Perioperative medicine: Overview

Abstract
Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients' health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients.

Abstract
Patients presenting for elective surgery in the Bay of Plenty area in New Zealand are increasingly elderly with significant medical comorbidities. For these patients the risk-benefit balance of undergoing surgery can be complex. We recognised the need for a robust shared decision-making pathway within our perioperative medicine service. We describe the setup of a complex decision pathway within our district health board and report on the audit data from our first 49 patients. The complex decision pathway encourages surgeons to identify high-risk patients who will benefit from shared decision-making, manages input from multiple specialists as needed with excellent communication between those specialists, and provides a patient-centred approach to decision-making using a structured communication tool.

Abstract
Purpose of review: Although there are extensive studies of postoperative and postdischarge nausea and vomiting (PONV/PDNV) up to 24 h, few investigate 'delayed PDNV'. With an increasing outpatient surgical population, specific 'delayed PDNV' risk identification and management is necessary for improving outcomes and helping patients after discharge. This review will discuss possible PDNV specific risk factors, successful prevention and management of PDNV following ambulatory anesthesia and the principles and pharmacology of these interventions.

Recent findings: Current research has demonstrated beneficial PDNV management up to 72 h with the long-acting 5-hydroxytryptamine-3 receptor antagonist palonosetron. Neurokinin-1 antagonists have demonstrated superior antiemesis, but not antinausea compared with more traditional and less expensive options. Dexamethasone provides improvements in quality of recovery associated with improved PDNV outcomes.

Summary: Further PDNV specific research is needed, including PDNV predictive models in directing antiemetic interventions. Long-acting antiemetics and postdischarge oral antiemetics are effective in PDNV pharmacologic management. Neurokinin-1 receptor antagonists are effective in reducing the incidence of vomiting, but not nausea. The addition of nonpharmacologic interventions such as acustimulation may reduce PDNV. Multimodal analgesia including nonopioid analgesics and ambulatory continuous peripheral nerve blocks are encouraged to achieve adequate postoperative analgesia and reduce opioid induced PDNV.