Prehabilitation -Getting fit for surgery and treatment

Prehabilitation (prehab) is a proactive approach to help you prepare for upcoming medical or surgical treatment. This preparation aims to enhance your fitness, health and mental resilience, thereby reducing the risk of complications and promoting faster recovery and better outcomes.

Surgery today is safer than it has ever been. The majority of patients make a full recovery and return to their previous level of health.

However, a small proportion may suffer a complication after surgery. This might include an infection, such as a chest infection, wound infection or problems with the function of the heart, lungs or kidneys. Such complications can result in a longer stay in hospital, a delayed recovery and may even cause longer-term health issues. Importantly, there are things you can do to reduce the risk of complications.

The staff at NHS Lothian work together to make your operation and recovery go smoothly, but it all starts with you. We are here to support you through this process. Surgery, and recovery afterwards, puts an extra strain on the body, particularly the heart and lungs.

Being in the best health you can be will improve your chances of recovering quickly and help prevent complications. A few small changes will make a big difference.

What are the factors that I can improve before Surgery

Having an operation and the recovery afterwards have been compared to exercise because they place a strain on the heart, lungs and muscles.

Physical activity and’ training’ your body before surgery and treatment allows your body to cope better with the physical stress of surgery and will reduce your chances of complications.

Those most at risk post-operatively are generally older adults that already live with other chronic diseases, take various medications and have a lower fitness level.

Critically, scientific evidence suggests that an individual’s fitness level may be a stronger predictor of post-operative risk than traditional risk factors, as small improvements in fitness have been associated with substantial improvements in survival.

Significant improvements in your fitness can be made within as little as 2-4 weeks if you stick to the task and perform the exercises you regularly.

The benefits of Improved fitness prior to surgery or treatment:

1. Getting mobile sooner after surgery
2. Leaving hospital sooner
3. Returning to a normal quality of life more quickly
4. Reducing your risk of heart disease, stroke and diabetes
5. Improving blood pressure control and cholesterol levels
6. Helping with weight control
7. Reducing anxiety, stress, better mood and more energy

Some ideas…

How you do this is up to you, and there are lots of options:

You should be exerting yourself hard enough so that your heart rate goes up and your body feels warm and you are sligthly out of breath.

The great news is that we know that many types of exercise training are effective, including brisk walking or jogging, high-intensity interval training, weightlifting, breathing exercises and muscle- or joint-specific training

So why not find something that you enjoy and make a start today? Get your friends and family involved, or join a group, to make it even more enjoyable and help you stay motivated. It is important to increase the amount of exercise you do gradually.

 If you have a heart or lung condition, or have any concerns, speak to your GP, Anaesthetist, surgeon or pre-assessment nurse before starting an exercise program.

Local Excercise classes are offered at Edinburgh Leisure:

Health and Wellbeing Programmes – Active Communities – Edinburgh Leisure

Some specific classes that you may be interested in are:

Get Active Classes – range of classes designed to encourage people to be active – classes cost £4

Ageing Well – range of low-level physical activity options for older adults

Movement for Memories – programme supporting adults with dementia (or going through a dementia diagnosis) (people can self-refer)

For Orthopedics Prehabiliation esp ahead of joint replacement there is a free 12 week program :

. Nuffield Health – Joint Pain Programme (https://www.nuffieldhealth.com/services/joint-pain-programme

NHS Inform Keeping Active website

Nutrition

In order for your body to recover from surgery and treatment, it needs the right energy and nutrients. A healthy balanced diet is important to help prepare your body for surgery.

Being overweight or underweight can both increase the risks when having an operation. It is therefore important to try to achieve a normal body weight before your operation or treatment.

Aim for a healthy weight – A normal Body Mass Index (BMI) is between 20-25 kg/m² Watch Out for Eating Problems – If you have trouble eating (like swallowing or dental issues) seek help

You should aim to eat three regular meals with a good balance of the food groups – protein, carbohydrates and healthy fats. Try to avoid adding any extra sugar or salt to your diet.

For more information see the NHS Inform Eatwell Guide: How to eat a healthy balanced diet

Benefits of improving nutrition prior to surgery

1. Improves your wound healing
2. Lowers your risk of infection
3. Could result in a shorter hospital stay
4. Feeling more energetic
5. Better weight management

Energy needs

Carbohydrates are the body’s main fuel source which are represented in yellow on the eat well plate. Under eating these foods can lead to a lack of energy, low mood, and reduced concentration. Overeating carbohydrates especially when physical activity is low can cause weight gain. Prior to your surgery we recommend meeting the advised portion sizes for carbohydrates and spreading them throughout your meals. Wholegrain options are recommended due to the nutrients they contain and the fibre content which is good for bowel health.

