Stefan De Hert, ESA President-Elect
Let’s go for the 100,000 € question. What has changed in the anaesthesiologist’s practice in the past 50 years?
Yes, the routine implementation of basic and advanced monitoring tools has greatly helped in the early recognition of perioperative problems.Yes, the use of newer and safer short-acting drugs has minimized the risk of perioperative drug overdose.
Yes, we have a better understanding of perioperative fluid management and believe that the application of goal-directed hemodynamic support improves outcome. Yes, we made big progress in blood management, etc.
We can indeed identify a multitude of advancements but we all probably have one change in common: the name of our department has changed from ‘Department of Anaesthesiology’ (and Intensive Care, Critical Care, Pain, Emergency Medicine, … where applicable) to ‘Department of Anaesthesiology and Perioperative Medicine’.
Parallel to this evolution we have seen the appearance of a series of new journals dealing with perioperative medicine and if you take a look at the editorial boards, it seems that anaesthesiologists have a very prominent role.
So, what is this perioperative medicine that we so eagerly want to be part of our portfolio, really? Is this perioperative medicine a domain that is generally accepted as being the responsibility of anaesthesiology? Second, if it is indeed a part of our portfolio, what does it imply in terms of workload and responsibility?
The first question is already open for discussion. Wikipedia, for instance, defines perioperative medicine as the ‘medical care of patients from the time of contemplation of surgery through the operative period to full recovery, but excludes the operation or procedure itself’. In that concept, perioperative care may be provided by an anaesthesiologist, intensivist, an internal medicine generalist, or a hospitalist working with surgical colleagues.
This is definitely not how we – the anaesthesiological community – would define perioperative medicine. There is now ample evidence that a variety of discrete – also intraoperative – interventions, such as the maintenance of normothermia, adequate fluid management, multimodal pain management, and enhanced recovery packages, greatly contribute to improve outcome after surgery.1-3 This implies that artificially isolating the surgical intervention from the perioperative period makes no sense. By definition, the operative period is an integral part of the perioperative course, and as such it is only normal that the anaesthesiologist should be the central person in the perioperative period. This central role is underscored in the 2014 ESC/ESA Guidelines on non-cardiac surgery: Cardiovascular Assessment and Management: The Joint Task Force on non-cardiac surgery, cardiovascular assessment and management of the European Society of Cardiology (ESC), and the European Society of Anaesthesiology (ESA). These guidelines literally state: ‘Anaesthesiologists, who are experts on the specific demands of the proposed surgical procedures, will usually coordinate the preoperative evaluation’. This central role is acknowledged with a class IIb recommendation with level C evidence, which is expert opinion.4,5
Surprisingly, little research has been done on which specialty would be best suited to take the lead in perioperative medicine. I found one Canadian study surveying surgeons’ opinions about the role of internists in perioperative medicine.6 Interestingly, this study indicated that the main concern of surgeons related to the cardiovascular risks of patients and of course medication management. We know that postoperative outcome goes beyond cardiovascular status, as failing of other organ systems7 and even quality and extent of postoperative care (failure to rescue)8 may affect outcome. This means that the person supervising the perioperative period should be trained – both theoretically and in practice – in the subtle interactions between the operative injury and the various organ systems. This is our expertise as anaesthesiologists. We are probably best placed as experts to assess perioperative risk based both on the risk related to the operative procedures – which we know the best – and the risk related to the patient’s phenotype. As such we also know when additional specialized consult for optimization of the patient’s condition is indicated. This is also the reason why the family practitioner should not be put as the (sole) responsible person to guide the patient through this vulnerable period.
Taking perioperative medicine as a part of our portfolio implies that we need to go beyond the classical view of the anaesthesiologist as the individual solely administering anaesthesia. We need to take additional responsibilities extending in both the pre- and postoperative periods. There is no need to say that there are substantial differences in the degree of enthusiasm and commitment with which individual practitioners take this role. Certainly this is because in many reimbursement systems, no financial compensation or compensation in terms of manpower are foreseen for taking these additional responsibilities.
Nevertheless, if we do not take this role, other specialities will try to fill the gap and limit anaesthesiologists (again) to the confined boundaries of the operating room. This is not what we want. It is our task to guide the patient’s perioperative course. The challenge will be to have our hospital administrators and social security systems provide the appropriate resources necessary to take this role and to further improve the operative patient’s outcome.
- 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;9:337–45.
- Grace C, Kuper M, Weldon S, et al. Service redesign. Fitter, faster: improved pathways speed up recovery. Health Serv J 2011;121:28–30.
- Grocott MP, Pearse RM. Perioperative medicine: the future of anesthesia? Br J Anaesth 2012;108:723–6.
- Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol 2014;31:517–73.
- Longrois D, Hoeft A, De Hert S. 2014 European Society of Cardiology/European Society of Anaesthesiology guidelines on non-cardiac surgery: cardiovascular assessment and management. A short explanatory statement from the European Society of Anaesthesiology members who participated in the European task force. Eur J Anaesthesiol 2014;31:513–6.
- Pausjenssen L, Ward HA, Card SE. An internist’s role in perioperative medicine: a survey of surgeons’ opinions. BMC Fam Pract 2008;9:4.
- Le Manach Y, Collins GS, Ibanez C, et al. Impact of perioperative bleeding on the protective effect of b-blockers during infrarenal aortic reconstruction. Anesthesiology 2012;117:1203–11.
- Pearse RM, Moreno RP, Bauer P, et al. Mortality after surgery in Europe: a 7-day cohort study. Lancet 2012;380:1059–65.