Enhanced Recovery Program and Length of

Stay After Laparotomy on a Gynecologic Oncology

Service: A Randomized Controlled Trial.
Dickson EL1, Stockwell E, Geller MA, Vogel RI, Mullany SA, Ghebre R, Witherhoff BJ, Downs
LS Jr, Carson LF, Teoh D, Glasgow M, Gerber M, Rivard C, Erickson BK, Hutchins J, Argenta
PA.
Author information
Abstract

OBJECTIVE:

To estimate whether a rapid recovery program would reduce length of stay among patients undergoing laparotomy on a gynecologic oncology service.

METHODS:

We conducted a prospective, randomized, controlled trial comparing an enhanced recovery after surgery protocol with routine postoperative care

among women undergoing laparotomy on the gynecologic oncology service. Protocol elements included: preoperative counseling, regional anesthesia,

intraoperative fluid restriction, and early postoperative ambulation and feeding. A sample size of 50 per group (N=100) was planned to achieve 80%

power to detect a two-day difference in our primary outcome, lengthof hospital stay; secondary outcomes included: total daily narcotics used, time to

postoperative milestones, and complications.

RESULTS:

A total of 112 women were enrolled between 2013 and 2015. Nine patients did not undergo laparotomy and were excluded, leaving 52 and 51 patients

in the control and intervention groups, respectively. There was no difference in length of stay between the two groups (median 3.0 in both groups;

P=.36). Enhanced recovery after surgery patients used less narcotics on day 0 (10.0 compared with 5.5 morphine equivalents in the control and

intervention arms, respectively, P=.09) and day 2 (10.0 compared with 7.5 morphine equivalents, respectively; P=.05); however, there was no

statistically significant difference between groups in any of the secondary outcomes. Post hoc analysis based on actual anesthesia received also failed

to demonstrate a difference in time to discharge.

CONCLUSION:

When compared with usual care, introducing a formal enhanced recovery after surgery protocol did not significantly reduce length of stay.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, https://clinicaltrials.gov, NCT01705288.

METODE: Kami melakukan percobaan prospektif, acak, terkontrol yang membandingkan pemulihan yang disempurnakan setelah

protokol operasi dengan perawatan pasca operasi rutin di antara wanita yang menjalani laparotomi pada layanan onkologi

ginekologi. Unsur-unsur Protokol termasuk: konseling pra operasi, anestesi regional, pembatasan cairan intraoperatif, dan ambulasi

awal pasca operasi dan pemberian makan. Ukuran sampel 50 per kelompok (N = 100) direncanakan mencapai daya 80% untuk

mendeteksi perbedaan dua hari pada hasil utama kami, lamanya tinggal di rumah sakit; Hasil sekunder meliputi: total narkotika

harian yang digunakan, waktu untuk kejadian pasca operasi, dan komplikasi. HASIL: Sebanyak 112 wanita terdaftar antara tahun
2013 dan 2015. Sembilan pasien tidak menjalani laparotomi dan dikeluarkan, masing-masing memiliki 52 dan 51 pasien dalam

kelompok kontrol dan intervensi. Tidak ada perbedaan panjang tinggal antara kedua kelompok (median 3.0 pada kedua kelompok;

P = .36). Pemulihan yang disempurnakan setelah pasien operasi menggunakan lebih sedikit narkotika pada hari ke 0 (10,0

dibandingkan dengan 5,5 morfin setara pada kelompok kontrol dan intervensi masing-masing, P = .09) dan hari ke 2 (10,0

dibandingkan dengan 7,5 morfin setara, masing-masing; P = .05) ; Namun, tidak ada perbedaan yang signifikan secara statistik

antara kelompok dalam hasil sekunder. Analisis post hoc berdasarkan anestesi aktual yang diterima juga gagal menunjukkan

perbedaan waktu untuk dibuang. KESIMPULAN: Bila dibandingkan dengan perawatan biasa, perkenalkan pemulihan yang

disempurnakan secara formal setelah protokol operasi tidak mengurangi lama tinggal secara signifikan. PENDAFTARAN KLINIK

TRIAL: ClinicalTrials.gov, https://clinicaltrials.gov, NCT01705288.

Aust J Physiother. 2003;49(3):165-73.

