TELEANESTESIA - ANESTESIA CON CONTROLLO REMOTO TRANS-CONTINENTALE

Il progetto è stato chiamato Teleanestesia. Quest'ultima potrebbe, essere definita come il controllo a distanza dell’anestesia – valutazione preoperatoria e gestione perioperatoria attraverso il controllo a distanza di un sistema, presente localmente, che mantiene il livello di anestesia in modo automatico. La valutazione pre-operatoria è effettuata tramite un sistema di video-conferenza tra l’Italia e il Canada, l’anamnesi del paziente e la valutazione delle vie aeree è eseguita a distanza . I dati del paziente sono in seguito inseriti in un sistema che infonde i farmaci anestetici(Oppioide, ipnotico e miorisolutore) in modo automatizzato. L’anestesia (con tutti e tre le componenti), induzione - tra cui intubazione videolaryngoscopica, il mantenimento ed il risveglio, che avviene a Pisa è monitorizzata e controllata a distanza dal Canada tramite una rete virtuale. I requisiti specifici sono: una postazione remota (Montreal) con computer che permettono il monitoraggio del paziente e il controllo del sistema di somministrazione automatizzata dell’anestesia (presente a Pisa). Quest’ultimo fornisce lo stato dell'arte dell’anestesia totale per via endovenosa. I due centri universitari sono in collegamento audio-video in modo continuo mantenendo cosi una comunicazione permanente durante l’intervento. Quattro telecamere poste strategicamente monitorizzano - in tempo reale a Pisa - ogni aspetto della cura del paziente: una schermata video mostra i parametri ventilatori (come ad esempio la frequenza respiratoria del paziente), un altro video mostra i segni vitali (ECG, frequenza cardiaca, saturazione di ossigeno), una videocamera fornisce immagini in diretta della chirurgia ed infine un’altra videocamera permette inizialmente di visualizzare le immagini della videolaringoscopia e poi serve come eventuale backup. Questa prova di concetto vuole dimostrare che l'uso di mezzi di comunicazione standard - video-conferenza, reti virtuali – permettono di eseguire a distanza un’anestesia grazie anche all’impiego di sistemi automatizzati presenti localmente. In effetti, si potrebbe, ad esempio, realizzare la valutazione preoperatoria anestesiologica e la somministrazione dei farmaci anestetici, in aree remote oppure nei paesi del terzo mondo o, semplicemente, regioni in cui un ato livello di esperienza non è disponibile

Sevoflurane causes less arrhythmias than desflurane after off-pump coronary artery bypass grafting: a pilot study.

Background: Volatile anesthetics provide myocardial protection during cardiac surgery. Sevoflurane and desflurane are both efficient agents that allow immediate extubation after off-pump coronary artery bypass grafting (OPCABG). This study compared the incidence of arrhythmias after OPCABG with the two agents. Materials and Methods: Forty patients undergoing OPCABG with immediate extubation and perioperative high thoracic analgesia were included in this controlled, double-blind study; anesthesia was either provided using 1 MAC of sevoflurane (SEVO-group) or desflurane (DES-group). Monitoring of perioperative arrhythmias was provided by continuous monitoring of the EKG up to 72 hours after surgery, and routine EKG monitoring once every day, until time of discharge. Patient data, perioperative arrhythmias, and myocardial protection (troponin I, CK, CK-MB-ratio, and transesophageal echocardiography examinations) were compared using t-test, Fisher′s exact test or two-way analysis of variance for repeated measurements; P < 0.05. Results: Patient data and surgery-related data were similar between the two groups; all the patients were successfully extubated immediately after surgery, with similar emergence times. Supraventricular tachycardia occurred only in the DES-group (5 of 20 patients), atrial fibrillation was significantly more frequent in the DES group versus SEVO-group, at five out of 20 versus one out of 20 patients, respectively. Myocardial protection was equally achieved in both groups. Discussion: Ultra-fast track anesthesia using sevoflurane seems more advantageous than desflurane for anesthesia, for OPCABG, as it is associated with significantly less atrial fibrillation or supraventricular arrhythmias after surgery

