Perioperative medicine spans the entire surgical care continuum, improving patient outcomes while reducing morbidity and mortality. Anesthesiology is uniquely positioned to influence the continued development of perioperative medicine. Recognizing this opportunity, the American Society of Anesthesiologists (Schaumburg, Illinois) established the Center for Perioperative Medicine as an organizational framework to actively implement perioperative medicine. Whereas earlier efforts focused on why anesthesiology must evolve, the Center emphasizes how the specialty is advancing through rigorous, inclusive collaboration. Building on previous initiatives, the Center for Perioperative Medicine is a multidisciplinary partnership including anesthesiologists, surgeons, hospitalists, and other specialists, and incorporates both national and global perspectives. This article describes how perioperative medicine is characterized across clinical, educational, research, and leadership domains; summarizes key themes from discussions at the 2024 and 2025 Stakeholder Summits; highlights areas of convergence and variation across global viewpoints; and situates these perspectives within the evolving landscape of perioperative medicine practice worldwide today collectively.

Agreement of minimally invasive pulse wave analysis with pulmonary artery and transpulmonary thermodilution cardiac output measurements in perioperative and intensive care medicine: a systematic review and meta-analysis.

Practice Changing Updates in Perioperative Medicine Literature 2025. A Systematic Review.

Perioperative risk assessment still relies largely on models that estimate outcomes from variables measured at a single time point. These tools remain useful for cohort stratification, communication of baseline risk, and perioperative planning, but they often underrepresent the temporal dynamics that shape individual postoperative trajectories. That mismatch may reflect more than ordinary clinical variability. At least in part, it may point to a limitation in how perioperative risk itself is conceptualized. This paper offers a conceptual analysis drawing on physiology, critical care medicine, and dynamic systems theory. Its central claim is simple: perioperative risk may be better understood as a trajectory through physiological state space than as a fixed probability assigned before surgery. Surgical interventions can then be viewed as structured perturbations imposed on already reconfigured biological systems, with responses shaped by prior states, adaptive capacity, and physiological resilience. From this perspective, postoperative complications are not merely isolated adverse events. They may instead mark transitions between physiological regimes. Processes such as sterile inflammation, microcirculatory dysfunction, organ crosstalk, and loss of physiological complexity may help explain why postoperative trajectories diverge so sharply. Cardiac surgery provides a particularly clear setting in which these dynamics become visible, although the broader argument likely extends beyond it. The analysis has practical implications for clinical reasoning in high-risk settings. Rather than displacing static prediction, it highlights dimensions of perioperative risk, such as state dependence, irreversibility, and loss of resilience, that static models represent only incompletely. That shift does not solve the problem of perioperative uncertainty. It does, however, describe it more faithfully.

Anaesthesiologists, intensive care, and perioperative physicians work within multidisciplinary teams in high-risk environments where adverse events may threaten patient safety and are often avoidable. They face converging challenges, including multimorbidity and increasing clinical complexity, workforce shortages and burnout, technological evolution, and rising expectations for safety, equity, and sustainability. In this expert-driven evidence-based consensus review, we aim to demonstrate that simulation-based education and training (SBET) is uniquely positioned to address these challenges. We review how SBET adds value across the professional lifespan, from initial training to high-stakes examinations and continuing professional development. We further examine how SBET enhances team performance, identifies latent system threats, and supports organisational redesign through translational simulation. We examine how SBET can prepare for the future by fostering digital and ecological competencies. We explore key barriers to implementation, as despite SBET's value, its adoption across anaesthesiology, intensive care, and perioperative medicine remains fragmented, with limited interprofessional integration and few national frameworks. Above all, we advocate for coordinated value-based adoption of SBET across education and healthcare systems, recognising it not merely as an educational method but as a strategic infrastructure for high-reliability healthcare systems. Sustained investment, protected time, faculty development, and interprofessional integration are essential to realise its full potential. Aligned strategies to close the gap between evidence and practice are crucial. Without decisive and collective action, education and healthcare risk losing one of the most effective tools for improving patient safety, enhancing individual and system resilience, and maintaining the highest standards of excellence across our specialty and interprofessional practice.

