Dr. John Ulatowski, Director of the Department of Anesthesiology and Critical Medicine for Johns Hopkins University School of Medicine, explains the importance of research in anesthesia.
Research on function of the brain and injury to the brain are very important in anesthesia because the brain is compromised during anesthesia. We give patients medications that induce coma. We call it general anesthesia, when patients are completely unaware of their environment. Anything that can jeopardize blood flow to brain is potentially injurious to patients. The more we know about control of cerebral blood flow, which is the way that oxygen and other nutrients get to the brain, the better anesthesiologist and others may care for patients having brain surgery.
There is a tremendous amount of research currently in anesthesiology on function of the brain and delivery of needed nutrients during normal states and when the brain is compromised by disease or while under anesthesia. Brain resuscitation after cardiac arrest is another major interest of anesthesiologists and is an area of intense study to determine better methods of preservation of brain after the heart is restarted.
Regional anesthesia has become an area of intense interest for anesthesiologists in the last 10 years and it is projected to have greater interest over the next 20 years. The major driver is a societal challenge because the baby boom generation is coming into the elder years. We are seeing many older patients coming to the operating room having aggressive surgical procedures. Our ability to support these patients depends on advanced techniques and experience in anesthesiology and critical care medicine.
One of the advances that have helped is regional anesthesia. Regional anesthesia provides complete numbing and paralysis of an area of the body which provides a motionless state helping the surgeon and also offering the potential for postoperative pain management. The other advantage of regional anesthesia is less of a general anesthesia. The elderly are sensitive to the drugs of general anesthesia and we have seen an increase in what is called postoperative cognitive dysfunction (POCD) in the elderly. POCD can prolong hospital stay and lead to further complications. It is reason to propose that using and more regional anesthesia and less systemic drug (in the blood stream) may lessen this risk.
Regional anesthesia has significant advantages but it does not stop there. The added benefit of postoperative pain control locally delivered to an area of the body were the painful stimulus begins that limits the amount of systemic pain medication that patients require. Anesthesiology has taken this to the next level by developing techniques of continuous delivery of drugs to treat pain “regionally” throughout the postoperative period. Indwelling catheters, small tubes placed using ultrasound guidance near the nerves carrying pain, allow delivery of smaller amounts of pain killers precisely where they are needed. These catheters, with their associated pumps, can be actually sent home with patients who continue to receive pain control well into the postoperative period. The major benefit, the patient gets direct pain control without the systemic side effects of an oral or an intravenous pain medication.
Anesthesiologists have made fantastic strides through discovery of new techniques and safer anesthetic drugs. One of the greatest challenges going forward despite the tremendous advancement in safety in the perioperative period is the challenge of the elderly population presenting for procedures that have multiple medical concerns.
The elderly patient has a cumulative health history many with chronic diseases, which affect the body over time to an ever increasing degree. We are now caring for patients who are in their 80s and 90s having aggressive surgery. Many of them have chronic medical conditions like hypertension, diabetes, heart and lung disease, and cancer. These medical conditions require a complex plan of management over and above the administration of an anesthetic. The anesthetic plan is often modified to take into account many of these diseases which are already compromising body functions. These diseases must be managed at the same time as we are managing the anesthetic delivery and monitoring of vital signs. So the challenge of today’s anesthesiologist is really to balance a multitude of medical illnesses, providing amnesia and comfort, and providing optimal operating conditions for the surgeon all at the same time.
Another challenge for anesthesiologists is the increasing request to care for patients outside of the operating room in procedure areas. As medicine advances to include procedures that can be done by radiologists, cardiologists, gastroenterologists, anesthesiologists are being asked to care for these patients often in unfamiliar surroundings compared to the traditional operating room. Even though the procedures are less invasive than open surgery the risk imposed by the anesthesia many times remains the same. We are designing new ways of monitoring and delivery of anesthesia care suitable for these environments.
I believe anesthesiology will continue to move forward in three ways. Anesthesiology will continue to improve our very good record in maintaining safety for individuals undergoing surgical or other invasive procedures. This will occur through continued development of safer drugs and better monitoring of the vital functions of the body under anesthesia. Computer technology will continue to be disruptive in a positive way. The brain is a particular focus for the future. Better monitors of depth of anesthesia, and we have some now, will allow us to tailor the dose of anesthesia to an individual patient need. These computers will insure appropriate comfort and amnesia and will limit potential side effects of giving too much medication.
Anesthesiology has been cited by the Institute of Medicine and other organizations as being one of the safest practices in medicine. This has been possible by having an expert anesthesiologist tailor the anesthetic care for one patient at a time, initially one patient at a time in an operating room. However, advances in safety beyond what we have been able to achieve in one single operating room or intensive care bed will happen because we are now creating safe systems of care encompassing operating room suites and entire ICUs, and with a scope of care that spans the preoperative preparation process, through the operating room, post anesthesia recovery units, and even to the recuperative hospital bed. These “safe systems” will enhance our success throughout the entire hospital stay and help prevent well meaning caregivers from making mistakes.
Finally, the future research will extend our ability to protect patients and deliver a precise anesthetic by knowing the genetic differences between individuals. Anesthesiologists are involved in perioperative gene projects which will characterize a patient based on their genetic makeup and allow us to predict patient response to anesthetic agents or other drugs and even predict potential complications of surgery. If we can predict how someone is going to respond in this period based on their genetic pattern, we can better tailor their care to ensure safety and focus on preventing complications.
The future of anesthesiology is bright and advancing safety for patients in the perioperative period has much more work to do and successes to come.
John Ulatowski, the Mark C. Rogers Professor of Anesthesiology and Critical Care Medicine, is the director of that department and the Anesthesiologist-in-Chief of the Johns Hopkins Hospital. Ulatowski is one of the world’s leading investigators into the regulatory mechanisms of cerebral blood flow and oxygen delivery to the brain.