Perioperative medicine: Overview

Abstract
Perioperative care transitions or handoffs represent a high-risk period frequently compromised by communication failures and the loss of essential patient information. Handoffs play a pivotal role in mitigating these risks. A comprehensive assessment of implementation and clinical outcomes is essential to identify protocols that enhance patient safety, improve care quality, and support reproducibility. This study identifies and synthesizes existing evidence on handoff strategies, evaluating their impact on both implementation success and clinical outcomes. A systematic search of PubMed, EMBASE, and CINAHL databases was conducted to identify observational and descriptive studies addressing preoperative, intraoperative, and postoperative handoffs. Eligible studies were published in peer-reviewed, English-language journals. The selection process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality was evaluated using the Quality Scoring System. Eleven studies evaluating the impact of handoff interventions on both implementation and clinical outcomes were included. Key implementation outcomes, including sustainability and acceptability, were commonly assessed through staff satisfaction surveys. Clinical outcomes included length of stay, duration of mechanical ventilation, and pain scores. All studies incorporated a structured preimplementation planning phase and reported significant improvements in at least 1 implementation outcome, with acceptability being the most consistently improved measure. Each study demonstrated meaningful improvements in at least 1 implementation outcome, while 7 of 11 studies reported significant enhancements in clinical outcomes. The consistent success of various methodologies-whether through expert consultation, frontline involvement, or quality improvement strategies-indicates that a tailored, site-specific approach may be more critical to success than the specific intervention strategy used.

Abstract
Ketamine is an N-methyl-d-aspartate receptor antagonist approved for use in anaesthesia, with analgesic properties. Despite publication of numerous trials and expert guidelines on its use for pain management, administration of ketamine as part of multimodal perioperative analgesia remains 'off-label'. We conducted an online, prospective survey of ANZCA Fellows, exploring current prescribing practices of intravenous ketamine for perioperative analgesia. We surveyed 2000 Fellows and received 806 responses. The factors mostly likely to influence their administration of perioperative ketamine included pre-existing chronic pain, and heavy or multiple opioid use by patients preoperatively. Amongst respondents, less senior anaesthetists and those working in public hospitals were more likely to administer intraoperative ketamine. The surgical procedures most likely to result in ketamine administration intraoperatively were open pelvic/abdominal, thoracic and major spinal surgery, where ketamine administration was likely practice for the majority of respondents, with typical loading doses that ranged widely. The commonest choices of intraoperative loading dose were between 0.2 mg kg-1 and 0.6 mg kg-1. The commonest choice of intraoperative and postoperative infusion rate was in the range of 0.1-0.2 mg kg-1 h-1. Postoperative ketamine infusion was most commonly prescribed as third-line or rescue analgesia. The majority of respondents thought it either 'likely' or 'very likely' ketamine would reduce postoperative chronic pain after thoracic surgery, but not in other surgical categories. Our findings suggest that off-label perioperative administration of ketamine at analgesic dose ranges is routine or common practice in major surgery for a majority of specialist anaesthetists in Australia and New Zealand.