Surgery - Preparation and Recovery
The Postoperative (Recovery) Period
When patients first recover from anesthesia, they may feel groggy and confused as the drugs wear off. Nausea is a common side effect of many of the medications used during surgery. After these initial symptoms, the patient's primary complaint is typically pain. The medical team monitors the patient's pain level to find a medication plan that improves the patient's comfort level without limiting the patient's ability to move or eat (Nimmo 2017). Many hospitals are also trying to reduce the use of opioids, which can become addictive (Grant 2017).
Excellent preoperative care and nutrition to prepare the patient for surgery can reduce the amount of pain the patient experiences after surgery (Sarin 2017; Kratzing 2011). Non-medicinal interventions can also be helpful for alleviating pain. Even a single massage was shown to significantly reduce pain after some procedures (Kukimoto 2017). Hypnosis and guided distraction/imagery can decrease both pain and anxiety after surgery (Duparc-Alegria 2018; Abdeshahi 2013; Davidson 2016; Tusek 1997).
A certain amount of inflammation is necessary for proper wound healing. Cytokines and other inflammatory mediators are required for building a sufficient blood supply to the healing and newly forming tissue (Lin 2017; Boniakowski 2017; Gharaee-Kermani 2001; Barrientos 2008). Inflammatory cells are also required to fight infections; however, excessive inflammation can also impair the healing process (Boniakowski 2017; Smith 2017; Xu 2017).
Supplemental oxygen, a very frequent part of postoperative treatment, ensures that adequate oxygen is available to rapidly healing tissue (de Smet 2017; Gottrup 2017). Wound healing is known to be accelerated by moderately elevated tissue oxygen levels (Guo 2010; Chambers 2011). Doctors are also exploring how to use oxygen to fight infections in surgical wounds (Dryden 2017; Dunnill 2017). However, very high oxygen levels can damage tissue in the wound site (Andre-Levigne 2017; Bhutani 2012). Micronutrient supplementation and good nutrition have been shown to promote surgical wound healing (Ellinger 2014).
Pressure ulcers, or bedsores, are a type of wound that may develop at pressure points in patients who are unable or unwilling (because of pain) to shift their positions in bed (Atkinson 2018). Constant pressure reduces local blood flow, producing ischemia (reduced oxygen levels), lack of nutrients, and eventually cell death (Akbari 2014; Agrawal 2012; Kruger 2013). Areas of dead and dying tissue can be a breeding ground for bacteria.
Prevention of pressure ulcers is one of the chief priorities of the medical team in the postoperative period. Poor nutritional status is a major risk factor for pressure ulcer development (Lussi 2018; Taylor 2017), and many nutritional interventions have been shown to be helpful (Karahan 2018; Cox 2014). Supportive mattresses, frequent repositioning, and special wound dressings may help prevent and treat pressure ulcers (Boyko 2018; Serraes 2018; Elsabrout 2018).
For additional information on wound healing, see the Trauma and Wound Healing protocol.
Food and Fluid Intake
Enhanced recovery after surgery protocols emphasize optimal nutrition and maintaining an adequate fluid balance (Steenhagen 2016). For most types of surgery, patients should be able to eat and drink on the day of the surgery (Ljungqvist 2017). Energy needs and requirements for nutrients increase after surgery (Ellis 1991; Wischmeyer 2018; Demling 2009; Finnerty 2013). By maximizing nutrition and caloric intake, patients heal and recover faster (Demling 2009; Russell 2001; Wild 2010; Gruen 2010).
Before, during, and after surgery, patients typically receive IV fluids to compensate for fluids lost during the procedure. Too much IV fluid can be harmful to the patient, leading to swelling and organ damage (Sweeney 2013; Steenhagen 2016). Well-trained medical teams are able to find the right balance (Ramsay 2018). In many cases, limiting postoperative IV fluids can shorten hospital stays and improve recovery (Onyekwelu 2016).
The recovery period is an excellent time to optimize nutrition in the diet. Patients should focus on foods and supplements that can boost the immune system and promote wound healing. For some patients, immunonutrition formulas may be helpful (Xu, Sun 2018; Probst 2017; Song 2017). For more information on immunonutrition, see the “Integrative Interventions” section of this protocol.
Patients should begin moving around as soon as possible after surgery (Steenhagen 2016). Programs to actively encourage movement may be helpful. In one study of patients undergoing abdominal surgery for cancer, 38.9% of those treated with standard care were unable to walk unassisted five days after surgery versus 16.7% of those participating in a supervised program of strength, flexibility, and aerobic training (de Almeida 2017). Prolonged bed rest can increase the risk of deep vein thrombosis (DVT), muscle weakness, and poor wound healing (Steenhagen 2016; Grey 2006). Even lying in bed, patients can help prevent DVT by moving their legs in a bicycle motion or tracing letters in the air with their toes (Stanford Health Care 2017d).
