Introduction
Major surgical procedures are associated with a significant drop in an individual's functional capacity. Prehabilitation is described as enhancing a patient's functional capability before a surgical procedure so the patient can resist any postoperative inertia and associated decline. Typically, the more fit and active individuals are, the more likely they will retain significant functionality afterward. In addition, prehabilitation works with a multimodal approach, including reduced hospital stay, less postoperative pain, and fewer postoperative complications.
What Is Prehabilitation?
Prehabilitation is the approach of enriching the patient’s functional ability before surgery to improve postoperative consequences. Several weeks may elapse between the determination to proceed with surgery and the surgery itself; thus, the period is called the teachable moment. A suitable time to positively influence a patient’s health behavior, which directly affects the long-term survival rate. Initiating an exercise program makes patients feel physically more adept at exercise than at any other moment during the perioperative period. A span of four to eight weeks with lifestyle modification can immensely change the postoperative state of the individual.
Prehabilitation equips patients to "weather the storm" of their procedure and to prevent or deal with setbacks. A "teachable moment" in healthcare is the preoperative stage. People may be more open to systematic behavioural interventions within this interval. The recent study has shown that patients are very motivated to alter their behaviour for postoperative advantages, but that there is a relative lack of confidence that indicates a need for organised assistance. Surgery presents a larger public health opportunity to entrench long-term lifestyle change, and this chance should not be overlooked. Prehabilitation that is effective puts the patient at the centre of the perioperative process and is person-centered. Patients can reclaim some authority over their own results. Prehabilitation assistance should be cross-sectoral and interdisciplinary, involving the knowledge and contribution of a variety of experts.
What Is the Prehabilitation Approach?
The multimodal approach outlines these essential aspects to enhance individual functionality:
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Medical optimization.
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Physical exercise.
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Nutritional support.
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Stress or anxiety reduction.
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Psychological support.
These interventions are delivered by a multidisciplinary unit consisting of surgeons, physicians, nutritionists, anesthetists, geriatricians, physiotherapists, and psychologists based on anthropometric dimensions like height, weight, and percentage of body fat obtained.
What Is Medical Optimization?
The preoperative state of an individual directly affects the postoperative status.
Starting with lifestyle modifications such as:
1. Smoking Cessation: Carbon monoxide (CO) and nicotine cause the most acute harm from smoking. CO decreases the tissue’s oxygen-carrying capacity, whereas nicotine has sympathomimetic properties and raises the work of the heart. Preoperative smoking cessation is a refreshing approach to decrease the risk of cardiopulmonary complications and promote wound healing.
2. Reduction in Alcohol Intake: Alcohol abuse advances the postoperative morbidity rate as alcohol exhibits a dose-response relationship with underlying mechanisms, including immuno-suppression, cardiac insufficiency, hemostatic imbalance, and exaggerated surgical stress response, which leads to:
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Postoperative infections.
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Cardiopulmonary complications.
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Bleeding events.
3. Weight Optimization: The major postoperative complications occur in underweight patients than normal weight patients. In addition, healthy patients encounter rarer wound infections, less intraoperative blood loss, and shorter operation times than the obese.
4. Medicational Based: Pharmacological optimization desires to achieve optimal control of chronic (long-term) conditions like:
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Anemia: Impairs functional capacity and raises the chance of perioperative blood transfusion, postoperative morbidity, and mortality. Therapeutic choices include iron supplementation, either by parenteral or oral route.
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Chronic Obstructive Pulmonary Disease and Heart Disease: The physician will rule out these diseases and advise the medication accordingly.
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Hypertension: Regular medication and follow-up help to control the hypertensive state.
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Drug-Interaction: It is recommended to evaluate the regular medication and prescribed medication’s adverse effects and the outcomes and modify the dosage of the drug under the physician's supervision.
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Diabetes: To achieve a state of equilibrium in blood sugar level before surgical intervention.
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Bleeding Conditions: To identify the associated bleeding disorder and treat them before a proper investigation is assessed by expertise.
How Can Physical Exercise Prepare the Patient for the Surgical Intervention?
To assess functional capacity, two often used tests are the cardiopulmonary exercise test (CPET) and the six-minute walk test. Six-minute walk test is a simple exercise that estimates how far a patient can walk in six minutes. The supervising technician records heart rate, dyspnea, and fatigue statuses at the beginning and end of the test, total distance walked, and in case the test was ended prematurely, then finds out why, like pain in the heart and severe dyspnoea.
The optimal exercise regime has yet to be described. Generally, the regimes comprise physically active exercise to increase blood flow and are conducted in one to five sessions per week, each of 30 to 60 minutes duration, including warm-up and cool-down stages.
What Is the Nutritional Support That Helps the Patient?
There is a definite correlation between poor nutritional status and poor postoperative outcomes. The malnourished patients require preoperative nutrition therapy, irrespective of surgery grade. Nutritional interventions include:
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Preoperative Carbohydrate Intake: Lowers insulin resistance and enables an anabolic state, decreasing protein loss.
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Protein Intake: The European Society for Clinical Nutrition and Metabolism recommends a daily protein input of 1.5 grams per kilogram of body weight in surgical patients to restrict nitrogen losses.
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Immunonutrition: Intake of amino acids such as glutamine and arginine, omega-3 fatty acids, and nucleotides counteracts the inflammation status and immune impairment rendered by the surgical stress response.
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Vitamins (C, K, E, B, A): Stimulates wound healing, declines infection rates, and shortens the length of stay.
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Proper Hydration: Enriched with essential minerals such as coconut water and fresh fruit juice.
How Stress-Related Issues Are Solved for the Surgical Patient?
Most patients suggested for surgical intervention undergo poor mental health in the form of anxiety and negative thoughts related to poor outcomes. The underlying diagnosis, surgery, anesthesia, pain, survival rate, complications, and recovery are all causes for apprehension. These psycho-social factors provoke immunological dysregulation via the immune-brain loop, which acts via the identical pathways that create the surgical stress reaction. Thus the patient requires maximum motivation and empowerment to capitulate with the exercise and nutritional aspects with proper counseling.
Conclusion
Prehabilitation improves preoperative functional exercise capacity with the help of multimodal approach programs, which reduces the hospital's length of stay. It is essential to highlight that the prehabilitation program, which is of a specific period, is indicative for all patients as it helps to restore the body's capacity to counteract stress-induced surgical intervention. Overnight fasting is only required in some cases where the surgical intervention is in the gastrointestinal tract. The surgeon and physician will guide the diet plan to provide the best nutritional food with the best outcomes.
