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British Journal of Anaesthesia
BJA

Perioperative medicine: the future of anaesthesia?

  • M.P.W. Grocott
    Correspondence
    Corresponding author
    Affiliations
    Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, CE93, Mailpoint 24, Level E, Centre Block, Tremona Road, Southampton SO16 6YD, UK

    Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton SO16 6YD, UK

    NIAA Health Services Research Centre, London WC1R 4SG, UK
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  • R.M. Pearse
    Affiliations
    Intensive Care Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary's University of London, London EC1M 6BQ, UK
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      For time and the world do not stand still. Change is the law of life. And those who look only to the past or the present are certain to miss the future.US President John F. Kennedy, Frankfurt, June 25, 1963.
      Perioperative medicine is the future of anaesthesia, if our speciality is to thrive.
      Traditionally, the care of patients undergoing major surgery has been tailored to the index operation and the disease being treated by this procedure. However, a strong case can be made that the development of postoperative adverse outcomes relates primarily to the interaction between the inflammatory response to the tissue injury of surgery and a patient's physiological reserve, modulated by the type and quality of surgery.
      • Pearse RM
      • Holt PJ
      • Grocott MP
      Managing perioperative risk in patients undergoing elective non-cardiac surgery.
      From this perspective, the response to surgery becomes the primary ‘disease process’ and the consequent organ dysfunction the condition to which care should be focused. The aim of perioperative medicine is to deliver the best possible pre-, intra- and postoperative care to meet the needs of patients undergoing major surgery.
      • Pearse RM
      • Holt PJ
      • Grocott MP
      Managing perioperative risk in patients undergoing elective non-cardiac surgery.
      • Kehlet H
      • Mythen M
      Why is the surgical high-risk patient still at risk?.
      This will be achieved through refining existing care pathways and by developing new pathways where current approaches are not fit for purpose.
      As anaesthetists, we are faced with a choice between narrow and broad definitions of the scope of our practice. On the one hand, a tightly defined focus on administering anaesthesia of the highest quality risks limiting us to a technical role. On the other hand, we can embrace the opportunities presented by the broader role of the perioperative physician encompassing many aspects of the ‘non-operative’ care of the patient undergoing major surgery. Along with the many other aspects of anaesthetic practice, this would allow us to consolidate our position as a mature and respected medical speciality alongside our peers. This proposition highlights the critical decisions we face as a speciality. Indecision is a choice in itself, and will most likely result in progressive loss of influence as other specialities embrace the concept of perioperative medicine.
      However, important questions remain as follows:
      • What unmet needs does the perioperative physician fulfil?
      • How can the anaesthetist contribute?
      • How should the speciality of perioperative medicine be organized?
      In this editorial, we will attempt to address these questions.

      Unmet needs in perioperative care

      Anaesthetists rightly take pride in the outstanding track record of our speciality in improving safety and reducing avoidable patient harm. However, while harm directly attributable to the conduct of anaesthesia is rare (<1 in 50 000 mortality),
      • Lagasse RS
      Anesthesia safety: model or myth? A review of the published literature and analysis of current original data.
      • Kawashima Y
      • Takahashi S
      • Suzuki M
      • et al.
      Anesthesia-related mortality and morbidity over a 5-year period in 2,363,038 patients in Japan.
      there is arguably an epidemic of avoidable harm after major surgery, with dramatic variation in patient outcomes between institutions and nations which highlight the gap between what is achievable and what is actually achieved.
      • 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.

      D Saunders, D Murray, AC Pichel, S Varley, CJ Peden, Variations in mortality following emergency laparotomy; the first report of the United Kingdom Emergency Laparotomy Network, Br J Anaesth, in press.

