Importing practices from Europe to improve the perioperative process

To improve the perioperative trajectory of patients, particularly for those with multiple comorbidities and increased risk for postoperative complications, the Sunday session “ESA Panel: Perioperative Medicine: Role of Anesthesiologists in Europe” spanned the globe. It showcased recent advances and programs anesthesiologists from around the world are implementing to optimize outcomes for surgical patients during the preoperative, intraoperative and postoperative phases. What might be worth importing into your own practice?

Optimizing the preoperative period
Bonn, Germany

“Anesthesia-related mortality is extremely rare as opposed to surgical or perioperative mortality,” said Andreas Hoeft, M.D., Ph.D., Department of Anesthesiology at the University Hospital Bonn.

Andreas Hoeft, M.D., Ph.D., discusses optimizing the preoperative period.

The real challenge during the preoperative period is finding the patient at risk for common postoperative complications such as PONV, bleeding, infection, pulmonary and cardiac complications, stroke and coma.

Dr. Hoeft noted that patients are evaluated the day before surgery, so one can’t change a lot.

Enter the “One-Stop Shopping” preoperative clinic the University Hospital Bonn developed to reduce postoperative complications. During the clinic, which operates from 8 a.m. to 5 p.m. daily, Dr. Hoeft and his team see patients immediately after surgery has been indicated. Anesthesiologists do the risk classification themselves and try to avoid referring patients to specialists, including hematologists. Also, the anesthesiologists perform many pre-surgical diagnostic tests, such as cardiac risk screening, lab work, ECG, TTE and pulmonary function testing. They use the Preoperative Score to Predict Postoperative Mortality (POSPOM) to predict postoperative mortality. POSPOM is easy, and it accounts for risk factors due to surgery, he said.

Optimizing intraoperative surgical management
Nancy, France

At the University Hospital of Nancy, Enhanced Recovery After Surgery (ERAS) protocols are used to reduce preoperative, intraoperative and postoperative complications, including morbidity and mortality.

“ERAS also reduces costs,” said panelist Thomas Fuchs-Buder, M.D., School of Medicine Nancy/Frankreich. Dr. Fuchs-Buder focused on the risks and benefits of neuromuscular-blocking agents, which should still be part of the general anesthetic regimen.

Improving postoperative care

Roughly 1,700 patients die every year after surgery in the Netherlands due to postoperative infections, including pneumonia, deep-wound infection, organ-space infection and septic shock, as well as acute kidney injury and myocardial infarction.

“The hospital mortality rate is mainly driven by postoperative morbidity and mortality in surgical patients,” said Wolfgang Buhre, M.D., Ph.D., University Medical Center Maastri, Maastricht, Netherlands. “The process of perioperative care has been largely unchanged in 50 years in terms of mortality.”

To improve postoperative outcomes, the University Medical Center Maastri established a small, three to six bed PACU for patients with surgical complications. Dr. Buhre presented research supporting his conclusion that a PACU with a step-down unit is safer for postsurgical patients with a normal predicted complication spectrum.

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