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Delphi Study Results

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Delphi Study Results
 

Phase 2: Summary of Comments

Group 1: Abdominal Surgery

  • Clinical Algorithm for the physiotherapeutic management of non intubated patients following upper abdominal surgery

      • Subject 1 : Importance of coughing
      • Subject 2 : Stability criteria for patient mobilization
      • Subject 3 : Breathing techniques
      • Subject 4 : Need and content of the directed mobilization protocol


Clinical algorithm for the physiotherapeutic management of non intubated patients following upper abdominal surgery

SUBJECT 1: Comments on the importance of coughing and procedure adopted to facilitate coughing

AGREEMENT: 2/5
DISAGREEMENT: 3/5

POSTED COMMENTS:

  • The need for suctioning is questionable. There are many management approaches before doing that

  • While mobilization and positioning also facilitate clearing of secretion it should be added to sitting. In the Nordic countries suctioning is not used for this category of patients (or other patients as well because that it facilitate the mucus production and its side-effects). Our choice is instead active breathing exercises including deep breathing, PEP, high-pressure PEP and CPAP in combination with FET (or adjusted autogenic drainage) and huffing/coughing. We also combine the exercises with nebulization of medication.

  • Sit patient out of bed (not over edge of bed as is unstable position). Teach huff /wound support yes. I would not suction unless really needed. First I would try other techniques such are CPAP

 


SUBJECT 2: Comments on the criteria to determine the stability of patients following abdominal surgery to be mobilized

AGREEMENT: 2/5
DISAGREEMENT: 3/5

POSTED COMMENTS:

  • T1. Dyspnea makes sense and not clear about the Pain criteria. Seems high. How would dyspnea be measures? Borg or MRC scale?

  • I miss one important factor and that is level of oxygen saturation or PaO2 and PCO2. Should it fit in here or in the box for breathing techniques? I base my prescription of mobilization and breathing techniques on the patients saturation and/or blood-gas levels together with other factors as level of pain and which kind of surgery they have undergone. Dyspnoea is a clinical sign of changes in blood-gases but hypoxia may be present in a patient who hasn't dyspnoea.

  • I would add that if they have an epidural they do not have a motor block Alas I am not sure that 'cough effectively ' would be the sole criteria I divide patients on. Patients with significant atelectasis may still be able to cough effectively
 

SUBJECT 3: Comments on the use of breathing techniques
(specific techniques and frequency) if patient is unable to mobilize

AGREEMENT: 2/5
DISAGREEMENT: 3/5

POSTED COMMENTS:

 


SUBJECT 4: Comments on the need and content of the directed mobilization protocol

AGREEMENT: 2/5
DISAGREEMENT: 3/5

POSTED COMMENTS:

  • Not sure about 20 dorsiflexion

  • Positioning and mobilization are the most important treatment methods we have to facilitate the patient's return to preoperative status. Therefore I suggest that the scale should not be limited to 30 meters. An extended one, for instance with 50, 75 and 100 meters walks and also climbing stairs would be preferable. Mobilization at least 3 times daily is also important. In trials evaluating multi-modal rehabilitation programs after open surgery of the intestines or nephrectomy (As trials by the Danish Prof Kehlet) it is reported that the program, including very intensive mobilization, decreases hospital stay and the patients are more active.

  • On the first postop day to SOOB for a minimum of one hour twice daily AND walk 5 m should be the goal. To then progress as much as possible, rather than meet ANY of these goals. I think patients need more intensive mobilization. The Fast track research from Kellet and Wind support this is min invasive surgery. Three times a day is good. Borg is good. Foot and ankle exercise at that rate are unnecessary if the patient is up and mobilizing
 
 
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