The purchase of a large number of super premium systems by teaching institutes and a major inclination by others to stay away from refurbished and competitively priced, imported models reveals the discerning nature of the buyers.
Anesthesiologists work in an increasingly complex technological environment inside and outside of the operating room. Every day, they rely on sophisticated devices to provide safe care to patients. These devices include anesthesia machines, drug delivery systems, physiologic monitors, diagnostic imaging equipment, and electronic health records (EHRs). Anesthesia machine manufacturers are continuously introducing technological advances in their newest machine models. New technology focuses on patient safety as well as optimizing the efficiency of anesthetic delivery and minimizing anesthetic gas waste. Target-controlled low-flow anesthesia systems automate the fresh gas flow rate and vaporizer settings to achieve a specific end-tidal percentage that is set by the anesthesiologist. Each manufacturer continues to explore opportunities to integrate anesthesia machines with hospital information systems, including data sharing with anesthesia information management systems (AIMS) for automatic documentation. Improved connectivity and integration will offer new opportunities to enhance workflow efficiency and patient safety.
Indian Market Dynamics
The Indian anesthesia systems market in 2016 is estimated at Rs.167.5 crore, with sales of 5115 numbers. Super premium segment had excellent sales with the teaching institutes making major procurements. This trend is of course one of a kind, and may not be repeated in 2017. The mainstay continues to be the mid-tier and value segment, which together contributed 53 percent to the market in value terms in 2016. The premium and performance segment each have a market share in the 14 percent vicinity, whereas super value contributes 8.6 percent to the market. The buyer is increasingly exhibiting less inclination for refurbished systems and competitively priced imported models.
The teaching institutes made major procurements, with a preference for the super premium segment. Major buyers in 2016 included AIIMS; NEIGRIHMS (North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences), Shillong; BMSICL (Bihar Medical Services & Infrastructure Corporation) Patna; Indira Gandhi Institute of Medical Sciences, Patna; and AP Health Corporation, Hyderabad. Mindray had good success in this category.
With increasing competition on price, vendors are shifting to offering products from their Chinese partners, rather than European ones, and also focusing on Tier-II and Tier-III cities.
The global anesthesia devices market is estimated at Rs.52,125 crore in 2016, projected to reach Rs.90,500 crore by 2021, at a CAGR of 11.64 percent in the period, 2016 to 2021. Anesthesia and respiratory devices, owing to their capability to resolve various environmental and lifestyle induced respiratory disorders are expected to witness substantial growth. Increasing incidences of respiratory illnesses such as chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are high-impact rendering drivers for this market. Moreover, the increasing base of geriatric population and rising rates of environmental pollution are key drivers.
Based on product type, while anesthesia machines dominate the segment, the positive airway pressure devices are seeing maximum growth in the respiratory devices segment.
Region-wise, maximum growth is expected from the Asia-Pacific market, with rising disposable income, healthcare reforms, and economic development in the region.
Manufacturers are constantly investing and upgrading their product range. Over the past few years, the preference of people has shifted from hospital care to home healthcare services. This has encouraged leading players to introduce varieties of portable medical devices. The availability of a variety of home healthcare devices has propelled the market in the recent past.
The slow adoption rate of AIMS is expected to be a major challenge. However, destinations where the cost of manufacturing anesthesia and respiratory devices is low are expected to offer many growth opportunities to the global market.
Going forward, the global anesthesia and respiratory devices market is expected to benefit from the rise in pulmonary diseases. As per The American Society of Anesthesiologists (ASA), in the US, every year approximately 40 million anesthesia treatments are administered.
A cutting-edge anesthesia management system developed at the University of Washington (UW) Medical Center in Seattle, has generated an estimated return of USD 1 million annually for the hospital while providing a major boost to patient care. The new Smart Anesthesia Manager (SAM) has resulted in a far more efficient use of expensive inhalation agents.
Developed over the past five years by Dr Bala Nair, PhD, associate professor of anesthesiology and pain medicine, UW, with assistance from other medical center colleagues, SAM has also boosted clinical care. The use of SAM has significantly improved blood pressure, glucose, and antibiotic management, resulting in greater compliance with institutional guidelines. Other benefits include barcode verification of drugs at the time of administration and a handoff tool, particularly helpful for the transfer of care from anesthesia to nursing at the end of a procedure.
In addition to the UW Medical Center, SAM also has been installed at Harborview Medical Center, also in Seattle, and at Ochsner Medical Center in New Orleans.
