The practice of perioperative medicine is one of the most illustrative approaches in medicine of the famous proverb “prevention is better than cure”. Modern “perioperative critical care” describes the medical care of patients at high risk from the time of the first anesthesia consultation, which evaluates risk factors for postoperative complications through the operative period and eventually to full recovery. This pathway may include an intensive care unit (ICU) stay [1]. Contrary to the management of typical patients admitted to medical ICUs, where admissions are largely unplanned, the aim of perioperative medicine is to optimize the management of the surgical patient and to avoid ICU admission if possible. If admission to the ICU is necessary, it is often planned and careful preoperative assessment and intraoperative care can lead to improved outcome. In the practice of perioperative medicine, the surgeon, anesthesiologists, intensivists, and medical consultants all work in concert for the patient’s benefit.

It is estimated that more than 230 million patients per year undergo a surgical procedure, often requiring general anesthesia with endotracheal intubation and controlled mechanical ventilation [2]. Although successful surgery is a necessary condition for satisfactory postoperative outcomes, the benefits of any surgical procedure may be mitigated by the development of postoperative complications. Cardiovascular and respiratory postoperative complications are a leading cause of increased morbidity and mortality [3]. These postoperative complications are often associated with ICU admission, prolonged ICU and hospital stay, and increased health care utilization and costs. Identification of patients with high risk of postoperative complications is a challenge in all surgical specialities [4, 5]. Improved preoperative identification can lead to preoperative, intraoperative, and postoperative optimization of care and result in reduced morbidity and mortality. Evidence supporting best practices in perioperative medicine is expanding, though historically this field has been directed by common practice and experience.

Modern critical care was founded by European anesthesiologists taking the skills learned in the operating room (OR) and applying them to the victims of the polio epidemics of the 1950s [6]. In the last decade, lessons learned in the modern ICU are being taken back to the OR. This cross-pollination between the ICU and the OR benefits patients in both of these areas, reducing morbidity and mortality. The OR and the ICU are similar environments and indeed anesthetic care can be viewed as the short-term, intensive care of a single patient. In both areas continuous monitoring of physiological variables (i.e., hemodynamic and ventilatory function) allows immediate management. Among recent developments are (1) an anesthesia-surgical safety checklist designed to improve team communication [7]; (2) perioperative hemodynamic management in cardiac and noncardiac surgeries [8–11]; (3) ventilatory management by the application of preventive “lung protective ventilation” in abdominal surgery [12, 13]; (4) use of neuromuscular blockade to facilitate mechanical ventilation [14]; and (5) preventive postoperative noninvasive ventilation [15] and (6) anesthesia and pain management using regional anesthesia methods.

ICU management of ARDS patients using lung protective mechanical ventilation including low tidal volume (6 ml/kg of ideal body weight, IBW) with moderate to high PEEP (5–15 cmH2O) with or without recruitment maneuver has led to improved outcomes [16]. This lung protective strategy has been transferred from the ICU to the OR care not only in patients with lung injury but also in patients with healthy lungs [13]. For example, it was recently shown that development of postoperative lung injury was dependent on the intraoperative ventilation strategy and, therefore, should be seen as a complication that is potentially preventable by the use of lung protective mechanical ventilation strategies during surgery [13]. The Intraoperative PROtective VEntilation (IMPROVE) trial was a prospective randomized controlled study [12] in which a multifaceted strategy composed of low VT (6–8 ml/kg IBW) ventilation, moderate levels of PEEP (6–8 cmH2O), and repeated recruitment maneuver aimed at keeping the lung open was compared with nonprotective ventilation in 400 intermediate to high-risk patients undergoing major abdominal surgery. Consistent with previous findings in similar abdominal procedures, an overall postoperative respiratory failure rate of 12 % was found. Compared with nonprotective ventilation, prophylactic lung-protective ventilation was associated with improved postoperative clinical outcomes, as suggested by a 69 % reduction in the patients requiring intubation or noninvasive ventilation for postoperative respiratory failure (relative risk 0.29, 95 % CI 0.14–0.61, P = 0.001).

In the field of perioperative hemodynamic management, Pearse et al. [9] reported the results of a randomized clinical trial exploring the effects of a cardiac output-guided hemodynamic therapy algorithm on the incidence of postoperative complications compared with usual care. OPTIMISE is the largest trial of a perioperative care, cardiac output-guided hemodynamic therapy algorithm. This trial [9] evaluated the clinical effectiveness of a perioperative cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm. A total of 734 high-risk patients, aged 50 years or older, undergoing major gastrointestinal surgery at 17 acute care hospitals in the UK were enrolled. Intervention group patients received intravenous fluid and inotropes according to a cardiac output-guided hemodynamic therapy algorithm. This algorithm was developed for OPTIMISE by an expert group. It was designed to be delivered in the OR and the postanesthetic care unit by both medical and nursing staff, ensuring that critical care admission was not necessary for protocol adherence. The OPTIMISE study was considered as a negative study because it did not reduce a composite outcome of complications and 30-day mortality. However, the authors performed an updated meta-analysis with the inclusion of the OPTIMISE study data and founded that the intervention was associated with a reduction in postoperative complications. One important lesson of both OPTIMISE and IMPROVE is that, while large, randomized controlled trials are never easy to conduct, and they may be easier to complete in the OR than in the ICU as a result of the large numbers of patients at risk. Hopefully the lessons learned in these trials will, in many cases, be applicable in the ICU as well.

Intensive Care Medicine recognizes the importance of the learning relationship between the ICU and the OR. Studies in the perioperative care of critically ill patients have implications not only for this specific population but also for critically ill patients in general. Table 1 reports the main studies published in the field of perioperative care in Intensive Care Medicine since 2013.

Table 1 Main studies published in the field of perioperative care in Intensive Care Medicine since 2013
Full size table

Intensive Care Medicine is opening a call for additional, high-quality papers in perioperative medicine mainly in the fields of cardiac, thoracic, abdominal, and neurologic surgeries to be published in these pages. The submission deadline is 1 October 2015.