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Skip to 0 minutes and 9 seconds ‘Perioperative Medicine as a concept’. Is it real? Why do we need it, and what is it? So first of all, I would argue fundamentally that it is real. I think that the needs have changed, the demographic of the population that we serve has changed quite considerably, since we were junior doctors. We’re now dealing with a population that is thankfully older, living longer. We’ve advanced significantly with the surgical procedures we can offer. But as a result of that, we’ve really pushed the envelope from the point of view of multiple disease processes and polypharmacy that comes with those patients, many of whom I think that when we were young doctors would not have been operated upon.

Skip to 0 minutes and 51 seconds So that perioperative care pathway requires some expertise. It’s not really delivered by any single organ doctor. It’s no longer simple as let’s ask the cardiologist to look at the heart side of it or the pulmonary doctor to look at the lung side of it. The closest thing I would say that we have at the moment to a perioperative physician that’s quite well-established are the orthogeriatricians, those people who support orthopaedic surgeons and other orthopaedic surgery caregivers to provide holistic care for the frail and elderly patient having a joint replacement, for example. So let’s now talk about the new pathway then.

Skip to 1 minute and 33 seconds So I’m 84, and I’ve got bowel cancer, but I’ve also got type 2 diabetes, a impaired ventricle, had a CVA a few years ago. What’s my pathway now for perioperative medicine. Who do I see? And looks after me and how do you make things better? So one of the objectives is to make sure that we have a system, whereby we can identify you at greater risk. You’ve already immediately given some things that are easy to identify from the point of view of age and co-morbidities. Pretty much any existing scoring system would rate you as red, the higher risk patient.

Skip to 2 minutes and 13 seconds The ambition is to get to you much earlier in the pathway, such that not only can we inform the decision-making about whether surgery can help you or not, but also to start to prepare you for the possibility of that surgery. So start to deal with issues with regards to your mental health, your social health, your physical well-being that relates to both fitness and nutrition, so that whole preparatory package.

Skip to 2 minutes and 43 seconds So not only are we giving it a greater chance if surgery does proceed, but also at the same time, you’re getting this self-awareness of, well, you’ve given me this challenging exercise programme, and I’m really struggling to do the exercise programme before the surgery, let alone the challenge of doing it after the surgery. So maybe I should take a different view of how much this surgery may benefit me. OK, so I’ve got two questions. The first of which is the obvious one, does that work? I mean, if I am that patient I’ve just described and I come and see you, am going do better than if I just follow the traditional pathway and how much better?

Skip to 3 minutes and 19 seconds Well, I think that we can’t say with absolute certainty from all forms of surgery at the moment. But for each of the fields where this has been explored, the signals are definitely in favour of that. Then the second question, I suppose, is we all know that going after people with very high blood pressure on a population base isn’t very sensible, because whilst I might have a very high blood pressure and a very high risk of stroke. Most strokes happen in people who are not in a high risk group. So are we devoting too many resources to an identified high risk group when most surgical complications happen in low risk groups? Or actually are those low risk groups actually safe?

Skip to 3 minutes and 57 seconds So I think there’s an excellent point. We know that most of the bad things that happen are in that very high risk group. They make up the minority of the patients number wise. But that group is where you find four out of five of the deaths, for example. So it’s a very, very high risk group. Now to help the masses, the large number of people who are not in that high risk group, there does appear to be a penumbra effect. So by focusing on that group and by trying to deliver the best evidence-based practise, more carefully to find pathways within reduced variability, it seems as though everybody benefits.

Perioperative medicine as a concept

In the previous step you discussed what a perioperative pathway might look like. Over the next few steps we will explore the Royal College of Anaesthetists’ vision of high quality perioperative care and hear about a successful example of a perioperative care pathway from York Teaching Hospital.

Before we learn about these it is important to understand what perioperative medicine is. In the video Professor Monty Mythen, RCOA Council member, and Professor Hugh Montgomery, UCL Professor of Human Performance and Consultant Intensivist, discuss what perioperative medicine is and why it is needed, as well as what a pathway for a high-risk patient may look like.

How did their vision compare with your own from the previous discussion step?

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This video is from the free online course:

Perioperative Medicine in Action

UCL (University College London)