Anaesthesiology Wakes Up

9 September 2007 (Last Updated September 9th, 2007 18:30)

Anaesthesiologists are having to adapt to a period of change as their practices and role come under increasing scrutiny. Nic Paton reports.

The top priority of anaesthetists and anaesthesiology remains patient safety, and much drug research now focuses on the task of reducing the side effects of the current generation of anaesthetics.

Dr Roberta L Hines, Nicholas M Greene professor of anaesthesiology at Yale University School of Medicine, says: "Morbidity and mortality rates are now very low, but memory loss in older patients post-anaesthesia, for example, is an issue, and is becoming a focus for research.

"Neuro-cognitive dysfunction following anaesthesia was first identified in a few cardiac surgery patients, but now we are beginning to see it more widely, which is disconcerting. So we are trying to look at the differences between anaesthesia products. It's a question of taking something that is very safe and making it even safer. It's about making drugs that are very specific, drugs that alleviate pain but have fewer side effects."

"Neuro-cognitive dysfunction following anaesthesia was first identified in a few cardiac surgery patients, but now we are beginning to see it more widely."

Another question exercising specialists is the lack of standardised definitions for events and outcomes in surgical anaesthesia. In a recent edition of the journal Anesthesiology, doctors Mark Warner of the Mayo Clinic and Terri Monk of the Duke University Medical Center warned that the absence of such definitions had major implications for anaesthesiology research and practice, as well as for public perceptions of anaesthesia care.

Their warning came in an editorial accompanying a study suggesting wide variation in definitions of intraoperative hypotension (IOH), or reductions in blood pressure. The Dutch research looked at 140 definitions of IOH from recently published reports. Lead researcher Dr Cor J Kalkman of University Medical Center Utrecht said: "We found that there is a wide variety of definitions of IOH and that, depending on the definition used, the frequency with which it occurs in surgical patients can vary from 5% to 99%."

TREATMENT PLANS

Hines argues that another issue in anaesthesiology is the time available for preoperative assessment and postoperative monitoring. As surgery becomes more advanced and less interventionist, it is often assumed that it will have less physiological impact on patients and that patients do not need the level of preoperative assessment and postoperative monitoring that they have had in the past. However, this may not always be the case.

Hines adds: "Anaesthesiologists already have less time to evaluate patients, because they are presenting closer to the day of surgery. A patient may come in for, say, a 45-minute procedure, but they could have seven co-morbid diseases. We must have to time to do a full pre-anaesthetic assessment."

Hines is also concerned that we are sending patients straight home after procedures that three or four years ago would have required a hospital stay, so the follow-up may not be optimal.

"I worry about the level of care that we can provide for some patients," she says. "I see patients in their 80s and 90s routinely coming back from surgery and being sent home, often to be cared for by an 80- or 90-year-old spouse. It is important for surgeons to understand that we do not have as much data as we would like about outcomes, and it is really important that we work together to develop appropriate new treatment plans."

CHANGING ROLE

Another big change in anaesthesia is the gradual movement of anaesthesiologists out of the operating theatre. "We are still primarily associated with providing care in the operating theatre, and I think that will continue," Hines says. "But we are now caring for patients in a variety of clinical settings, particularly in perioperative care, and being more involved in pre-operative assessment."

"Extending the anaesthesiologists role into surgical territory could be the logical next step – they could also move into the field of pharmacology."

Anaesthesiologists are beginning to take on the role of 'hospitalist'. The term 'hospitalist' first emerged in the US in the late 1990s. Hospitalists are essentially inpatient physicians who spend more of their time managing medical inpatients than primary care physicians do.

The idea of anaesthesiologists taking on the role of surgical hospitalist has been discussed in the medical profession. Although it risks treading on the toes of surgeons, extending the anaesthesiologists role into surgical territory could be the logical next step – they could also move into the field of pharmacology.

"Surgeons are being asked to spend more and more time on procedures to generate income, and they have less time and resources overall," says Hines, "so this is something that is being talked about."

Anaesthesiologists are already playing a greater role in areas such as interventional radiology, aneurism coiling, aortic stents and some gastrointestinal procedures, because of the need for sedation when dealing with sicker patients. So much so that, according to Hines, we are seeing the skillset moving out of the operating room.

"Moving out of the operating room is an even bigger issue in paediatric anaesthesiology," she adds. "[Anaesthesiologists] are increasingly dealing with MRIs and cardiac catheterisation where children need to be sedated." Anaesthesiologists could also become more involved in the management of paediatric and chronic pain.

"More children with chronic diseases are surviving, but they require chronic pain management," Hines says. "We have done a really good job in the adult world, but we haven't done as well in the paediatric world."