An exciting new era in anesthesiology

Social engineering, business efficiency principles, and technological advancement all contribute to improving the quality and value of anesthesia care.

Technology is indispensable to the practice of anesthesia. Anesthesia was initially made possible, then became more secure, and is now more scalable and effective, thanks in part to developments in monitoring and delivery technology. Consumer technology and telemedicine have exploded onto the outpatient medical scene, and perioperative management is no exception. Teleconference preoperative evaluations have been conducted, and there is a wealth of consumer-generated health data available. However, concerns about privacy, data ownership/security, and validity still exist. Regulators have acknowledged the enormous potential found in the application of consumer technology to medical practice.

Clinical-decision support systems are widespread, and monitoring has become less intrusive inside the operating room. Even though these technologies are vulnerable to the garbage-in, garbage-out problem that plagues artificial intelligence (AI), they will get better as network latency goes down. A comprehensive system for the delivery of closed-loop anesthesia is being tested, which raises concerns about automation in the field of anesthesia.

Consumer health businesses will look for uses for their technology in the future, and markets for healthcare that are less tightly regulated will adopt new technology sooner. The provider of anesthesia is increasingly viewed as a part of the patient-care apparatus, so innovations in this field will need to take human factors into consideration.

Salient technology advances
Modern-day anesthesiology is heavily dependent on technology. Anesthetics have become safer and more efficient due to advances in monitoring and delivery since its introduction in 1846. Some of the recent advances in anesthesiology include:

Advances in non-invasive monitoring. With innovation, monitoring has become less invasive. Cardiac-output monitoring, which first required invasive catheters and the use of thermodilution, has been commercially available via analysis of the peripheral arterial pressure waveform for some years. More recently, truly non-invasive assessment of cardiac output became available by using a blood pressure cuff applied to the finger, such as in the CNAP system or the ClearSight system. Cerebral pulse oximetry has similarly unlocked valuable data with the potential for meaningful clinical impact, including brain autoregulation assessment. New monitoring technology is not the only means of advanced non-invasive data gathering. Clinical information sometimes can be derived from established monitors via further in-depth analysis of the data already provided. As with the measurement of cardiac output via pulse-wave contour analysis of the radial arterial line or the treasure trove of data that can be extracted from the electrocardiogram (merely a plot of voltage varying with time), data derived from existing monitors of pulse oximetry, continuous end-tidal CO2, arterial pressure hold potentially valuable information to derive hemodynamic variables. The analgesia nociception index, surgical pleth index, and nociception level index (NoL) are examples.

Closed-loop TIVA (total intravenous anesthesia). Anesthesiologists and pharmacologists have been working on the pharmacokinetics of automated administration of intravenous anesthetics for years. Utilizing EEG monitoring data (BIS monitor levels) to titrate the depth of anesthesia shows promise. For a typical anesthetic, TIVA requires more work than vapor anesthesia with sevoflurane, because the anesthesiologist must load a syringe with propofol and/or remifentanil, attach an infusion line, load the syringe into the infusion pump, and program the pump to the correct infusion rate. In contrast, a sevoflurane vaporizer is already loaded with liquid anesthetic, is easy to use, and merely requires the pushing of one button and turning of one dial. Closed-loop TIVA is not in clinical use at this time, but you can expect that the future anesthesia recipes will include automated sedation/anesthetic depth titration via computer administration. The TIVA research of the past ten years has paved the way for this advance.

The ultrasound-guided regional anesthesia boom. In the past ten years the number of ultrasound-guided regional anesthesia blocks has mushroomed. Regional nerve blocks decrease the need for postoperative narcotics. Evidence shows that ultrasound guidance reduces the incidence of vascular injury, local anesthetic systemic toxicity, pneumothorax, and phrenic nerve block for interscalene blocks, but there has not been consistent evidence that ultrasound guidance is associated with a reduced incidence of nerve injury. The ultrasound-guided regional anesthesia boom has led to tens of thousands of additional nerve blocks, and an unfortunate fact is that a small but non-zero number of these patients develop permanent nerve damage in their arms or legs after their blocks. Regional anesthesia specialists who publish in the medical literature have made little effort to quantify or report these complications. Prospective data on nerve injuries is needed. Honest verbal informed consent to each patient before a nerve block is needed.

AIMS and CDSS systems. Documentation is a necessary component of the anesthesia provider’s work. Previously, information like vital signs, fluid status, and degree of sedation flowed from the patient to the provider by way of direct observation, or through monitors, or the anesthesia workstation. Documentation was a one-way act of scribing data for potential review at a later time. Now, the electronic medical record and anesthesia information management systems (AIMS) act as hubs for information gathered by the provider, monitors, and anesthesia workstation. With the anesthetic record becoming a comprehensive repository of real-time patient information, the possibility of clinical-decision support (CDS) systems became reality.

