Integrating perioperative medicine
Integrating perioperative medicine with anesthesia is the need of the hour. The evolution of a new super-specialty called perioperative anesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. Keywords: Enhanced recovery after surgery, perioperative medicine, surgical home
Perioperative medicine signifies medical care of the patient right from admission, spanning the entire preoperative, intraoperative and postoperative periods. Worldwide, it is gaining acceptance that 'perioperative medicine' is the future of anaesthesiologists. RD Miller, whose writings are gospels in anaesthesia, while chairing the American Society of Anesthesiologists' 'task force on future (2025) paradigms of anaesthesia practice', stressed that we need to diversify our practice paradigms to ensure a future leadership position in medicine. The future is bright for anaesthesiologists who include perioperative medicine in their domain. Perioperative medicine can impart a new lease of life and relevance to our specialty which is largely retreating into the operation theatres (OTs): always behind the mask!
A literature search was performed in January 2019 in MEDLINE, PubMed, EMBASE and the Cochrane Central Register of Controlled Trials for original peer-reviewed manuscripts pertaining to surgery-specific PSH models involving preoperative, intraoperative, and postoperative initiatives spanning the past 5 years. A comprehensive search using PubMed and Google Scholar and reference crawling of all the selected articles retrieved 88 potentially relevant studies using keywords 'perioperative surgical home' and 'enhanced recovery after surgery. We narrowed our review down to 35 studies after reviewing the abstract and methods' section of each article. There exists a paucity of Indian studies on surgery-specific PSH models.
Perioperative medicine is a network of vertical and horizontal pathways. Vertical pathways are based on surgical branches, for example, ERAS pathway for colorectal surgery and PSH model initiated for orthopedic surgery. Here different sets of skills are required to run each constituent microsystem: nursing, nutritionists, physiotherapy, laboratory services, human resource, central sterilisation and supply department, information technology, social service and so on.
Burden of comorbidities, emergent nature of surgery, weekend timing of surgery and the income bracket of the country influence the postoperative morbidity and mortality rate. The common string in these four factors is the lack of patient optimisation and inadequate perioperative care. The perioperative physician needs to fulfil this unmet need. In developed countries, it is the anesthesiologist who is the perioperative and his involvement leads to improvement in the surgical outcome. Developing nations, including India, are still undergoing this transition.
By virtue of training, special skills and experience, anaesthesiologists are the most suitable perioperativists. Preoperative screening, evaluation, preparation, intraoperative anaesthetic and medical management, and acute postoperative care all fall in their purview. Many anaesthesiologists have additional training in critical care and are also pivotal members of multidisciplinary pain management teams. If anaesthesiologists can manage the potentially crisis-prone intraoperative period, they can be trusted upon to manage the pre- and postoperative periods too with equal efficiency. At the hands of a competent anaesthesiologist, this will also ensure continuity of care.
While surgical branches, like minarets of a monument, are quasi-independent units whose decisions and conduct are not controlled by others, anesthesia is like the common platform holding these minarets. It traditionally caters to all surgical branches, each anaesthetist rotating between different surgical branches: neurosurgery, obstetrics, gastrointestinal surgery and so on.