination of perioperative care
components built upon a multimod-
al approach that integrates evidence-based
interventions to reduce convalescences across
multiple surgical procedures. Since ERAS
was first implemented within hospitals over
twenty years ago, post-surgical outcomes have
improved for patients (Kehlet and Wilmore
2008). Length of stay has decreased, with
no subsequent increase in readmission rates
(Paton et al. 2014), with concurrent improve-
ments in clinical outcomes whilst having a
beneficial impact on healthcare resources.
ERAS programmes are supported by evidence-
based preoperative, intraoperative and postop-
erative procedures to accelerate the achieve-
ment of discharge criteria. ERAS originated in
elective colorectal surgery, but has spread to
other surgical subspecialties, including, but
not limited to, gastrointestinal, hepatobiliary,
orthopaedic, cardiac, thoracic, head and neck,
breast and gynaecologic surgery.
Physiotherapy and ERAS
The role of physiotherapy within ERAS path-
ways is important in both preoperative and
postoperative routines. Implementing a preop-
erative strength programme has been shown
to promote musculoskeletal improvements in
preparation for a forthcoming physiological
stressor (Carli et al. 2010), and is an emerging
key component of ERAS. A literature review
found preoperative exercise in patients sched-
uled for cardiovascular, thoracic, abdominal
and major joint replacement surgery to be
well tolerated and effective (Hoogeboom et
al. 2014). Postoperative exercise programmes
are also recommended by ERAS guidelines,
promoting muscle hypertrophy and the return
to function after major surgery (ERAS Society
2017).
Early postoperative mobilisation is a
fundamental principle of good physiother-
apy practice and of ERAS programmes. It has
been shown to reduce the rate of morbidity
and length of stay following major surgery
(Epstein 2014; Kehlet and Wilmore 2008),
with immobilisation due to hospitalisation
causing a decline in muscle strength, insu-
lin adherence and functional ability. Early
mobilisation can accelerate the achievement
of discharge criteria, and has been evidenced
to reduce the rate of postoperative pulmonary
complications, venous thromboembolism and
infection (Epstein 2014). Early mobilisation
can only be achieved through adequate pain
control; multimodal opiod-sparing regimes,
which are central to ERAS programmes are
essential. This is a fundamental principle with-
Thomas W. Wainwright
Associate Professor
in Orthopaedics
Bournemouth University
Bournemouth, UK
twainwright@bournemouth.ac.uk
@twwainwright
David A. McDonald
Service Improvement Manager
Scottish Government
Edinburgh, UK
david.mcdonald@nhs.net
Louise C. Burgess
Research Assistant
Bournemouth University
Bournemouth, UK
lburgess@bournemouth.ac.uk
Enhanced recovery after surgery (ERAS) is an evidence-based, multi-
modal approach to optimising patient outcomes following surgery. The
role of physiotherapy within ERAS and intensive care units (ICU) is impor-
tant. Patients admitted to an ICU following elective major surgery may
suffer from physical, psychological and cognitive problems, which can
impact their return to function and quality of life. ICU physiotherapists
can enable patients to achieve ERAS programme aims throughout their
stay in an ICU and this may accelerate the achievement of discharge
criteria and subsequent return to function. Functional limitations and
persistent weakness may exist long after discharge, and therefore there
is a need to increase the awareness and involvement of physiotherapists
within the outpatient setting. Establishing a standardised rehabilitation
programme, informed by key ERAS principles and delivered by specialist
physiotherapists supported by a well-informed ICU team can have long-
term benefits to patients post-discharge.
ICU Management & Practice 3 - 2017
146
COVER STORY: RecoveRy
©For personal and private use only. Reproduction must be permitted by the copyright holder. Email to copyright@mindbyte.eu.
in ERAS, in that each intervention, whether
surgery and/or analgesic regimens, must
consider its impact on rehabilitation goals
and how to best support early postoperative
mobilisation. There are many surgery-specific
barriers to early mobilisation, highlighting
the importance of a multidisciplinary care
team approach.