Portal vein Doppler ultrasound has emerged as a promising tool for haemodynamic assessment in critical care and peri-operative medicine. This educational narrative review integrates fundamental cardiovascular physiology concepts, including Guyton's venous return model and the hepatic arterial buffer response, with practical clinical applications of portal vein assessment at the bedside. The portal vein's position at the intersection of splanchnic circulation and hepatic perfusion makes it relevant in evaluating venous haemodynamics. We describe the technical aspects of portal vein Doppler measurement, including probe positioning, anatomical landmarks and measurement standardisation. Portal vein Doppler ultrasound characteristics (diameters, flows, pulsatility) are primarily determined by backward right ventricular pressure wave transmission through the hepatic venous system, modulated by right ventricular function and systemic venous compliance. We present portal flow patterns across different haemodynamic conditions and discuss their clinical interpretation in three settings: cardiac surgery, general intensive care and peri-operative medicine. The relationship between portal vein Doppler and other venous congestion assessment tools, including the venous excess ultrasound score, is discussed. While portal vein pulsatility provides valuable information to guide clinical strategies regarding volume status and venous congestion, the current evidence is predominantly observational. Prospective multicentre validation studies are needed before portal vein Doppler-guided algorithms can be recommended for routine clinical use.

The Standardised Endpoints in Perioperative Medicine Initiative recommends the 12-item WHO Disability Assessment Schedule (WHODAS) 2.0 to measure postoperative functional impairment. However, evidence describing long-term postoperative disability, particularly at 1 year, remains limited. This study aimed to: describe disability up to 1 year after non-cardiac, non-neurosurgical procedures; examine associations between periprocedural risk, postoperative complications and new-onset disability; and evaluate associations between social support, delirium, and frailty and postoperative disability. We conducted a prospective, multicentre cohort study. The primary endpoint was new onset clinically significant disability (an increase in WHODAS 2.0 score ≥ 5% points from baseline to a final score ≥ 35%) or death at 1 year. Independent variables included: periprocedural risk; postoperative complications; frailty; and patient-reported social support. In total, 1081 patients were included: 726 (67%) male, median (IQR) [range] age 67 (60-75 [50-101]) y. New onset clinically significant disability was present in 139/1081 (12.9%) patients at 1 year and in 238/1066 (22.3%) patients at 30 days. Periprocedural risk (adjusted odds ratio (aOR) 1.05, 95%CI 1.03-1.07, per percent in American College of Surgeons National Surgical Quality Improvement Program score) and postoperative complications of all grades were associated with 1-year new onset clinically significant disability. New onset (1 year) clinically significant disability was not associated with social support: OR 0.87, 95%CI 0.54-1.39 for moderate; and OR 0.76, 95%CI 0.47-1.24 for strong social support. Frailty was strongly associated with new onset clinically significant disability after 1 year (aOR 3.97, 95%CI 2.54-6.21). One year after non-cardiac surgery, 13% of surviving patients experienced anew onset clinically significant disability. Postoperative complications, even those of low severity, were associated with new onset postoperative disability.

Genomic screening is an essential, but potentially time-consuming procedure, especially in neoadjuvant settings. We evaluated the preoperative screening of the BRAF V600E mutation for recruitment to a clinical trial among patients with resectable colorectal oligometastases (CRM). In April 2022, an investigator-initiated trial was launched to investigate the efficacy and safety of perioperative use of the BEACON triplet regimen for BRAF V600E mutant resectable CRM. BRAF screening was retrospectively conducted in patients with resected colorectal liver metastases in 2019 for planning the trial and prospectively conducted in preoperative patients with resectable CRM from January 2022 to June 2025 for patient recruitment to the trial. BRAF V600E mutation was detected in 12 (3.2%) of 379 postoperative patients retrospectively and in 36 (1.7%) of 2140 preoperative patients prospectively, with 1840 patients (86.0%) carrying the wild-type and 264 patients (12.3%) classified as untested. The detection rate of the BRAF V600E mutation was significantly lower when the screening was performed prospectively in preoperative patients (P < 0.001). The untested rates varied across metastatic organs, with 10.3% in the liver, 18.1% in the lungs, 12.0% in the lymph nodes, 16.7% in the peritoneum, and 7.8% in other organs. The untested rates decreased consistently across semiannual comparisons: 28.5% in the first evaluation, followed by 15.0%, 12.0%, 8.4%, 9.1%, 7.3%, and 7.1% (P < 0.01 when compared with the first period). Raising physician awareness, as reflected by the untested rate, is a crucial factor in conducting clinical trials to implement perioperative cancer genomic medicine.

