Early ambulation after surgery

EARLY AMBULATION ERNEST

AFTER SURGERY *

T. TRICE, M.D.

Richmond, Virginia

E

ARLY ambuIation after surgery has come of age as a vaIuabIe aid in postoperative management. Its maturity, however, has not been attained without certain vicissitudes during its adoIescence. Throughout the period of growth and deveIopment the courage of Leithauserl and ShouIdice2 and the physioIogic endorsement of CarIson3 and others have been very conspicuous. The court of pubIic opinion, habit and tradition had to be overcome. UnfortunateIy, their preceptors discouraged the practice but now, after observing reports and otherwise widening their sphere of investigation, they are enthusiastic advocates of the practice. The great surgeons of the past were excelIent anatomists. Surgeons today, from expanded research in physioIogy and because of a better opportunity to study applied physiology which have aIways been cIoseIy reIated to pIanning and therapy, find that increased basic’ knowIedge in that fieId is shedding new light upon many of the probIems in surgery. Postoperative compIications may be referred to as the major probIem. It is a probIem of crippIed physioIogy caused by surgica1 trauma, drugs, pain, pathoIogy disorders and nervous reactions. The point of view many of us hoId is that ambuIation during the immediate postoperative period does more to correct crippIed respiration, circuIation and digestion than any other aid or drug. Patients who are ambuIatory during the immediate postoperative period exhibit conspicuous improvement both subjectiveIy and objectiveIy for the reason that the approach to rehabiIitation is more physioIogic. The time has arrived for us to accept proper exercise during the immediate postoperative period as an aid to heaIing and to prevent compIications just

as we accept infection.

aseptic

technic

to prevent

Respiratory Factors. PuImonary secretion of Auids presents a serious probIem in postoperative management. From HiIding4 we have Iearned that by reffex action and the use of anaesthetic drugs an abnorma1 amount of mucus is produced. Furthermore he points out that from the same inffuences, viscosity of the mucus is higher than norma and often beyond the abiIity of the ciIiated epitheIium to move. Accordingiy there is a firmIy fixed mucous pIug which changes the diameter of the bronchus. McMicheI and McGibbon5 have impressed upon us the effect of poStura1 changes on Iung voIume. ChurchiI16 has made many reports on the usefuIness of the spirometer and by its use it is we11 estabIished that vita1 capacity is reduced after surgery and during recumbency to the extent of about 340 cc. It is reduced because of puImonary capiIIary congestion but returns to norma in the ambuIatory patient in three days and tweIve to fourteen days in the patient confined to bed. The standing position and waIking during the immediate postoperative period stimuIate the cough reffex. The diaphragm assumes its norma position and there is prompt expectoration of quantities of siIver-coIored mucus which may measure up to 12 cc. AteIectasis and other complications have been averted. No corroboration is needed to convince one of the vaIue of waIking and invoIuntary coughing when it is observed that convaIescence cIoseIy paraIIeIs the return of vita1 capacity. The influence of waIking and coughing on puImonary physioIogy is direct; puImonary ventiIation is further heIped indirectIy by waIking, a favorabIe inffuence on the circuIation. It must be remembered that anatomicaIIy the respiratory system functions

* From the Grace HospitaI. Richmond,

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AmbuIation

against the speciaI handicap of draining uphiI1. Circulatory Factors. CircuIatory complications brought on by unphysioIogic postoperative care are more dangerous than those compIications affecting the reCases

TABLE

497

emphasize that too Iong a bed period is a conspicuous feature in the deveIopment of the thromboembolic syndrome. If bed rest is so favorabIe an influence to the development of circuIatory compIications, we shouId not hesitate to utilize simple I

Threatened AteIectasis

Thrombophkbitis

Atelectasis

PhIebothrombosis

Deaths

-I-

Leithauser .......................... ShouIdice ..........................

3

0

0

0

Trite ..............................

0

0

14 I 0 _-.

Total ..............................

