The Case for Perioperative Care

Trends in perioperative care must mirror those of the wider NHS. Our reliance on care in hospital is unsustainable, inefficient and frequently fails to meet patients’ hopes and expectations.

Communication between primary and secondary care

As we work to ensure patients recover quickly after surgery, the number of days they spend in hospital will steadily decrease. This in turns places demands on the system to communicate more effectively between primary and secondary care, an interface that most agree does not function as well as it should.

As we offer surgery to more older patients, and to those with long-term disease than we ever have before, it is vital that we consider the impact of major surgery in the context of patients’ long-term health. Primary care services need support and excellent communication from a team of experts who understand the impact major surgery has on their individual patients, advising on specific medical problems that have arisen after surgery, coordinating onward referrals if specialist input is needed, and ensuring the GP is fully informed of their patient’s progress in the weeks and months following surgery.

Kidney injury after major surgery

Acute kidney injury (AKI) is a serious clinical problem which has a significant impact on both short and long-term patient outcomes after surgery. As we offer major surgery to more and more patients with risk factors for kidney disease, more patients experience damage to their kidneys as a result of the systemic inflammatory response to surgery. The rising prevalence of risk factors such as older age, chronic kidney disease, diabetes and hypertension indicates that surgery will have a growing impact on the long-term health of patients.

We now recognise that even mild episodes of AKI trigger step-wise deteriorations in renal function, eventually leading to chronic kidney disease. This in turn results in a dramatic increase in cardiovascular risk, reduced survival, and of course increased NHS resource use. For technical reasons, it is very difficult to predict a patient’s risk of kidney disease at the time of hospital discharge. This partly relates to the reliability of routine kidney blood-tests in patients who have major surgery. Local and national collaborations between clinical teams in nephrology, perioperative medicine, intensive care and biochemistry have led to more effective screening systems for AKI and pathways for follow-up.

A major NHS trust in London has taken this a step further by creating an AKI follow up clinic. This is a collaborative venture between several hospital departments, offering patients at risk an expert assessment and screening for the presence or worsening of chronic kidney disease in the months following surgery. This creates key opportunities to improve long-term health by reducing the progression of kidney disease and its cardiovascular consequences. We now realise that many acute illnesses have an important impact on long-term disease. In time, we expect to see routine screening of patients for acute myocardial, kidney and other organ injuries triggered by major surgery. This will allow us to minimise the long-term effects of short-term harm.