Does removal of deep breathing exercises from a

physiotherapy program including pre-operative education
and early mobilisation after cardiac surgery alter patient
outcomes?
Brasher PA1, McClelland KH, Denehy L, Story I.
Author information
Abstract

The aim of this study was to establish whether removal of breathing exercises from a regimen including early mobilisation changes the incidence

of post-operative pulmonary complications for patients after cardiac surgery. Two hundred and thirty patients undergoing open heart surgery at Monash

Medical Centre, Melbourne, were enrolled in this randomised controlled trial. All patients received physiotherapy treatment pre-operatively and post-

operatively for three days. Patients were mobilised as soon as possible after surgery. Breathing group (control) patients performed a set routine

of deep breathing exercises at each physiotherapy visit while those in the intervention group did not perform this routine. Other than

the breathing exercises, patient management was similar between groups in terms of assessment, positioning and mobility. The incidence of

postoperative pulmonary complications, post-operative length of stay, oxyhaemoglobin saturation and pulmonary function were measured pre-

operatively and post-operatively. Intention-to-treat analysis was performed for post-operative pulmonary complications and length of stay. Other data

were analysed using t-tests, chi square and repeated measures analysis of variance. There were no significant differences between the groups in the
primary dependent variables. It is concluded that removal of breathing exercises from the routine physiotherapy management of open heart surgery

patients does not significantly alter patient outcome.

PMID:

12952516

Tujuan dari penelitian ini adalah untuk menentukan apakah pengangkatan latihan pernafasan dari rejimen termasuk
mobilisasi awal mengubah kejadian komplikasi paru pasca operasi untuk pasien setelah operasi jantung. Dua ratus
tiga puluh pasien yang menjalani operasi jantung terbuka di Monash Medical Center, Melbourne, terdaftar dalam
percobaan terkontrol secara acak ini. Semua pasien mendapat perawatan fisioterapi secara preoperatif dan pasca
operasi selama tiga hari. Pasien dimobilisasi sesegera mungkin setelah operasi. Pasien kelompok nafas (kontrol)
melakukan serangkaian rutin latihan pernapasan dalam setiap kunjungan fisioterapi sementara kelompok intervensi
tidak melakukan rutinitas ini. Selain latihan pernapasan, manajemen pasien serupa di antara kelompok dalam hal
penilaian, penentuan posisi dan mobilitas. Kejadian komplikasi paru pasca operasi, lama tinggal pasca operasi,
saturasi oxyhaemoglobin dan fungsi paru diukur secara pra-operasi dan pasca operasi. Analisis intensi-to-treat
dilakukan untuk komplikasi paru-paru pasca operasi dan lama tinggal. Data lain dianalisis dengan menggunakan uji
t, chi square dan analisis ukuran berulang. Tidak ada perbedaan yang signifikan antara kelompok dalam variabel
dependen utama. Disimpulkan bahwa pengangkatan latihan pernapasan dari manajemen fisioterapi rutin pasien
bedah jantung terbuka tidak secara signifikan mengubah hasil pasien.
PMID:

Deep breathing after surgery

After surgery it is important to take an active role in your recovery. One way to do so is by doing deep breathing exercises.

Deep breathing keeps your lungs well-inflated and healthy while you heal. Many people feel weak and sore after surgery, and taking big breaths can be
uncomfortable. But if you do not do deep breathing after surgery, you may develop lung problems, like pneumonia.
A device called an incentive spirometer can help you take deep breaths correctly. If you do not have this device, you can still practice deep breathing on your own.

How to Breathe Deeply

Following measures should be taken:
 Sit upright. It may help to sit at the edge of the bed with your feet hanging over the side. If you cannot sit
like this, raise the head of your bed as high as you can.

 If your surgical cut (incision) is on your chest or belly, you may need to hold a pillow tightly over your
incision. This helps with some of the discomfort.

 Take a few normal breaths, then take a slow, deep breath in.

 Hold your breath for about 2 to 5 seconds.

 Gently and slowly breathe out through your mouth. Make an "O" shape with your lips as you blow out,
like blowing out birthday candles.

 Repeat 10 to 15 times, or as many times as your doctor or nurse told you.

 Do these deep-breathing exercises as directed by your doctor or nurse.

References
do Nascimento Junior P, Módolo NS, Andrade S, Guimarães MM, Braz LG, El Dib R. Incentive
spirometry for prevention of postoperative pulmonary complications in upper abdominal
surgery. Cochrane Database Sys Rev. 2014;2:CD006058. PMID:
24510642 www.ncbi.nlm.nih.gov/pubmed/24510642.
Kulaylat MN, Dayton MT. Surgical complications. In: Townsend CM, Beauchamp RD, Evers
BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier
Saunders; 2012:chap 13.
Restrepo RD, Wettstein R, Wittnebel L, Tracy M. Incentive spirometry, 2011. Respir Care.
2011;56:1600-1604. PMID: 22008401 www.ncbi.nlm.nih.gov/pubmed/22008401.

