January FY21

[clawry]

This month's journal article has been submitted by Ben Waldbaum, CRNA. The editorial is titled Robots Will Perform Anesthesia in the Near Future. Robotic anesthesia, defined as anesthesia delivered by an automated control system, will soon become available. Automation and artificial intelligence utilization are increasing across many industries with improved results, cost savings, and better efficiency. Nearly 15 years ago GE developed Sedasys, which is 1st generation closed loop robot FDA approved for the delivery of anesthesia in specific situations. Because of its narrow approval, its market use is limited. Given the cost pressure on hospitals, and the reality that most anesthesia groups survive only through hospital subsidies, the unfortunate reality is that there will be continued pressure to lower anesthesia costs. Interestingly, more than 90 percent of the costs of an anesthesia group is from the salary and benefits of its staff. Equipment and supplies are usually only around 10 percent. This means opportunities for meaningful cost savings are more substantial with cutting salary and benefits. Currently, many hospitals have increased use of CRNAs which saves money from the salary of paying an anesthesiologist. These cost savings seem to not be enough as anesthesia groups across the country continue to have financial stability issues.



The attached editorial from Anesthesiology is a glimpse into the future that more and more anesthesia will be provided by robots. Below are 2 questions to think about.


1.) Assume that closed loop robots will be implemented and FDA approved for major surgical procedures and that an anesthesiologist could supervise multiple robots. What can a CRNA do now to preserve their role in the perioperative care of the surgical patient?



2.) Artificial intelligence is being utilized more and more every day. What safety mechanisms would you suggest to make an anesthesia robotic safe?


Here is a link to the article.

[clawry]

1.) Assume that closed loop robots will be implemented and FDA approved for major surgical procedures and that an anesthesiologist could supervise multiple robots. What can a CRNA do now to preserve their role in the perioperative care of the surgical patient?

Support the AANA and state PAC. Become involved in a leadership position with MANA or AANA. Practice to our full scope of practice to maintain higher level skills such as epidurals, blocks, central lines, etc.



2.) Artificial intelligence is being utilized more and more every day. What safety mechanisms would you suggest to make an anesthesia robotic safe?

Ensure that the most up to date drug information is uploaded into robot. Make sure that the robot can adjust for ages across the spectrum and various comorbidities where drug dosages would need to be adjusted, such as cardiomyopathy and renal failure.

[LarSharVeA Bailey]

Closed loop robots WILL undoubtedly be approved for major surgical procedures in the near future. There are run of the mill cases that somehow make a catastrophic turn everyday, so the elimination of human error should be well received. To maintain our place in the field of anesthesia, CRNAs must be proactive in roles of developing and implementing said healthcare artificial intelligence. Inventing, training, trialing, and participation in the research and quality improvement processes is paramount.

The robot's ability to communicate with the patient must be infallible. I would love to have wireless, bluetooth monitors.

[Christine Velarde]

How do we keep CRNA relevant in a world full of robots? I think people always want the human touch no matter how far we are in the artificial intelligence world. We should be savvy in understanding the robot and making sure there are people to operate and explain the purpose of the robot. I do not think people would be comfortable knowing a robot will be giving them anesthesia. I agree that Bluetooth will help monitor a patient better.

[Kels]

In order to preserve our role in the perioperative care of the surgical patient I think getting involved with the robots as much as possible from the development stages to the maintenance would be helpful . The more we know about the robots the better and when the robots fail we can be there to intervene. I also agree that Bluetooh mechanisms would help with robot safety and a somewhat easy override button of the robot would be helpful .

[Shannon S. Yorkman, CRNA]

1.) Assume that closed loop robots will be implemented and FDA approved for major surgical procedures and that an anesthesiologist could supervise multiple robots. What can a CRNA do now to preserve their role in the perioperative care of the surgical patient?

Thank you for this topic. I love this kind of stuff. My rebuttal question is why can’t the CRNA supervise the robots? Seems to me that would be the most economical approach. This immediately comes to mind is because CRNAs currently operate efficiently all of the computers in the O.R. I have been asked on more than one occasion, by an anesthesiologist to set-up or troubleshoot an Alaris pump, BIS monitor, etc. We also are experts in anesthesia, sooooooo?

Also, the CRNA can invest in the anesthesia robot company and be part owner of the company. What’s the ticker symbol?


