Anesthesia as a field has greatly expanded in the recent years. It is progressing in leaps and bounds. The spectrum of anesthesia has now sheltered not only operative patients but also patients with chronic pain, terminal illnesses and cancer. With a brief prologue to changes in the field of anesthesiology, this article focuses on palliative care, chronic pain management and perioperative medicine.

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spinal anesthesia

Image: “Spinal anaesthesia.” by User:MrArifnajafov – Own work – Privatarchiv Foto von MrArifnajafov Yükləyənin öz işi. License: CC BY 3.0


Changes in Anesthesiology

Medicine has matured over the century and has become sophisticated and well-organized. The operating room (OR) is no exception. The modifications in the OR have altered the perspective and mutual behavior of its inhabitants, brought in the concept of “team spirit”, upholding the greater good of the patient at the pedestal, affecting one and all, including the anesthetics.

Changes in the team structure

There are evident changes in the behavior of the team in the operating room. The surgeons, anesthesiologists and the nursing staff form the core team. All three need to maintain a harmonious balance. Good teamwork, improved interpersonal relations and communication skills evidently culminate in improved technical performance, non-technical skills and the operative outcomes. Non-technical skills encompass cognitive and social responsibility around the OR and are largely dispensed by the nursing staff.

Interdisciplinary simulation-based team training is feasible and well acknowledged by surgical teams.

Watchful monitoring and surveillance makes it feasible for hospital systems to be aware of bad behavior. The relationship between surgeons and anesthesiologists is more collegial. The system is set up to support the surgeon and provide assistance during the operation, as a team.

There is great respect between the surgeon and the scrub nurse. Nursing personnel is more ensured of their own rights. The skills of the nurse are vital for smooth execution of the operation. They are:

  • Bring equipment in the OR
  • Take equipment out of the OR
  • Provide information to the waiting areas
  • Notify the recovery room and the holding area
  • Support to the anesthesiologist.

Critical evaluation of the team as a whole to ameliorate per-operative adverse events is receiving considerable attention. The ultimate goal is to enhance safety in surgery and excel the team performance.

Anesthesiologists have dared into ventures of great significance in the modern times. While more than half of the population is plagued by chronic pain, cancer and other terminal illness are truncating the quality of life. It is a paradox of the 20th century, that life expectancy has increased but the quality of life of the terminal years has not escalated in a parallel manner. The involvement of anesthesiologists in new areas has been elaborated below:

Palliative Care

The concept of “palliative care” was proposed by Kristjanson et al in 2003. They hypothesized the “palliative approach” to emphasize the need for palliative care in diseases other than cancer. They proposed care for those patients with terminal chronic illnesses who may not be served with specialized palliative care services, but rather be comforted by identification of their end of life concerns way earlier in the course of their disease progression.

In the same vein, the World Health Organization (WHO) defined “palliative care” as an approach that is applicable early on in illness trajectories. It has been incorporated in their cancer control strategy.

The Worldwide Palliative Care Alliance (2014) attested and acknowledged the WHO definition stressing that palliative care be affirmed by all, not just by professionals trained in palliative care.

Other terms coined as adjuncts to palliative care include “early palliative care”, “geriatric palliative care” and “dementia proofing end of life care”.

Healthcare initiatives intended for palliative care include Australian Palliative Residential Aged Care (APRAC) Project and the Program of Experience in the Palliative Approach funded by the Australian Government; and Gold Standards Framework initiated to enhance primary palliative care in the United Kingdom. These organizations have stimulated research in palliative care and have provided impetus for development of guidelines for enhanced end of life management.

The iPANEL team (Initiative for a Palliative Approach in Nursing: Evidence and Leadership) addresses multiple primary research questions pertaining to palliative care. They emphasize on healthcare systems policy, education and practice guidelines for palliative care.

Thus, palliative medicine entails care of patients who are dying. It is the management of pain, depression and immobility. Historically, palliative care has been managed by family doctors and internists – not anesthesiologists. The ability to provide patient controlled analgesia (PCA), epidural analgesia and interventional treatment such as spinal cord stimulation to improve the life experience of terminal pain has brought anesthesiologists to the forefront of palliative medicine.

Ultrasound guided regional blocks are also useful for some patients and can be provided by ultrasound trained anesthesiologists. There is increasing emphasis in using non-opiate drugs in palliative care patients. Again, the experts from anesthesiology are well equipped to provide this care.

Chronic Pain Management

30% of adults suffer “chronic pain” at any given time. In temporal terms, any pain lasting for more than 3-6 months is called “chronic pain”. Of these, about 2% have disabling pain, while 12 % have severe pain.

Multidimensional Pain Inventory (MPI) is an inventory designed to assess chronic pain.

Pain is reported by 30-50% of cancer patients on treatment and by almost 70-90% of those with terminal disease.

WHO has devised a “three-step-ladder” for cancer pain relief in adults. A two-step-ladder has been developed for pediatric population.

This approach recommends administering the right drug at the right time, rather than “on demand” drug administration. It is relatively inexpensive and 80-90% effective.

The pain relief ladder can be tabulated as:

Step in the ladder

Treatment options

First step

Non-opioid analgesic (aspirin and paracetamol) with/ without adjuvant therapy (additional drugs to calm fears and anxiety)

Second step (if pain is persistent/ worsened)

Opioid for mild to moderate pain (codeine) with/ without non-opioid and adjuvant therapy

Third step (if pain is persistent/ worsened after the second tier of management)

Opioid for moderate to severe pain (morphine) with/ without non-opioid and adjuvant therapy

Surgical intervention is considered if these drugs are not completely effective.

Analgesics, opiates have been used for management of refractory pain for times immemorial. Opiates represent the most potent and reliable analgesic agents.

