Perioperative Medicine Physicians are specialist medical practitioners who hold fellowships in a primary speciality such as anaesthesia, intensive care or general medicine in addition to further qualifications in perioperative medicine.

Perioperative Medicine encompasses the entire hospital care journey of surgical patients. Perioperative Physicians may be involved from the initial decisions to undergo surgery until the time patients are discharged to the care of their GP.

At each phase of surgical care, Perioperative Medicine Physicians assist in optimising treatment in order to limit risk and avoid complications (e.g. deep vein thrombosis, cardiovascular and respiratory complications) in order to improve surgical morbidity and mortality.

Initially used for colorectal surgery, protocolised Perioperative Medicine such as Enhanced Recovery After Surgery (ERAS) pathways is now finding a place in many other surgical fields including vascular surgery and obstetrics^{1,2,3 .} Perioperative Medicine Physicians care for patients who have severe or complex medical problems such as ischaemic heart disease and sleep disordered breathing and collaborate with other healthcare practitioners including anaesthetists, intensive care specialists, physicians and allied health practitioners⁴.

Preoperative Care involves patient assessment and risk stratification to ensure that the safest procedures are performed whilst limiting the chances of harm, and patients may be categorised into low, medium or high risk. The proposed surgical procedure is also stratified into its’ risk level. Prehabilitation and optimisation of comorbidities aims to bring patients to their optimum health before undergoing surgery. An individualised care plan unique to each patient is finally derived through this shared decision making approach.

Intraoperative Care involves the choice of surgical and anaesthesia techniques that are minimally invasive, enhance pain relief and limit complications such as cerebral and renal hypoperfusion, myocardial ischaemia, venous thromboembolism, and chronic pain.

Postoperative Care involves the short, medium and long-term care of patients after surgery. This includes the care provided in the post anaesthesia care unit (PACU), and high dependency (HDU) and intensive care units (ICU) where the focus of care is on optimising pain relief, fluid balance, wound care, preventing deep vein thrombosis and other complications, and avoiding unnecessary returns to surgery. Risk stratification and minimisation is a dynamic process, occurring continuously throughout the perioperative period.

Diploma of Perioperative Medicine

In October 2022 the Australian and New Zealand College of Anaesthesia established an accreditation program leading to the award of the Diploma of Perioperative Medicine. To be eligible, the candidate would usually have undertaken a further 12 months of specialised training and assessment in perioperative medicine. Because of their further training and assessment in perioperative care, Perioperative Medicine Physicians are uniquely placed to unravel cause and effect in complex surgical patients where multiple perioperative factors are at play. The perioperative journey and care framework that involves Perioperative Medicine Physicians is illustrated below in Figure 1.

References

1. Gustafsson, UO, Scott, MJ, Hubner, M. et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS^®) Society Recommendations: 2018. World J Surg. 2019; 43:659–695.
2. Stenberg, E, dos Reis Falcão, LF, O’Kane M. et al. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World J Surg. 2022; 46:729–751.
3. Macones GA, Caughey AB, Wood SL, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G, Wilson RD. Guidelines for Postoperative Care in Cesarean Delivery: Enhanced Recovery After Surgery (ERAS) Society Recommendations (Part 3). Obstetric Anesthesia Digest. 2020; 40:69-70.
4. Grocott MPW, Plumb JOM, Edwards M, Fecher-Jones I, Levett DZH. Re-designing the pathway to surgery: better care and added value. Perioper Med (Lond). 2017; 6:9.
5. Australian and New Zealand College of Anaesthetists (ANZCA) (2022) ‘A framework for perioperative care in Australia and New Zealand.’ Available at https://www.anzca.edu.au/education-training/perioperative-medicine-qualification/the-perioperative-care-framework [Verified 29 October 2022]

This article was written by Dr John Beck, Specialist Anaesthetist & Perioperative Physician