Worldwide, over 200 million people undergo major surgery every year. Although patients are unlikely to die from anesthesia, the burden of perioperative complications falls more on exacerbations of underlying medical conditions, in part because we are operating on older and sicker patients. While it is unrealistic to believe that perioperative deaths and complications can be completely eliminated, our goal is to minimize this risk as much as possible.
With the explosion of medical knowledge, treatment innovation, and increasing specialization, it is difficult for any physician to keep current with the constant influx of information. While surgeons, anesthesiologists, and some hospitalists may spend a major portion of their clinical time caring for patients in the perioperative period, many other hospitalists, primary care physicians, and their teams of nurse practitioners and physicians assistants may need guidance to address specific issues for their patients before and/or after surgery. The goal of this book is to provide a simple, direct guide to the medical, as opposed to surgical and anesthetic, aspects of perioperative care. It is not intended to be a comprehensive textbook, and references have deliberately been limited to keep the focus on the practical aspects of patient care. This book is intended for use by all members of the perioperative team - hospitalists, general internists and specialists, anesthesiologists, surgeons, advanced practice providers, and residents in-training who are caring for patients before and after surgery.
The genesis of this book comes from a lecture I gave at the annual meeting of the American College of Physicians. Attendees at the session asked many questions - which risk calculator should I use, how long should surgery be delayed after percutaneous coronary intervention (PCI), should aspirin be continued, how long before surgery should I stop a direct-acting oral anticoagulant (DOAC), who needs bridging, should surgery be delayed for a sleep study, and many more. They also repeatedly requested lists of risk factors, tables for medication management, and algorithms for the approach to evaluation and management of various comorbid conditions. This book is a response to these requests. I invited leading experts to distill their vast knowledge and experience into focused, need-to-know information that will be useful to clinicians at the point-of-care. Over two-thirds of the book contributors are senior faculty members with professor or associate professor appointments and serve as section chiefs and perioperative clinic or service directors. The result is this practical decision-making reference which incorporates information from multiple guidelines, clinical trials, and expert opinion. It uses algorithms, tables, and clinical pearls to summarize the key concepts and takeaways.
Our collective goal is to navigate clinicians to the best evidence-based and most cost-effective decisions that will in turn ensure quality, patient-safety, and optimal perioperative outcomes. To this end, the content has been organized into four sections:
key takeaways on perioperative evaluation, testing, anesthesia, and medication management;
prophylaxis to prevent venous thromboembolism, surgical site infection, and endocarditis;
guidance on specific risk factors by organ system to help clinicians evaluate the effect of various comorbidities on surgical outcome and provide perioperative management to minimize risk; and
a brief review of common postoperative medical complications and their treatment.
The field of perioperative medicine continues to evolve, and new information may make previous guidelines and recommendations obsolete. Errors, inaccuracies, and omissions are an inevitable part of any human endeavor, and the reader is urged to use this book in the context of clinical judgment and confirm information, particularly as it relates to medications and dosing. This book was written during a difficult time – the COVID-19 pandemic. We have not witnessed anything like this in the modern era. At the time this book was going to press, over 2,100,000 lives have been lost worldwide (over 425,000 in the U.S. alone), and the numbers continue to increase. It has burdened our health system and changed surgical practice. The coronavirus affects multiple organ systems, and we do not fully know the extent of its after-effects. Scheduling and operating room procedures have changed and continue to evolve, guided by recommendations from various societies, and perioperative testing for COVID-19 varies by hospital and test availability. There are currently no specific guidelines for any changes to perioperative evaluation and testing of patients who have had COVID-19. Due to this lack of information and the evolving nature of the problem, I have chosen not to include a chapter on this topic.
With over 30 years of experience in perioperative medicine and having served as the director of preoperative clinics and medical consultation services at two major academic medical centers (SUNY Downstate Medical Center/Kings County Hospital and University of Miami Miller School of Medicine/Jackson Memorial Hospital), I have dedicated my medical career to the field of perioperative medicine. I hope that this book will provide key information to increase knowledge and instill confidence in clinicians providing perioperative care, and as a result help ensure optimal patient outcomes.
–Steven L. Cohn, MD, MACP, SFHM