3

0

‘3

spiratory system and, happiIy, the benefits of ambuIation during the immediate postoperative period are even more striking. Relative circuIatory stasis initiated by surgica1 trauma and intensified by proIonged bed rest Ieads to periphera1 circuIatory coIIapse of varying degrees, thrombophIebitis, phIebothrombosis and consequent embolism for the reasons that bIood voIume is Iost and circuIation time is longer. We are obiigated to de Takats’ and his co-workers who reported in 1943 and 1945 their work on coaguIabiIity of the bIood. They beIieve that at the site of trauma an enzyme, presentIy referred to as thrombokinase, is Iiberated from the tissues and is an active thrombopIastic agent in the production of thrombin, an insoIubIe protein not found in norma bIood and beIieved to be essentia1 to the cIotting mechanism. It is equaIIy interesting to know about the studies of Baker and Sedwitz* on venography of the lower extremities. These studies iIIustrate how quickIy the materia1 is shunted out of the deep veins after waIking and how sIowIy it moves in the absence of muscuIar activity. According to CutIerg these dysfunctions initiated by metaboIic and retlex changes foIIowing surgica1 trauma are present during the fn-st twenty-four hours. BarkerlO reports one case of fata puImonary emboIism which occurred during the first postoperative day. Our wish, therefore, is to October, I 949

waIking during the immediate postoperative period as a procedure that reduces and aImost removes circuIatory compIication. Anticoagulants, prophyIactic Iigation, bandages and bed exercise are poor substitutes. As far as our experience goes there are few physioIogic and anatomic reasons for not waIking during the immediate postoperative period. TabIe I iIIustrates a series of consecutive major operations. AI1 patients were ambuIatory during the immediate postoperative period. Postoperative compIications are conspicuousIy reduced and the serious postoperative compIication of phIebothrombosis did not occur. Gastrointestinal Factors. The harmfu1 effects of abdomina1 distention shouId not be accepted as an inevitabIe consequence of the surgica1 procedure but shouId be anticipated as a complication that greatIy affects morbidity. Therefore, a pIan based on better understanding of the nervous mechanism controIIing intestina1 motiIity shouId be made to defeat or modify it. That pIan wouId center around the remova of inhibition to the parasympathetics. The nervous contro1 of intestina1 motor function is compIex. This contro1 is mediated through the myenteric pIexus and the autonomic nervous system, the former exerting the greater influence. WhiIe motiIity may be restored independentIy of the autonomic nervous system, under ordinary conditions

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FIG. I. This photograph of a sixty-six year old man who had a MiIes’ resection was taken during the fifth postoperative hour. Before walking he w& in subctinical shock; after walking he was much restored.

the autonomic nervous system exerts favorabIe influence on the myenteric pIexus by removing inhibition. The same measures used to prevent reTABLE

II

Hospital Days Operation

No. of Hours Cases in Bed No.

Average per Patient

Comptications

spiratory and circuIatory compIications appIy to the digestive system, the chief one being ambuIation during the immediate postoperative period. AmbuIation directIy restores activity to the digestive tract and indirectIy reduces distention by improving respiration and circuIation. It contributes to the maintenance of proper pressure reIationship between the abdomen and thorax and improves muscIe tone. In ambuIatory patients the administration of food is guided IargeIy by the appetite; we take that as a certain sign that motiIity is being restored. Enemas, there-

AmbuIation

average nutrition Gaintain nitrogen equiIibrium which is an aid to heaIing. TabIe II, IIIustrates a number of patients who were ambulatory in the operating room. Immediate recoveries were exceIIent. In these cases the anesthetic agent was procaine, I per cent soIution, with 3 mm. of epinephrine to each 30 cc. of soIution. StainIess stee1 wire was used for suturing and Iigation. Skin cIips were used in the skin and removed in twenty-four hours. No narcotics were required, the capsuIe of aspirin and nembuta1 being adequate. Two of the patients with appendicitis required decompression and drainage. These two patients, we beIieve, required exercise earIier than the others in this tabIe and from cIose observation the physioIogy of important systems was restored rapidIy. The practice of earIy ambuIation has been in use since JuIy, 1945. Patients who have been ambuIatory during the immediate postoperative period have had surgery of the pancreas, biIe tract, stomach, intestines, femaIe peIvis and vagina, amputations of the Iower extremities, femaIe breast, thyroid gIand and a11 types of hernias. (Figs. I and 2.) It is our beIief, as reported, that vita1 systems are crippIed by surgica1 trauma. The crippIing is thought to be functiona and, if not haIted, wiI1 Iead to structura1 changes. AI1 of these changes occur during the immediate postoperative period when American

Journal

of Surgery

Trite-Early drugs and reactions have their maximum influence. AccordingIy, the day of operation or, preferably, the first few hours after operation is the time to begin walking and not the first postoperative day. This is basic to the rationale of early ambmation for the physioIogic reasons given. After the first day structural changes are welf estab&shed and the influence of exercise could be harmful. COMMENT

