Perioperative medicine: a changing model of care

Comprehensive overview of the anesthesiology research landscape: A machine Learning Analysis of 737 NIH-funded anesthesiology primary Investigator's publication trends

Background

Anesthesiology plays a crucial role in perioperative care, critical care, and pain management, impacting patient experiences and clinical outcomes. However, our understanding of the anesthesiology research landscape is limited. Accordingly, we initiated a data-driven analysis through topic modeling to uncover research trends, enabling informed decision-making and fostering progress within the field.

Methods

The easyPubMed R package was used to collect 32,300 PubMed abstracts spanning from 2000 to 2022. These abstracts were authored by 737 Anesthesiology Principal Investigators (PIs) who were recipients of National Institute of Health (NIH) funding from 2010 to 2022. Abstracts were preprocessed, vectorized, and analyzed with the state-of-the-art BERTopic algorithm to identify pillar topics and trending subtopics within anesthesiology research. Temporal trends were assessed using the Mann-Kendall test.

Results

The publishing journals with most abstracts in this dataset were Anesthesia & Analgesia 1133, Anesthesiology 992, and Pain 671. Eight pillar topics were identified and categorized as basic or clinical sciences based on a hierarchical clustering analysis. Amongst the pillar topics, "Cells & Proteomics" had both the highest annual and total number of abstracts. Interestingly, there was an overall upward trend for all topics spanning the years 2000-2022. However, when focusing on the period from 2015 to 2022, topics "Cells & Proteomics" and "Pulmonology" exhibit a downward trajectory. Additionally, various subtopics were identified, with notable increasing trends in "Aneurysms", "Covid 19 Pandemic", and "Artificial intelligence & Machine Learning".

Conclusion

Our work offers a comprehensive analysis of the anesthesiology research landscape by providing insights into pillar topics, and trending subtopics. These findings contribute to a better understanding of anesthesiology research and can guide future directions.

Frail Patients Undergoing Optimization Before Surgery: Preliminary Results

BACKGROUND

It is estimated that 10% or more of patients older than 65 years are affected by frailty, a mental and physical state of vulnerability to adverse surgical outcomes. Frailty can be assessed using the Edmonton Frailty Scale: a reliable and convenient multidimensional assessment before surgery. The correlation between frailty score, presurgical optimization, and surgical outcomes was investigated in this preliminary pilot study.

STUDY DESIGN

A retrospective study was performed on patients referred to the surgical optimization clinic and assessed for frailty from September 2020 to May 2023. Patients received presurgical optimization for reasons including diabetes, smoking cessation, prehabilitation and nutrition, and/or cardiopulmonary issues. Outcomes were evaluated whether they proceeded to surgery, were referred to the High-Risk Surgical Committee, surgical case canceled, or not scheduled. For those who proceeded to surgery, infection rates, complications, and 30-day emergency department (ED) and readmission rates were evaluated.

RESULTS

Of 143 unique patients, 138 (men = 61, women = 77) were evaluated for this study. The average Edmonton frailty score for patients who proceeded to surgery was 7.013 (n = 78) vs 9.389 with cancelation and 9.600 for not scheduled or not optimized for surgery. Postoperative infection rates were <3%. However, 30-day ED and readmission rate was 21% (16 of 78).

CONCLUSIONS

Patients with lower average Edmonton frailty scores were more likely to proceed to surgery, whereas those with higher average Edmonton frailty scores were more likely to have surgery canceled or delayed. Frail patients cleared for surgery were found to have a high 30-day ED and readmission rate.

Perioperative Considerations for the Surgical Treatment of Crohn's Disease with Discussion on Surgical Antibiotics Practices and Impact on the Gut Microbiome

Crohn's disease, a chronic inflammatory process of the gastrointestinal tract defined by flares and periods of remission, is increasing in incidence. Despite advances in multimodal medical therapy, disease progression often necessitates multiple operations with high morbidity. The inability to treat Crohn's disease successfully is likely in part because the etiopathogenesis is not completely understood; however, recent research suggests the gut microbiome plays a critical role. How traditional perioperative management, including bowel preparation and preoperative antibiotics, further changes the microbiome and affects outcomes is not well described, especially in Crohn's patients, who are unique given their immunosuppression and baseline dysbiosis. This paper aims to outline current knowledge regarding perioperative management of Crohn's disease, the evolving role of gut dysbiosis, and how the microbiome can guide perioperative considerations with special attention to perioperative antibiotics as well as treatment of Mycobacterium avium subspecies paratuberculosis. In conclusion, dysbiosis is common in Crohn's patients and may be exacerbated by malnutrition, steroids, narcotic use, diarrhea, and perioperative antibiotics. Dysbiosis is also a major risk factor for anastomotic leak, and special consideration should be given to limiting factors that further perturb the gut microbiota in the perioperative period.

