Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 1-2

Perioperative medicine: a new concept for anesthetic care


Department of Anesthesia, Intensive Care, and Pain Management, Ain Shams University, Cairo, Egypt

Date of Web Publication3-Aug-2018

Correspondence Address:
Kerolos E Moris
Department of Anesthesia, Intensive Care, and Pain Management, Ain Shams University, Cairo, 11341
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.238445

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  Abstract 


Perioperative medicine is the future of our specialty, and it is defined as patient-centered multidisciplinary superior medical care from the time of taking the decision of surgery till the patient’s full recovery and discharge. Formerly most of the anesthetic practice focused on the index of the operation and the disease being treated by this procedure; however the appearance of postoperative related outcomes modulated by the type and quality of surgery had encouraged the development of that new concept.

Keywords: anesthetic, care, medicine, perioperative


How to cite this article:
Moris KE, Hilal AM. Perioperative medicine: a new concept for anesthetic care. Ain-Shams J Anaesthesiol 2017;10:1-2

How to cite this URL:
Moris KE, Hilal AM. Perioperative medicine: a new concept for anesthetic care. Ain-Shams J Anaesthesiol [serial online] 2017 [cited 2018 Sep 25];10:1-2. Available from: http://www.asja.eg.net/text.asp?2017/10/1/1/238445




  Introduction Top


Perioperative medicine is the future of our specialty, and it is defined as patient-centered multidisciplinary superior medical care from the time of taking the decision to perform surgery until the patient’s full recovery and discharge. Previously, most of the anesthetic practice focused on the index of the operation and the disease being treated by this procedure; however, the appearance of postoperative outcomes related to the type and quality of surgery encouraged the development of the new concept of perioperative medicine. The anesthetist should acknowledge that inadequate care during surgery can result in organ dysfunction [1].

To achieve the best practice of perioperative medicine five major components should be fulfilled: collaborative decision making [3], preoperative lifestyle modification, standardization of perioperative care, targeting full postoperative recovery, and using data for quality improvement [4].

As anesthetists, we are faced with two different definitions that characterize the scope of our practice: the first is narrow in scope and includes administering anesthetic drugs with the lowest possible risk, limiting us to a technical role; the second is broader in scope and includes many aspects of nonoperative care of patients undergoing major surgery [2].

However, there are many important questions that should be answered:
  1. What are the missed needs that the perioperative physician will add?
  2. What is the role of the anesthetist in perioperative medicine?
  3. How should this novel subspecialty be organized?


In this review we will attempt to answer these questions.

What are the missed needs that the perioperative physician will add?

For the perioperative pathway, a multidisciplinary team is needed to fulfill the unmet needs, and the care pathway should be initiated in a large tertiary referral hospital or university hospital. These unmet needs include improving the safety of the patient and reducing patient harm [7]. It is started preoperatively by standardization of patient assessment and modification of his/her lifestyle to be followed intraoperatively by maintenance of normothermia and normovolemia and facilitating enhanced recovery to reduce the incidence of adverse outcome after major surgery [8]. Furthermore, timely and effective handling of postoperative complications is a more important determinant of long-term postoperative survival than either comorbid disease or intraoperative adverse events [9].

Perioperative medicine offers a unique opportunity to add value through improved outcome and reduced resource utilization in patients undergoing major surgery. Comparable national data are available (2008) that show that postoperative 30-day mortality of patients undergoing elective colorectal surgery for cancer is 3.0%, whereas the hospital mortality rate of patients undergoing isolated elective coronary artery bypass surgery is 1.5%. Clinical practice in these areas is widely divergent, with substantially more resources being focused on patients undergoing cardiac surgery, despite the greater risk of death after colorectal surgery. Patients undergoing cardiac surgery can expect multidisciplinary team meetings to plan care, advanced and invasive cardiovascular monitoring (e.g. transesophageal echocardiography, pulmonary artery catheterization, central venous catheterization, and invasive blood pressure monitoring), and postoperative critical care, whereas patients undergoing colorectal surgery rarely benefit from such a package of care. It is highly likely that more patients would die after noncardiac surgery if they are not given the same quality of care as in cardiac surgery. Finally, although successful surgery is a necessary condition for good postoperative outcomes, technical proficiency alone is not sufficient. The role of the perioperative physician is to fulfill this unmet need [10].