“Timing of notification is as critical as the decision rule itself. The strategy is to get the provider’s attention in a very optimal fashion without bombarding them with a lot of messages,” Dr Nair said, “You have to balance that.”
Dr Nair began developing SAM in 2009 as a way of building on existing technology that had proved to be limited in its utility. His idea was to build a support module for the AIMS, a documentation system that turned out to have limited ability to improve quality of care and revenue.
The new SAM system conveys a real-time stream of prompts and information, a major upgrade over AIMS. That capability, in turn, has boosted revenue while enabling tighter monitoring on the clinical care side and improved quality of care.
SAM’s savings. SAM’s biggest bottom line impact has been in the use of gas. The system has resulted in far more efficient use of expensive inhalant agents, leading to reduction in use of sevoflurane, desflurane, and isoflurane (28, 33, and 12%, respectively). That change alone has saved the UW Medical Center an estimated USD 120,000 a year.
More efficient billing has been another important benefit. SAM captures charges for procedures that were previously missed through lack of supporting documentation, including some invasive line special procedures and physician attestations. There also has been a significant improvement in billing accuracy and documentation compliance as well. Meanwhile, patient care and safety also has improved. SAM has more than halved extended gaps in blood pressure monitoring at the UW Medical Center, from 15.7 instances per 1000 cases to 6.7 instances. Before SAM, the maximum gap in blood pressure monitoring was 64 minutes, but after the new system was installed, it dropped to 28 minutes.
Additionally, SAM has also proved helpful to clinicians dealing with unusually complex or rare cases. Dr Nair has also developed a handoff tool through SAM that can be used when transferring patient care from one provider to another. SAM will page the ICU or post-anesthesia care unit nurse coordinator when a patient is in transport and print a transfer summary report to supplement a handoff checklist.
Technology has been integrated into almost every facet of anesthesia practice, from patient monitors and anesthesia machines to documentation and drug delivery. In the course of a typical day, anesthesia practitioners care for patients using an array of technologies whose sophistication and utility are continually increasing.
Physiologic monitors. Accelerometers, magnetometers, and gyroscopes in consumer devices such as smartphones and activity trackers allow for monitoring various aspects of individuals’ daily lives, from exercise to sleep. Medical device manufacturers are exploring the role of wearable devices integrated in physiologic monitors. Research groups are integrating wearable devices and motion sensors in patients’ homes to detect cognitive impairment in vulnerable populations, such as older adults. There is potential for growth in this sector, particularly to maximize patient safety on both an inpatient and ambulatory basis. However, the benefits of monitoring physiologic data remotely on an outpatient basis require scrutiny, particularly if such monitoring requires significant time and resources for implementation.
Capnographic analysis. Continuous respiratory monitoring is one of the most essential components of anesthesiologists’ vigilance. Minimally invasive monitoring of ventilation is appealing, particularly for settings outside of the operating room. Noninvasive monitors range from oxygen delivery systems with integrated capnography masks to transcutaneous measuring devices. Anesthesiologists often administer 100 percent inspired oxygen to minimize the risk for hypoxemia during periods of apnea, such as during laryngoscopy.
Surgical blood loss monitoring. Monitoring surgical blood loss is fraught with imperfections. Suction canisters may contain blood and other body or irrigation fluids. Visual estimation based on number of sponges and saturation of sponges also is inaccurate. Weighing sponges is time-consuming and may be inaccurate, particularly if there are other body fluids intermixed with blood.
Simulation. Medical simulation continues to play an integral role in education in the operating room. In 2016, consumer devices for consumption of virtual reality content are entering the market. Generating content is also becoming increasingly easy with consumer cameras. Medical simulation and education may benefit from this increased accessibility. Virtual reality headsets range from the cardboard box frames that house a smartphone to sophisticated devices. The virtual-reality industry is just beginning to find applications in the consumer and healthcare markets.
Consumer and medical device electronics continue to develop at a rapid pace. Will patients take home wearable monitors after discharge from the post-anesthesia care unit? Will anesthesiologists rely on physiologic data recordings during the preoperative period for perioperative counseling and risk stratification? Will immersive virtual reality revolutionize medical simulation and training? The answers to these questions will be an exciting endeavor indeed!
