For centuries, the chief training for surgeons was in anatomy, almost to the exclusion of other aspects of the art. Only in the twentieth century did the increasing scope of surgery and unremitting efforts to reduce the number of deaths and complications to a minimum lead inevitably to the realization that a sound understanding of physiology is as important as a thorough grounding in anatomic relationships. In the twenty-first century, there is increasing interest in evidence-based preoperative and postoperative care and the application of scientific knowledge and compassion to restore patients to a normal physiologic state and equilibrium as readily as possible after minor or major surgery. The discipline of surgical critical care represents the ultimate merging of the art of surgery with the science of physiology.
The surgeon of the twenty-first century is concerned not only with the proper preoperative preparation of the patient and technical conduct of an operative procedure but also with the preparation of the operating room and an understanding of the problems created by illness in the patient as a whole. Because of the complexities of a patient population with many medical comorbid conditions, preoperative preparation may require a team approach. It is important for surgeons to understand potential complications and their recognition and prevention. In the ideal situation, preoperative preparation of the patient begins in the ambulatory setting prior to admission. The surgeon assesses the patient and determines the need for surgery for the specific diagnosis.
The surgeon advises the patient on the benefits and risks of the procedure in general as well as those that are specific to the operation being recommended. Informed consent is more than a signature on a piece of paper: it is a process of discussion and a dialogue between the surgeon and patient in which the patient has the opportunity to ask questions. The surgeon should also include a discussion of the possible use of blood products and, if deemed appropriate, advise the patient about autologous blood donation.
In assessing the patient’s condition, it is important to identify major acute and chronic health issues. Chronic illnesses of the heart, lungs, kidneys, and central nervous system all need to be assessed, and all have the potential to put the patient at great risk even if the operation is performed perfectly. Heart disease, in the form of heart failure and myocardial ischemia, is important to identify preoperatively. A history of a myocardial infarction, angina, cardiac rhythm abnormality, use of an antiplatelet agent or other anticoagulant, shortness of breath on exertion, valvular heart disease, or a previous coronary revascularization may suggest the need for further cardiac evaluation. Many patients with these historical findings will already be seeing a cardiologist. Seeking input from the cardiologist in such patients may allow for a better perioperative risk assessment.
Pulmonary diseases, including chronic obstructive pulmonary disease and ...