Anaesthesia
-
Peri-operative risk estimation has traditionally focused on assessing the likelihood of postoperative morbidity and mortality using pre-operative functional assessment. Although this strategy is currently recommended by most major society guidelines, contemporary evidence suggests that cardiac biomarker measurement has important advantages over pre-operative functional assessment. ⋯ In this review, we provide an overview of the evidence supporting the peri-operative utilisation, compare risk estimation methods and discuss which patients may benefit most from cardiac biomarker screening. We also discuss protocols for biomarker screening and management of patients with abnormal results.
-
The traditional approach for measuring outcomes after surgery involves ascertaining whether a patient survived surgery while avoiding major complications. This approach does not capture the full spectrum of events that are meaningful to patients, especially because mortality risks after elective surgery are relatively low, and different complication types vary considerably with respect to their impact on postoperative recovery. This review discusses the application, advantages, disadvantages and select examples of patient-centred outcomes in peri-operative medicine. When applied appropriately, these outcomes complement traditional clinical outcomes, identify important changes in postoperative function that impact patients without discernible complications and ensure that the definition of success after surgery is more meaningful to all relevant stakeholders.
-
The increasing age and subsequent medical complexity of patients presenting for surgery grants the opportunity to examine the processes and delivery of peri-operative care. There is a need to redesign peri-operative pathways allowing room for shared decision making and personalised, evidence-based care. In times of financial constraint, this is no easy task. ⋯ Challenges in redesigning peri-operative care pathways include identification and optimisation of those at highest peri-operative risk to inform the difficult conversations surrounding the appropriateness of surgery. The moral burden of these conversations on patient and professionals alike is increasingly recognised and managing this issue requires innovative models of collaborative, multidisciplinary and interprofessional working. To operate or not can be a challenging question to answer with a number of different perspectives to consider; not least that of the patient.
-
Enhanced postoperative recovery programmes (ERAS) were developed about 20 years ago based on improved understanding of the pathophysiology of postoperative recovery within an integrated multidisciplinary approach. The results across surgical procedures have been extremely positive with a reduction in hospitalisation and medical complications, without increased re-admission rates. However, several challenges lie ahead including improved implementation of existing scientific evidence, increased focus on post-discharge recovery problems and a need for improved design of future ERAS studies. ⋯ These efforts should focus on: the inflammatory and neurohumoral surgical stress responses; fluid management; pain management; blood management; mechanisms of orthostatic intolerance; postoperative cognitive dysfunction; risk factors for thrombo-embolic complications; and mechanisms and prevention of postoperative ileus. Finally, more focus should be made on the different barriers to post-discharge functional recovery and the choice of (pre- and postoperative) rehabilitation. These efforts should be made on a procedure-specific as well as on a patient-specific basis.