Social Determinants of Health and Preoperative Care

Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are important, particularly for patients with complex medical histories and those requiring major surgery. Preoperative care improves planning and determines the clinical pathway and discharge disposition. The role of nonmedical social factors in the preoperative planning is not well described in anesthesiology. Research to improve outcomes based on social factors is not well described for anesthesiologists but could be instrumental in decreasing disparities and advancing health equity in surgical patients.

Recognizing and Maximizing the Nexus of Perioperative Medicine and Narrative Medicine

Perioperative medicine remains an evolving, interdisciplinary subspecialty, which encompasses the unique perspectives and incorporates the respective vital expertise of numerous stakeholders. This integrated model of perioperative medicine and care has a wide-ranging set of clinical, strategic, and operational goals. Among these various programmatic goals, a subset of 4, specific, interdependent goals include (1) enhancing patient-centered care, (2) embracing shared decision-making, (3) optimizing health literacy, and (4) avoiding futile surgery. Achieving and sustaining this subset of 4 goals requires continued innovative approaches to perioperative care. The burgeoning field of narrative medicine represents 1 such innovative approach to perioperative care. Narrative medicine is considered the most prominent recent development in the medical humanities. Its central tenet is that attention to narrative-in the form of the patient's story, the clinician's story, or a story constructed together by the patient and clinician-is essential for optimal patient care. If we can view the health care experience through the patient's eyes, we will become more responsive to patients' needs and, thereby, better clinicians. There is a potential clinical nexus between the perioperative medicine practice and narrative medicine skills, which, if capitalized, can maximize perioperative patient care. There are a number of untapped educational and research opportunities in this fruitful nexus between perioperative medicine and narrative medicine.

Perceptions and practices surrounding the perioperative management of frail emergency surgery patients: a WSES-endorsed cross-sectional qualitative survey

BACKGROUND

Frailty is associated with poor post-operative outcomes in emergency surgical patients. Shared multidisciplinary models have been developed to provide a holistic, reactive model of care to improve outcomes for older people living with frailty. We aimed to describe current perioperative practices, and surgeons' awareness and perception of perioperative frailty management, and barriers to its implementation.

METHODS

A qualitative cross-sectional survey was sent via the World Society of Emergency Surgery e-letter to their members. Responses were analysed using descriptive statistics and reported by themes: risk scoring systems, frailty awareness and assessment and barriers to implementation.

RESULT

Of 168/1000 respondents, 38% were aware of the terms "Perioperative medicine for older people undergoing surgery" (POPS) and Comprehensive Geriatric Assessment (CGA). 66.6% of respondents assessed perioperative risk, with 45.2% using the American Society of Anaesthesiologists Physical Status Classification System (ASA-PS). 77.8% of respondents mostly agreed or agreed with the statement that they routinely conducted medical comorbidity management, and pain and falls risk assessment during emergency surgical admissions. Although 98.2% of respondents agreed that frailty was important, only 2.4% performed CGA and 1.2% used a specific frailty screening tool. Clinical frailty score was the most commonly used tool by those who did. Screening was usually conducted by surgical trainees. Key barriers included a lack of knowledge about frailty assessment, a lack of clarity on who should be responsible for frailty screening, and a lack of trained staff.

CONCLUSIONS

Our study highlights the ubiquitous lack of awareness regarding frailty assessment and the POPS model of care. More training and clear guidelines on frailty scoring, alongside support by multidisciplinary teams, may reduce the burden on surgical trainees, potentially improving rates of appropriate frailty assessment and management of the frailty syndrome in emergency surgical patients.

Perioperative use of intra-articular steroids during the COVID-19 pandemic

PURPOSE

There are growing concerns with the widely used glucocorticoids during the Coronavirus disease-19 (COVID-19) pandemic due to the associated immunosuppressive effects, which may increase the risk of COVID-19 infection and worsen COVID-19 patient outcome. Heavily affecting orthopaedics, the pandemic led to delay and cancellation of almost all surgical cases, and procedures including perioperative intra-articular corticosteroid injections (ICIs) saw similar decreases. However, the benefits of ICI treatments during the pandemic may outweigh these potential risks, and their continued use may be warranted.

METHODS

A literature search was conducted, and all relevant articles including original articles and reviews were identified and considered in full for inclusion, and analysed with expert opinion. Epidemiological statistics and medical guidelines were consulted from relevant authorities.

RESULTS

ICIs allow a targeted approach on the affected joint and are effective in reducing pain while improving functional outcome and patient quality-of-life. ICIs delay the requirement for surgery, accommodating for the increased healthcare burden during the pandemic, while reducing postoperative hospital stay, bringing significant financial benefits. However, ICIs can exert systemic effects and suppress the immune system. ICIs may increase the risk of COVID-19 infection and reduce the efficacy of COVID-19 vaccinations, leading to important public health implications.