Autonomous systems in anesthesia : where do we stand in 2020? A narrative review

As most of us are aware, almost every facet of our society is becoming, for better or worse, progressively more technology-dependent. Technological advancement has made autonomous systems, also known as robots, an integral part of our life in several fields, including medicine. The application of robots in anesthesia could be classified into 3 types of robots. The first ones are pharmacological robots. These robots are based on closed-loop systems that allow better-individualized anesthetic drug titration for optimal homeostasis during general anesthesia and sedation. Recent evidence also demonstrates that autonomous systems could control hemodynamic parameters proficiently outperforming manual control in the operating room. The second type of robot is mechanical. They enable automated motorized reproduction of tasks requiring high manual dexterity level. Such robots have been advocated to be more accurate than humans and, thus, could be safer for the patient. The third type is a cognitive robot also known as decision support system. This type of robot is able to recognize crucial clinical situation that requires human intervention. When these events occur, the system notifies the attending clinician, describes relevant related clinical observations, proposes pertinent therapeutic options and, when allowed by the attending clinician, may even administer treatment. It seems that cognitive robots could increase patients' safety. Robots in anesthesia offer not only the possibility to free the attending clinicians from repetitive tasks but can also reduce mental workload allowing them to focus on tasks that require human intelligence such as analytical and clinical approach, lifesaving decision-making capacity, and interpersonal interaction. Nevertheless, further studies have yet to be done to test the combination of these 3 types of robots to maintain simultaneously the homeostasis of multiple biological variables and to test the safety of such combination on a large-scale population

Robotic anesthesia - A vision for the future of anesthesia

This narrative review describes a rationale for robotic anesthesia. It offers a first classification of robotic anesthesia by separating it into pharmacological robots and robots for aiding or replacing manual gestures. Developments in closed loop anesthesia are outlined. First attempts to perform manual tasks using robots are described. A critical analysis of the delayed development and introduction of robots in anesthesia is delivered

Automated sedation integrated with a decision support for patients undergoing hip or knee arthroplasty under spinal anesthesia with controlled sedation

Automated systems for propofol delivery and decision support system (DSS) have been shown to decrease anesthesiologists' workload and increase their vigilance during surgery, respectively. However, automated systems have been used mainly for general anesthesia but never for controlled sedation alone. In addition, DSSs have never been used before to help anesthesiologists to monitor patients receiving a spinal anesthesia with sedation. Thus, we have developed the first medical device incorporating a closed loop system for sedation and a decision support system for controlled sedation for patients undergoing knee or hip arthroplasty under spinal anesthesia with controlled sedation. The present project aims to determine the performances and the safety of this novel hybrid medical device. The hypothesis is that this novel device provides better sedation than manual control and could help to detect critical events, which could occur during spinal anesthesia with sedation, more promptly. The hybrid system tested in this trial can control sedation better than manually delivered propofol sedation and can detect critical events in a shorter time length allowing faster therapeutic treatments.Les systèmes automatisés pour l'administration de propofol et les systèmes d'aide décisionnel (DSSs) permettent de diminuer la charge de travail des anesthésistes et d'accroître leurs vigilances pendant la chirurgie, respectivement. Cependant, les systèmes automatisés d'injection de prpofol ont été utilisés principalement pour l'anesthésie générale, mais jamais pour la sédation consciente. De plus, les DSSs n'ont jamais été utilisés auparavant pour aider les anesthésistes à surveiller les patients recevant une rachianesthésie avec sédation. Ainsi, nous avons développé le premier dispositif médical incorporant un système en boucle fermée pour la sédation automatisée avec propofol incluant un DSS pour la surveillance de patients subissant une intervention d'arthroplastie du genou ou de la hanche sous rachianesthésie et sédation consciente. Le projet vise à déterminer les performances et la sécurité de ce nouveau dispositif médical hybride. L'hypothèse est que ce nouveau dispositif offre une meilleure sédation que le contrôle manuel et une détection plus précoce des événements critiques qui peuvent survenir pendant la rachianesthésie avec sédation utilisant le propofol. Le système hybride testé dans cet essai permet de contrôler la sédation avec propofol mieux que l'administration manuelle et peut détecter les événements critiques plus vite permettant un traitement de ces derniers plus rapide

Reduced Length of Hospital Stay for Cardiac Surgery—Implementing an Optimized Perioperative Pathway: Prospective Evaluation of an Enhanced Recovery After Surgery Program Designed for Mini-Invasive Aortic Valve Replacement