Technological Advancements and Emerging Trends on ADS
From the purely manual to modern automated electronic versions, anesthesia delivery systems (ADS) have evolved with technological advancements in each of its components. A modern ADS device consists of these key subsystems: an anesthetic ventilator that delivers breaths as set; a circle absorber that removes CO2 from exhaled gas; flow control systems that monitor flow rate of each gas in the mixture; an anesthetic gas scavenging system that recovers vented anesthetic gases; many vaporizers that control the precise addition of anesthetic gas; and most importantly alarm systems for safety. Modern ADS systems tightly integrate these subsystems resulting in a minimized workload and better usability for the anesthesiologist. Modern ADS devices also offer the option of being ceiling-pendent-mounted rather than floor mounted for optimum space utilization.
Each of the above ADS subsystems has undergone technological transformation. Today’s anesthetic ventilators use sophisticated closed-loop algorithms that employ accurate flow and pressure sensors and can deliver tidal volume from 20 to 2000 mL with precise delivery accuracy. Advanced support modes like SIMV-VC, SIMV-PC, and PSV are becoming integral parts of the equipment. Modern circle absorbers integrate with the ventilator on measurements and offer hot swappable soda lime canisters and the bypass option to switch to manual ventilation, when needed. Flow control systems have evolved from old mechanical valve-based rotameters to new electronic valve-based flow sensors with precise control and monitoring of Air, O2, and N2O.
An anesthesiologist trained to use such ADS devices only needs to set minute volume/tidal volume while relying on the device for precise gas concentrations in the mixture. Anesthetic gas scavenging system reduces the exposure of operating room personnel to waste anesthetic agents vented from the breathing system.
ADS devices also work in concert with patient monitors that measure SpO2 and EtCO2 in addition to data connectivity options that comply with the HL7 interconnect standard.
With all these technological advancements, the anesthesiologist can focus on clinical practice with the assurance of safety and performance by the ADS device.
Emerging Trends in Hemodynamic Monitoring
Hemodynamic is the throb of life (TOL), flawless flow of blood to perfuse organs and every tissue. Franklin Bayliss Starling postulated that force of cardiac contraction is directly proportional to end diastolic stretching. Leonard Da Vinci added further that muscle of its own only contract and not stretch which is passive.
William Harvey 1628 introduced concept of circulation, heart, arteries, veins, strengthened further by Stephen Hales – 1710 – Blood pressure and Rene 1816 the stethoscope. W.T.G. Morton father of modern anesthesia 1946 – onward hemodynamic monitors are developed in three phases.
Phase I – (till 1950 – 60) included pulse, B.P., oscillometry apart from clinical features.
Phase II – Monitoring the cardiac filling pressure (1950-2000).
Phase III – Current hemodynamic monitor is non/minimally invasive.
Paradigm shift in hemodynamic monitoring started using Fick principle with partial rebreathing and oxygen utilization. Subsequently – dye dilution (indocyanine green dye concentration monitored in arterial blood following transveinous injection). Subsequently dye is replaced by Ice cold saline – 12.5 °C ± or heating coil in pulmonary artery branch used to monitor cardiac output. Lithium chloride bolus 100mM injected in a vein simultaneously ion – selective electrode in arterial line series to give cardiac output. Picco, Lidco, Lidco rapid CNAP module. Flowtrack, EV1000, volume view, continuous co from ECG SPO2 PWTT are the newer generation of hemodynamic monitor.
With growing need of hemodynamic monitor, electrical bioimpedence, ultrasound/Doppler, oesophageal Doppler, transthoracic Echo (TEE), measuring organ perfusion (Mixed venous oxygen saturation), blood lactate, blood lactate, gastro – intestinal tonometry, near infrared spectroscopy, tissue oxygen tension, pulse wave transit time escco are the other alternatives available with their relative value.
Flood of hemodynamic monitors displaying beat to beat values, goal directed fluid therapy, tissue utilization of oxygen, have flooded the market. Before procuring service facility, sturdiness, life of the instrument, electrically operative with battery support and cost effectiveness must be considered. We should not be a victim of high pressure marketing either.
Dr Dipankar Das Gupta
Director – Department of Anesthesia,
Jaslok Hospital & Research Centre, Mumbai
Steady Rise in Demand for Quality Anesthesia Workstations
The last decade has witnessed a steady rise in the demand for quality anesthesia workstations due to availability of advanced and cost-effective technology. Having a good reliable anesthesia workstation with temperature-compensated anesthesia vaporizers and in-built electronic ventilation has now become the new norm. We are witnessing increased number of customers upgrading from existing Boyle’s-type basic anesthesia machines to high-end anesthesia machines and workstations packed with safety features. Our range of workstations is designed in such a manner as to offer a range of customizable features to suit varied budget requirements depending on the customer needs without compromising on the safety standards of the equipment, safety of the patient and the user, and environment.
