THE TEN MOST SIGNIFICANT ADVANCES IN ANESTHESIOLOGY IN THE PAST DECADE

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

What were the ten most significant advances in anesthesiology in the past decade, 2010 – 2020? Here are my picks:

  • 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 my 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 $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. Five stars.
  • Use of Zoom. In the era of COVID, Zoom videoconferencing made person-to-person communication involving anesthesiologists possible. During the early days of the COVID outbreak, the American Society of Anesthesiologists was able to keep its members informed and educated via Zoom conferencing. At the present time, almost all anesthesia continuing medical education (CME) is conducted effectively via Zoom. I attend the Stanford anesthesia Grand Rounds each Monday morning via Zoom, and the educational value is as high as it was when I attended in person. Expect Zoom CME to continue as a major vector in the years to come. Although Zoom may adversely affect in-person attendance at medical meetings forever, I believe widespread videoconferencing education is a tremendous advance. Five stars.
  • The Stanford Anesthesia Emergency Manual. See this link.  The algorithms set out in the red laminated ring-bound Stanford Anesthesia Emergency Manual filled a fundamental need in acute care medicine. When perioperative emergencies arise, a delay in treatment can result in death or irreversible brain damage. The presence of this Stanford book of checklists assures that every operating room is equipped with the cognitive aids needed for standard of care treatment. The manual is available at https://emergencymanual.stanford.edu. The authors chose not to glean profits from the publication of the Stanford Emergency Manual, but instead made it available for physicians and nurses everywhere for free. Five stars.
  • 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. The Anesthesia Patient Safety Foundation is a hub of all advances. Five stars.
  • Pubmed/Internet/the Cloud. This past decade saw an explosion of handheld mobile devices and phones, as well as an expansion in the use of the cloud and the internet. Anesthesiology benefited from these technological advances. Information regarding anesthesia care is immediately available to any anesthesia provider anywhere in the world, if they have internet access. The ability to do a Google search on any topic is outstanding and immediate. Pubmed is a National Library of Medicine website which catalogs an abstract on every medical publication. Pubmed is an essential tool for every physician who is investigating previously published medical knowledge. Five stars.
  • 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. Three stars.

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. See this link. Three stars.

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. Three stars.

  • ASA Monitor/Dr. Steven Shafer. I list this development last, but my enthusiasm for the ASA Monitor and its Editor-in-Chief Steven Shafer is extremely high. The American Society of Anesthesiologists revamped their ASA Monitor publication into a monthly newsletter reporting up-to-date information regarding our specialty. The ASA hired Steven Shafer MD PhD as the editor. Dr. Shafer is a Professor of Anesthesiology at Stanford, and is an outstanding scientist, author, and humorist. I’ve known Steve for nearly forty years, since he was a medical student. He has authored more than 200 peer-reviewed publications in the field of anesthesiology, and was the Editor-in-Chief for Anesthesia and Analgesia from 2006-2016. Dr. Shafer possesses a razor-sharp intellect and a flippant sense of humor seldom seen in scientific writing. His lead editorial in each month’s issue of the ASA Monitor is required reading for every anesthesia professional. Dr. Shafer also personally authors a daily update on COVID research and statistics—a Google group which you can personally subscribe to as an email offering. See this link. Five stars.

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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

TRENDS FOR THE FUTURE OF ANESTHESIOLOGY

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

What can we expect in the next 10 years of anesthesiology? What will be the trends for the future of anesthesiology? I’m writing this in January 2016. God willing, we’ll all be alive and well to reread this in 2026, and find out how many of these predictions about the future of anesthesiology came true.