Analgesics have revolutionized the patient management in many ways. But, in human hands, these drugs are fraught with complications such as drug overdose, toxicity, side-effects, withdrawal, tolerance, dependence, abuse and systemic complications. Hence the latest rank in the hierarchical management of pain is “NO” analgesics.

Terminal cancer patients and those with advanced diseases are positively encouraged to resort to adjuvant therapies like music therapy, yoga and meditation. Many patients seek solace and comfort in these modalities.

Evidence indicates that only a multi-disciplinary “pain team” can be successful in treating chronic pain. There is vast need for specialized physicians for pain management. Anesthesiologists are the leaders in this process. The Australian model is the best way for management of chronic pain.

Professor Michael Cousins is the world leader for developing chronic pain management programs.

The impact of comprehensive chronic pain management under able guidance of anesthesiologists on our populations is hard to overemphasize given the vast number of people suffering from chronic pain.

Perioperative Medicine

Perioperative medicine is not a subset of internal medicine or family medicine but a component of medical sciences that endeavors to optimize medical illness during the perioperative period, assess operative risk-versus-benefit ratios and emergently manage complications.

The natural choice for perioperative medicine expert erroneously seems to be physicians. Evidence attests the fact that even though adept in medicine illness, drug dosages and management of chronic conditions, physicians lack the insight to management of pain, anesthetic drugs and perioperative complications prevalent in few chronic medical illnesses secondary to the stress of surgical intervention.

In pre-operative evaluation, most physicians have been found to use all basic investigations as “routine” work-up. This practice is strongly condemned by the American Society of Anesthesiologists. The society upholds that preoperative tests should be performed scrupulously to enhance perioperative management. The guidelines urge that patient information as recorded from the medical records, patient interview, and physical examination and the anticipated nature of the surgical intervention planned should determine the tests needed.

Also, many primary care physicians fail to appreciate the physiologic changes underlying varied anesthetic procedures such as induction of anesthesia and intubation. They were less proficient in assessment of pharmacodynamics, safety and efficacy of regional anesthesia in different circumstances. Indeed, an insight for expected hemodynamic changes during the perioperative period ensures better patient preparation.

As the “team concept” takes on in almost every walk of medicine, cooperation between anesthesiologists and physicians to improve perioperative care is nearly inevitable in the near future. Indeed, perioperative medicine essentially involves conditions conducive to the anesthesiologists seeing patients routinely before surgery. Patients with serious medical problems are best prepared by the anesthesiologists. Special internal medicine problems such as diabetes, heart failure or rheumatoid arthritis are well handled this way.

Advancements in perioperative medicine stands to ensure formulation of apt guidelines, protocols and algorithms to objectively teach, promote and assure safe and customized perioperative care.

Changes in the Care of Patients

Technological advances have moved hand in hand with scientific research and progression. New equipments in our armamentarium have made surgical interventions more safe and effective. To ameliorate the anesthesiologist’s trouble in times of intra-operative crisis, few simple but highly relevant instruments are discussed below:

Pulse oximeter

pulse oximeter

Image: “Pulse oximeter.” by Rama – Own work. License: CeCILL

Pulse oximetry is extensively used for monitoring a person’s oxygen saturation. So there is enough time to deal with a problem before the patient arrests. Consequently, there is mark decrease in the numbers of operating room deaths.

End-tidal CO2 concentration monitor (EtCO2)

End-tidal carbon dioxide assessment helps predict whether the ventilation of the patient is right. Introduction of the small fiber-optic bronchoscope has been of immense assistance in specialized circumstances such as one-lung ventilation for numerous thoracic surgical procedures.

Better care of acute pain through anesthesiologists has positively enhanced patient comfort and patient satisfaction from surgical interventions.

Other Potential Visions

The scope of anesthesiologists has scaled new heights. Envisaging greater leaps in future are few of these predicaments:

  • The anesthesiologist becomes the hospital physician for surgical patients.
  • The anesthesiologist takes care of the patients prior, during and after the surgery.
  • The anesthesiologist is the ideal physician to care for medical problems even outside the hospital.

Summary

There have been radical changes in anesthesiology. Sophisticated behavior of surgeons, nurses and anesthetists in the OR, the rising concept of “surgical team”, interdisciplinary cooperation and enhanced communication skills are all positively encouraged to ensure improved patient care and surgical outcome.

Palliative care is an emerging subspecialty of medical sciences, which aims to start end of life care early in an anticipated manner in patients with steep illness trajectories. It is highly specialized and anesthesiologists have a significant role to play in the same.

Chronic pain is a vice of modern life and is here to stay. Armed with multiple drugs, interventional procedures meant to ameliorate pain, anesthesiologists have a definitive role to play in pain management.

Perioperative medicine encompasses complete comprehensive management of chronic medical illnesses of the patient in the light of the planned surgical procedure. The mutual effects of the medical illnesses and the surgical procedure are best realized by anesthesiologists and anticipated aggressive action taken can potentially evade patient morbidity.

Thus, the future of anesthesia is promising.

Review Questions on the Future of Anesthesia

The correct answers can be found below the references.

  1. Which of the following is an example of palliative care organization?
    1. PAIN project
    2. EPIC project
    3. APRAC project
    4. VANTAGE project
  2. Which of the following is not true regarding chronic pain management?
    1. Opiates are the most potent drugs for chronic pain management.
    2. Chronic pain affects almost 30% of the population.
    3. WHO has proposed a three-step-ladder for pain management in adult cancer patients.
    4. WHO has proposed a three-step-ladder for pain management in pediatric cancer patients.
  3. Who is potentially better placed to be a perioperative medicine expert?
    1. The anesthesiologist
    2. The surgeon
    3. The scrub nurse
    4. The physician
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