Perioperative Medicine
The Future of Anesthesiology
What is perioperative medicine?
Definition: The practice of peri-operative medicine is defined as the integrated, multidisciplinary medical care of patients from the moment of contemplation of surgery until full recovery.
"The aim of peri-operative medicine is to decrease peri-operative morbidity and mortality by identifying patients at increased risk of postoperative complications, advising patients and surgical teams of these risks, and implementing risk reduction strategies. (SM Ruzycki et al)"
It's the concept of the right surgery for the right patient.
The perioperative medicine pathway begins at the moment that patient and physician decide on surgery and ends when the patient makes a full recovery.
It is most applicable in high-risk patients undergoing major surgery, and it considers the implications of the stress of a major surgery on long-term diseases such as diabetes or chronic kidney disease.
Before surgery, the perioperative consultant assesses the needs of the individual patient, optimizes treatments of chronic diseases and determines the risk of the proposed surgery (and ultimately holds discussions about whether to even proceed with surgery). The knock-on effect improves patient outcomes post-operatively while reducing "surprises" (requiring cancellations) on the day of surgery.
During surgery, perioperative medicine can improve patient outcomes without treating the actual index disease (i.e. cancer). Treatment of pain is a good example - optimizing pain control in the intra-operative and early post-operative period has been shown to increase the chances of a speedy recovery.
Early after surgery, with a coherent perioperative medicine system in place, the surgical patient will end up at the correct level of care depending on their individual need (ICU vs. regular ward) without cancelling surgery if say, a critical care bed is not available. For example, a "fast-track" cardiac surgery unit functions as a PACU in the 24hr post-cardiac surgery period, which allows patients to be transferred either to ICU or general ward depending on need.
Later after surgery, perioperative medicine acts as a bridge between the hospital-environment to the primary care providers. Co-ordinating follow-up appointments for recent complications, changes in home medications, or notifying GPs in worsening of long-term conditions as a result of the surgery.
As an evolving specialty, the model that is chosen for your hospital should focus on improving short and long term outcomes.
Anesthesiologists are in a unique position in that we have a great understanding of how complications arise in the post-operative period -- however, without a perioperative medicine program in place, we have very little opportunity to assess the patient in the post-operative period (e.g. on the ward).
Relevant Literature
The Royal College of Anaesthetists, London (2015).
Bottom Line: The Royal College of Anaesthetists' (UK) Perioperative Medicine Programme outlines the vision for a national programme for the delivery of perioperative medicine. An outline for the impetus for change, highlights of existing models of best practices, and discussion on how these models can be combined to form a unified national policy for the delivery of perioperative medicine in the UK.
Major Points:
1. Even for the highest-risk patients modern surgery is very safe in the operating theatre. Most complications, including death, occur in the post-operative period.
2. Perioperative medicine provides an added level of care from the moment that surgery is decided on, until the patient makes a full recovery through co-ordination between consultants and application of evidence-based screening and treatments.
3. On a systems level, effective perioperative medicine reduces cancellations, reduces complication rates and decreases hospital length of stay, thereby making the implementation of a perioperative medicine programme a decision of economic importance.
Grocott MPW, Edwards M, Mythen MG, Aronson S. Peri-operative care pathways: re-engineering care to achieve the 'triple aim'. Anaesthesia. 2019;74 Suppl 1:90-99. doi:10.1111/anae.14513
Bottom Line: Systematic changes to elective surgery pathways provide a radical way to achieve the triple aim: improvements in population health and patient experience with a reduction in per capita healthcare costs. Physicians with a peri-operative skillset, such as anesthesiologists, are in a unique position to lead in the re-engineering of these pathways.
Major points:
1. US Institute for Health Improvement's triple aim strives to achieve: (a) improvements in patient experience, (b) improvements in population health, (c) reduction in healthcare costs per capita.
2. Peri-operative physicians can influence the triple aim by leading radical change to current peri-operative pathways.
3. Preoperatively, via shared-decision making (e.g. deciding not to have surgery), optimizing comorbid conditions and encouraging behavioral change (e.g. smoking cessation).
4. Intra-operatively, by ensuring standardized care among anesthetic providers and individualized care for the patient based on their individual risk-profile.
5. Post-operatively, by focussing on early discharge of low-risk patients undergoing uncomplicated surgeries, while triaging the appropriate level of care (e.g. ICU vs general ward) and preventative treatments for higher-risk patients, all the while ensuring a smooth transition into the community via effective communication with primary care providers.