The emerging specialty of perioperative medicine: a UK survey of the attitudes and behaviours of anaesthetists

Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group

Objectives. Perioperative myocardial injury (PMI) is increasingly recognised as an important complication of non-cardiac surgery, with often clinically silent presentation, but detrimental prognosis. Active screening for PMI, involving the detection of dynamic and elevated levels of cardiac troponin, has recently been advocated by an increasing number of guidelines; however, active PMI screening has not been reflected in clinical practice. Design. As consensus on a common screening and management pathway is lacking, we synthesise the current evidence to provide suggestions on the selection of patients for screening, organisation of a screening program, and a potential management pathway, building upon a recently published perioperative screening algorithm. Results. Screening should be performed using high-sensitivity assays both preoperatively and postoperatively (postoperative Days 1 and 2) in patients at high-risk of experiencing perioperative complications. Conclusion. This expert opinion piece by an interdisciplinary group of predominantly Norwegian clinicians aims to assist healthcare professionals planning to implement guideline-recommended PMI screening at a local level in order to improve patient outcomes following non-cardiac surgery.

Perioperative care for older people

Increasing numbers of older people are undergoing surgery with benefits including symptom relief and extended longevity. Despite these benefits, older people are more likely than younger patients to experience postoperative complications, which are predominantly medical as opposed to surgical. Comprehensive Geriatric Assessment and optimisation offers a systematic approach to risk assessment and risk modification in the perioperative period. Clinical evidence shows that Comprehensive Geriatric Assessment and optimisation reduces postoperative medical complications and is cost effective in the perioperative setting. These benefits have been observed in patients undergoing elective and emergency surgery. Challenges in the implementation of perioperative Comprehensive Geriatric Assessment and optimisation services are acknowledged. These include the necessary involvement of a wide stakeholder group, limited available geriatric medicine workforce and ensuring fidelity to Comprehensive Geriatric Assessment methodology with adaptation to the local context. Addressing these challenges needs a cross-specialty, interdisciplinary approach underpinned by evidence-based medicine and implementation science with upskilling to facilitate innovative use of the extended workforce. Future delivery of quality patient-centred perioperative care requires proactive engagement with national audit, collaborative guidelines and establishment of networks to share best practice.

FARGO-360: a multi-disciplinary survey of practice and perspectives on provision of care for patients with frailty presenting with gynecological cancers in the UK and Ireland

OBJECTIVES

Frailty has been associated with worse cancer-related outcomes for people with gynecological cancers. However, the lack of clear guidance on how to assess and modify frailty prior to instigating active treatments has the potential to lead to large variations in practice and outcomes. This study aimed to evaluate current practice and perspectives of healthcare practitioners on the provision of care for patients with frailty and a gynecological cancer.

METHODS

Data were collected via a questionnaire-based survey distributed by the Audit and Research in Gynecological Oncology (ARGO) collaborative to healthcare professionals who identified as working with patients with gynecological malignancies in the United Kingdom (UK) or Ireland. Study data were collected using REDCap software hosted at the University of Manchester. Responses were collected over a 16 week period between January and April 2021.

RESULTS

A total of 206 healthcare professionals (30 anesthetists (14.6%), 30 pre-operative nurses (14.6%), 51 surgeons (24.8%), 34 cancer specialist nurses (16.5%), 21 medical/clinical oncologists (10.2%), 25 physiotherapists/occupational therapists (12.1%) and 15 dieticians (7.3%)) completed the survey. The respondents worked at 19 hospital trusts across the UK and Ireland. Frailty scoring was not routinely performed in 63% of care settings, yet the majority of practitioners reported modifying their practice when providing and deciding on care for patients with frailty. Only 16% of organizations surveyed had a dedicated pathway for assessment and management of patients with frailty. A total of 37% of respondents reported access to prehabilitation services, 79% to enhanced recovery, and 27% to community rehabilitation teams.

CONCLUSION

Practitioners from all groups surveyed considered that appropriate training, dedicated pathways for optimization, frailty specific performance indicators and evidence that frailty scoring had an impact on clinical outcomes and patient experience could all help to improve care for frail patients.