To the Editor:
I read with interest the Editorial by Sessler1 on the implications of practice variability. There is considerable interpatient variability in the response to surgical stress, hemodynamic perturbations, anesthetics, fluids, vasopressors, inotropic therapy, extracorporeal-circulation, hemotherapy, ischemia-reperfusion, and others, and also considerable interindividual variation in the incidence and severity of the perioperative complications. Although personalized or precision medicine is gaining implementation generally in disease prevention and treatment, the potential of precision perioperative medicine remains to be fully explored and implemented, such as in hemodynamic optimization, anesthetic regimens, pharmacologic therapy, pain management, mechanical ventilation, and other organ protective strategies.2 The guideline- and protocol-based perioperative approach constitutes the antithesis of precision medicine in perioperative practice. Nevertheless, the proponents of precision perioperative medicine embrace the notion that most of the standardized therapies are designed for an average patient and are insensitive to the wide heterogeneity wherein different subsets of patients respond differently to an allocated treatment. In addition, they cite an assortment of confounding factors ranging from Hawthorne effect to the impact of a heightened vigilance in modulating the outcomes under evaluation while adhering to a protocol. Moreover, the lack of firm evidence on the results of protocolized interventions, such as early goal-directed therapy in sepsis, accentuates the debate furthermore.3 Interestingly, the theory of refuting a free pass to the clinical pathways on evidence to preclude the extrapolation of the same to procedures and populations they were never investigated upon begets the need of a robust context-appropriate evidence.1 As precision medicine evolves across diverse clinical settings, the lack of acknowledgment to this evolving paradigm shift under the preconceived notion that the standardized approach is sacrosanct in perioperative practice is a disfavor to the speciality when the impetus to execute precision medicine in other clinical fields is captivating society.
The author declares no competing interests.