Miller’s Anesthesia, 2-Volume Set 9th Edition

Book Preface

KEY POINTS

□ The scope of modern anesthesia practice includes preoperative evaluation and preparation; intraprocedural care; postoperative care including acute pain management; critical care, resus-citation, and retrieval; chronic pain management; and palliative care. Anesthesia plays a key role in health service delivery and has a significant impact on population health and the burden of disease.
□ Global and national forces for change include changing patient populations, locations of care, workforce, costs, quality and safety initiatives, research capability, and the availability of data. These forces have major implications for the delivery of care, evaluation and organization of the anesthesia practice, and education and training of physician anesthesiologists.
□ The volume of patients presenting for perioperative and obstetric care continues to grow. Increasingly more patients at extremes of age are requiring anesthesia services. Many of the pa-tients are elderly and have significant comorbidities, including obesity and opioid use disorder. This has important implications for delivery of care and health system issues.
□ Anesthesia care is shifting from the traditional surgical suite to other procedural areas, ambula-tory sites, office-based facilities, and home environments. As anesthesia care expands, anesthe-siologists must focus on maintaining the safety and quality of care in these diverse settings.
□ Global and regional deficits in the availability of high-quality anesthesia care must be managed by improving the supply of both physician and non-physician anesthesia providers, by better use of technology, and by limiting demand through health promotion and disease prevention strategies.
□ Internationally, the costs of health care continue to escalate; unfortunately the increased spend-ing has not consistently translated into improved health outcomes. Health policy initiatives including alternative approaches to healthcare financing and payment systems are increasingly being implemented to encourage efficient and effective team-based anesthesia care.
□ Anesthesiology was among the first medical specialties to focus on improving the safety of patient care. As anesthesia has become safer, attention has intensified on quality improvement, a process designed to improve patient experience and outcomes through systematic change and evaluation.
□ Basic, translational, clinical, and implementation research is vital to continuous improvement in outcomes. Opportunities to optimize care are supported by the availability of large datasets generated using electronic health records as well as novel analytic techniques. These changes create new opportunities for anesthesiologists to collaborate with basic and translational scien-tists to better understand current practices and define better ways to deliver care. As always the provision of resources to support these research initiatives is a challenge.
□ The scope of modern anesthetic practice is continually expanding and changing. The changes occurring in health care in the 21st century create opportunities for anesthesiologists to assume a broader role in clinical practice and health policy, providing exciting opportunities for the next generation of physicians in our specialty.

Introduction

Anesthesia is fundamental to the overall practice of medi-cine worldwide. Hundreds of millions of patients receive anesthesia care each year in association with a wide range of medical, surgical, and obstetric procedures. In addition to direct delivery of anesthesia to patients undergoing a surgical procedure, the scope of anesthesia practice extends beyond the traditional surgical suite to include preoperative evaluation and management of underlying clinical condi-tions (see Chapter 31); postoperative care including acute pain management (see Chapter 81); critical care, resusci-tation, and retrieval (see Chapter 67); chronic pain man-agement (see Chapter 51); and palliative care (see Chapter 52). Anesthesia therefore plays an essential role in health service delivery (see Chapter 3) and has a significant impact on global health and the burden of disease (see Chapter 2). The purpose of Miller’s Anesthesia is to cover the full scope of contemporary anesthesia practice, from fundamental prin-ciples to advanced subspecialty procedures.
Every edition of this textbook begins with comments about the novel diagnostic and therapeutic procedures that have been developed since the last edition and the increas-ing complexity of patients presenting for anesthesia and perioperative care, especially those at the extremes of life. Each edition also provides descriptions about advances in anesthesiology that have facilitated patient care, includ-ing improved understanding of the processes that under-lie disease and injury, the increasing sophistication of the pharmacologic and technical resources available, and the improvements in systems designed to promote safety and quality in health care. The 9th edition is no exception: in the last decade the advances in anesthesia and surgical care, especially for patients receiving complex clinical care, have been truly remarkable.
None of these advances would have been possible with-out the commitment of anesthesiologists to leadership, teaching, and research. Evidence of their contributions can be found in every chapter of the book, extending from improved understanding of the mechanisms of anesthesia and the processes that regulate organ function and drive organ failure; through new technologies, drugs, and sys-tems of care and education; to improved understanding and acknowledgement of the critical role patients and their families play in decision making about healthcare and end-of-life issues.
The future of anesthesiology is filled with opportu-nities and challenges. Global and national forces will drive evidence-based, cost-effective perioperative and obstetric care by multiprofessional and multidisciplinary teams. These changes will be supported by integrated electronic medical records and large databases and registries of healthcare outputs and outcomes. Increas-ingly, anesthesia care has expanded outside the operat-ing room, into preoperative clinics, intervention suites, extended postanesthesia care units, and even into patients’ homes. As is true for other medical special-ties, anesthesiologists have adopted telehealth strategies to extend the care provided to patients and colleagues beyond face-to-face encounters. Technological advances have and will continue to facilitate less invasive inter-ventions and improved anesthesia delivery and moni-toring systems. As a result, seriously ill and injured patients and those at the extremes of age, often with associated comorbidities now have access to care previ-ously not available to them. Care is also becoming more personalized, in large part because of the availability of genetic testing and an improved understanding of the unique needs of each patient based on disease severity and his or her probability of responding to specific treat-ment modalities. Partially as a result of these improve-ments in care, the costs of caring for an aging population with progressively sophisticated therapies challenge all nations. These forces will likely have a major effect on the scope of perioperative care in general and anesthesia services in particular. Therefore, anesthesiologists must be involved in health policy decisions about the distribu-tion of resources and the need for high-quality evidence to guide practice. In the rest of this chapter we will deal with some of these forces in detail.