File
Boden I1,2, Sullivan K2,3, Hackett C4, Winzer B5, Lane R6, McKinnon M4, Robertson I7
1University of Melbourne, Melbourne, Australia, 2Launceston General Hospital, Physiotherapy, Launceston, Australia, 3Monash University, Melbourne, Australia, 4Princess Alexandra Hospital, Physiotherapy, Brisbane, Australia, 5Northeast Health Wangaratta, Physiotherapy, Wangaratta, Australia, 6Australian Catholic University, Ballarat, Australia, 7University of Tasmania, Biostatistics, Launceston, Australia
Background: Respiratory complications, paralytic ileus, delayed physical recovery, prolonged hospital stay, and in-hospital mortality are significant problems following emergency abdominal surgery. Chest physiotherapy and targeted rehabilitation in the critical care unit and on surgical wards aims to prevent complications and aid recovery. Despite ubiquitous provision in most first-world hospitals, there are no randomised controlled trials testing the effect of physiotherapy on reducing postoperative complications and improving recovery following emergency abdominal surgery.
Purpose: ICEAGE was designed to test the hypothesis that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation would prevent respiratory complications and improve physical recovery after emergency abdominal surgery when compared to standard care alone. Other outcomes included incidence of paralytic ileus, rehabilitation referrals, hospital length of stay (LOS), quality of life (QoL) on hospital discharge and at three months, post-discharge hospital readmissions and complications, and all-cause mortality to one-year.
Methods: ICEAGE was a prospective multicentre, parallel-group, double-blinded, active-placebo, randomised controlled trial powered for superiority. Standard-care physiotherapy (15-minutes daily ambulation and a single session of coached breathing exercises) was compared to enhanced physiotherapy care (30-minutes daily rehabilitation and twice daily coached breathing exercises) in 288 participants admitted for emergency abdominal surgery at three hospitals in Australia. Primary outcome was a respiratory complication within 14 postoperative days.
Results: From 2016 to 2018, 284 participants completed the trial. Compared to standard-care, enhanced postoperative physiotherapy halved respiratory complications; 27% v 13% (ARR 15% (95%CI 5 to 24%), NNT 7 (95%CI 4 to 19, p=0.002)), rehabilitation referrals (20% v 8%, p=0.02), and discharge to formal rehabilitation services (12% v 5%, p=0.02). Acute hospital LOS was reduced by 2.7 days (13.4 days v 10.8 days, p=0.05). No difference was found in paralytic ileus rates. Patients receiving enhanced postoperative physiotherapy reported better quality of life and physical function (WHODAS 30 (9) v 33 (10)) on hospital discharge and this difference remained at 3-months post-surgery. All-cause one-year mortality follow-up is yet to be completed.
Conclusion(s): Twice daily chest physiotherapy and 30-mins of daily exercise therapy in the first seven postoperative days following emergency abdominal surgery prevents respiratory complications, reduces LOS, and improves physical function and quality of life up to three months after surgery. Further research is required to determine the dosage threshold required for benefit and the cost-benefit of service implementation.
Implications: ICEAGE is the first multicentre randomised controlled trial testing physiotherapy following emergency abdominal surgery. This trial has reproduced findings from similar trials in elective abdominal surgery. There is a large effect size in reducing respiratory complications and consistent positive findings across outcomes that are of benefit to the patient, hospital, and community alike. This would suggest that enhanced physiotherapy care packages should be implemented in all acute-care hospitals.
Keywords: Abdominal surgery, perioperative physiotherapy
Funding acknowledgements: ICEAGE was an investigator-initiated trial funded by competitive research grants from the Clifford Craig Foundation, Launceston, Australia.
Purpose: ICEAGE was designed to test the hypothesis that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation would prevent respiratory complications and improve physical recovery after emergency abdominal surgery when compared to standard care alone. Other outcomes included incidence of paralytic ileus, rehabilitation referrals, hospital length of stay (LOS), quality of life (QoL) on hospital discharge and at three months, post-discharge hospital readmissions and complications, and all-cause mortality to one-year.
Methods: ICEAGE was a prospective multicentre, parallel-group, double-blinded, active-placebo, randomised controlled trial powered for superiority. Standard-care physiotherapy (15-minutes daily ambulation and a single session of coached breathing exercises) was compared to enhanced physiotherapy care (30-minutes daily rehabilitation and twice daily coached breathing exercises) in 288 participants admitted for emergency abdominal surgery at three hospitals in Australia. Primary outcome was a respiratory complication within 14 postoperative days.
Results: From 2016 to 2018, 284 participants completed the trial. Compared to standard-care, enhanced postoperative physiotherapy halved respiratory complications; 27% v 13% (ARR 15% (95%CI 5 to 24%), NNT 7 (95%CI 4 to 19, p=0.002)), rehabilitation referrals (20% v 8%, p=0.02), and discharge to formal rehabilitation services (12% v 5%, p=0.02). Acute hospital LOS was reduced by 2.7 days (13.4 days v 10.8 days, p=0.05). No difference was found in paralytic ileus rates. Patients receiving enhanced postoperative physiotherapy reported better quality of life and physical function (WHODAS 30 (9) v 33 (10)) on hospital discharge and this difference remained at 3-months post-surgery. All-cause one-year mortality follow-up is yet to be completed.
Conclusion(s): Twice daily chest physiotherapy and 30-mins of daily exercise therapy in the first seven postoperative days following emergency abdominal surgery prevents respiratory complications, reduces LOS, and improves physical function and quality of life up to three months after surgery. Further research is required to determine the dosage threshold required for benefit and the cost-benefit of service implementation.
Implications: ICEAGE is the first multicentre randomised controlled trial testing physiotherapy following emergency abdominal surgery. This trial has reproduced findings from similar trials in elective abdominal surgery. There is a large effect size in reducing respiratory complications and consistent positive findings across outcomes that are of benefit to the patient, hospital, and community alike. This would suggest that enhanced physiotherapy care packages should be implemented in all acute-care hospitals.
Keywords: Abdominal surgery, perioperative physiotherapy
Funding acknowledgements: ICEAGE was an investigator-initiated trial funded by competitive research grants from the Clifford Craig Foundation, Launceston, Australia.
Topic: Cardiorespiratory; Critical care
Ethics approval required: Yes
Institution: Tasmanian Health Service - North
Ethics committee: Human Research Ethics Committee (Tasmania) Network, Tasmania, Australia
Ethics number: H0013666
All authors, affiliations and abstracts have been published as submitted.