What is the role of the anesthetist in perioperative medicine?

In the past the anesthetist was defined as the individual giving or administering the anesthetic drugs to the patient and anything beyond this narrow vision was considered the domain of the internal medicine physician who visits the patient preoperatively. However, nowadays most anesthetists practice perioperative medicine to some extent [11],[12].

Perioperative medicine is a multidisciplinary subspecialty composed of practitioners who can identify the complex medical needs of patients at particular risk from the adverse effects of surgical treatment. This may require intervention before, during, or after surgery and may extend beyond the index admission for surgery.

Anesthetists are the best doctors who can lead the perioperative medical team. As surgeons are focusing on new and more specialized technical procedures, anesthetists are taking more responsibility for the wider care of the patient population with complex medical needs [13].

Perioperative medicine is started from the time of taking the decision to operate until hospital discharge and beyond, aiming to improve the quality of the treatment outcome and maximize the benefits. The perioperative physician may be an anesthetist, general surgeon, cardiologist, or intensivist. This physician will have undergone a program of training, followed by certification in perioperative care and risk assessment [14].

How should this novel subspecialty be organized?

Perioperative medicine needs a well-resourced environment to enable the perioperative physician to reduce patient harm [4].

Also the perioperative physician must integrate the training and experience of team members, from the specialized surgeon to the general practitioner [6]. This will allow the perioperative physician to create a new level of care and maximize the benefits [5].

We need to educate patients, the public, healthcare professionals, and policymakers about the scope and significance of these unmet needs of patients undergoing major surgery.


  Conclusion Top


Perioperative medicine is needed to ensure an integrated approach, maximizing the opportunities for improvements in preoperative optimization and postoperative care. Moving the evaluation of risk to earlier in the preoperative pathway offers opportunities for risk mitigation, collaborative decision-making, and optimization of patient health before surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Grocott MP, Mythen MG. Perioperative medicine: the value proposition for anesthesia?: a UK perspective on delivering value from anesthesiology. Anesthesiol Clin 2015; 33:617–628.  Back to cited text no. 1
    
2.
Pearse RM, Holt PJ, Grocott MP Managing perioperative risk in patients undergoing elective non-cardiac surgery. Br Med J 2011; 343:d5759.  Back to cited text no. 2
    
3.
Kehlet H, Mythen M. Why is the surgical high-risk patient still at risk? Br J Anaesth 2011; 106:289–291.  Back to cited text no. 3
    
4.
White SM, Griffiths R, Holloway J, Shannon A. Anaesthesia for proximal femoral fracture in the UK: first report from the NHS Hip Fracture Anaesthesia Network. Anaesthesia 2010; 65:243–248.  Back to cited text no. 4
    
5.
Saunders D, Murray D, Pichel AC, Varley S, Peden CJ. Variations inmortality following emergency laparotomy; the first report of the United Kingdom Emergency Laparotomy Network. Br J Anaesth 2012; 109:368–375.  Back to cited text no. 5
    
6.
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with in patient surgery. N Engl J Med 2009; 361:1368–1375.  Back to cited text no. 6
    
7.
Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372:139–144.  Back to cited text no. 7
    
8.
Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A et al. Identification and characterization of the high-risk surgical population in the United Kingdom. Crit Care 2006; 10:R81.  Back to cited text no. 8
    
9.
Moola S, Lockwood C. Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment. Int J Evid Based Healthc 2011; 9:337–345.  Back to cited text no. 9
    
10.
Grace C, Kuper M, Weldon S, Lees J, Modasia R, Mythen M. Service redesign. Fitter, faster: improved pathways speed up recovery. Health Serv J 2011; 121:28–30.  Back to cited text no. 10
    
11.
Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005; 242:326–341.  Back to cited text no. 11
    
12.
National Bowel Cancer Audit. 2009.  Back to cited text no. 12
    
13.
Sixth National Adult Cardiac Surgical Database Report. 2008. Available at: http://www.scts.org/_userfiles/resources/SixthNACSDreport2008withcovers.pdf. [Accessed 20 March 2012]  Back to cited text no. 13
    
14.
Grocott MP. Improving outcomes after surgery. BMJ 2009; 339:b 5173.  Back to cited text no. 14
    




 

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