      • Ghaferi AA
      • Birkmeyer JD
      • Dimick JB
      Variation in hospital mortality associated with inpatient surgery.
      • Bennett-Guerrero E
      • Hyam JA
      • Shaefi S
      • et al.
      Comparison of P-POSSUM risk-adjusted mortality rates after surgery between patients in the USA and the UK.
      The scope of unmet need in the care of patients undergoing major surgery is becoming clearer. The global volume of surgery has been estimated at close to 250 million procedures per year and this activity is increasing as a consequence of patient characteristic change, technological advances, and economic development, as national surgical activity correlates closely with gross domestic product.
      • Weiser TG
      • Regenbogen SE
      • Thompson KD
      • et al.
      An estimation of the global volume of surgery: a modelling strategy based on available data.
      In the UK, estimates of the volume of in-patient surgery vary, but an accurate figure is likely to be in excess of 1.5 million procedures each year.
      • Pearse RM
      • Harrison DA
      • James P
      • et al.
      Identification and characterisation of the high-risk surgical population in the United Kingdom.
      Thus, even a low rate of avoidable harm would be associated with a large number of preventable deaths.
      Evidence is growing for a variety of discrete interventions, such as maintenance of normothermia,
      • Moola S
      • Lockwood C
      Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment.
      and packages of care, like enhanced recovery,
      • Grace C
      • Kuper M
      • Weldon S
      • Lees J
      • Modasia R
      • Mythen M
      Service redesign. Fitter, faster: improved pathways speed up recovery.
      that reduce the incidence of adverse outcome after major surgery. Furthermore, the importance of timely and effective handling of complications when they do develop is achieving greater prominence with the development of the ‘failure to rescue’ paradigm.
      • Ghaferi AA
      • Birkmeyer JD
      • Dimick JB
      Variation in hospital mortality associated with inpatient surgery.
      • Silber JH
      • Williams SV
      • Krakauer H
      • Schwartz JS
      Hospital and patient characteristics associated with death after surgery: a study of adverse occurrence and failure to rescue.
      Finally, the long-term impacts of short-term postoperative harm are increasingly recognized. Postoperative complications are a more important determinant of long-term postoperative survival than either co-morbid disease or intraoperative adverse events.
      • 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. Participants in the VA National Surgical Quality Improvement Program.
      Comparison of processes of care between surgical specialities highlights striking contrasts. For the most recent period when directly comparable national data are available (2008), the 30 day mortality of patients undergoing elective colorectal surgery for cancer was 3.0%, whereas the hospital mortality rate of patients undergoing isolated elective coronary artery bypass surgery was 1.5%. Clinical practice in these areas is widely divergent with substantially more resources 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 cardiovascular monitoring (e.g. transoesophageal echocardiography) and postoperative critical care admission as standard, whereas patients undergoing colorectal surgery rarely benefit from such a package of care. It is highly likely that fewer patients would die after non-cardiac surgery if the quality of care typical in cardiac surgery was available to all patients undergoing major surgery. The care of patients undergoing emergency surgery, such as hip fracture surgery or emergency laparotomy, within the UK offers particularly striking examples of variations in outcomes alongside divergent process of care and institutional mortality rates vary by a factor of 10.
      • 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.

      D Saunders, D Murray, AC Pichel, S Varley, CJ Peden, Variations in mortality following emergency laparotomy; the first report of the United Kingdom Emergency Laparotomy Network, Br J Anaesth, in press.

      Many of us confidently assert that we work in institutions where standards of care are among the best and claim little room for improvement. However, the paucity of robust audit data suggests that most of us cannot know how effective our perioperative care is. Failure to implement interventions with a substantial, albeit imperfect, evidence base is a recurring theme. There is a risk that critical appraisal becomes all critical with limited true appraisal. Unpicking the contributions of various elements of perioperative care to surgical outcome is not straightforward, but it is clear that a substantial proportion of harm is attributable to variations in the non-surgical elements of perioperative care. While successful surgery is a necessary condition for good postoperative outcomes, technical proficiency alone is not sufficient. The role of the perioperative physician is to fulfil this unmet need.