CONCLUSION

Perioperative ICI treatments may bring significant, multifaceted benefits during the pandemic. However, ICIs increase the risk of infection, and perioperative COVID-19 is associated with mortality. The use of ICIs during the COVID-19 pandemic should therefore be considered carefully on an individual patient basis, weighing the associated risks and benefits.

Can Previous Levels of Physical Activity Affect Risk Factors for Cardiorespiratory Diseases and Functional Capacity after COVID-19 Hospitalization? A Prospective Cohort Study

Purpose

To evaluate the influence of previous levels of physical activity on hemodynamic, vascular, ventilatory, and functional outcomes after coronavirus disease 2019 (COVID-19) hospitalization.

Methods

Sixty-three individuals with COVID-19 had their clinical status and previous levels (12 month) of physical activity (Baecke Questionnaire of Habitual Physical Activity) assessed at hospital admission. Individuals were then allocated to lower levels of physical activity (ACT_LOWER; N = 22), intermediate levels of physical activity (ACT_INTERMEDIATE; N = 22), or higher levels of physical activity (ACT_HIGHER; N = 19) groups, according to tertiles of physical activity. Resting hemodynamic (heart rate and brachial/central blood pressures) and vascular (carotid-femoral pulse wave velocity, augmentation index, and brachial artery flow-mediated dilation) variables, pulmonary function (spirometry), respiratory muscle strength (maximal respiratory pressures), and functional capacity (handgrip strength, five-time sit-to-stand, timed-up and go, and six-minute walking tests) were measured at 30 to 45 days after hospital discharge.

Results

ACT_LOWER showed lower levels (P < 0.05) of forced vital capacity, forced expiratory volume in the first second, maximal voluntary ventilation, and maximal expiratory pressure than ACT_HIGHER. ACT_LOWER also had lower (P = 0.023) walking distance (~21%,) and lower percentage of predicted walking distance (~20%) at six-minute walking test during follow-up than ACT_INTERMEDIATE. However, hemodynamic and vascular variables, handgrip strength, five-time sit-to-stand, and timed-up and go were not different among groups.

Conclusion

ACT_LOWER showed impaired ventilatory parameters and walking performance when compared with ACT_HIGHER and ACT_INTERMEDIATE, respectively. These results suggest that previous levels of physical activity may impact ventilatory and exercise capacity outcomes 30 to 45 days after COVID-19 hospitalization discharge.

Narrative Medicine: Perioperative Opportunities and Applicable Health Services Research Methods

Narrative medicine is a humanities-based discipline that posits that attention to the patient narrative and the collaborative formation of a narrative between the patient and provider is essential for the provision of health care. In this Special Article, we review the basic theoretical constructs of the narrative medicine discipline and apply them to the perioperative setting. We frame our discussion around the 4 primary goals of the current iteration of the perioperative surgical home: enhancing patient-centered care, embracing shared decision making, optimizing health literacy, and avoiding futile surgery. We then examine the importance of incorporating narrative medicine into medical education and residency training and evaluate the literature on such narrative medicine didactics. Finally, we discuss applying health services research, specifically qualitative and mixed methods, in the rigorous evaluation of the efficacy and impact of narrative medicine clinical programs and medical education curricula.

Wireless wearables for postoperative surveillance on surgical wards: a survey of 1158 anaesthesiologists in Western Europe and the USA

Background

Several continuous monitoring solutions, including wireless wearable sensors, are available or being developed to improve patient surveillance on surgical wards. We designed a survey to understand the current perception and expectations of anaesthesiologists who, as perioperative physicians, are increasingly involved in postoperative care.

Methods

The survey was shared in 40 university hospitals from Western Europe and the USA.

Results

From 5744 anaesthesiologists who received the survey link, there were 1158 valid questionnaires available for analysis. Current postoperative surveillance was mainly based on intermittent spot-checks of vital signs every 4-6 h in the USA (72%) and every 8-12 h in Europe (53%). A majority of respondents (91%) considered that continuous monitoring of vital signs should be available on surgical wards and that wireless sensors are preferable to tethered systems (86%). Most respondents indicated that oxygen saturation (93%), heart rate (80%), and blood pressure (71%) should be continuously monitored with wrist devices (71%) or skin adhesive patches (54%). They believed it may help detect clinical deterioration earlier (90%), decrease rescue interventions (59%), and decrease hospital mortality (54%). Opinions diverged regarding the impact on nurse workload (increase 46%, decrease 39%), and most respondents considered that the biggest implementation challenges are economic (79%) and connectivity issues (64%).

Conclusion

Continuous monitoring of vital signs with wireless sensors is wanted by most anaesthesiologists from university hospitals in Western Europe and in the USA. They believe it may improve patient safety and outcome, but may also be challenging to implement because of cost and connectivity issues.