A useful review of the role of rehabilitation in frail patients by Milder, Pillinger and Kam.

• They note that there is no gold standard to measure frailty, although there are many attempts to reliably identify and measure frailty across its many domains.

• Nonetheless frailty is strongly associated with perioperative morbidity and mortality.

• One proposed indicator of physical frailty is the presence of three of Fried's five factors: unintentional weight loss; grip strength weakness; exhaustion; slow walking speed; and low physical activity.

• Frailty is "...a multidimensional state of reduced physiological reserve, resulting in increased vulnerability to stressors, decreased resilience, and loss of adaptive capacity."

• Prehabilitation aims to increase physiological reserve through pre-operative intervention, including but not limited to exercise, nutrition and inspiratory muscle training.

Final word: although attractive, prehab has not yet been shown to improve outcomes in frail patients, though this is likely due to the absence of high quality studies.

summary

• David A Milder, Neil L Pillinger, and Kam Peter C A PCA Department of Anaesthetics, Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, Australia. .
• Concord Repatriation Hospital, Concord, NSW, Australia.
• Acta Anaesthesiol Scand. 2018 Nov 1; 62 (10): 1356-1366.

IntroductionIncreasing emphasis is being placed on the detection of frailty in the pre-operative setting given its association with surgical morbidity and mortality. Prehabilitation seeks to increase the physiological reserve of frail patients, attenuating the risk of irreversible functional decline following surgery.Aim/HypothesisThis systematic review appraises the evidence available for prehabilitation in frail surgical patients. We proposed that exercise prehabilitation would especially benefit frail patients, with improvements in pre-operative functional capacity, and reductions in complications and length of hospital stay.MethodsA literature search was conducted in MEDLINE, PubMed and CINAHL databases. Studies were included if they consisted of a prehabilitation intervention in frail patients undergoing surgery and specified a frailty model/index. Eight studies were included for analysis, 2 of which are ongoing studies.ResultsIn 3 studies, prehabilitation consisted of an exercise intervention alone. There was a high feasibility of prehabilitation and a trend to improved pre-operative function, however, no evidence of improved post-operative functional recovery was there. In 2 studies, prehabilitation consisted of both exercise and nutritional interventions. Reductions in mortality and duration of hospital stay were reported, but the quality of evidence was judged to be very low. There was a lack of evidence of improved outcomes following pre-operative inspiratory muscle training in frail patients.DiscussionThis systematic review focuses on prehabilitation in frail surgical patients and reports that evidence supporting any outcome is limited, despite high feasibility and acceptability. There is a need for large randomised controlled trials to better establish the effects of prehabilitation in frail patients.© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

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