Every hospital is now focused on improving its patient safety and comfort standards. The safety features offered by modern anesthesia workstations are at a huge advantage and substantially minimize chances of any accidental incidents during anesthesia. Precise delivery of anesthesia is possible with the help of these latest technologies. All our workstations are equipped with a twin station manifold for mounting two selectatec-type temperature-compensated anesthesia vaporizers with interlocking safety, an anti-hypoxic system, an inbuilt integrated electronic ventilator with direct switching controls from the circle absorber system, and integrated patient alarms.
The high-luminance and wide display screens are offered in a series of sizes and touch/non-touch variants to meet varied customer requirements. Electronic ventilators offer a choice of ventilation modes comprising CMV (continuous mandatory ventilation), PCV (pressure controlled ventilation), SIMV (synchronized intermittent mechanical ventilation), and manual ventilation modes. The advanced versions offer an addition of PSV (pressure support ventilation) and SIMV with pressure/flow triggers, and spontaneous mode of ventilation.
The workstations are offered with our Meditec Pisces vaporizers, which are suitable for delivering halothane, isoflourane, enflurane, and sevoflourane anesthetic drugs. The vaporizers offer a drug-delivery range starting from 5 to 8 percent and come with a choice of drug-filling options. The vaporizers are accurate and precise and are designed to compensate for variance in temperatures and flow. The workstations are offered with a choice of monitoring options starting from basic monitoring of ECG, NIBP, SP02, RESP, and dual temperatures. The monitors offer several upgradeable features such as EtC02 monitoring, anesthetic gas monitoring, invasive blood pressures, cardiac output, depth of anesthesia monitoring and many others used for advanced anesthesia monitoring. Peripherals like syringe pumps, suction devices, and scavenging units are also a part of the modern anesthesia workstation to make it a complete solution for anesthesia delivery.
Director-Sales & Marketing,
Allied Medical Limited
Anesthesia equipment has evolved over time from basic pneumatic devices to sophisticated electronic devices. Now technology has a major role for safety practices in anesthesia practice starting from vital monitoring to highly complex anesthesia machines and drug delivery systems.
Recent technology developments in anesthesia have been in software-related solutions and hardware.
AIMS and CDSS. Anesthesia information management system (AIMS) is continuous automated electronic anesthesia record, which captures vital parameters of the patients and allows manual notation of various intraoperative events. As AIMS is usually a part of HIS (hospital information system), it allows the user to retrieve relevant patient information, e.g., any history of previous anesthesia administration and its outcome. This has improved the quality and safety of patient care. Clinical decision support system (CDSS) is currently an active area of anesthesia research and development due to huge potential to improve patient care and outcome by reducing intraoperative complications. CDSS integrates aggregated data from AIMS, vitals monitors, and HIS to present quality and safety alerts to clinicians.
Barcode labeling and readers. Medication error in the OR is one of the leading causes of adverse events during intraoperative period. However, various modalities are available to prevent errors like color-coded drug labels, customized drug trays, prefilled syringes, integrated AIMS warning, and barcode readers. Out of all these, barcode labeling of drugs is the latest. Barcoding has improved compliance for labeling requirements. Barcode technology has been applied as safety check for blood products transfusions where it has decreased the near-miss events.
Computer-controlled drug infusion delivery system. Intravenous infusion is a common mode of delivery of drugs during perioperative period. For patient safety, drug delivery and dosages should be optimized to near accuracy. These smart pumps have incorporated drug library and error reduction systems, which have reduced programming errors.
Noninvasive patient monitoring system. We are now shifting toward noninvasive monitoring system, which is more acceptable to patients as well as clinicians. For respiratory rate monitoring, the acoustic sensor method has been shown to be more precise than thoracic impedance and is better tolerated than capnography with face mask in postoperative period. Noninvasive monitoring technology has also been developed to trend blood hemoglobin levels continuously with CO oximetry.
If we integrate the data at national level through AIMS and HIS system, then we can have a greater pool of data for research and data mining. Along with so much of technological advancement, other modalities like robotic anesthesia and teleanesthesia have to come up which is the future of anesthesiology.
Dr Narender Kumar
Artemis Hospital, Gurgaon