Perioperative Medicine Past, Present and Future BSOA Spring Scientific Meeting, Birmingham 4 th June Mike Swart Torbay Hospital Torquay Devon

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1 Perioperative Medicine Past, Present and Future BSOA Spring Scientific Meeting, Birmingham 4 th June 2015 Mike Swart Torbay Hospital Torquay Devon

2 A simple definition of perioperative medicine Anaesthesia is safely and humanely keeping the patient still for the surgery Perioperative medicine is every thing else that you do

3 The Past: 1944

5 The Lancet 1944 Anaesthetist should help bridge the gulf between the physiologists and pharmacologist and the clinician They must bestir themselves now, go into the wards, and take their share of preoperative and postoperative treatment of patients If they can show that their efforts are of value they will be welcomed, and recognition will certainly follow

take their share of preoperative and postoperative treatment of patients If they can show

6 The Anaesthetist and Care of the Surgical Case John Beard Anaesthesia 1946: 1; and 2; Preop: Exercise, Nutrition, Haemaglobin Postop: Oxygen, Fluids, Fluid balance chart, Keep warm, Thromboembolism At the onset of his career the attention of the anaesthetist is focussed almost entirely on the actual administration of anaesthesia during the operation A prophylactic attitude can do much to prevent or minimise complications Application by the anaesthetist of a special knowledge of postoperative complications should benefit the patient

focussed almost entirely on the actual administration of anaesthesia during the operation A prophylactic attitude can do much to prevent

7 The Anaesthetic Out-Patient Clinic Alfred Lee Anaesthesia 1949; 4: J A patient should be asked to stop smoking 3 to 4 weeks before an operation to tell him to stop smoking a day or two before his operation is both psychologically cruel and therapeutically futile the breath-holding test of Sebrasez in which the patient is timed while he holds his breath after full inspiration less than 25 seconds shows that the cardio-respiratory function is poor

psychologically cruel and therapeutically futile the breath-holding test of Sebrasez in which the patient is timed

8 The Present 2015

9 Present Perioperative Medicine Pre assessment clinics Allergy clinics High risk surgery clinics Day surgery Acute pain PACU and HDU And more

10 The Future?

11 Predicting the future 4 days after predicting he would be in post for 4 more years

13 It is difficult to make predictions, especially about the future Niels Bohr Nobel Prize for Physics 1922

14 You cannot predict the future, but you can create it Dennis Gabor Nobel Prize for Physics 1971

15 The Simpsons Predicting or creating the future

16 Creating the future of orthopaedic perioperative medicine? Aging population and the cost and volume of health care Training Clinical management Outcome data Shared decision making and high risk patients Post operative level 1.5 care

Training Clinical management Outcome data Shared decision

17 Aging population and the cost and volume of health care UK 2002 Primary THR 50,000, TKR 50,000 UK 2012 Primary THR 75,000, TKR 70, 000 UK 2012 Rev THR 5,000, Rev TKR 2,500 UK by million will be over day mortality after THR <65 yr male 0.1% 90 day mortality after THR >80 yr male 1.9%

20 Training

23 Clinical management

26 Outcome data

30 Shared decision making and high risk patients Orthopaedic pathway: GP, Physiotherapist, Surgeon High risk pathway: POPS (Guys), CPET (Torbay)

31 PERSPECTIVE Redesigning Surgical Decision Making for High-Risk Patients Laurent G. Glance MD, Turner M. Osler MD and Mark D. Newman MD N Engl J Med April ; 370:

32 Post operative level 1.5 care Ward HDU Level 1 Critical care HDU Level 2 PACU Level 1.5 the new enhanced recovery?

33 Maslow s Hierarchy of Needs Personnel Needs Social Needs Safety Needs Basic Needs

34 Level 1.5 Care Personnel needs Social needs, family and friends visiting and supporting facilities Safe environment, medical and nursing staff, arterial line, blood gas and lactate, metaraminol, blood transfusion, treat fast AF Safe environment, water, food, warmth, quiet, sleep, toilets, washing facilities

35 Perioperative medicine Past, present and future Anaesthesia is safely and humanely keeping the patient still for the surgery 175 years old and on going Perioperative medicine is every thing else that you do 75 years old and evolving

36 Thank You:

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