For patients undergoing lung surgery, postoperative breathing exercises may be beneficial (Stanford Health Care 2017d). Medical teams may teach recovering patients how to take deep breaths and safely cough (while supporting the incision) help remove chest secretions and prevent pneumonia. Specific exercises called inspiratory muscle training, or IMT, can improve blood oxygen levels after surgery (Brocki 2016).
Postoperative Cognitive Dysfunction
Acute confusion and impaired consciousness within a few days after major surgery is quite common, especially among older adults. This phenomenon is called postoperative delirium, and typically resolves before hospital discharge (Whitlock 2011). Whether or not general surgery under anesthesia directly causes long-term cognitive problems—termed postoperative cognitive dysfunction—is less clear. While there may be a true effect in some people, current evidence suggests surgery and anesthesia are not robustly and directly linked to long-term cognitive impairment in most patients (Tsai 2010; Rundshagen 2014; Avidan 2016).
Ongoing research has not found strong evidence of a link between persistent cognitive deficits and major surgery independent of overall health of the patient and their cognitive status trajectory before surgery (Avidan 2016; Aiello Bowles 2016; Dokkedal 2016). Predisposing factors to worse cognitive outcomes after surgery include preexisting low-grade cognitive decline and early Alzheimer-type changes (Rundshagen 2014; Berger 2015). Observational evidence linking surgery to cognitive decline is relatively weak, and rigorous study data suggest any true effect on long-term cognitive function is likely negligible (Dokkedal 2016; Jiang 2017). It may be that much of the apparent decline in cognitive function observed after surgery in older people is attributable to the post hoc ergo propter hoc fallacy—“after this, therefore because of this.” But the expected continuation of a preexisting cognitive decline trajectory is thought to be the true culprit in many cases (Avidan 2016).
One study found that, in pairs of middle-aged to elderly twins—who have very similar genetic and biochemical susceptibility—when one had undergone major surgery and the other had not, their cognitive scores were nearly identical. Another analysis in this study compared the twin who underwent surgery to a control group and found a small, clinically insignificant tendency to a lower cognitive score (Dokkedal 2016). In a meta-analysis that pooled data from 19 studies, no clear association was found between general anesthesia and dementia risk. Nevertheless, when the analysis was limited to studies that used records of anesthesia rather than subjective patient recall, the authors found a small increased risk of dementia in those who had received general anesthesia, highlighting the need for high-quality study designs when this phenomenon is studied in the future (Jiang 2017).
The current lack of evidence does not mean that post-operative cognitive dysfunction is not worthy of a clinician's attention. Some studies have indeed found that surgery and general anesthesia are associated with negative effects on cognition in the elderly (Evered 2017; Schenning 2016), negatively impacting the brain's immune system (Schenning 2016), and that post-operative cognitive dysfunction that persists three months after surgery is associated with an increased risk of dying from any cause (Steinmetz 2009). As surgical trauma induces a body-wide surge in inflammation, it has been proposed that inflammation of the brain, and failure to promptly resolve inflammation, may be causative factors for this syndrome. It has been proposed that measures to mitigate the trauma and inflammation resulting from major surgery may help prevent this problem (Rundshagen 2014; Berger 2015).
Novel treatments for preventing post-operative cognitive dysfunction (POCD) are currently under investigation. Perhaps one of the best-studied ones is ulinastatin, an enzyme-inhibiting agent that can be either synthesized or isolated from human urine (Jiang, Hu 2016). It is used in several Asian countries, but not yet approved in the United States (Liu, Yu 2017). A 2016 review of the scientific literature found five randomized controlled trials examining intravenously-administered ulinastatin’s effect on POCD. In these trials, which enrolled a total of 461 elderly patients, ulinastatin reduced POCD compared to control treatment at three and seven days after surgery, but not on the day immediately following the procedure. Ulinastatin also reduced levels of the pro-inflammatory cytokine interleukin-6 within two days after surgery (Lv 2016). A 2017 controlled clinical trial confirmed these results. In this study, 80 elderly patients receiving chemotherapy and undergoing radical esophagectomy were randomized to ulinastatin or a control group. Those in the ulinastatin group experienced less POCD seven days after surgery, an effect the authors hypothesized might have resulted from the observed lower levels of interleukin-6 and C-reactive protein, and higher levels of the protective cytokine interleukin-10 (Wang, Yang 2017).
Two natural interventions have attracted attention for the prevention of POCD. In a randomized controlled trial, 61 patients aged 30‒70 years undergoing cardiopulmonary bypass received either 2 capsules of a Valeriana officinalis root extract per day or placebo. The intervention started a day before surgery and continued until 60 days after surgery. Subjects treated with the root extract had a significantly lower likelihood of POCD than those in the placebo group (Hassani 2015). A second intervention trial, underway as of mid-2018, is evaluating the potential of N-acetylcysteine as a treatment for POCD (Skvarc 2016).
Many of the integrative interventions discussed in this protocol that may help promote surgical recovery may also help promote healthy postoperative cognitive function. Also, refer to the Age Related Cognitive Decline protocol, which reviews many integrative interventions that may support brain health.