The increasing use of AIMS and CDSS systems across anesthesia departments and practices has enabled the establishment and growth of large data sets describing anesthesia patients, procedures, and outcomes. These data sets present a potential, prediction, decision, support, and ultimately allow data transmission to quickly integrate information directly from the monitors in real time and provide vital information to the anesthesia specialist.

The practicality of housing this processing power locally on an anesthesia workstation remains to be seen, but experts suspect that a central processing model similar to that used by web service providers will shift this demand to low-latency networking, enabling greater portability and lower cost of the peri-procedural equipment. This will place demands on the networking and processing capacity already implemented in most practice environments. The advent of consumer-grade low-latency networking is expected (for example, 5G cellular network) to lessen this barrier significantly.

Even as connective and data processing continue to intensify, practices in security and property rights over healthcare data will continue to evolve. The human data, which has been created and gathered during the 21st century, will be unfathomable in scale, scope, and impact. Finding meaning in the data remains a fundamental challenge for the current technological age.

Point-of-care ultrasound (POCUS). In recent years, anesthesiologists began to aim their ultrasound probes at the abdomen, thorax, and airway to gain real-time information and immediate knowledge of the anatomy and pathology beneath the skin and to better manage and treat critically ill patients. POCUS is proving useful in trauma, chest examination, and pediatric anesthesia. Because POCUS is a recent development, the majority of anesthesiologists do not have the training, skills, or knowledge needed to use this new technique. Recent graduates of residency and fellowship programs will lead the way as the anesthesia workforce transitions toward mastery of POCUS.

Zacceleromyographic monitors. Another attractive class of devices is Zacceleromyographic (AMG) monitors. These devices measure the acceleration, using a piezoelectric sensor attached to a freely moving thumb. These devices take advantage of the direct proportionality between acceleration and force to measure the evoked force of the thumb. A significant impediment to this type of monitoring is the fact that the piezoelectric sensor may not always be properly aligned to the optimal plane of the thumb movement. Several other attractive noninvasive monitoring systems, smart pumps, and computer-controlled drug infusion delivery, have been released and promoted in the anesthetics community and to the general public as accessible vital signs tracking systems.  Integrated pulse oximeters, smartphone electrocardiogram single-lead devices, and applications for at-home screening for intermittent hypoxia in children are also now available.

Safer care. Anesthesia care has become safer and safer. Deaths and adverse outcomes continue to decrease because of improved monitoring, vigilance, education, and training. The Cleveland Clinic writes, “In the 1960s and 1970s, it wasn’t uncommon to have a death related to anesthesia in every one of every 10,000 or 20,000 patients. Now it’s more like one in every 200,000 patients – it’s very rare.” The continuing advances in anesthesia safety are a bellwether for other specialties, who must envy the progress made in anesthesiology quality assurance.

Sugammadex. Sugammadex was FDA-approved in December 2015, and the practice of chemically paralyzing surgical patients and reversing their paralysis has been forever changed. For non-medical readers, sugammadex is an intravenous drug, which reverses the paralysis of rocuronium, the most commonly used anesthetic paralytic drug, in approximately one minute. Sugammadex replaced the decades-old practice of injecting a combination of neostigmine and glycopyrrolate to reverse paralysis. Neostigmine and glycopyrrolate were slow to act (a wait of up to nine minutes), and could not reverse paralysis if zero twitches were present on a nerve stimulator monitor. In addition, 16 mg/kg of sugammadex IV can reverse an intubating dose of rocuronium, which makes rocuronium more quickly reversible than succinylcholine for rapid sequence intubation. Sugammadex is not cheap (a cost of USD 100 per 200 mg vial), but since the availability of sugammadex, no anesthesia practitioner should ever have an awake and still-paralyzed patient at the conclusion of an anesthetic. A terrific advance.

Outlook
The administration of anesthesia, its evaluations prior to surgery, and its postoperative care vary by health system, resource availability, and society. In contrast, the trends in our industry toward automation, non-intrusive monitoring, remote monitoring and management, and CDS enabled by AI and better information technology infrastructure, are evident. Leapfrog innovation will result from inter-system variation, where a set of innovations that are implemented more quickly in one environment will provide the knowledge needed to support their application elsewhere.

Social engineering, business efficiency principles, and technological advancement all contribute to improving the quality and value of anesthesia care. This process will be guided by an ever-more-complex synthesis of the enormous volume and breadth of health system and patient metrics. The implementation of CDS systems, supported by the technologies mentioned above, will also be guided by behavioral science and economics with the intention of reducing provider fatigue and errors.