2.) Artificial intelligence is being utilized more and more every day. What safety mechanisms would you suggest to make an anesthesia robotic safe?

Safety measures would include an emergency stop button….kinda like the one on a Treadmill.

I guess a back-up robot.

Emergence – something that will absolutely ensure that the patient does not move or buck when emerging. Say for example, the robot is emerging and the count is off....will the robot be able to re-anesthetize in a timely fashion.....or will the patient have to continue to wake up and then be put back to sleep.

One of the reported complaints with Sedasys is that the patient was too alert and could not tolerate then colonoscopies. This was before the BIS monitor, so maybe that will benefit the automation more.

I believe the robot can certainly cover the science of anesthesia, but what about the art? The art of anesthesia is best displayed in the emergence in my opinion. Would love to see how that looks.

[Soo-Ok Kim]

Thank you for the great article to think about the future of anesthesia.

1.) Assume that closed loop robots will be implemented and FDA approved for major surgical procedures and that an anesthesiologist could supervise multiple robots. What can a CRNA do now to preserve their role in the perioperative care of the surgical patient?

The trend to use AI in health care setting including anesthesia is inevitable. We are already using robots for surgical procedure (abdomen, chest, even spine surgery, and bronchoscopy).
Shannon beat me the idea of CRNA supervising robots. I can imagine the robot can be controlled in the room with remote control device and information of surgical steps can be entered to adjust anesthetics.
We, as CRNAs, need to update the new knowledge and skills and can be pioneer in implementing safe anesthesia with robots.


2.) Artificial intelligence is being utilized more and more every day. What safety mechanisms would you suggest to make an anesthesia robotic safe?
On top of what was mentioned above, the strong cybersecurity measure is must and back up plan has to be in place in case robot fails.

[Jessica Hadley]

1. As CRNA's we can get involved in the development and integration of robots into anesthesia. The more we understand how the AI and robot algorithms work the more relevant we will be in operating them. I may be wrong but I don't foresee a time in the immediate future where a robot is giving anesthesia in an OR independently. Anesthesia technology has advanced tremendously from the days of open drop ether but so far an anesthesia provider remains an integral part of the team within the OR. Is the robot going to manage complications or massive transfusions. Will they be able to emerge independently if the supervising attending is busy with another OR?

2. As was mentioned before an easy off switch needs to be available in case of emergency. I also like Soo-ok's point regarding Cyber security needs as attacks become more frequent and sophisticated.

[Dahlia Rouchon]

The article provided gave pause for consideration of AI and anesthesia. It seemed interesting how the author frequently referred to humans as motor vehicles which can be programmed for care. The danger in this mode of practice is not substantial consideration to proactive anesthesia, management for example in anticipating large volume blood loss, managing unintentional vascular injury, air embolism, MH, or other sentinel events. The frequent insult to vigilance the author attributes to anesthesia providers as we don't frequently make adjustments to infusions or anesthetics was contumelious. There seems to be a fundamental vacancy of consideration given to the intuition that comes with anesthesia. When there is a picture or something not right with a particular clinical case. Not enough concern was addressed as well to other scenarios such as the comprehensive picture of electrolyte and systemic changes to surgical theatre during procedures. The numerous variables of comorbidities.
Anesthesia providers who manage a patient at a distance (monitoring suite) vs. in OR I believe diminishes the patient to an object and less care and attention, nay rather vigilance- the hallmark of anesthesia- is compromised.

1. So what can the CRNA do to preserve their role? serve on safety and clinical review boards to these procedures. advocate for the CRNA profession. speak up on patient security and welfare. Be at the forefront of experience to prove how prudent it is to have a CRNA caring for patients.
2. N/A. AI algorithms cannot replace human perceptions and discernment.

[kelseyleonard]

1.) Assume that closed loop robots will be implemented and FDA approved for major surgical procedures and that an anesthesiologist could supervise multiple robots. What can a CRNA do now to preserve their role in the perioperative care of the surgical patient?

Getting involved from the beginning in the advanced of these technologies is important for the CRNA to solidify their role in the perioperative period if and when closed loop robots are approved. The more we understand the algorithms, mechanics, advantages and disadvantages the more vital our presence will be.


2.) Artificial intelligence is being utilized more and more every day. What safety mechanisms would you suggest to make an anesthesia robotic safe?