Intensive care unit stay
A patient may be admitted to an intensive
care unit (ICU) after elective major surgery if
they require postoperative support either due
to the complexity of surgery, or because of
co-existing medical conditions. ICU admis-
sion is not always routine amongst all major
surgeries that adopt ERAS principles, with
orthopaedic procedures generally being the
most well-tolerated by patients, and conse-
quently rarely requiring ICU admission
(AbdelSalam et al. 2012). ERAS guidelines
highlight that gynaecologic, cardiac, pancreat-
icduodenectomy, colorectal, hepatic and head
and neck cancer patients may require trans-
fer to an ICU, depending upon their condi-
tion following surgery. Admission to an ICU
is patient- and surgery-specific, with many
programmes using preoperative risk models
in an attempt to predict need for and length
of stay within intensive care. Standardising
postoperative ICU management can lead to
reductions in length of stay with no increase
to postoperative complications (Agarwal et
al. 2012). Programmes within ICUs should
consist of a multidisciplinary team who utilise
a model of perioperative care components of
enhancing recovery.
Physiotherapy within intensive care
units
The aim of physiotherapy treatment provided
within ICUs can be broadly separated into
two: improving respiratory function, and
initiating the rehabilitation process. Patients in
an ICU may require mechanical ventilation to
help their breathing; however this can lead to
pulmonary complications. Respiratory phys-
iotherapy involves early mobilisation where
possible, repositioning patients within bed
to optimise respiratory function, and utilis-
ing manual techniques or the manipulation
of ventilator settings to clear lung secretions
that build up within the lungs, when mobility
and consequently deep breathing is limited.
This helps to reduce the risk of pulmonary
issues. Rehabilitation physiotherapy focuses
initially on maintaining range of joint motion
to prevent contractures, and on reducing the
muscle loss that occurs due to immobility
whilst a patient is in an ICU. Rehabilitation
then focuses as soon as possible to sitting,
standing and then walking, in order to facili-
tate their return to physical function. Patients
can become weak quickly, and the use of exer-
cises, electrical stimulation and ambulation
practice can reduce muscle atrophy and joint
stiffness that may occur.
The aforementioned roles of a physio-
therapist within an ICU assimilate strongly
with the key ERAS principles for accelerat-
ing the achievement of discharge criteria. To
ensure a patient admitted to ICU continues
to achieve functional recovery, the role of the
physiotherapist is important. The impact of
a perioperative ERAS programme has been
shown to reduce the incidence of pulmonary
complications with sustained improvement
evident one year after implementation in
patients admitted to an ICU following elec-
tive major surgery (Moore et al. 2017). Using
an evidence-based physiotherapy protocol
that addresses pulmonary dysfunction and
promotes early mobility has been found to
be safe and effective in comparison to non-
specialist care for patients on ICU (Hanekom
et al. 2013). An appropriate level of clinical
expertise should be required to safely work
in a critical care environment, and creating an
algorithm to guide non-specialist therapists
can encourage best practice physiotherapy
(Sommers et al. 2015) promoted within ERAS
guidelines.
Early mobilisation of critically ill patients
in an ICU is a safe and effective intervention
that may lead to significant improvements
to functional outcomes (Adler and Malone
2012). An admission to ICU should therefore
not mean that a patient is removed from an
ERAS pathway. In fact, it may be argued that
it is the ICU-admitted patients that need ERAS
the most. Mobilising a patient can include
activities such as sitting, standing, ambulation
and passive exercises performed by the phys-
iotherapist. Functional exercise capacity, self-
perceived functional status and muscle force
have been reported to be greater at hospital
discharge for patients receiving a passive or
active exercise training session for 20 minutes
a day (Burtin et al. 2009). Early mobilisation
has also been linked to a decrease in mechani-
cal ventilation duration when a multidisci-
plinary team with a recognised leader can
implement change to the ICU culture and
practice (Hashem et al. 2016).
Barber and colleagues (2015) found barri-
ers to early mobilisation within ICUs to be a
lack of resources and communication; high-
lighting the importance of educating and
including the ICU team within the traditional
ERAS team of anaesthetists, surgeons, and
ward-based nurses and allied health profes-
sionals. Education should include the clinical
aspects as well as combined working to ensure
logistical factors are coordinated, such as the
use of standard documentation. For example,
ERAS patients are often managed on a specific
ERAS pathway document; this needs to work
seamlessly with ICU pathway documentation.
Rehabilitation post discharge
Following a critical illness or prolonged stay
in an ICU, patients may suffer from physical,
psychological and cognitive problems, which
can negatively impact their health-related
quality of life (Jones 2012). Intensive care
unit-acquired weakness (ICUAW) is a clini-
cal syndrome that occurs due to muscle atro-
phy and loss of muscle mass whilst a patient
is intubated and mechanically ventilated.
Recovery time increases with length of stay,
and an effective rehabilitation programme is
vital to ensure a patient can return as close
as possible to their preoperative physical and
mental health.
