This will be the next big thing….

This will be the next big thing….

This entertaining Sunday session at Euroanaesthesia in Vienna was one in which the four speakers were asked to persuade the audience what would be ‘the next big thing’ in a particular area of anaesthesia or critical care medicine.

Professor Burkhard Gustorff (Medical University of Vienna), was asked to describe the next big thing in pain medicine. “Unsolved problems of pain medicine are high interindividual variability of pain and pain therapy as well as high rates of side effects of pain therapies,” he explained. “In neuropathic pain this results in insufficient and unspecific therapy. No causal treatment of neuropathic pain diseases is known.”

He explained how, in 1901 Karl Landsteiner, who worked at the same hospital (Wilhelminenspital in Vienna) discovered the ABO blood groups.  This was a milestone in blood transfusion based on phenotyping genetics. But what, asked Prof Gustorff, would be the next milestone of genetics in pain medicine?

He said: “Pharmacogenetics are on the way to provide widely available, personal information on efficacy and risk of side effects of analgesics. Pharmacogenetic-guided pain therapy will therefore be the next big thing.”

He added: “Moreover, sodium channelopathies are a leading example of successful phenotyping of genetics in neuropathic pain. Specific sodium-channel-blockers showed analgesic efficacy in this type of neuropathic pain. And finally, gene replacement therapy is on the way to turn the next big screw, not only for the FDA approved indication for rare muscular dystrophy but also for neuropathic pain like in Charcot-Marie-Tooth-Neuropathy.”

He concluded: “Genetics in pain medicine are on the way and will be the next big milestone, overcoming insufficient analgesia and the risk of limiting side effects.”

Professor Oliver Kimberger (also Medical University of Vienna) then told the audience he believed robotics will be the next big thing in the operating room. Indeed, he described examples of robotic anaesthesia that are already happening, such as clinical decision support systems, closed loop systems, robotic intravenous access, robotic resuscitation and robotic nerve blocks.

However, Prof Kimberger also made clear there will always be certain tasks that are difficult or near-impossible to be fully automated. For example, interpretation of radiological images, while possible with computers, needs to combined with medical judgement, interventional procedures, patient preferences and a host of other factors that mean a computer could never take over the decision making process alone.

Dr Paul Zajic of the University Hospital of Graz, Austria, addressed the next big thing in the ICU.  He said: “What will the future ICU look like? Will it have robots performing clinical tasks? New equipment aiding monitoring and diagnostics? New drugs and new treatments to treat critically ill patients? No one can know for sure.”

He said that one thing can safely be assumed though: there will be an ever-rising number of critically ill patients to be cared for. Over the last decades, outcomes in these patients have improved steadily. There never was, however, any “magic bullet” that led to a drastic change in measurable outcomes in this patient population. And there probably never will be.

Dr Zajic said: “Partly because past efforts to improve care were employed in patient groups rather vaguely defined by syndromes, the majority of trials failed to demonstrate improvements in outcomes. Therefore, much is still unknown about the ideal care for critically ill patients.”

He concluded: “So, the next big thing in critical care will most likely neither be a machine nor a drug. It will much rather be means and methods to identify patients that may profit most from treatments – or those that may actually be harmed. Several modes come to mind: genetic phenotyping may allow for more precise aiming of interventions; comprehensive data sets and modern methods of analysis may lead to a better understanding of real-world effects of interventions; alternative and variable endpoints in clinical trials may demonstrate benefits that remained undetected in the past. A way to integrate this information and make it applicable to the bedside may just be the next big thing in critical care.”

In the other talk, Professor Harald Wilschke (Medical University of Vienna) discussed the next big thing in emergency medicine.