It is diflicuh to convey the extremeIy favorabIe impression made on me by the departure from a IirmIy entrenched routine of postoperative care. The favorable reasons for this practice do not lend themselves we11to any genera1 description which equaIs the experience of observing these patients. Emphasis has been directed toward physioIogic considerations in surgica1 management, especiahy to a routine that prevents “deconditioning.” Contraindications to early ambmation after surgery are extremeIy few. CIinicaIIy, profound shock and prediction of fata outcome are the only two; technicaIIy, unanatomic incisions and poor choice of suture materia1. Infection, peritonitis, fever and moderate circulatory deficiency do not contraindicate waIking. The Iatter circumstances do, however, invoIve the judgment of the surgeon. EarIy ambuIation restores nitrogen equilibrium promptly which shortens the lag period of healing. Local in~Itration has proved to be a very satisfactory anaesthetic procedure.

Ambulation

logic, psychologic and economic advantages to the practice of early ambulation. 5. Review of 6,130 cases indicates that respiratory and circuiatory complications have been reduced by earty ambuIation and voIuntary and invoIuntary coughing. REFERENCES

I. LEITHAUSER, DANIEL, J. Early Ambufation in SurgicaI Management. Springfield, III., 1946. 2. SHOULDICE, E. E. Surgical Treatment of Hernia. Read at annual meeting of the Ontario Medical Association, District g and IO. September, 1944. 2. CARLSON. A. J. Earlv Ambulation in Surgical Management. Spring&eld, III., 1946. Charles C. Thomas. 4. H~~nrnc, A. C. Production of negative pressure in the respiratory tract by ciliary action and its refation to postoperative atelectasis. Anestbesiology, f : 225-236, 1944. 5. MCMICHAEL, J. and MCGIBBON, J. P. Postural changes in lung volume. Clin. SC., 4: 175-183, 1939.

6. CHURCHILL, E. D. and MCNEIL., D. The reduction in vita1 capacity folIowing operation. Surg., Gynec. tY Obst., 44: 483-488, 1927. 7. DE TAKATS, GEZA and FOWLER, E. F. The problem of thrombo-embolism. .Sur,qeqr, I 7: I 53-r 77, 1945.

DE TAKATS, GEZA. The response to heparin; a test of the clotting mechanism. Suq., Gynec. e* Obst., 77: 31. ‘943. 8. BAKER, E. C. and SEDWITZ, S. H. Observations on venography of the Iower estremities, Radiology, 41: 450-458, 1943. 9. CUTLER, E. C. and HUNT, ALICE M. Postoperative puImonary complications. Arch. Swg., 1: I 14-157, 1920. IO. BARKER, N. W. NYGAARD, K. K., WALTERS, WALTMA& and PRIESTLEY, J. T. Statistica study of postoperative venous thrombosis and puimonary embolism. IV. Location of thrombosis: relation of thrombosis and embolism. Proc. Staff Meet., Mayo Clin., 16: 34-37, 1941. BARKER. N. W.. NYGAARD. K. K.. WALTERS. WALTMAN and P&STLEY, J: T. Statistical study of postoperative venous thrombosis and pulmonary embolism. 111. Time of occurrence during the postoperative period. Proc. Stuf Meet., Mqyo CEin., 16: 17-21, 1941. BARKER, N. W., NYG~ARD, K. K., WALTERS, WALTMAK and PKIESTLEY. J. T. Statistical studv of postoperative venous thrombosis and pulmonary embolism I. Incidence in various types of operations. Proc. .%a$ Meet., ~~~~0 C&n., I $: 76~773 ,

SUMMARY I. Prolonged bed rest has been practiced because of respect for tradition and fear of comphcations. 2. Immobihzation of surgica1 patients vioIates physioIogic principIes and contributes to postoperative comphcations. 3. EarIy ambuIation is a Iogical step in the progress of surgery and offers an exceIIent perspective. 4. There are definite anatomic, physio-

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BARKER, N. W., CROMER, H. E., HURN, MARGARET and WAUCH. J. M. The use of dicumarol in the prevention of postoperative thrombosis and embohsm with specia1 reference to dosage and safe administration. Surgery, I 7: 207-2 I 7, 1945. TRICE, ERNEST T. The application of the principles of earIy ambulation to surgical patients. Read before Richmond Academy of Medicine, January ~4, 1947. Virginia M. Mont&r, 74: Io3-107, 1947.