New Technology, New Thinking

Two papers in this issue of Anesthesia & Analgesia collectively make an important point about the introduction of new technology to medical practice.1,2 Progress should occur not just through making old procedures more efficient or safer but also through creating new possibilities. When we add something new to our practice, we should learn to ask the question: “If we were starting from scratch, how would we use this tool?” The papers by Beccaria et al2 and Sappenfield et al1 both discuss a different approach to central venous catheter (CVC) insertion—direct access of the brachiocephalic vein. While this approach was first postulated many decades ago,3 it was not favored over either internal jugular or subclavian vein access in the era when lines were placed based on anatomic landmarks. With the advent of ultrasound guidance, this may be changing. Ultrasound to facilitate internal jugular vein cannulation, either static (look and then stick) or dynamic (stick while looking), has a number of potential benefits, many of which have been well documented. Speed of placement, fewer attempts, and reduced complications have all been described. Secondary benefits such as reduction in infectious complications have been suggested. But what if ultrasound could do more than merely facilitate an existing procedure? What if the ability to directly examine the patient’s anatomy could lead to a new approach to CVC placement? The papers by Beccaria et al2 and Sappenfield et al1 suggest that the direct brachiocephalic approach—guided by ultrasound—is at least a viable alternative and may even offer advantages to the more traditional approaches. As ultrasound technology improves, and ultrasound machines become a ubiquitous part of the clinical environment, it is possible that other new approaches to old clinical needs will be discovered. This is already happening in ultrasound-guided regional anesthesia practice. A number of blocks that were challenging when based on anatomic landmarks are now easy with ultrasound guidance. These include transverse abdominal plane blocks, midfemoral sciatic nerve blocks, and interscalene blocks. A new paradigm for nerve blockade, enabled by new technology, has led to significant change in clinical practice. Ultrasound in a different form—transesophageal echocardiography—has produced a paradigm shift in the assessment of cardiac function that has rendered obsolete the venerable pulmonary artery catheter. The ability to directly examine cardiac filling and myocardial contractility—not to mention anatomy, valve function, and embolism—has greatly advanced the subspecialty of cardiac anesthesiology. Use of transesophageal echocardiography and surface ultrasound to facilitate the diagnosis of cardiovascular conditions in the intensive care unit and emergency department is becoming commonplace. The paper by Sappenfield et al1 includes another disruptive technology: simulation. Rapid advances in information technology and steady improvements in “hands-on” simulator equipment have enabled more realistic simulation of anesthesia procedures and cases. Simulation is now a required part of the medical school curriculum, anesthesiology residency, and board certification. This a disruptive technology based on the idea presented above: simulation is not just delivering traditional anesthesia education faster or better, rather simulation is leading to an entirely new approach. We do not have to let trainees learn procedural skills on live patients anymore, nor are we concerned that they might not experience rare critical events. Instead, we can provide a curriculum that we know is complete, and deliver trainees to the bedside with a much greater fund of knowledge and skills than ever before. This capability will expand even faster as simulation capability advances. We are now moving from expensive and immobile simulation centers to on-the-fly bedside and unit-based simulation, simulation integrated into real clinical equipment (eg, in surgical robots), and even simulation based on video game technology. As screen-based simulation takes off—as in the American Society of Anesthesiologist’s recent SimStat offering4—it will become ever easier to deliver critical clinical education outside of the operating roomo (OR) and even outside of the traditional classroom. One can imagine a day not far off when all anesthesiologists, just like all pilots, will periodically train in simulated cases. Cognitive skills will be acquired through screen-based simulation delivered inexpensively to the anesthesiologist’s home computer, while both cognitive and technical skills will be learned in “full-mission” simulation that will include not just the look and feel of a real OR but also random anatomic and physiologic variations, just like in real patients. New medications are a common source of incremental improvement, but also present opportunities for big-picture disruption. Sugammadex was developed to improve the speed and completeness of reversal of neuromuscular blockade, but in turn this might fundamentally change how we provide anesthesia for some kinds of cases and patients. Deeper relaxation—provided in the confidence that it can be fully reversed—may change the approach to short, painful procedures. Today it is common in private practice to use smaller than desired doses of muscle relaxation for intubation because the case itself will be short. This doubtless leads to greater struggle with intubation, and potentially to greater harm in the process. On the surgical side, those last few minutes of a laparoscopic or robotic procedure might be easier (and quicker and safer) with full relaxation than with the present state of partial block in anticipation of case completion. Time will tell. There is 1 new-technology paradigm shift that is still in the making: the potential for information technology to change how we document anesthesia cases. Despite advances made in the ability to digitize and store data, the anesthesia record of today still looks and feels like the anesthesia record of yesterday, albeit more legible. Electronic anesthesia charting still requires substantial input from the anesthesia provider—in fact, often consuming more time than the paper it replaces. Where is the promised advance? Why can we not passively record all the patient’s vital signs and all the time points of a case? Medications and doses could be captured through a barcode system reading prefilled syringes. Patient position and the phases of the surgery could be captured from sensors in the operating room. Indeed, all of the provider’s activities could be captured by continuous video monitoring, and stored for future reference. Imagine being able to view a previous intubation effort in real time, rather than trying to decipher it from a record written in haste after the fact. The potential for this kind of technology to change the practice of anesthesiologists is real, but so far realized only in isolated research settings.5 Why should an anesthesiologist need to waste even 1 moment in nonpatient facing activity? Many might decry such an advance as an unwanted intrusion into the privacy of our practice, yet it is already happening. Cell phone usage records are the first documents subpoenaed in many malpractice cases now, because they show where the providers were and provide insight into what they were doing. Pretending that this technological genie is going to go back into the bottle is unrealistic—rather we should embrace the capability and put it to work for ourselves and our patients. Changing the entire face of anesthesia practice is a long way from a small improvement in the speed of central venous catheter insertion, but the underlying concept is the same. If we really want to advance our profession, we must learn to think about every new bit of technology in a different way—not just as an incremental advance, but as the opportunity to make fundamental changes in how we function. This is the pathway to progress. DISCLOSURES Name: Richard P. Dutton, MD, MBA, FASA. Contribution: This author conceived this editorial and wrote it himself. This manuscript was handled by: Avery Tung, MD, FCCM.