Australasian Anaesthesia 2011 - Australian and New Zealand ...

204 Australasian Anaesthesia 2011What next for anaesthesia in Australia? 205in the media. 5,6Anaesthesia has been applauded for its progressive improvement in patient safety. Mortality, directly attributedto anaesthesia, is probably 1 in 100,000 patients having anaesthesia. This figure has propelled anaesthesia to bea leader in patient safety. It seems difficult, or even unnecessary, to spend further resources on reducing the verylow rate of anaesthesia related mortality. However, this mortality rate is only a short-term measure. Emergingevidence now indicates that anaesthesia has an important influence on long-term morbidity and mortality. 7 Thiscan be months or years after surgery. Although our anaesthetic drugs are shorter and shorter acting, they can haveimportant consequences due to interference with organ function in the perioperative period. Examples of anaesthesiarelated long-term morbidity include cognitive dysfunction 8 wound infection, persistent pain 9 and cancer recurrence. 10This effect is further exacerbated by undertaking surgery in sicker patients who have diminished ability to withstandthese effects. What of the potential effects of the general anaesthetic state itself? Accumulating evidence fromseveral observational trials indicates that deep, prolonged general anaesthesia increases long-term mortality. 11Future improvements in anaesthesia care will need to measure and improve these long-term outcomes. Long-term,disability-free survival is an important goal for future anesthesia care.COST OF HEALTHCAREThe escalating cost of healthcare is an increasing concern, and it has no clear solution. The rate of medical inflationcontinues to outpace general inflation. It is fueled by the introduction of new drugs and technologies that are moreexpensive than the older ones they replace, and the care of elderly patients near the end of life. Unfortunately, whilewe would all wish for the best possible treatments, there are economical limits to what even the wealthiest societiescan provide. All scarce economic resources are rationed and this is accepted in other areas of our lives. If thecurrent growth of medical inflation is to continue unchanged, then the proportion of GDP in Western societies willeconomically cripple future generations. The Australian Treasury estimates that by 2050 spending on healthcarefor those aged over 65 will increase 7 times and for those aged over 85 will increase by 12 times present-daylevels. 12 Recent US data shows that the elderly undergo high rates of surgery towards the end of their life. 31.9%had surgery within the last year of life and 18.3% within the last 30 days of life. Interestingly this treatment intensityat the end of life varied by a factor of three across regions and was strongly associated with the number of hospitalbeds and surgeons per capita. This calls for all physicians to identify and recommend appropriate treatment goalsfor the elderly and their families. 13Each of us has a maximum price we would pay for treatment that will extend our life by an extra year. This hasbeen examined by the eminent bioethicist, Peter Singer, at Princeton. 14 A suggested approach is for each speciality,including our own, to decide on which tests or treatments are expensive, yet make no improvement to patientoutcome. 15 For anaesthesia this could begin with reviewing preoperative testing, choice of anaestheic drugs andtechniques, and then extend to preventing futile surgery. The decision to operate is traditionally left to the surgeonand their consultation with the patient. However from time to time these decisons may not benefit the patient foreither a cure of disease, or palliation. Surgeons may feel more comfortable to operate than to advise the patientnot to have surgery.The treatment of the very elderly has caused a reassessment of the benefit of medical treatment regarding lifeexpectancy and quality of life. It has been argued that treatment of single-organ diseases in the very elderly doesnot increase longevity due to the concurrent effect of multiple diseases in the elderly patient. For example, thetreatment of hyperlipidaemia with statins in the elderly reduces cardiac deaths, but does not reduce all-causemortality. 16 Consequently, the focus on treating one isolated illness in a very elderly patient may produce no benefitin longevity. This is because one of the other multiple morbidities of the elderly will step in to take its place.RISK AND OUTCOMEMajor surgery in the elderly typical carries a 5%, 30-day mortality. 17 This problem has been referred to as the‘forgotten group’ in surgery. 18 This issue is further exacerbated when the high-risk elderly patient has a prolonged,stormy and expensive recovery in the intensive care unit. Ultimately this produces no benefit for the elderly patientand diverts resources away from other more beneficial areas of care.How can we predict which patients are at high risk having surgery and anaesthesia, and how can we reducethis risk? The multi-factorial cardiac risk assessment index was first published in 1977 and the most recent updatewas in 1999. 19 However, since then there have been significant changes in the techniques of surgery and anaesthesiaalong with the characteristics of patients presenting for surgery. The VISION study is an observational study of40,000 patients that is aiming to answer some of these questions. It will develop a new predictive model of patientrisk and particularly look at the value of biomarkers such as brain natriuretic peptide (BNP) and high-sensitivitytroponin. When a high cardiac-risk patient is presented for surgery what preventive drug strategies do we haveavailable? Until recently, perioperative beta-blocker therapy was commonly advocated as beneficial, but doubtabout this therapy has followed the findings of the POISE I trial. The POISE II trial, which is currently recruiting, willexamine the effects of other drugs such as aspirin, clonidine or their combination to reduce cardiac events.The approach of using a single-therapy intervention to improve patient outcome and recovery after surgery hasbeen criticised. 