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Integrated Cardiovascular Responses
Published in Peter Kam, Ian Power, Michael J. Cousins, Philip J. Siddal, Principles of Physiology for the Anaesthetist, 2020
Peter Kam, Ian Power, Michael J. Cousins, Philip J. Siddal
Cardiopulmonary exercise testing (CPET) is a non-invasive, dynamic, integrated test of cardiovascular, respiratory and skeletal muscle function. Its use in perioperative medicine is to objectively assess the functional capacity and guide prehabilitation of patients scheduled for major surgery. It mimics the perioperative stress the patient will experience in the immediate postoperative period. The test involves a limited exercise programme on a cycle ergometer with continuous gas exchange analysis with a metabolic cart. The physiological data are displayed on a standard nine-panel plot, and various parameters such as anaerobic threshold, maximal oxygen consumption and ventilatory equivalent for carbon dioxide are calculated.
Perioperative issues
Published in Neeraj Sethi, R. James A. England, Neil de Zoysa, Head, Neck and Thyroid Surgery, 2020
Gordon A. G. McKenzie, David J. H. Shipway
Within the oncogeriatric population, where (radical) surgery offers an important curative modality for head, neck and thyroid cancer, decision-making and perioperative care particularly challenges the surgeon. It is increasingly recognised that many perioperative complications experienced by older surgical patients are in fact medical and not necessarily related to the specific surgical procedure. This observation has generated authoritative guidelines and successful models of geriatrician-led preoperative optimisation and proactive, embedded surgical liaison [3–5]. These models of care probably represent a future surgical model whereby issues with surgical training [6] can be overcome by greater collaboration between surgical and medical teams. For now, perioperative medicine remains the responsibility of the surgical team, with support from perioperative physicians, most of whom remain anaesthetists.
Approach to risk stratification in cardio-oncology
Published in Susan F. Dent, Practical Cardio-Oncology, 2019
Christopher B. Johnson, Gary Small, Angeline Law, Habibat Garuba
Cancer patients make up an increasing number of all surgeries, both elective operations to improve prognosis and urgent operations when dealing with surgical complications of cancer. In the VISION trials, approximately one in four patients had active cancer at the time of surgery, and such patients had twice the 30 day adjusted mortality compared to patients without cancer (81,82). As cardiologists approach perioperative cardiac assessment, it is important to recognize the cancer patient as a high risk patient. The mechanism of this excess risk is currently not well understood. The effects of upstream cancer treatment using chemotherapy or radiation, the risk increase associated with multimorbidity and frailty owing to a concomitant cancer diagnosis, or perhaps biological mediators that may increase risk (35,75). Further research in perioperative medicine is needed to better understand factors that make cancer patients high risk, and cardio-oncology research should consider the issue of cancer surgery as a time of particular vulnerability to short-term events.
Surgical and medical co-management optimizes surgical outcomes in older patients with chronic diseases undergoing robot-assisted laparoscopic radical prostatectomy
Published in The Aging Male, 2023
Wenning Lu, Chaoyang Liu, Jing He, Rong Wang, Dewei Gao, Rui Cheng
Early preoperative risk identification and medical conditions optimization for surgery risk reduction are important aspects of clinical practice in perioperative medicine. Several approaches to perioperative risk stratification have been proposed with risk scores and additional testing including cardiopulmonary exercise testing [19,20]. High-risk patients could benefit from the optimization of their physical and mental status to minimize the risk of adverse events [21]. In our study, internists identify comorbidity disease conditions by providing risk stratification and performing interventions for the optimization of their physical and mental status. The SMC process follows preoperative assessment and management guidelines, which recommend specific steps for improving care in several domains, including cognition, nutrition, mobility, medication management, and caregiving. With this approach, patients’ medical comorbidities would be optimized preoperatively to prevent organ dysfunction by surgery injury.
Current Status and Future Directions of Pain-Related Outcome Measures for Post-Surgical Pain Trials
Published in Canadian Journal of Pain, 2019
Ian Gilron, Henrik Kehlet, Esther Pogatzki-Zahn
Relevant to the management of early postoperative pain, the Standardised Endpoints in Perioperative Medicine (StEP) initiative used a Delphi approach to develop and propose 6 defined outcomes for the domain of “patient comfort” in perioperative medicine including: 1) pain intensity (at rest and during movement, 24 hours postop), 2) nausea and vomiting, 3) quality-of-recovery, 4) time to gastrointestinal recovery, 5) time to mobilisation, and 6) sleep quality.61 However, due to a broader perspective, procedure specific pain-related aspects were not considered and patient’s perspective was not taken into account. Future research is needed to elucidate these further in order to identify (a set of) pain-related outcome domains and instruments that are best suited for certain surgical procedures based on evidence. Important here is a consensus procedure that includes patients, for example similar to an approach recommended by the comet initiative (http://www.comet-initiative.org). Important for measurement instruments to be recommended at the end of clinical trials is feasibility, good content validity and good internal consistency (http://www.comet-initiative.org). In addition, future pain trials should include detailed information on patient-specific pain risk factors, such as pain catastrophizing, pre-operative opioid use or other types of “pain-sensitized” patients.11
Undergraduate education in anaesthesia, intensive care, pain, and perioperative medicine: The development of a national curriculum framework
Published in Medical Teacher, 2019
Andrew Smith, Christopher Carey, Jonathan Sadler, Helen Smith, Robert Stephens, Claire Frith
Anesthesia has gradually become the largest hospital specialty (Brennan 2016). Aside from work in the operating theater, anesthetists staff critical care units, provide care for obstetric patients, manage acute and long-term pain, and provide cardiopulmonary resuscitation. More recently, they have also become more closely involved in co-ordinating patient care before and after surgery, and perioperative medicine is evolving as a sub-specialty to meet this need (Carlisle et al. 2016; Bougeard et al. 2017). Anesthetists’ key capabilities can be summarized as: manipulation of consciousness; airway and circulation management; pain management; understanding and communication of risk and patient safety; recognition and care of the deteriorating patient; discussions about end of life care; and procedural skills. The anesthetist’s expertise covers many areas that are unique to anesthesia. Anesthetists and intensive care physicians can also offer a useful complementary perspective in other areas of clinical practice and basic science. Many of these clinical capabilities, not to mention the underpinning basic sciences of physiology and pharmacology in the pre-clinical years, are examined at medical school and expected of newly qualified doctors. Although most UK medical graduates feel prepared for much of their work in the first year after graduation, many report difficulties with communication, dealing with error and safety, and practical procedures (General Medical Council 2014).