      The anaesthetist as perioperative physician

      Perioperative medicine is a multidisciplinary subspeciality composed of practitioners who can effectively identify and meet 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. Doctors from many specialities are starting to identify themselves as ‘perioperative physicians’, but it is anaesthetists who are best placed to lead in this field, with an ideal combination of training, skills, and experience. As surgeons increasingly focus on new and more specialized technical procedures, other specialists are taking more responsibility for the wider care of a patient population with complex medical needs. Perioperative care is a focus of growth that is starting to develop the type of a collaborative culture at the bedside which has proved so successful in critical care. In some institutions, physicians now lead perioperative care, for example, of elderly patients with hip fractures.
      The perioperative physician is a qualified medical practitioner with an appropriate portfolio of competencies whose patient interaction is temporally defined by the index surgical admission. From the decision to operate, which may be before hospital admission, to hospital discharge and beyond, the role allows us to use every opportunity to maximize patient benefit. The perioperative physician may come from one of various base specialities, including anaesthesia, surgery, acute medicine, cardiology, and care of the elderly but sits at the centre of a web of relevant specialists. This individual will have undergone a programme of appropriate education, training, and certification to arm them with the necessary competencies, either essential, such as evaluating perioperative risk, or desirable, for example, echocardiography, to fulfil a defined scope of practice, the limits of which will require clarification.
      From this perspective, the anaesthetist is defined as the individual administering anaesthesia. Anything beyond this narrow definition spills into the role of the perioperative physician. Implicitly, most anaesthetists practice perioperative medicine to some extent. However, there are clear differences in the degree of enthusiasm with which individual practitioners embrace this role. The warning is clear, if the speciality of anaesthesia does not take the lead in developing more sophisticated and effective approaches to perioperative care, then many other specialities are ready to do so. At a recent educational meeting held at the Royal College of Physicians, more than 200 physicians attended lectures given by anaesthetists on perioperative medicine while in the private sector, non-anaesthetists are already offering their services as perioperative physicians.

      How should the speciality of perioperative medicine be organized?

      To understand the answer to this question, it is necessary to consider the nature of the role of perioperative physician. In a well-resourced environment, the perioperative physician will have many opportunities to minimize perioperative harm, adding further value to the episode of patient care. For many patients, surgery represents a sentinel event. Having had few previous encounters with the medical profession, their health risks have often not been fully evaluated. The experienced anaesthetist will be familiar with this problem, frequently making new medical diagnoses in the 24 h before surgery is conducted. For the perioperative physician, this situation is not an inconvenience, but an opportunity to provide primary and secondary screening and to initiate general health interventions. Thus, for many patients, surgery will become a catalyst event, providing a brief but vital opportunity to impact on postoperative survival and quality of life in the long term. Consequently, the speciality of perioperative medicine must integrate the training, experience, and organization to link effectively with a range of hospital and community specialists from the surgeon to the general practitioner. This will allow us to establish a new standard of care, maximizing the long-term benefit associated with each surgical episode.
      Clearly, the full scope of the role of perioperative physician is not currently covered by any single medical training scheme or college. It will be necessary to define the core knowledge, skills, and experience expected of perioperative physicians. It will also be necessary to define the required competencies, basic, intermediate, and advanced, for training as a perioperative physician and, potentially, for the competent generalist and the subspecialist. Integrated cross-speciality training programmes will be required to deliver this training and define appropriate qualifications.
      The consequences of perioperative medicine for the professional identity of anaesthetists are uncertain. As this field develops towards being a speciality, the need for certification of training and competence will increase. How should our professional organizations address these changes? Should the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland rebrand? Perioperative medicine is so fundamental to anaesthetic practice; it seems inconceivable that the two fields would ever be led by separate colleges. How, then, do we meet the needs of perioperative physicians from other specialities, without following the same path as critical care? Whether we welcome the prospect of perioperative medicine or not, it is time to widen the debate about the implications of such change for the speciality of anaesthesia allowing advanced and rational planning of our speciality's future.
      In conclusion, the speciality of Anaesthesia is clearly best placed to drive the development of perioperative medicine both nationally and locally. We need to educate patients, the public, healthcare professionals, and policymakers about the scope and significance of the unmet needs of patients undergoing major surgery. We need to define and drive an integrated agenda for healthcare policy, quality improvement, education, training, and research, around the emerging healthcare challenge of achieving consistent best-practice and expert care of the patient undergoing major surgery. We must conduct rigorous audit of outcomes
      • Grocott MP
      Improving outcomes after surgery.
      and capitalize on opportunities to provide long-term benefit for all patients having surgery. If we duck this challenge, others will not, and anaesthetists risk being sidelined from the activities we trained for so many years to perform.

      Declaration of interest

      M.P.W.G. is the British Oxygen Professor of Anaesthesia at the Royal College of Anaesthetists. M.P.W.G. is also supported by the Southampton Biomedical Research Centre which receives some of its funding through the UK Department of Health's National Institute of Health Research Biomedical Research Centre/Unit Funding Scheme. R.M.P. holds a National Institute for Health Research Clinician Scientist Award.

      Post Publication Comments

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