20 This has lead to the growing adoption of multimodal interventions. These are commonly referredto as ‘fast-track surgery’ or ‘enhanced recovery after surgery (ERAS)’. They typically involve a combination of pre,intra, and postoperative interventions (‘bundles of care’) to improve patient outcome. This has seen significantuptake in several European countries with initiation of government-funded programs. This approach is yet to seespecific government or non-government financial support in Australia but this would be likely to change in thefuture. The components include interventions such as regional anaesthesia, minimising systemic opioids, nutrition,goal-directed fluid therapy, pain relief, and early mobilisation. Anaesthetists, by having a central role throughout apatient’s surgical care, are well placed to lead in this reorganisation of practice. In the future there is a need todetermine which components are the most important and which are not worthwhile.ROLE OF THE ANAESTHETISTWhat are the attributes that an anaesthetist should have in the future? Is it enough to be an expert in the knowledgeand skills of anesthesia alone? This is being addressed through the development and introduction of the newANZCA curriculum. Traditionally, the role of the anaesthetist is considered to be a medical expert. This is coveredby the attributes of knowledge and skill in the realm of direct patient care. With the changes that have occurred inhealthcare, society and patient expectation there is a recognised need to broaden the attributes of a good anaesthetist.These broader roles have been developed and promoted by the Royal College of Physicians and Surgeons ofCanada in 1996 and were updated in 2005. This framework has had widespread acceptance in medical educationand has been adopted in many universities and medical colleges. Importantly it emphasises the non-traditionalattributes which make up the broader role of a medical specialist in contemporary society. These includethe attributes of scholar, educator, communicator and manager. These are described further in the CanMEDSdocumentation. 21INFORMATION TECHNOLOGYHealthcare has lagged behind in the adoption of information technology (IT). We are familiar with and use thebenefits of modern IT in our lives every day. Most of us are users of internet banking, social media, email, Wikipediaand Google. We all expect banks, insurance companies and major companies to use IT in their activities. Yethospitals and healthcare still cling to paper-based records. Patient records are called ‘patient notes’ because theyreally are on paper. X-rays and pathology results are still mostly paper or film based. Medications are prescribedin barely legible handwriting on medication charts. Medication errors are a common cause of preventable patientharm. Electronic medication management systems can have inbuilt decision support to prevent allergic reactions,drug interactions and wrong doses. This physical record system is made more problematic when patients haveattended several hospitals, doctors and pharmacies in the past. This results in fragmentation of patients’ healthinformation and the risk of losing critical information. This has left us stuck in the traditional practice of eachundertaking and redoing, a clinical history, a medication history and a physical examination. Tests are repeated justbecause old results are lost, or not readily accessible. Old patient files are not easily obtainable especially in anemergency. These are the obvious weaknesses and risks of continuing with our current paper-based work-practices.Why have anaesthesia and the rest of medicine been so reluctant to adopt IT systems? Key reasons are the needfor mobile access and adequate software design. Unlike workers in the corporate world, we do not stay workingin one location. Throughout the day we move from wards, to clinics, to operating rooms and recovery rooms. Theconventional work practice of sitting in front of a PC at each location is time consuming and distracting. Typicallythe software available has a sub-optimal user-interface that further adds to non-acceptance. However these hurdlesnow seem to be surmountable. We are now seeing the widespread uptake of affordable mobile computing, suchas tablets and smart phones, which are easy to use and carry throughout the day. When coupled with wireless dataaccess it seems that we may soon see the acceptance and widespread uptake of this new technology in ourclinical practice.Will technology eventually replace the anaesthetist? Current developments suggest the introduction of computingto replace the decision making of the anaesthetist could happen. This seems likely, with Ethicon seeking FDAapproval for its SEDASYS system for propofol sedation during colonoscopy. 22 This system has recently been givenapproval for use in patient sedation for endoscopy in Europe, Canada and Australia. A recent study showed thesystem produced better and safer sedation for colonoscopy than physician-administered sedation. 23 A furtherdevelopment is the fully computerised delivery of general anaesthesia using a system developed at McGill Universitycalled “McSleepy.” 24 Recently, McSleepy has been teamed up with the Da Vinci surgical robot, to together treat apatient having a prostatectomy. 25 Fortunately the aim of the researchers who developed McSleepy is to ensure thedelivery of consistently high quality anaesthesia despite any idiosyncratic human vagaries.CONCLUSIONThe future is approaching us whether we pay attention or not. With the changes in politics and society, we neglectit at our peril. For the advancement of anaesthesia as a specialty, and for better patient care, we must be proactiveabout our own future. To ignore this call is to leave our profession at risk. Peter Drucker, the preeminent managementthinker, said “The best way to predict the future is to create it.” 26 We should heed his advice.