Prehabilitation in Anesthesiology

Prehabilitation is a proactive approach to post-surgical rehabilitation that starts before the surgery even begins. The program is based on the assumption that enhancing the functional capacity of a patient will assist him or her in enduring the stressful postoperative period. A complete prehabilitation plan includes all members of the surgical team and involves the perioperative physician and anesthesiologist working in tandem to create a patient-centric plan in advance of a surgery [1].

Prehabilitation often begins with an assessment of functional capacity, which helps the surgical team understand the risks associated with a surgery for a specific patient. Ultimately, the goal is to improve an individual’s functional capacity [2]. Current approaches usually include exercise, dietary interventions, stress interventions and cessation of habits that lead to poor health such as smoking. As Carli and Feldman note in their review of studies on prehabilitation, the approach is not a “one size fits all” program, but rather requires an individualized program that takes into account each patient’s unique needs. [3]

Several studies have examined the efficacy of traditional programs. Gillis et al. observed 77 patients undergoing colorectal resection for cancer. Those who underwent prehabilitation were 22% more likely to recover to baseline exercise capacity 2 months after the surgery compared to those who did not [4]. A similar study by Howard et al. looked at patients undergoing major abdominal surgery. Those who underwent prehabilitation saw their systolic and diastolic blood pressures improve significantly faster than control patients. The study also found that, due to shorter recovery times and lower risk of complications, prehabilitation saved hospitals an average of $21,946 per patient [5].

Prehabilitation can prove particularly helpful to elderly patients, many of whom are frail or lead sedentary lives. Poor nutrition status, which is a risk factor for postoperative complications in adults, is also a common trait in elderly patients. A systematic review of studies focusing on postoperative outcomes in elderly general surgery patients by van Stijn et al. found that weight loss prior to surgery and serum albumin were significant preoperative indicators of postoperative outcome [6]. Indeed, when put into practice, a pre-operative program was found to reduce incidences of delirium in elderly patients from 11.7% in control groups to 8.2% in experimental groups [7].

While most efforts in this area have focused on physical measures, psychological prehabilitation can also protect against anxiety and depression, which sometimes emerge in patients who have undergone anesthesia. A systematic review of psychological prehabilitation for cancer patients by Tsimopoulou et al. found that these interventions appear to have positively affected patients’ immunologic function, as well as postoperative quality of life [8].

While prehabilitation has been around in one form or another since the 1940s, studies on the practice are relatively recent and have had small sample sizes. Currently, a series of large-scale studies are examining its impact on broader populations. While the concept is still in its infancy, existing research suggests that prehabilitation has the potential to improve care, enhance recovery, and lower costs.

References 

[1] Carli, Francesco. “Prehabilitation for the Anesthesiologist.” Anesthesiology, Published Ahead of Print, 2020. doi:10.1097/aln.0000000000003331. 

[2] Arena, Ross, et al. “Assessment of Functional Capacity in Clinical and Research Settings.” Circulation, vol. 116, no. 3, 2007, pp. 329–343. doi:10.1161/circulationaha.106.184461. 

[3] Carli, F., and L.s. Feldman. “From Preoperative Risk Assessment and Prediction to Risk Attenuation: a Case for Prehabilitation.” British Journal of Anaesthesia, vol. 122, no. 1, 2019, pp. 11–13. doi:10.1016/j.bja.2018.10.021. 

[4] Gillis, Chelsia, et al. “Prehabilitation versus Rehabilitation.” Anesthesiology, vol. 121, no. 5, 2014, pp. 937–947. doi:10.1097/aln.0000000000000393. 

[5] Howard, Ryan, et al. “Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery.” Journal of the American College of Surgeons, vol. 228, no. 1, 2019, pp. 72–80. doi:10.1016/j.jamcollsurg.2018.09.018. 

[6] Stijn, Mireille F. M. Van, et al. “Preoperative Nutrition Status and Postoperative Outcome in Elderly General Surgery Patients.” Journal of Parenteral and Enteral Nutrition, vol. 37, no. 1, 2012, pp. 37–43. doi:10.1177/0148607112445900. 

[7] Janssen, T. L., et al. “Multimodal Prehabilitation to Reduce the Incidence of Delirium and Other Adverse Events in Elderly Patients Undergoing Elective Major Abdominal Surgery: An Uncontrolled before-and-after Study.” Plos One, vol. 14, no. 6, 2019. doi:10.1371/journal.pone.0218152. 

[8] Tsimopoulou, Ioanna, et al. “Psychological Prehabilitation Before Cancer Surgery: A Systematic Review.” Annals of Surgical Oncology, vol. 22, no. 13, 2015, pp. 4117–4123. doi:10.1245/s10434-015-4550-z.