Setelah operasi penting untuk berperan aktif dalam pemulihan Anda. Salah satu cara untuk melakukannya adalah dengan
melakukan latihan pernapasan dalam-dalam. Pernapasan dalam membuat paru-paru Anda membesar dan sehat saat Anda
sembuh. Banyak orang merasa lemas dan pegal setelah operasi, dan mengambil napas dalam-dalam bisa jadi tidak nyaman. Tapi
jika Anda tidak melakukan pernapasan dalam setelah operasi, Anda mungkin mengalami masalah paru-paru, seperti pneumonia.
Perangkat yang disebut spirometer insentif dapat membantu Anda menarik napas dalam-dalam dengan benar. Jika Anda tidak
memiliki perangkat ini, Anda masih bisa berlatih bernafas dalam-dalam sendiri. Cara Menghirup napas dalam-dalam Langkah-
langkah berikut harus diambil: • Duduk tegak. Ini mungkin membantu untuk duduk di tepi tempat tidur dengan kaki Anda tergantung
di samping. Jika Anda tidak bisa duduk seperti ini, angkat kepala tempat tidur setinggi mungkin. • Jika luka bedah Anda (sayatan)
ada di dada atau perut Anda, Anda mungkin perlu memegang bantal dengan ketat di atas sayatan Anda. Ini membantu dengan
beberapa ketidaknyamanan. • Ambil beberapa napas normal, lalu tarik nafas dalam-dalam. • Tahan napas Anda selama sekitar 2
sampai 5 detik. • Lembut dan perlahan bernapas melalui mulut Anda. Buatlah bentuk "O" dengan bibir Anda saat Anda meniup,
seperti meniup lilin ulang tahun. • Ulangi 10 sampai 15 kali, atau sebanyak dokter atau perawat Anda memberi tahu Anda. •
Lakukan latihan pernapasan dalam seperti yang diperintahkan oleh dokter atau perawat Anda.
Optimal technique for deep breathing exercises after
cardiac surgery.
Westerdahl E1.
Author information
Abstract

Cardiac surgery patients often develop a restrictive pulmonary impairment and gas exchange abnormalities in the early postoperative period. Chest

physiotherapy is routinely prescribed in order to reduce or prevent these complications. Besides early mobilization, positioning and shoulder

girdle exercises, various breathing exercises have been implemented as a major component of postoperativecare. A variety

of deep breathing maneuvres are recommended to the spontaneously breathing patient to reduce atelectasis and to improve lung function in the

early postoperative period. Different breathing exercises are recommended in different parts of the world, and there is no consensus about the most

effective breathing technique after cardiac surgery. Arbitrary instructions are given, and recommendations on performance and duration vary between

hospitals. Deep breathing exercises are a major part of this therapy, but scientific evidence for the efficacy has been lacking until recently, and there is

a lack of trials describing how postoperative breathing exercises actually should be performed. The purpose of this review is to provide a brief overview

of postoperative breathing exercisesfor patients undergoing cardiac surgery via sternotomy, and to discuss and suggest an optimal technique for the

performance of deepbreathing exercises.

Teknik optimal untuk latihan pernapasan dalam setelah operasi jantung. Westerdahl E1. Informasi penulis Abstrak Pasien bedah
jantung sering mengalami gangguan paru-paru yang terbatas dan kelainan pertukaran gas pada periode awal pasca operasi.
Fisioterapi dada secara rutin diresepkan untuk mengurangi atau mencegah komplikasi ini. Selain mobilisasi dini, latihan posisi dan
latihan bahu, berbagai latihan pernapasan telah diimplementasikan sebagai komponen utama postoperativecare. Beragam
maneuvres pernapasan dalam direkomendasikan kepada pasien bernafas secara spontan untuk mengurangi atelektasis dan
memperbaiki fungsi paru pada periode pascaoperasi awal. Latihan pernapasan yang berbeda direkomendasikan di berbagai
belahan dunia, dan tidak ada konsensus tentang teknik pernapasan yang paling efektif setelah operasi jantung. Instruksi sewenang-
wenang diberikan, dan rekomendasi tentang kinerja dan durasi bervariasi antara rumah sakit. Latihan pernapasan dalam adalah
bagian utama dari terapi ini, namun bukti ilmiah untuk khasiatnya kurang sampai saat ini, dan ada kekurangan uji coba yang
menjelaskan bagaimana latihan pernapasan postoperatif benar-benar harus dilakukan. Tujuan dari tinjauan ini adalah untuk
memberikan gambaran singkat tentang latihan pernapasan postoperatif bagi pasien yang menjalani operasi jantung melalui
sternotomi, dan untuk mendiskusikan dan menyarankan teknik optimal untuk melakukan latihan deepbreathing.