Perioperative Medicine: A Burgeoning Field with Profound Importance to a Modern Clinician

Abstract

AIMS AND SCOPE

This article serves in introducing the readers to the developing field of perioperative medicine. We have made an effort to come up with the latest management guidelines covering multiple subspecialties in form of a special supplement. This compendium in perioperative medicine serves as a comprehensive guide to a practicing clinician, in managing patients with various medical comorbidities undergoing surgical procedures and avoiding common pitfalls.

One of the cornerstones of health services research is the quest for improved quality of health care. Improved quality often means better processes of care that lead to better outcomes. These better outcomes not only carry with them improved quality of life for those who use health services but they also hold the promise of lower health care costs and increases in the cost-effectiveness of the elements of care. Hospitals can be dangerous places, and surgeries often present patients with additional risk. Investigating and understanding how to minimize the risk of avoidable complications and poor surgical outcomes with better perioperative practices is an important avenue for improving the quality of acute care, an issue at the heart of health services research.

Perioperative medical care is an indispensable component of overall surgical case management, involving concerted efforts from surgeons, anesthesiologists, internists, and subspecialists alike. With increasing intricacy of the surgical procedures being performed on a spectrum of patients ranging from those in the pediatric age group to geriatric patients with multiple comorbidities, perioperative medicine is being increasingly recognized as a subspecialty unto itself. Institutions have started constituting perioperative care teams to satisfy the unmet demand created by advances in technology paving way for innovative and more challenging surgical techniques.

Most of the complications from surgical procedures do not occur during or as a result of the intervention itself but paradoxically from medical events (predominantly cardiopulmonary) occurring in the perioperative period. Therefore, it is imperative that there has to be a coordinated and an inclusive effort from all parties involved in the care of the patient—both surgeons and nonsurgeons alike.

It has been estimated that 234 million major surgeries are performed worldwide every year with the rates being manifold in high-income countries when compared with low-income countries, ¹ making surgical safety an important global public health goal. The ramification of such huge numbers is that protocol-based perioperative optimization, monitoring of safety, and standardization of surgical techniques are the need of the hour. The dichotomy between inpatient and outpatient day surgeries presents a unique set of logistic and medical challenges to physicians involved.

This compendium includes papers from various subspecialties summarizing perioperative management of conditions commonly encountered in clinical practice. We included a paper by Dr Tariq dealing with logistics in setting up a perioperative care facility. The issue includes a paper from Dr Skylar that serves as a quick reference tool for internists and surgeons as to how to approach patients with cardiovascular implantable electronic devices and a comprehensive review of cardiac risk stratification and optimization by Dr Bella.

The papers dealing with perioperative management of thyroid dysfunction by Dr Palace and perioperative management of diabetes by Dr Leung enlighten the readers about the common pitfalls in the management of these ubiquitous conditions and their numerous and diverse complication. We also covered management of surgical patients having chronic end-stage liver and kidney diseases. The paper by Dr Balar elucidates the importance of giving special attention to nutritional status, fluid and electrolyte balance, control of ascites, correction of coagulopathy and thrombocytopenia, and avoidance of hepatotoxic medications in a cirrhotic patient going for surgery. In another paper, Dr Nasr, a nephrologist, deals with the management of patients with advanced kidney dysfunction going for surgery.

A comprehensive review by Dr Diaz-Fuentes deals with the perioperative management of patients with suspected or established pulmonary conditions undergoing noncardiothoracic surgery, with a focus on obstructive airway disease, pulmonary hypertension, obstructive sleep apnea, and chronic hypoxic respiratory conditions.

We also dedicated a section for perioperative management of surgical patients with coagulopathy from pathological or iatrogenic reasons. Dr Jadhav deals with the perioperative management of a coagulopathic patient, whereas Dr Sunkara provides guidance on the management of direct oral anticoagulants in the perioperative period. We thought that it is of paramount importance that physicians be able to manage patients on these medications because of their increased use among patients requiring both short- and long-term anticoagulation, owing to their ease of use and the lack of monitoring requirements.

We hope this supplement serves as a concise yet up-to-date reference covering an expansive range of conditions encountered in perioperative clinical scenarios. With the advent of novel surgical techniques previously thought not possible and new drugs for a variety of chronic medical conditions, the field of perioperative medicine is fast changing and physicians must be ready to meet the challenges that arise. We hope that our supplement serves as a tool toward achieving that goal.