THE iCONTROL-RP ANESTHESIA ROBOT
On May 15, 2015, the Washington Post published a story titled, “We Are Convinced the Machine Can Do Better Than Human Anesthesiologists.”
Is this true? Are anesthesiologists on the verge of being replaced by a new robot?
In a word, “No.”
The new device being discussed is the iControl-RP anesthesia robot.
In recent years there have been significant advances in the automated delivery of the intravenous anesthetic drugs propofol and remifentanil. (Orliaguet GA, Feasibility of closed-loop titration of propofol and remifentanil guided by the bispectral monitor in pediatric and adolescent patients: a prospective randomized study, 2015 Apr;122(4):759-67). Propofol is an ultra-short-acting hypnotic drug that causes sleep. Remifentanil is an ultra-short-acting narcotic that relieves pain. Administered together, these drugs induce what is referred to as Total Intravenous Anesthesia, or TIVA. Total Intravenous Anesthesia is a technique anesthesiologists use when they choose to avoid using inhaled gases such as sevoflurane and nitrous oxide. Anesthesiologists administer TIVA by adjusting the flow rates on two separate infusion pumps, one infusion pump containing each drug.
A closed-loop system is a machine that infuses these drugs automatically. These systems include several essential items: The first is a processed electroencephalogram (EEG) such as a bi-spectral monitor (BIS monitor) attached to the patient’s forehead which records a neurologic measure of how asleep the patient is. The BIS monitor calculates a score between 0 and 100 for the patient’s level of unconsciousness, with a score of 100 corresponding to wide awake and 0 corresponding to a flat EEG. A score of 40 – 60 is considered an optimal amount of anesthesia depth. The second and third essential items of a closed-loop automated system are two automated infusion pumps containing propofol and remifentanil. A computer controls the infusion rate of a higher or lower amount of these drugs, depending on whether the measured BIS score is higher or lower than the 40- 60 range.
Researchers in Canada have expanded this technology into a device they call the iControl-RP, which is in clinical trials at the University of British Columbia. The iControl-RP is a closed-loop system which makes its own decisions. The initials RP stand for the two drugs being titrated: remifentanil and propofol. In addition to monitoring the patient’s EEG level of consciousness (via a BIS monitor device called NeuroSENSE), this new device monitors traditional vital signs such as blood oxygen levels, heart rate, respiratory rate, and blood pressure, to determine how much anesthesia to deliver.
Per published information on their research protocol, the iControl-RP allows either remifentanil or propofol to be operated in any of three modes: (1) closed-loop control based on feedback from the EEG as measured by the NeuroSENSE; (2) target-controlled infusion (TCI), based on previously-described pharmacokinetic and pharmacodynamic models; and (3) conventional manual infusion, which requires a weight-based dose setting. (Reference: Closed-loop Control of Anesthesia: Controlled Delivery of Remifentanil and Propofol Dates, Status, Enrollment Verified by: Fraser Health, August 2014, First Received: January 15, 2013, Last Updated: March 5, 2015, Phase: N/A, Start Date: February 2013, Overall Status: Recruiting, Estimated Enrollment: 150).
In Phase 1 of the iControl-RP testing involving 50 study subjects, propofol will be administered in closed-loop mode and a remifentanil infusion will be administered based on a target-controlled infusion. In phase 2 involving 100 study subjects, both propofol and remifentanil will be administered in closed-loop mode. The investigators aim to demonstrate that closed-loop control of anesthesia and analgesia based on EEG feedback is clinically feasible.
In both phases, an anesthesiologist will monitor the patient as per routine practice and have the ability to modify the anesthetic or analgesic drugs being administered. That is, he or she will be able to adjust the target depth of hypnosis, adjust the target effect site concentration for remifentanil, immediately switch to manual control of either infusion, administer a bolus dose, or immediately stop the infusion of either drug. iControl-RP is connected to the NeuroSENSE EEG monitor, the two infusion pumps for separately controlled propofol and remifentanil administration, and the operating room patient vital signs monitor. A user interface allows the anesthesiologist to set the target EEG depth level, switch between modes of operation (manual, target-controlled infusion, or closed-loop), and set manual infusion rates or target effect-site concentrations for either drug as required.