I agree with others that it is hard for me to imagine a robot that can function completely or almost completely independent from a trained anesthesia provider. So much of what we do to care for our patients every day is proactive NOT reactive. Will a robot be able to notify the CRNA or "call for help" before there is a drastic shift in the patient vitals? Will the surgeons be able to communicate with the robot the way they do us now, altering us to issues happening on the field that immediately change our anesthetic technique, plan of care, etc that ultimately prevents a negative outcome before it happens? Our patient population at JHH is extremely diverse and their anesthetics are often times meticulously managed by the CRNA/anesthesiologist. I find it hard to believe that human intuition, critical thinking, judgment, and experience can be so easily replaced by AI.

[Anne McNulty CRNA]

This is many years away but inevitable. The ASA will be in control. CRNAs will Have to be competitively involved in development and use of the robotics. How will the programming algorithms anticipate intra- op events? There will be an endless need of supervision. Lets start with one robot at a time. Preserving your role will require expertise in many other skills. The lack of humanity involved may be tolerated as we may have chips implanted in our brains and cell phones implanted in our hands. there will be more professional strife than exists now.

[Ben Waldbaum]

1.) I think we need to realize that money talks, and especially when utilization of robots may be cheaper and provide better outcomes. Artificial intelligence is the way of the future. If we want to preserve any role in the OR, CRNAs need to realize this is the future and embrace it. With this embracing, real discussion of ideas on what the role of the future CRNA will be can occur.

2.)I think safety mechanisms are best developed with iterative simulation.

[Belinda G]

I agree with Chris, Shannon and Jess, Dahlia and Kelsey- I'm sure AI will be coming to an operating room near you soon (as far as anesthesia) but I think as Chris stated we can't underestimate the importance of human touch and empathy that a robot can't provide. I have a hard time believing that anyone would be OK with an MD hooking a patient up to a machine and then waking away for the duration of the case which it sounds as though this is what the writer is describing. This may work OK in some sedation situations but a huge part of our job is to be vigilant, make changes in our anesthetic based on dynamic changes that frequently occur during any case often before hemodynamic or respiratory changes happen. This comes with experience, vigilance, communication and not being a robot! And, also is different from patient to patient and procedure to procedure. Who is managing the airway in these sedation cases? And does the robot know to communicate bradycardia to the surgeon and pretreat or treat before severe hemodynamic sequelae occur during mesenteric traction/ insufflation or a multitude of other problems that may occur quickly in the OR? I think the answer to question #1 and #2 is that we remain the providers at the head of the bed as we always have to intervene and manage the robot or any issues that need human intervention with the robot more likely to be an extension of us.

[Amy Swank]

1. What can a CRNA do now to preserve their role in the perioperative care of a surgical patient?

I also believe that AI is coming, faster, perhaps than we realize, and at least in some form or another. CRNAs need to continue to have a seat at the table of legislative, hospital and safety boards and committees, and with education of these advances. CRNAs need to continue to evolve and grow. We have a long history of being at the head of the table and we can continue to do so with a headset as well as a caring hand-hold which is one of our greatest strengths as a nurse anesthetist.

2. What safety mechanisms would you suggest to make an anesthesia robot safer?
Start with smaller cases and work up to more complex ones? Always with a skilled person as back-up. I wonder how this will actually play out in real life. I mean the flying cars still aren't happening in 2021, so maybe this will take a bit longer ;-)

[mary clothier]

1. Great possibility that closed loop Robots will be implemented and FDA approved for major surgical procedures, with anesthesiologist supervising several Robots.
Very tough to provide sedation with a robot, nothing can replace the human touch, individualizing the sedation necessary for each patient.
The "Art" of anesthesia, using common sense and critical thinking would be difficult to program, replace with a robot.
We can rely on the AANA, and social media to educate the public to the value of having a CRNA vs a Robot with them during their surgical procedure, and anesthetic, powerful!

2. AI is just that Artificial, not Real, Live, or Human!
Impossible for a Robot to Anticipate, React, or Treat the constant changes during a surgical procedure and Anesthetic!
The common sense, critical thinking, experience, and Art of anesthesia will be impossible to program into the Robot and the Algorithm(s)!
Again we will have the AANA and social media get the word out, powerful! "Would you rather have a Nurse Anesthetist or a Robot with you during your Surgery to maintain your
Anesthesia"?