Protein needs

Protein is the body’s main fuel for building muscle and strength. You may need to build some strength prior to your surgery. Ensuring your protein intake is adequate can help with this. Protein also plays a vital role in your immune system. Some excellent sources of protein are chicken, meat, fish, eggs, Greek yoghurt, nuts and lentils.

Meat is a source of protein, Iron and B12 however it is known that excessive intakes can be linked to colorectal cancer. It is therefore recommended to keep to a limited daily intake ( 70g) and avoid processed, high fat and high salt options. More information to make informed decisions is linked below.

Hydration

Drinking enough water is essential for energy levels, brain function, digestion and helps to regulates temperature. Drinking enough fluids can help make you feel your best. The minimum daily fluid recommendations are 1600mls for women and 2000mls for men, unless there is a clinical condition that requires a different approach.

Micronutrients

Micronutrients are vitamins and minerals. We can get adequate amounts from diet.

Having a well-balanced diet rich in micronutrients can help with immune function, wound healing, muscle function and antioxidant protection.

In the UK during autumn and winter everyone is advised to take a supplement containing 10 micrograms (400 international units) of vitamin D per day to support general health and in particular bone and muscle health. This is because we cannot make vitamin D from sunlight at this time of year. UK Government advice is linked below.

Fuelling your recovery after surgery

Vitamins and minerals are crucial to recovery after surgery, for example iron, folate, zinc and vitamins A, C and K. Try to get as many different types as possible by eating a healthy balanced diet with a good intake of fruit and vegetables. Aim to eat 5 different portions each day.

Poor appetite and/or weight loss

Depending on why you’re having surgery, some people may actually lose weight without trying before their operation. It is important your body has good energy stores to recover after surgery. If you have lost weight without trying to, or have a reduced appetite, try these simple changes to stop any more weight loss:

• Eat little and often – try 5-6 small snacks or meals per day
• Take drinks after meals and not before
• Use full fat milk and full fat dairy products
• Add margarine or butter to mashed potatoes
• Add grated cheese and/or cream to soups and sauces

More information…

If you want more information about a healthy balanced diet, and would like some delicious meal suggestions, then you can find more information

 NHS Eat Well 

British Dietetic Association 

For further information on Nutrition in cancer and Prehabilitation please visit the Scottish government prehab website – https://www.prehab.nhs.scot/prehab-and-me/diet-and-nutrition/

WEIGHT MANAGEMENT

Aim for a healthy weight – A normal Body Mass Index (BMI) is between 20-25 kg/m² 

.Am I at increased risk because of my weight? 

Although many overweight people are fit and healthy, there are increased risks associated with being obese. It’s more likely if you have central obesity and are apple shaped. 

You have an increased risk of suffering a serious complication during or after your operation if you have: 

After an operation obese patients may be more likely to have: 

• This is because the excess weight puts an extra strain on your organs making it harder to  function properly 

Increased Anaesthesia Risks:  

Obesity affects how your body reacts to medications, which increases the risk of complications such as breathing problems and heart disease. 

Technical Challenges During Surgery: 

•  Obesity makes it more difficult for the surgeon to position the patient, visualize the organs, and perform procedures. 

What can I do next? 

If you are keen to lose weight there are number of NHS Lothian  options listed below to help you and  as well your local  Leisure centre offers group exercise  sessions to aid weightloss. 

You should aim to eat three regular meals with a good balance of the food groups – protein, carbohydrates and healthy fats. Try to avoid adding any extra sugar or salt to your diet 

Top Tips 

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NHS Lothian offers several weight management programmes:https://www.bing.com/ck/a?!&&p=9882d6ac6ff3b167456dc0623d6ae29be28303c8d152a295e5bdcda3d21b22bbJmltdHM9MTczMDg1MTIwMA&ptn=3&ver=2&hsh=4&fclid=22b3dfcf-7cb2-6279-3fe6-cc1f7d946370&psq=nhs+lothian+weight+management+programme&u=a1aHR0cHM6Ly93d3cuZWRpbmJ1cmdobGVpc3VyZS5jby51ay9nZXQtbW92aW5n&ntb=1 

• Second Nature is a digital programme designed to support long term healthy habits and improve overall health. It is available for applicable adult weight management patients. Second Nature – Adult Weight Management and Type 2 Diabetes Prevention Service 

• NHS Inform 12 week Weight management program. This 12 week step by step programme has been designed for adults with a body mass index (BMI) of 25 or above, who want to be a healthier weight. 

12 Week Weight Management Programme | NHS inform 

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• Adult Weight Management and Type 2 Diabetes Prevention Service – NHS Lothian | Our Services 

• Specialist Weight Management Support – Adult Weight Management and Type 2 Diabetes Prevention Service 

• https://www.england.nhs.uk/digital-weight-management/how-to-access-the-programme/ 

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• https://www.nhs.uk/better-health/lose-weight/ 

Smoking

• Smoking increases the chances of problems after surgery.  
• Smokers are 40% more likely to die after surgery than non-smokers.  
• Stopping smoking before surgery helps reduce complications and makes surgery safer. 
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• You will achieve the most benefit if you can stop 4-6 weeks or more before surgery. However, if your surgery is sooner, stopping any time before surgery is beneficial. 
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• By stopping smoking you can reduce the risk of any postoperative complications by 60% and wound problems by 70%. 
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• All of these risks mean that your chances of having to be admitted to the intensive care unit increase or at the very least, your stay in hospital will be longer. 
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• How Smoking Affects Your Body 
• Heart 
• Reduces supply of oxygen to the heart 
• Increased risk of heart attack 
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• Lungs  
• Smoking damages your lungs, increases mucous production and makes your lungs more irritable this can lead to  
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•  making it difficult to breath after surgery 
• Increased risk of chest infection, pneumonia or collapsed lung 
• Blood clots 
• Smoking makes your blood thicker and more likely to clot therefore  
• increased blood clots in your veins (deep vein thrombosis) or lungs (Pulmonary Emboli’s) 
• increases chances of Heart attack and stroke  
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• Bones, skin and wounds 
• impaired healing and scaring 
• wound infection 
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• Immune system 
• increased risk of infection including chest infection , wound infection and sepsis.
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• How do I  Stop Smoking? 
• Stopping smoking is important for improving your condition after surgery and your overall long-term health. The best way to stop is by using a mixture of support from professionals, stop-smoking medications and friends and family. 
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• Below are some common methods for stopping:- 
• Cold Turkey: choosing a day and just stopping. 
• Nicotine replacement therapy (NRT): this includes patches, chewing gum, lozenges, inhalators etc. These treatments provide nicotine, to allow you to gradually stop smoking over time. You can receive advice from your local stop smoking services or your GP. 
• Bupropion: a tablet prescribed by your GP or stop smoking services that works by blocking the sensors in your brain that provide the enjoyment from smoking. 
• e-Cigarettes: we’re not yet sure if e-cigarettes pose a risk to health. However current evidence suggests they are safer than smoking tobacco. They are used like NRT to help you gradually stop smoking cigarettes 
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• Top Tips 
• Set a date to stop, don’t leave it a week. 
• Let friends and family know your plans so that they can support you. 
• Avoid temptation, throw away cigarettes/lighters/ashtrays. 
• Change your habits to avoid temptation. 
• Tell yourself you’re a non-smoker. 
• Take one day at a time. 
• Never have the odd one. 
• Congratulate yourself. 
• Use local support services 
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• Benefits of Stopping 
• Stopping smoking before surgery helps reduce the risk of complications. Stopping at least 4-6 weeks before surgery is ideal, but stopping any time before can help. 
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• Where to get help: 
• You can get help with quitting smoking from 
•  Quit Your Way Scotland https://www.nhsinform.scot/care-support-and-rights/nhs-services/helplines/quit-your-way-scotland 

NHS Inform stopping smoking website
Royal Infirmary Edinburgh: Help for inpatients and NHS staff. 
Pennywell All Care Centre in North Edinburgh. 
Bonnyrigg Health Centre: Serving Midlothian and East Lothian. 
Bathgate Primary Care Centre: Serving West Lothian 
 
 

Alcohol

Alcohol can affect your health and the way your body responds to surgery and treatment. You don’t need to totally avoid alcohol before your operation, but we would advise that you stay below the recommended maximum amounts. Start reducing the amount at least 4 weeks before surgery. 

The UK Government recommends for  both men and women this is less than 14 units per week, with no more than 3-4 units on any single day. 

3-4 units is equivalent to one and a half pints of beer, or two small glasses of wine per day only. 

You should avoid alcohol in the 48 hours before your operation.

How can Alcohol impact on my Surgery and medical treatment 

Drinking too much alcohol makes it harder for your body to handle the stress of surgery and increases your risk of complications.  

Benefits of reducing Alcohol before your surgery or treatment 

• Healthier immune system 

• Better wound healing 

• Faster recovery 

• Less bleeding and fewer blood transfusions 

• Better mood, more energy 

More information of the Impact of Alcohol On Your surgery  

• Anaesthesia and medication  

Alcohol Can reduce your liver function and its ability to deal with an anaesthetic, drugs and painkillers used during your operation. Reducing your drinking means your liver can handle these drugs better so you have a lower chance of experiencing any side effects like nausea and vomiting. 

• Delayed Healing – Alcohol can be harmful to  the immune system and increase the risk of infection. This can make recovery longer.Alcohol can also interfere with the healing process after your surgery such as  formation of new tissue, which is essential for healing. 

