Anaesthesia
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Just as there is growing interest in enhancing recovery after surgery, prehabilitation is becoming a recognised means of preparing the patient physically for their operation and/or subsequent treatment. Exercise training is an important stimulus for improving low cardiovascular fitness and preserving lean muscle mass, which are critical factors in how well the patient recovers from surgery. Despite the usual focus on exercise, it is important to recognise the contribution of nutritional optimisation and psychological wellbeing for both the adherence and the response to the physical training stimulus. This article reviews the importance of a multi-modal approach to prehabilitation in order to maximise its impact in the pre-surgical period, as well as critical future steps in its development and integration in the healthcare system.
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Pre-operative nutrition therapy is increasingly recognised as an essential component of surgical care. The present review has been formatted using Simon Sinek's Golden Circle approach to explain 'why' avoiding pre-operative malnutrition and supporting protein anabolism are important goals for the elective surgical patient, 'how' peri-operative malnutrition develops leading in part to a requirement for pre-operative anabolic preparation, and 'what' can be done to avoid pre-operative malnutrition and support anabolism for optimal recovery.
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Cardiac events remain the leading cause of peri-operative morbidity and mortality, and patients undergoing major surgery are exposed to significant risks which may be preventable and modifiable. Proper assessment and management of various cardiac conditions in the peri-operative period by anaesthetists can markedly improve patient safety, especially in high-risk patient populations. This involves understanding and applying current evidence-based practice and international guidelines on the main aspects of cardiac optimisation, including management of patients with hypertension, chronic heart failure, valvular heart diseases and cardiac implantable electronic devices. ⋯ There is an increasing need for anaesthetist-led services, including focused transthoracic echocardiography and management of implantable cardiac electronic devices. Anaesthetists should be encouraged to play a proactive role in pre-operative risk stratification and make timely multidisciplinary referrals if necessary. A personalised approach to pre-operative cardiac optimisation enables a safer peri-operative journey for at-risk patients undergoing major surgery.
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Postoperative pulmonary complications are common and cause increased mortality and hospital stay. Smoking and respiratory diseases including asthma, chronic obstructive pulmonary disease and obstructive sleep apnoea are associated with developing postoperative pulmonary complications. Independent risk factors for such complications also include low pre-operative oxygen saturation, or a recent respiratory infection. ⋯ Specific respiratory pre-operative interventions, such as deep breathing exercises and incentive spirometry, can help when used as components of a package of respiratory care. Pre-operative inspiratory muscle training programmes that involve inspiration against a predetermined respiratory load may also reduce some postoperative pulmonary complications. Pre-operative exercise programmes are recommended for patients having major surgery, or in those where pre-operative testing has shown low levels of cardiorespiratory fitness; interval training or respiratory interventions are more feasible as these reduce complications after a shorter pre-operative intervention.