The Silicon Takeover

The Silicon Takeover

Session took place on Saturday 2 June

One of the highlights of the Saturday sessions at this year’s Euroanaesthesia was ‘the silicon takeover’ that looked at automation within anaesthesia and what we may see in the future.

“We are not yet obsolete,” said Professor Oliver Kimberger (Medical University of Vienna, Austria), who gave the first presentation.  “In 2016 the plug was pulled on the world’s first commercially available anaesthesia robot: Sedasys (Ethicon, Inc.) at the young age of only seven years. What was Sedasys? A pharmacological computer-assisted personalised sedation robot, delivering mild to moderate sedation for endoscopies via automated propofol infusion for use in healthy patients.

Professer Kimberger asked in his talk what can we learn from this disruptive technology, saying that firstly, the device was aimed at non-anaesthesiologists to allow them a safe administration of propofol, fueling the debate about propofol in the hands of non-anaesthesiololgists. Secondly, for safety reasons, Sedasys provided anaesthesia erring rather on the lighter than on the deeper end – thus probably limiting patient and endoscopist satisfaction. Finally, financial incentives to purchase the device were missing, since anaesthesia charges were mostly reimbursed for endoscopy in the USA. Consequently, only a few of the devices were reportedly ever sold.

He concluded: Yet, the computer-assisted personalised sedation device Sedasys has to be seen as just the dawn of what is to come. It is right now that we need to deal with ethical, social and practical issues regarding artificial intelligence, machine learning and robotics in anesthesia and intensive care and actively participate in shaping our (inevitably) silicon based future.

“How automatic, real-time systems can support clinical decision-making” was the subject of the talk by Dr Alexandre Joosten, Erasme Hospital, Brussels, Belgium. He discussed Dr. Lucian Leape, MD: a physician and professor at Harvard School of Public Health, who has been very active in trying to improve the medical system to reduce medical error.  In 1994, Dr Leape published an article, Error in Medicine, in JAMA[1]which called for the application of systems theory to prevent medical errors. He also wrote: “Incompetent people are 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it is the processes that set them up to make these mistakes.”

In his lecture, Dr Joosten emphasised that today, there are large inconsistencies in the management of patient during the perioperative period.  He demonstrated through different examples how decision support and closed-loop systems can help reduce process variation; and also explained the potential benefits of using such technologies in the operating rooms. He said: “The main goal of this is to ensure consistent and cost-effective perioperative system performance”, before describing some closed-loop systems that his team is using on a daily basis in his institution (Erasme Hospital, Brussels Belgium) to ensure the delivery of highly reliable care.

He concluded: “I think that the use of clinical decision support and closed-loop systems in the operating room continues to accelerate, as evidenced by the growth of adoption of electronic health records and anaesthesiology information management systems. Researchers all around the world are actively developing and publishing data on exciting and innovative tools which have the potential to drastically improve the delivery of care.”

In the final talk, Dr Frederic Michard (Lausanne, Switzerland) addressed the future of haemodynamic monitoring. This was recently summarised by the mnemonic “NEWS”, that stands for Non-invasive, Ergonomic, Wearable and Smart(1).

Non-invasive solutions are becoming available to continuously monitor blood flow (bioimpedance tracheal tubes, bioreactance surface electrodes) (2), blood pressure and flow (volume clamp methods, applanation tonometry) (3), and central venous oxygen saturation (near-infrared spectroscopy) (4).

Echo-Doppler devices are becoming smaller and cheaper, transthoracic probes can now be connected to smartphones (5), and simulation boosts the clinical adoption of ultrasound techniques. Disposable transesophageal echocardiogram (TEE) probes are also available for continuous (up to 72h) qualitative evaluation of right and left ventricular function in mechanically ventilated patients (3).

Ergonomic monitoring systems such as gloves, shirts, or helmets with multi-tasking sensors should become available soon and will facilitate data integration, a key component of haemodynamic evaluations (1).

Finally, Wearable sensors will give us the opportunity to expand physiologic monitoring to ambulatory patients on the wards and beyond (home monitoring) (6). Such sensors already enable the continuous monitoring of heart rate, respiratory rate, SpO2, axillary temperature, and the detection of changes in blood pressure and thoracic fluid content.

Dr Michard concluded: “The flow of data (big data) generated by these sensors will be crunched by smart software enabling data filtering, data fusion and visual display (7). Predictive analytics and machine learning systems may help to detect clinical deterioration at an early stage and trigger proactive interventions (1).”

 

References

Dr Joosten: 1Leape LL, (1994) Error in medicine. JAMA : the journal of the American Medical Association 272: 1851-1857

Dr Michaud:

  1. https://www.ncbi.nlm.nih.gov/pubmed/28124086
  2. https://www.ncbi.nlm.nih.gov/pubmed/29516119
  3. https://www.ncbi.nlm.nih.gov/pubmed/28605474
  4. https://www.ncbi.nlm.nih.gov/pubmed/29777262
  5. https://www.ncbi.nlm.nih.gov/pubmed/29046768
  6. https://www.ncbi.nlm.nih.gov/pubmed/27566472
  7. https://www.ncbi.nlm.nih.gov/pubmed/26885656