Parents and caregivers play a critical role in the care of their child peri-operatively. Our team undertook previous research with parents/carers, which identified Australian parents' top 10 research priorities for paediatric anaesthesia and peri-operative medicine. While this was an important exercise, it focused on parent-reported experiences rather than the priorities of the children themselves; however, the experiences and concerns of parents/carers may not always reflect those of their child. It has been shown previously how integral it is to listen to each child's own voice to improve and create a more adaptive and safer peri-operative environment. This research prioritisation study was developed for children and used a modified James Lind Alliance method that involved surveys, a youth community conversation and a final consensus-based prioritisation meeting, all of which were conducted online. Participants were children and young people aged 6-18 y living in Australia. In total, we engaged 356 children and young people. We identified the top research priorities for Australian children and young people for paediatric anaesthesia and peri-operative medicine through a rigorous process of consensus. The final top 10 priorities were agreed by consensus after a multi-step process and included how to: reduce anxiety (including needle phobia); make anaesthesia safer; avoid postoperative complications (e.g. pain, sickness, agitation); and improve communication between children and doctors. The resulting priorities differed from those conducted in Australia for adult peri-operative medicine and from the parent/carer and clinician priorities identified previously for paediatric anaesthesia care. These research priorities can help guide future paediatric anaesthesia and peri-operative medicine research directions.

Climate change is already disrupting healthcare delivery with perioperative medicine, particularly pediatric anesthesia, being both highly exposed to climate-related shocks and a major contributor to healthcare-related greenhouse gas emissions (GHG). This review examines how mitigation and resilience strategies can be integrated into pediatric anesthetic practice. Sustainability measures in pediatric anesthesia are currently actionable and clinically beneficial. Reducing the use of volatile anesthetics through low-flow techniques, avoiding N2O or desflurane, and increasing the adoption of total intravenous anesthesia lead to substantial reductions in GHG and are associated with better clinical outcomes. EEG-guided anesthesia further reduces unnecessary exposure to anesthetics and improves recovery profiles. The use of reusable warming drapes or the implementation of 10R policies can markedly reduce our footprint without compromising the quality of care. Sustainable pediatric anesthesia is achievable today and aligns with improved clinical outcomes. Translating evidence into routine practice remains a challenge. Patient safety primacy or entrenched clinical habits continue to slow the adoption of sustainable practices, even when supported by robust data. Success will depend on reframing sustainability as a core component of quality and safety, embedding it within guidelines and audit structures, and supporting clinicians, thereby enabling durable behavior change.

Due to demographic change, the number of geriatric patients is increasing in the surgical field. This poses a major challenge in perioperative medicine. In order to improve patient safety, frailty has become a key element for risk assessment in the perioperative setting. This review aims to summarize the current state of anesthesia in frail patients. Frailty is an independent risk factor for intraoperative and postoperative complications, mortality, and length of hospital stay. The Clinical Frailty Scale has been shown to be a feasible, easy-to-use tool for frailty assessment. Frailty is likely to be modified through targeted preoperative optimization (prehabilitation). This should be carried out on a multidisciplinary basis. During preoperative risk assessment, special attention should be paid to polypharmacy and multimorbidity. Particularly in geriatric patients, maintaining intra- and postoperative homeostasis is essential. Adequate pain management and prevention of perioperative delirium are of utmost importance. Frailty is a common and highly relevant clinical risk factor in the perioperative setting. In future, efforts should focus on identifying methods to improve the status of preoperative frail patients.

Peri-operative medicine is a critical component of contemporary healthcare delivery. Despite significant advancements, peri-operative complications remain a relevant concern. Obtaining reliable risk estimates, identifying potential causes, and studying new interventions, revised policies or implementation of best practices to prevent complications, requires data from a large number of participants. Electronic Patient Record systems offer the opportunity to unlock these data, but the limited standardisation of databases and sharing frameworks available across Europe limit the effective use of the available data. We propose creating a European peri-operative shared data registry with continuous data collection, integrating clinical, bedside monitoring and outcome data in a collaborative network. Such network would facilitate outcomes research, could serve as a platform to optimise clinical practices by fostering quality improvement through benchmarking of care delivered by departments or individual physicians, and could be used to evaluate policy changes. This ESAIC initiative aligns well with the development of the European Health Data Space. This article provides examples of contemporary clinical research and practice evaluation questions to illustrate the need for a European collaborative data-sharing network, highlights inspiring examples of existing data-sharing initiatives and describes a road map to establish such network.

Consumer-driven co-design of an advanced practice nursing role for older adults undergoing surgery.

Diversity Science in Perioperative Medicine: Key Concepts and Guidance for Publishing and Reviewing.

Personalised care and subgroup evidence: anticipated effects, exploratory models, and evidentiary standards.

Improving Clinical Frailty Scale accuracy on a vascular ward for a perioperative medicine for older people undergoing surgery pilot.