Per the article in the Washington Post. (Todd C. Frankel, Washington Post, May 15, 2015), one of the machine’s co-developers Mark Ansermino, MD said, “We are convinced the machine can do better than human anesthesiologists.” The iControl-RP has been used to induce deep sedation in adults and children undergoing general surgery. The device had been used on 250 patients so far.
Why is this robotic device only a small step toward replacing anesthesiologists?
A critical realization is that anesthetizing patients requires far more skill than merely titrating two drug levels. Every patient requires (1) preoperative assessment of all medical problems from the history, physical exam, and laboratory evaluation of each individual patient, so that the anesthesiologist can plan and prescribe the appropriate anesthesia type; (2) placement of an intravenous line through which the TIVA drugs may be administered; (3) mask ventilation of an unconscious patient (in most cases), followed by placement of an airway tube to control the delivery of oxygen and ventilation in and out of the patient’s lungs; (4) observation of all vital monitors during surgery, with the aim of directing the diagnosis and treatment of any complication that occurs as a result of anesthesia or the surgical procedure; (5) removal of the airway tube at the conclusion of most surgeries, and (6) the diagnosis and treatment of any complication in the newly awake patient following the anesthetic.
In the future, closed-loop titration of drugs may lessen an anesthesiologist’s workload and free him or her for other activities. In the distant future, closed-loop titration of drugs may free a solitary anesthesiologist to initiate and monitor multiple anesthetics simultaneously from a control booth via multiple video screens and interface displays. But the handling of all tasks (1) – (6) by an automated robotic device is still the stuff of science fiction. The Washington Post article said an early role for the machine could be in war zones or remote areas where an anesthesiologist is unavailable. One could conjecture that a closed-loop anesthesia system may be used to facilitate surgery in outer space some day as well.
In either case, an anesthesiologist or some other highly-trained medical professional will still be required on site to achieve tasks (1) – (6).
The iControl-RP has not been approved by the U.S. Food and Drug Administration.
The iControl-RP team has struggled to find a corporate backer for its project. Dr. Ansermino, the anesthesiologist inventor in Vancouver, told the Washington Post, “Most big companies view this as too risky,” but he believed a device like this was inevitable. “I think eventually this will happen,” Ansermino told the Washington Post, “whether we like it or not.”
That may be, but I suspect companies are risk averse regarding the iControl-RP because investment is guided by analysts and physicians who must consider the practical applications and risks of any new medical device. The issues of leaving (1) – (6) up to a robotic device are impractical at best, and dangerous to the patient at worse.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.
On October 2, 2014 THE DOCTOR AND MR. DYLAN became the world’s #1 bestselling anesthesia Kindle book on Amazon.com.
The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:
Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.
Bang-Up Debut Novel, November 16, 2014
By Norm Goldman “Publisher & Editor of Bookpleasures”
This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.
This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.
TwinCities.com PIONEER PRESS Entertainment
by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press email@example.com, January 4, 2015
“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)
Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.
Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.
Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.
The Physician’s Late-Night Reading List
Two Pritzker alums pen captivating tales
By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine
For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.
Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.
Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”
One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.
The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80
“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.
From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”
After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.
“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”
Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:
BOOK REVIEW “THE DOCTOR AND MR. DYLAN”
This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.
Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.
Rick, I can’t wait for your next book. Bravo!
Hibbingite writes twisted medical tale
HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.
Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.
“The dialogue is sometimes funny, and there are lots of plot twists,” he said.
Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.
“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”
Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.
This review is from: The Doctor and Mr. Dylan (Kindle Edition)
Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.
Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below: