Navigating Phantom Pain and Vascular Post‑Operative Ambulation

Vascular surgery patients – those undergoing open or minimally invasive blood flow-related procedures including bypasses, angioplasties, and amputation – often present ambulation challenges to healthcare staff. The reasons are many and can include:

• High prevalence of co-morbidities that cause or contribute to chronic pre-operative and post-operative pain
• Reduced activity endurance on either side of a vascular procedure
• Cognitive decline (delirium in particular)
• Polypharmacy
• Osteoporosis
• Phantom pain in the event of an amputation

Ambulation barriers are problematic for any patient population, but especially this high-risk set. Beyond its benefits for vascular function, early mobility following vascular surgery is a critical building block in accelerating discharge, encouraging early return to baseline status, giving a patient a sense of purpose, and all in all increasing the likelihood of positive health outcomes.

The sooner vascular surgery patients get moving in a safe and effective way, the more likely they can participate in in-patient PT and OT and outpatient rehabilitation, and the better their trajectory is likely be overall. Every time a vascular surgery patient moves, it makes a difference, even if movement is minimal.

ANOTHER BARRIER: FALL RISK

The hurdles mentioned above don’t just make ambulating difficult – they also dramatically increase the likelihood of falls, which is a problem of new magnitude.

Per the Joint Commission, an astonishing 62% of patient falls result in severe harm. Falls can delay patient discharge, decrease patient outcomes, and even contribute to patient suicide and treatment delays. Then there’s the toll of falls on the healthcare system. The Journal of American Medicine Association (JAMA) found that patient falls on average cost an astounding $62,521; that number rises to $64,529 when there’s a fall-related injury.

While discussion of fall prevention is widespread, they are nonetheless frighteningly common. Since 2018, falls have ranked as the leading sentinel event in hospitals nationwide per the Joint Commission. This likely stems at least in part from staffing issues that plague healthcare. Whatever the cause, the prevalence of falls indicates the need for added measures to prevent them, among high-risk post-operative vascular patients especially.

ADJUSTING AMBULATION EXPECTATIONS

Before we examine ways to ambulate vascular surgery patients safely, it’s important to note: Many vascular surgery patients cannot ambulate independently pre-operatively, making them unlikely to ambulate independently post-operatively.

Remembering this reality is key to assessing a patient’s baseline status and integrating it into a successful post-op plan of care. Safe, realistic goals for vascular surgery patients are often minimal relative to non-vascular patients. Sitting up, sitting on the edge of the bed (made easier by the Q2Roller^® Lateral Turning Device), stretching, performing range of motion and strength exercises while seated, basic repositioning, or working with physical therapy might be the extent of what’s possible and advisable for post-operative vascular surgery patients in your care. The HoverMatt Half-Matt can reduce the exertion required by staff members for all of the movements listed above.

When a vascular surgery patient can ambulate, there’s a good chance they will require 1:1 assistance, and will therefore be time consuming. Keep this in mind as you assess staffing, resources, and your own availability.  

In sum, vascular surgery post-op ambulation can look quite different from standard patient ambulation; specifics vary dramatically from one vascular surgery patient to the next. Assessing each patient’s functional capacity should involve the following questions:

• What is the patient’s pre-operative versus post-operative functional capacity?
• What was the patient’s pre-operative pain level? What is their pain level now? What medication are they taking for pain?
• Does the patient have functional limitation?
• Is swelling present? Swelling can limit movement and often is indicative of the presence of pain.   
• Is there a chance of post-operative complications like infection, delirium, or hypotension? A hypotensive patient obviously can’t get out of bed; caregivers need to ensure they’re medically safe to ambulate before even transporting them to a chair or encouraging in-bed movement.  
• Do you have adequate supplies and resources?
• Do you have adequate staffing support? For heavier vascular surgery patients especially, the assistance of colleagues might be needed.
• Do you have adequate time? Slow and steady is key.
• Do you have adequate education and training, i.e. do you know what you’re doing?

Once you’ve properly assessed all of the above, answer the question: How can you maximize the patient’s functional capacity within these parameters – if you can at all? If it feels unsafe to move or reposition a patient even minimally, the patient unfortunately has to wait until more resources are at hand. After all, staff and patient safety is top priority.

MAXIMIZING FUNCTIONAL CAPACITY FOR AMPUTATION PATIENTS

UCSF Fresco’s Lower Extremity Ambulation Protocol (LEAP) is well-regarded framework for moving and caring for patients who’ve lost legs. Amputation is, of course, a major change in day-to-day life of patients, not to mention a psychological event. Fittingly, this holistic and interdisciplinary approach spans the entire amputation process, from preparing a patient for amputation surgery to working with them for three months post-operatively to maximize functional capacity and support and help ensure a positive health trajectory overall.  

Highlights of LEAP include the involvement of a social worker, counseling opportunities, PT and OT involvement, and early discussion of prostheses. If your healthcare setting isn’t familiar with LEAP, consider encouraging its adoption as protocol:

Per the LEAP framework, therapeutic exercises and movement can begin, whenever possible, as soon as one day post-amputation. As discussed, early post-amputation ambulation is often very limited. Those first days might include:

• Stretching. PT teams often can provide a wide range of stretch exercise options.
• Bilateral upper extremity (BUE) strengthening. For lower extremity amputations, BUEs are typically safe and realistic and help prepare a patient to use their arms to transfer to a chair or wheelchair in time. Better yet, BUE strengthening doesn’t involve ambulation, requires minimal oversight, and don’t present fall risk. The assistance of light weights and bands can increase the benefits.  
• Use of a mechanical ceiling lift to transfer patients from bed to chair. Patients unable to stand can sometimes be transferred to a chair with the assistance of a mechanical ceiling lift. This process becomes easier with the HoverSling Repositioning Sheet, which dramatically reduces effort needed to make lateral transfers as well as positioning changes. One note of caution: Use of mechanical lifts often requires the involvement of two caregivers; be sure to understand the process and your healthcare setting’s resources to ensure safety for the patient, you, and your team.

As amputation patient recovery progresses:

• Strengthen the residual limb. This is achieved by pressing the limb against resistance that won’t increase risk of infection or injury – a foam board, for example. Abduction and adduction exercises are additional strengthening options as recovery progresses.
• Manual transfers. Reaching the point where they can safely transfer from bed to a wheelchair, commode, or chair is a milestone for amputation patients – but does introduce the very real risk of falling. Go slowly, being entirely attentive to the patient as you guide them. Slide boards can be helpful here; enlist support from fellow team members as needed. Nursing students are often available and eager to assist with patient transfers.

Ambulating vascular surgery patients while ensuring safety for all involved is a complex topic. Learn more and earn one free contact hour by listening to the full on-demand webinar.

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