Conference Lectures
Should Robot replace Anesthesiologist
Dr Joyshankar J Jana , MD ; DNB
Associate Professor & Senior Consultant
Dept. of Anesthesia ,Pain Medicine & Critical Care
K.E.M. Hospital , Pune
This is a futuristic topic and we are debating about it now. Technology is developing fast and we all have to accept the changing advances in technology. Robots have been there for a very long time but the first Master Slave manipulator for medical use was developed at Stanford Research Institute, U.S in the early 1990. The first robotic assisted surgery using Da-Vanci system was performed on april 1997 by Jacques Himpsons and Guy Cardiere
In the year 2000 , FDA approval for Da-Vanci surgical robot made it possible for surgeons to use it on humans commercially. Since then further new generations of surgical robots have come and our surgical friends are enjoying the technology of precision and accuracy while doing the surgery sitting comfortably on the console at one corner of operation theatre ; whereas our anesthesiology friends are still turning the antique knobs of vapourisers
Why has Anesthesia not caught up with the technological advances of surgery ? Some of the reasons are concentration on safety , emphasizing on airway control , un-used technology , technological development which did not keep their promise and financial considerations
In terms of safety records we only look at how many patients have died or have life threatening events due to anesthesia but we need to look deeper in terms of over all performance and quality of anesthesia.
Robot will assist with accuracy and precision in –
- Maintainance of Haemodynamic and physiological control
- Maintain the body temperature irrespective of any type of surgery
- Maintain stable Electrolyte and Sugar level
- Improve the quality of Induction , Maintainance and Recovery from anesthesia , with effect on the memory of the patient
- Will remove the Inter-Individual quality difference
Classification of Robotic Anesthesia –
- Robots for Aiding or Replacing Manual Gestures
- Pharmacological Robots
Robots for Aiding or Replacing Manual Gestures –
- Kepler Intubating System (KIS) :
Developed by Dr Thomas M. Hemmerling and his team at McGill University , Montreal. It consists of a joystick which is controlled by the anesthesiologist , this joystick is linked via a carbon fiber robotic arm to a standard video laryngoscope which offers the advantage that the endotracheal tube can be attached to it on a special port. Using the joystick one can manipulate the video laryngoscope so that the cross-hair is placed over vocal cord then the endotracheal tube can be easily pushed into trachea
- Magellan Robot :
It is used for giving peripheral nerve block
- Da-Vanci Robot :
With the use of ultra-sound it can very precisely be used for giving regional anesthesia and passing central or arterial cannulation
Robot have the potential to deliver manual gestures with high degree of precision and with outfatique and hand tremors. All these robots are in development phase
Pharmacological Robots: ( McSleepy Anesthesia Robot)
These robots are being developed at McGill University by DrHemmerling and his team. In order to create a true robot all three components of anesthesia – Hypnosis, Analgesia and muscle relaxation is automatically controlled from induction to emergence. McSleepy integrates closed loop control of all three components of general anesthesia with a user interface. The user interface is the anesthesiologist who can choose between two options fully automated or semi-automated with manual control of one or more components. Patient data of height,weight,age, ASA classification, type of surgery, any specific drugs like beta blocker which can interfere with the system and additional information like concomitant neuro-axial blockade is uploaded to the computer system.
The Induction follows the Bayes Principle, i.e the system will use the pharmacodynamics results to categorize the patient’s pharmacological “personality” and adapt doses accordingly. Maintainance of anesthesia is provided through integrated closed loop control of hypnosis, analgesia and muscle relaxant using BIS score, Analgoscore and muscle twitch monitor . Drugs used are propofol, remifentanil and rocuronium or cisatracurium. But McSleepy needs to know the stage of surgery , so there three options like prepping , incision and 20 minutes to end , accordingly the doses will be adjusted or stopped . This is also in development phase .
Only robot approved by FDA for commercial use now is called “ Sedasys”
Sedasys: It is a Computer Assisted Personalized Sedation system approved by FDA on 3th May 2013. It is only for use onpatient’s who are above 18 years , ASA 1 or 2 and for screening colonoscopy and oesophago-gastro-duodenoscopy. It provides mild to moderate sedation. The parts of this system are Bedside monitoring unit (BMU) , Procedure room unit (PRU) which contains propofol infusion pump controller and additional patient monitoring , display monitors and disposable devices for single patient use
It is based on pharmacokinetic algorithym. Patient’s age , weight is uploaded to the computer, secure intravenous line and all monitors are attached. Sedasys then infuses the initial dose 30 to 50 mg of 1% propofol in a young patient or a smaller dose in a older patient over three minutes , then maintainance infusion of propofol at a pre-programmed rate of 50 microgm/kg/min is started. Monitoring of ECG, NIBP, SaO2, Et-CO2 , respiratory rate ,Hand held gripper device and ear phone with which the machine can give pre-programmed instructions to the patient. If there falling SaO2, depression of respiratory rate , failure of Et-CO2 curve and failure to squeeze the hand gripper on giving instruction then machine automatically stops the propofol infusion. Once the procedure is over sedasys is stopped and patient kept in recovery area.
It recommends the presence of a qualified anesthesiologist or certified anesthesia nurse to be present in the complex but need not be present in the procedure room.
Sedasys cannot be used on patients who are ASA 3 or 4, with multiple and long standing medical problems , those who are obese (BMI > 35), difficult airway and with obstructive sleep apnea syndrome , and also in those who are allergic to propofol. It also cannot be used in patients who require deeper sedation or some therapeutic procedure along with endoscopy.
Just as the Old Boyle’s machine has been replaced with the modern anesthesia workstations , the robot is the next step in the evolution of Anesthesia technology. These “Collaborative Robots” will be soon assisting us in our daily routine tasks in the operation theatre . As technology evolves they will become more safe , accurate , efficient , without getting tired aiding our vigilance and improving patient care , so the anesthesiologist can focus on higher level tasks and be more focused on patient condition rather than focus on equipment and paperwork.
Whether robot will completely replace anesthesiologist in future is rather more speculative to say now, but robots will definitely assist us in giving far more evidence based better patient care.
References
1.Kepler Intubating System ,CurropinAnesthesiolgy 2012 oct 25. Robotic anesthesia :not the realm of science fiction any more. HemmerlingTM ;Terrasini N, Department of Anesthesia;McGill university
2.McSleepy, CurropinAnesthesiolgy 2012 Dec 25 (6):736-42 , Robotic anesthesia: not the realm of science fiction any more , HemmerlingTM,Terrasini N
3. Da-Vinci Robot , AnesthAnalg 2010 sep;111(3):813-6, Epub 2010 jun 25, Technical communication : Robot assisted Regional Anesthesia :- a simulated demonstration , Tighe PJ, BadiyanSJ, Luria I, Boezaart AP, Parekathil S.
4. Magellan Robot ,Anesthesiolgy New ; 2012; 38-8
5. Sedasys, a division of Ethicon US, LLC.2014