BackgroundReliably distinguishing infection from sterile inflammation is a major clinical challenge. Uncertainty can lead to unnecessary courses of antibiotics, fueling antimicrobial resistance and adverse effects. Calprotectin, a biomarker released by activated immune cells, may inform decision-making.MethodsThis prospective, observational, single-centre study recruited patients with suspected infection who provided blood samples on enrolment from the Emergency Department (ED) and Intensive Care Unit (ICU) of a central London university hospital. A separate longitudinal study with five days’ blood sampling was performed in patients undergoing elective major non-cardiac surgery, in whom infection was adjudicated according to the Standardised Endpoints in Perioperative Medicine (StEP) initiative. Diagnostic adjudication was performed blinded to calprotectin. The primary outcome was the ability of calprotectin to diagnose infection. Secondary outcomes included a comparison to C-reactive protein (CRP).Results427 patients were included, of whom 186 (44%) were female. Of 245 ED patients, 71 (29%) had active cancer and 56 (23%) were on immunosuppressants. The median calprotectin level in the no-infection group was 1.97 mg/L (IQR 1.02–3.39), compared to 2.76 (IQR 1.65–5.08) mg/L in low-probability infection, 2.63 mg/L (IQR 1.83–5.23) in high-probability infection, and 2.64 mg/L (IQR 1.49–4.45) in patients with confirmed infection. Ordinal regression analysis found no meaningful association between calprotectin levels and infection, or bacterial infection. Logistic regression showed an unadjusted AUC of 0.53 (95%-CI 0.45–0.62) for calprotectin and a binary outcome of infection compared to an AUC of 0.63 (95%-CI 0.55–0.71) for CRP. Similar results were seen in a sensitivity analysis excluding patients with cancer or immunosuppression. In 98 ICU patients, neither calprotectin nor CRP showed a meaningful association with an adjudicated diagnosis of infection or ICU death. In the peri-operative cohort, calprotectin levels remained elevated over 5 days, but with no difference between patients developing or not developing infection.ConclusionCalprotectin showed only limited ability to differentiate infection from inflammation across ED, ICU, and elective surgery patients. Excluding patients with cancer or immunosuppression did not alter the overall findings.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40635-026-00923-3.

Superficial parasternal intercostal plane block with ropivacaine versus placebo for opioid exposure after cardiac surgery (EPOCH CardioLink-10): a multicentre, double-blind, randomised trial

Advancing Health Equity Research in Perioperative Medicine.

The neurological influence of the widely used inhalational anesthetic sevoflurane presents a context-dependent paradox, manifesting as either neurotoxicity or neuroprotection. The NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome, a central mediator of neuroinflammation and pyroptosis, has emerged as a key molecular underlying these divergent outcomes. This review integrates current evidence on the role of the NLRP3 inflammasome in the bidirectional effects of sevoflurane, offering a mechanistic framework to guide neuroprotective strategies in perioperative medicine. Analysis reveals that in vulnerable states such as Alzheimer's disease and postoperative cognitive dysfunction, sevoflurane-induced activation of the NLRP3 inflammasome contributes to neurotoxicity and cognitive decline. This process engages multiple CNS cell types, with microglia serving as the primary source of inflammasome-dependent pyroptosis, astrocytes amplifying the inflammatory response, and neurons representing the ultimate targets of injury. Key upstream triggers include mitochondrial dysfunction, oxidative stress, impaired autophagy, and disruption of ion homeostasis, with blood-brain barrier breakdown and gut microbiota dysbiosis further reinforcing this pathological cascade. Conversely, under specific pathological conditions, including cerebral ischemia and neuropathic pain, sevoflurane can suppress NLRP3 activation, indicating that its ultimate effect is determined by the host cellular stress landscape and the net balance of concurrently engaged signaling pathways. Pharmacological inhibition of the NLRP3 pathway demonstrates robust neuroprotective efficacy in preclinical models. Nevertheless, a substantial translational gap remains due to challenges in drug specificity, blood-brain barrier penetration, and safety concerns associated with prolonged suppression of innate immunity. In conclusion, the NLRP3 inflammasome serves as a pivotal integrator of sevoflurane context-dependent neurological effects. The current research landscape remains fragmented and predominantly correlative, relying on heterogeneous experimental models. Future studies should shift from descriptive phenomenology toward identifying decisive molecular switches that govern NLRP3 activation or suppression following sevoflurane exposure. Such insights are indispensable for developing context-dependent combinatorial therapeutic strategies and for bridging the translational gap through validated biomarkers and clinically relevant models, thereby advancing the objective of precision anesthesiology.