International audienc

A Medicoeconomic Evaluation of a Telehealth Platform for Elective Outpatient Surgeries: Protocol for a Randomized Controlled Trial

BackgroundThe number of elective outpatient surgeries in Canada has increased markedly in the last 10 years. However, unanticipated cancellations on the day of surgery and adverse postoperative events are frequent. Modern technologies have been shown to be of great help in the medical field in improving patient care. Thus, it is likely that dedicated technologies could also significantly improve surgical outpatients’ pathways. Therefore, the department of anesthesiology at the University of Montreal Medical Center, in collaboration with LeoMed, a telemedicine platform, has developed a telehealth solution to offer more efficient perioperative support and follow-up for patients undergoing ambulatory surgery. ObjectiveThe objective is to evaluate the medicoeconomic benefit of a dedicated perioperative telehealth platform for patients undergoing day surgery. Our hypothesis is that this dedicated telecare solution will allow more efficient patient care, which will reduce all types of medical costs related to day surgery pathways. MethodsThis study is a single-center, single-blinded, 2-group randomized controlled trial. One thousand patients aged over 18 years with internet access who are scheduled to undergo ambulatory surgery will be enrolled and randomized either to follow a perioperative path that includes a patient-tailored perioperative digital app via the LeoMed telecare platform for 1 month or to follow the standard of care, which does not offer personalized digital support. The primary outcome will be to evaluate the cost-effectiveness of the telecare platform, assessing direct costs from factors such as unanticipated cancellations on the day of surgery due to preoperative instructions not being followed, calls to the local health information line, calls to the provincial health information line, emergency department consultations, unplanned readmissions, or medical visits for problems related to the surgical procedure within the first 30 days after the intervention. The secondary outcome will be to evaluate cost utility using a questionnaire assessing quality-adjusted life years. A blinded independent research team will analyze outcomes. All data will be analyzed according to the intention-to-treat principle. A sample size of 500 subjects in each group was calculated to detect a 21% reduction in postoperative complications with a power of 90%. This study has been approved by the ethics board of Centre hospitalier de l’Université de Montréal (University of Montreal Health Centre). No employee of LeoMed was involved in the study conception, and none will be involved in either data collection or analysis. ResultsResults of this trial will be useful to determine the economic benefit of a telecare platform specifically developed for surgical outpatient pathways. ConclusionsWe believe that the deployment of a dedicated perioperative telehealth app will lead to better patient care and fewer postoperative complications, which will lower all types of costs related to surgical outpatient care. Trial RegistrationClinicalTrials.gov NCT04948632; https://ClinicalTrials.gov/ct2/show/NCT04948632 International Registered Report Identifier (IRRID)DERR1-10.2196/4400

A novel system for automated propofol sedation: hybrid sedation system (HSS)

Closed-loop systems for propofol have been demonstrated to be safe and reliable for general anesthesia. However, no study has been conducted using a closed-loop system specifically designed for sedation in patients under spinal anesthesia. We developed an automatic anesthesia sedation system that allows for closed-loop delivery of propofol for sedation integrating a decision support system, called the hybrid sedation system (HSS). The objective of this study is to compare this system with standard practice. One hundred fifty patients were enrolled and randomly assigned to two groups: HSS-Group (N = 75), in which propofol was administered using a closed-loop system; Control Group (N = 75), in which propofol was delivered manually. The clinical performance of the propofol sedation control is defined as efficacy to maintain bispectral index (BIS) near 65. The clinical control was called ‘Excellent’, ‘Good’, ‘Poor’ and ‘Inadequate’ with BIS values within 10 %, from 11 to 20 %, 21 to 30 %, or greater than 30 % of the BIS target of 65, respectively. The controller performance was evaluated using Varvel’s parameters. Data are presented as mean ± standard deviation, groups were compared using t test or Chi square test, P &lt; 0.05. Clinical performance of sedation showed ‘Excellent’ control in the HSS-group for a significantly longer period of time (49 vs. 26 % in the control group, P &lt; 0.0001). ‘Poor’ and ‘Inadequate’ sedation was significantly shorter in the HSS Group compared to the Control Group (11 and 10 % vs. 20 and 18 %, respectively, P &lt; 0.0001). The novel, closed-loop system for propofol sedation showed better maintenance of the target BIS value compared to manual administration