• Increased Risk of Bleeding– Alcohol can interfere with blood clotting, which can lead to excessive bleeding and complications during and after surgery 

• Longer Hospital Stay – Patients who consume alcohol may require more monitoring and care during their recovery, which can prolong their stay in the hospital 

Alcohol free days are beneficial to your health.  

PICTURE HERE

Risk of complications Drinking 3-5 units per day: 

 1.5 times more likely to have a complications 

Drinking more than 5 units per day: 4 times more likely to have a complications 

Reducing Alcohol Before Surgery  

Any amount of alcohol you cut back will help reduce the risks during surgery, but the goal should be to get down to safe levels (no more than 14 units per week).  

If you think you are drinking excessively, you should not stop suddenly. It’s safer to gradually reduce until you reach the recommended limits. It is best to be drinking within safe limits for at least 6 to 8 weeks before surgery to get the most benefit and reduce the risk of complications.  

Top Tips 

• Make a plan: set limits before drinking and stick to them. 

• Set a budget for alcohol. 

• Let friends and family know, they can provide support! 

• Take one day at a time. 

• Drink smaller measures or lower alcohol alternatives. 

• Make every other drink a glass of water. 

• Have alcohol free days every week. 

• Try and drink within safe limits (<14 units per week) for 6-8 weeks before your operation. 

How much am I actually drinking? 

For both men and women this is less than 14 units per week, with no more than 3-4 units on any single day. 

Count14 Website: Helps people calculate how much they are drinking and offers advice https://count14.scot/  

Support for Cutting Down:  

• Speak to your GP and ask for local services which may include counselling. 

• ECLA Counselling Service: Offers help to people worried about their drinking or someone else’s. They provide drop-in services, advice, and one-on-one counselling. ELCA Counselling Service 

• Pre assessment clinic- Be honest about the amount you drink as this will help staff care for you. They can give you help to reduce and make sure you are prescribed the correct amount of medication.  

NHS Lothian Wellbeing: Provides tools and information on how to improve mental health and reduce alcohol use.  Alcohol/Substance Issues – Wellbeing Lothian  

Drink aware: www.drinkaware.co.uk 

Medical Conditions

Medical conditions can affect your recovery from surgery. It is important to make sure any conditions you have are controlled as well as possible before your surgery.

Diabetes

Good blood sugar control is really important to reduce your risk of infections. Talk to your diabetes nurse early to see if they need to make any changes to your treatment.

Blood Pressure

Blood pressure should be controlled to reduce your risk of stroke. Have your blood pressure checked at your GP surgery in good time before your operation. Your GP can then change your medication if needed.

Heart, lung, and other medical problems

If you have any other long-term medical problems, consider asking your GP or nurse for a review, especially if you think your health is not as good as it could be.

Anxiety and mental health

Most people feel some anxiety about having surgery. If you are very anxious or upset, it may be helpful to talk about your concerns with your GP. Techniques including mindfulness, relaxation and breathing exercises or yoga could help you relax before and after your surgery.

Dental health

If you have loose teeth or crowns, a visit to the dentist may reduce the risk of damage to your teeth during an operation.

Are you going to get fit for surgery?

Are you going to prepare your body as best as possible and get fit for surgery? Although it may seem daunting, it is possible to make a few small changes that will make a big difference.

We are here to support you through this challenging time. If you have any questions about what you’ve just read then ask your pre-assessment nurse, surgeon or anaesthetist who will be able to guide you further.

Research

NHS Lothian is committed to supporting clinical research. If you are eligible for any research studies, someone from the research team may contact you with information that you can read. If you do not wish to take part in any research, this will not affect your clinical care in any way.

FURTHER INFORMATION
Fitter, Better, Sooner is a toolkit aimed at helping patients to prepare physically and psychologically for surgery. It was produced by the Royal College of Anaesthetists, with representatives from the Royal College of General Practitioners (RCGP) and the Royal College of Surgeons (RCS), and with patient representatives playing key roles on the working group, reflecting the importance of multidisciplinary input for optimal perioperative care. The resources have been endorsed by both the RCGP and RCS, and have been awarded ‘highly commended’ in the BMA Patient Information Awards 2019¹.

For more information see the Fitter, Better, Sooner website

PLEASE NOTE
This website includes content taken from the Royal College of Anaesthetists’ (RCoA) leaflets ‘Fitter, Better, Sooner (2018)’, ‘You and your anaesthetic (2020)’, ‘Anaesthesia explained (2015)’, and ‘Common events and risks in anaesthesia(2019)’. However, The RCoA has not reviewed the website as a whole. Some of the RCoA infographics used on the website have been adapted for web viewing.