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I’m writing this from the perspective of a busy clinician who has worked as an anesthesiologist in California in both private practice and at a major university hospital for over 30 years. I see 10 trends for the future of anesthesiology as:

  1. Lower income (as adjusted for inflation). There will be multiple causes for this: a) An aging population, with the significantly lower pay for attending to Medicare patients, b) Obamacare and other governmental payment cuts, c) Bundled insurance payments to hospitals, requiring anesthesiologists to negotiate for every nickel of that payment due to them, and d) Corporate anesthesia (see #9 below).
  2. More care team anesthesia and more Certified Nurse Anesthetists (CRNAs). Hospital systems will have increased incentives to perform anesthetics with cheaper labor. Rather than physician anesthesiologists personally performing anesthesia, expect to see CRNAs supervised by physician anesthesiologists in an anesthesia care team, or in some states, CRNAs working alone.
  3. There will be a paucity of new drugs to change the practice of operating room anesthesia. A few years ago I had a conversation with Don Stanski, MD, PhD, former Chairman of Anesthesiology at Stanford and now a leading pharmaceutical company executive, regarding new anesthetic drugs in the pipeline. Dr. Stanski’s reply was something along the line of, “There are almost no new anesthetic drugs in development. The ones we currently have work very well, and the research and development cost in bring an additional idea to market is high. Don’t expect much change in the coming years.” Consider sugammadex, a new drug for the reversal of neuromuscular blockade, recently approved by the Food and Drug Administration. The drug is more effective in reversing a rocuronium or vecuronium block than is neostigmine, but the cost is high. The acquisition cost of the smallest available vial of sugammadex is over $90, far exceeding the cost of neostigmine. In certain instances, faster reversal by sugammadex will be critically important, but for routine cases the cost is prohibitive. This trend of fewer new anesthesia drugs isn’t only a futuristic phenomenon. In my current private practice, I see my colleagues using the same medications that they used 25 years ago: propofol, sevoflurane, rocuronium, fentanyl, and ondansetron.
  4. An aging population, an increased volume of surgery, and an increased demand for anesthesia personnel. As the baby boomers age, there will be an increased number of surgeries on older, sicker patients. Anesthesia personnel will be in great demand.
  5. Anesthesiology will become more and more a shift-work job. A generation ago an anesthesiologist started a case and finished that case. An on-call anesthesiologist came to work at 7 a.m., took 24-hour call, and finished their last case as the sun came up the next morning. Certain instances of this model may persist, but as more anesthesiologist become corporate employees, expect more anesthesia practitioners working 8-hour or 12-hour shifts, just like employees in other jobs.
  6. Increased interest in the specialty of anesthesiology amongst medical students. Although several items on my list may seem discouraging, take heart, because the career of anesthesiology will remain extremely popular. Why? Because the other fields of medicine have problems, too. Bigger problems. Many future doctors will shun the primary care fields of family practice, internal medicine, and pediatrics. The primary care fields offer long days in clinics, dealing with a new patient every 10 – 15 minutes, and they suffer from low pay. Because of the higher reimbursement in procedural specialties, careers in surgery, anesthesia, cardiology, and invasive radiology will always be popular.
  7. Expect improved safety statistics regarding anesthesia mortality and morbidity. Anesthesia has never been safer. See “How Safe is Anesthesia in the 21st Century?” Expect further improvements in monitors, protocols, education, and the analysis of Big Data that will make anesthesia safer than ever.
  8. There will still be a non-zero incidence of anesthesia-related fatalities. There will still be disasters, particularly airway disasters. Some anesthesia clinical situations will always remain extremely difficult and challenging, and human error will not be eradicated.
  9. Large national corporations will continue buying up private anesthesia practices, perhaps eliminating the current model in which groups cover one hospital or one city alone. In the last three months, Sheridan, the physician services division of AmSurg, Corp has purchased the 60-physician, 140-anesthetist Northside Anesthesiology Consultants in Atlanta, and the 240-physician Valley Anesthesiologists & Pain Consultants in Phoenix. In these purchases, senior board members and partners receive seven-digit checks to sell their practice, then all physicians in the practice’s future labor for a discounted wage, perhaps as low as 50% of the prior income. If this trend becomes widespread, this subset of the anesthesia workforce will become low paid practitioners, while the purchasing corporations will make significant profits for their stockholders.
  10. Continued fascination with anesthesia practice, a discipline which makes all surgical treatments and cures feasible. Without anesthesia, there can be no major surgical procedures. Medical care without major surgical procedures is unthinkable. Whether as anesthesia providers, as patients requiring surgery, or just as observers of the process, we will all continue to value and marvel at the field of anesthesia.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

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Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

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