Functional limitations and persistent
weakness may exist long after discharge,
and therefore there is a need to increase the
awareness and involvement of physiothera-
pists within the outpatient setting (Pawlik and
Kress 2013). Physiotherapists are an essential
An admission to ICU
should therefore not mean
that a patient is removed from
an ERAS pathway
ICU Management & Practice 3 - 2017
147
COVER STORY: RecoveRy
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component of the rehabilitation pathway, and
can ensure that patients adopt ERAS principles,
proven to facilitate recovery, once they are
discharged from an ICU. The rehabilitation
needs of a patient should be individualised,
and assessments are important to determine
which physiotherapy and counselling resourc-
es are required. Consequently, an adequate
number of well-informed physiotherapists
who are competent at managing critical care
patients in an outpatient setting is needed.
There is limited evidence regarding the
effectiveness of physiotherapy interventions
following admission to an ICU, and ERAS
guidelines for post-discharge rehabilitation
are still evolving. Recent literature has suggest-
ed that high intensity rehabilitation could
lead to greater improvements in functional
outcomes in comparison to lower intensity
programmes (Bandholm and Kehlet 2012).
The use of progressive resistance training has
been highlighted for augmenting a patient’s
hypertrophy, improving their strength, balance
and muscular endurance (Borst 2004). Jones
et al. (2003) found a self-help rehabilitation
manual to be effective in aiding physical
recovery and reducing depression; howev-
er, many patients still recalled delusional
memories from ICU, prompting the need for
further psychological care. A physiotherapy-
led, outpatient rehabilitation programme,
involving education sessions and circuit-based
training has been proven to enhance exercise
capacity along with significant psychologi-
cal benefits following discharge from an ICU
(McWilliams et al. 2009).
With this considered, a Cochrane review
of exercise rehabilitation for recovery follow-
ing discharge from an ICU was unable to
determine an overall result for the effect of
exercise training on recovery. Six studies were
examined: three of the papers reported results
in favour of post-discharge exercise training
programmes and the remaining studies found
no effect. Interventions included walking,
strengthening exercises, education, arm and
leg cycling exercises and self-help rehabilita-
tion manuals (Connolly et al. 2015). Despite
inconclusive results, the authors highlight
the importance of physical rehabilitation for
recovery after a critical illness.
Conclusion
The role of physiotherapy within ERAS and
rehabilitation following intensive care is
important and will be increasingly more so, as
the development of ERAS programmes leads to
a shift in outcome measures, from the current
surrogate of length of stay, to functional and
activity-based markers of recovery. There is
limited research available that focuses on the
effect of an ERAS programme on outcomes
for patients discharged from an ICU following
elective major surgery. This cohort may have
the most to gain from a multimodal approach
that integrates evidence-based interventions.
Critical care physiotherapists adopt roles that
assimilate strongly with key ERAS principles,
and they can play a vital role in ensuring
patients remain on track with their ERAS
pathway whilst in an ICU. Providing a more
intense, coordinated rehabilitation programme
for patients following discharge from an ICU,
delivered by a specialised physiotherapist
and supported by a multidisciplinary team
is hypothesised to improve recovery (Walsh
et al. 2012).
Future research and investigation
Future research should focus on establish-
ing a standardised rehabilitation programme,
informed by ERAS principles, which can be
delivered by specialist physiotherapists within
an ICU and in an outpatient setting. Prospec-
tive studies are needed to determine the
long-term effect of early mobilisation and
exercise-based interventions. The ability to
recover following discharge from an ICU can
be more accurately measured when compared
to values of baseline function, allowing clini-
cians to consider patients with pre-existing
co-morbidities, who are less likely to respond
to rehabilitation interventions. Thus, a safe and
effective method for determining preopera-
tive functional ability should be researched.
Consideration of how to attain and impor-
tantly measure functional recovery should be
the focus for physiotherapy research in the
future, providing evidence for its inclusion
in the ERAS programmes of tomorrow.
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Abbreviations
ERAS enhanced recovery after surgery
ICU intensive care unit
ICUAW intensive care unit-acquired weakness
... Particular care is taken to build nursing teams that deliver protocol-led care of these complex patients including drain management, general physiology and an abdominal wall support binder. Physiotherapists are involved in encouraging incentive spirometry and early mobilisation in keeping with enhanced recovery principles [40]. ...
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Chapter
Physiotherapists play an important role within the multidisciplinary Enhanced Recovery After Surgery (ERAS) team by encouraging early ambulation and promoting the return to function for patients. While the physiological rationale for early ambulation is well understood, there is only emerging research evidence for early ambulation across surgical pathways. Data is often limited and in some cases compliance has been reported as low. Enabling patients to ambulate following surgery requires early planning and interdisciplinary collaboration to address potential patient, structural, and cultural barriers that may prevent early ambulation. Barriers may range from postoperative pain, lack of patient motivation, inadequate staffing, or a lack of culture for early ambulation. Evidence for postoperative physiotherapy in ERAS pathways is similarly limited but suggests that preoperative characterization of patients may in the future facilitate optimal, individualized care, which can accelerate the return to normal function and physical activity. Recovery of a patient’s physical fitness within the postoperative period is important to reduce the likelihood of poor functional outcomes and should be a focus of future research within ERAS.
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Despite the historical precedent of mobilizing critically ill patients, bed rest is common practice in ICUs worldwide, especially for mechanically ventilated patients. ICU-acquired weakness is an increasingly recognized problem, with sequelae that may last for months and years following ICU discharge. The combination of critical illness and bed rest results in substantial muscle wasting during an ICU stay. When initiated shortly after the start of mechanical ventilation, mobilization and rehabilitation can play an important role in decreasing the duration of mechanical ventilation and hospital stay and improving patients' return to functional independence. This review summarizes recent evidence supporting the safety, feasibility, and benefits of early mobilization and rehabilitation of mechanically ventilated patients and presents a brief summary of future directions for this field.
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Background: The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in other medical/surgical subspecialties. However, few spinal series have specifically focused on the “pros” of early mobilization for spinal surgery, other than in acute spinal cord injury. Here we reviewed how early mobilization and other adjunctive measures reduced morbidity and LOS in both medical and/or surgical series, and focused on how their treatment strategies could be applied to spinal patients. Methods: We reviewed studies citing protocols for early mobilization of hospitalized patients (day of surgery, first postoperative day/other) in various subspecialties, and correlated these with patients’ perioperative morbidity and LOS. As anticipated, multiple comorbid factors (e.g. hypertension, high cholesterol, diabetes, hypothyroidism, obesity/elevated body mass index hypothyroidism, osteoporosis, chronic obstructive pulmonary disease, coronary artery disease and other factors) contribute to the risks and complications of immobilization for any medical/surgical patient, including those undergoing spinal procedures. Some studies additionally offered useful suggestions specific for spinal patients, including prehabilitation (e.g. rehabilitation that starts prior to surgery), preoperative and postoperative high protein supplements/drinks, better preoperative pain control, and early tracheostomy, while others cited more generalized recommendations. Results: In many studies, early mobilization protocols reduced the rate of complications/morbidity (e.g. respiratory decompensation/pneumonias, deep venous thrombosis/pulmonary embolism, urinary tract infections, sepsis or infection), along with the average LOS. Conclusions: A review of multiple medical/surgical protocols promoting early mobilization of hospitalized patients including those undergoing spinal surgery reduced morbidity and LOS.
Article
Objectives: To compare the physiotherapy service provided when therapists' decisions are guided by an evidence-based protocol with usual care (i.e. patient management based on therapists' clinical decisions). Design: Exploratory, controlled, pragmatic sequential time block clinical trial. Setting: Level 3 surgical unit in a tertiary hospital in South Africa. Participants: All patients admitted consecutively to the surgical unit over a 3-month period were allocated to usual or protocol care based on date of admission. Interventions: Usual care was provided by clinicians from the hospital department, and non-specialised physiotherapists were appointed as locum tenens to provide evidence-based protocol care. Main outcome measures: Patient waiting time, frequency of treatment sessions, tasks performed and adverse events. Results: During protocol-care periods, treatment sessions were provided more frequently (P<0.001) and with a shorter waiting period (P<0.001). It was more likely for a rehabilitation management option to be included in a treatment session during protocol-care periods (odds ratio 2.34, 95% confidence interval 1.66 to 3.43; P<0.001). No difference in the risk of an adverse event was found between protocol-care and usual-care periods (P=0.34). Conclusions: Physiotherapy services provided in intensive care units (ICUs) when the decisions of non-specialised therapists are guided by an evidence-based protocol are safe, differ from usual care, and reflect international consensus on current best evidence for physiotherapy in ICUs. Non-specialised therapists can use this protocol to provide evidence-based physiotherapy services to their patients. Future trials are needed to establish whether or not this will improve patient outcome.