perioperative medicine past, present and future...uk 2002 primary thr 50,000, tkr 50,000 uk 2012...

Perioperative MedicinePast, Present and FutureBSOA Spring Scientific Meeting, Birmingham4th June 2015

Mike Swart

Torbay Hospital

Torquay

Devon

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

The Past: 1944

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”

The Anaesthetist and Care of the

Surgical Case John BeardAnaesthesia 1946: 1; 25-35 and 2; 28-32

• 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”

The Anaesthetic Out-Patient Clinic J

Alfred LeeAnaesthesia 1949; 4: 169-174

• “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”

The Present 2015

Present Perioperative Medicine

• Pre assessment clinics

• Allergy clinics

• High risk surgery clinics

• Day surgery

• Acute pain

• PACU and HDU

• And more

The Future

?

Predicting the future

4 days after predicting he would be in post for 4 more years …

It is difficult to make predictions, especially about the future

Niels Bohr Nobel Prize for Physics 1922

You cannot predict the future, but you can create it

Dennis Gabor Nobel Prize for Physics 1971

The SimpsonsPredicting or creating the future

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

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 2030 15.3 million will be over 65

90 day mortality after THR <65 yr male 0.1%

90 day mortality after THR >80 yr male 1.9%

Training

Clinical management

Outcome data

Shared decision making and high risk patients

Orthopaedic pathway: GP, Physiotherapist, Surgeon

High risk pathway: POPS (Guys), CPET (Torbay)

PERSPECTIVERedesigning 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 10 2014; 370:1379-1381

Post operative level 1.5 care

• Ward HDU Level 1

• Critical care HDU Level 2

• PACU

• Level 1.5 the new enhanced recovery?

Personnel Needs

Social Needs

Safety Needs

Basic Needs

Maslow’s Hierarchy of Needs

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

Level 1.5 Care

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

Thank You: michael.swart@nhs.net