AUTO-INTUBATION? Will future laryngoscopes be equipped with self-intubating endotracheal tubes?

Endotracheal tubes that locate the tracheas of challenging patients as easily and reliably as your GPS finds that new fusion restaurant everyone's been talking about. Crystal clear 3D ultrasound that makes placing blocks as easy as administering flu shots. Precise data that helps make sure every patient is given the optimal drug mix, based on his genetic makeup.

These are just a few of the innovations our prescient panel of anesthesia experts sees coming to an operating room near you in the coming years. Along with game-changing technology, our panel foresees continuing increased emphasis on outcomes, a continued shift away from long-standing anesthetic techniques, new wonder drugs, ongoing volatility in health care and possibly an entirely new business model.

BUILDING BLOCKS Regional anesthesia — with dramatically better visualization — is expected to be the wave of the future.

Block time
The trend toward regional anesthesia will be bolstered by improving technology, says Jay Horowitz, CRNA, owner of Quality Anesthesia Care Corp. in Sarasota, Fla. "Three-dimensional, high-definition, full-color ultrasound will replace the current grainy, one-dimensional views we get now." In their place, he says, will be a view as crisp and clear "as it would if you looked at it during surgery."

Anesthesiologist Gregory Hickman, MD, agrees. Regional is only going to get bigger. "The significant growth we've seen in the last decade will continue," says the medical director and director of anesthesia at the Andrews Institute for Orthopaedic & Sports Medicine in Gulf Breeze, Fla. And with opioids having recently become the subject of a national conversation, the pressure will be ratcheted up, says Dr. Hickman, for anesthesia providers to "show their value to the government and insurance payers by being involved in non-opioid post-op pain management." That, he says, will also hasten the trend toward multimodal pain management.

Anesthetics in the pipleline
Eugene R. Viscusi, MD, points out that where drugs are concerned "some new potential game changers," may be well on their way, including "intravenous analgesics that could significantly reduce the use of traditional opioids." Among those in development, says Dr. Viscusi, a professor of anesthesiology and the director of acute pain management at Thomas Jefferson University in Philadelphia, Pa., is a "biased opioid ligand" that could effectively act on the same pain receptors as morphine and fentanyl without promoting constipation, respiratory depression or analgesic tolerance. Elsewhere, a kappa opioid agonist, also in development, may be able to activate peripheral opioid receptors present on sensory nerves, but largely excluded from the brain. That in turn could provide pain relief without significant central nervous system side effects. If approved, it "should have no opioid respiratory depression and may be a better analgesic for visceral pain," says Dr. Viscusi.

Also piquing Dr. Viscusi's interest: a fixed-dose, long-acting combination of bupivacaine and the anti-inflammatory meloxicam. The tandem would simultaneously provide both a potent anesthetic and an anti-inflammatory agent directly to tissue, again potentially reducing the need for opioids. Yet another long-acting bupivacaine product under investigation would be instilled directly into surgical incisions with a blunt-tipped applicator, or injected into targeted spaces using endoscopic guidance. There it would form a biodegradable depot that would release therapeutic levels of bupivacaine over a 72-hour period. "One of these will likely be useful for infiltration as well as peripheral nerve blocks and will provide longer-term pain relief," he says.

Gadgets galore
"We have self-driving cars, why not self-intubating endotracheal tubes?" asks Mr. Horowitz. "Someone will build one with sensors or GPS — whatever it takes to find the trachea every time."

Clarence J. Biddle, CRNA, expects genomics to emerge as a key factor in drug administration, by deciphering the unique genetics of each patient and determining how to best promote pain relief with minimal side effects. The future will also bring monitoring platforms that are worn throughout the pre-operative course, to "provide valuable patient safety information," says Mr. Biddle, a professor and staff anesthetist in the departments of anesthesiology and nurse anesthesia at Virginia Commonwealth University Medical Center in Richmond, Va. He also expects to see less cumbersome cerebral oxygenation monitors "that provide more complete, real-time information about tissues deep within the organ," and a "redesign of the anesthesia workstation to decrease the risk of contamination and nosocomial infection."

Mike MacKinnon, CRNA, co-owner of ce2you.com, an ultrasound and vascular regional anesthesia company in Show Low, Ariz., sees articulating video scopes for easier tube placement in his crystal ball, along with refined, less-invasive hemodynamic and oxygen monitors, "further removing risk in a specialty that already nearly enjoys Six Sigma safety."

JOINT VENTURE Expect outpatient total knees to become the "standard" as time goes on.

Continued outpatient migration
Advances in technology and pain management will in turn let a greater number of patients safely have procedures without hospital stays, says anesthesiologist Jeffrey Cazier, MD, who practices in Huntsville, Ala. It all comes down to "increased safety and efficacy" and "evidence-based, standardized protocols," says Dr. Cazier.

Mr. MacKinnon also expects the doors to outpatient centers to be swinging open more often, with more challenging cases, like total knees, becoming the norm at 23-hour stay surgical centers.

No question, says Dr. Hickman. "The growth of outpatient total joints will continue." Shoulders and ankles should already be done in outpatient settings, he says, but for healthy patients who need total knees, outpatient procedures will become "standard." However, he adds, that transition will be much faster in some areas than others.

Of course, all of this assumes that someone will be willing to pay for those procedures. If, as Mr. Horowitz predicts, reimbursements continue to decline, practitioners will have to devise techniques and technologies that patients will be willing to pay more for, he says. "We've seen it in ophthalmology via femtosecond lasers and upgraded lenses, pretty soon it'll be hip and knee replacements."

Mr. MacKinnon expects anesthesia providers to have to work harder for the same reimbursements, thanks to an aging population and "an obesity epidemic" that will "shift the population from private insurance to Medicare and Medicaid."

MDs vs. CRNAs
The future of the sometimes prickly relationship between anesthesiologists and CRNAs is also up for discussion, and it's one that, perhaps not surprisingly, looks different to different practitioners as they turn their gazes forward.

"I foresee greater usage of CRNAs in anesthesia staffing," says Mr. Horowitz, citing a record of both "safety and cost effectiveness." Mr. Horowitz wonders, in fact, whether anesthesiologists will eventually be priced out of the market. "I think they'll increasingly be used more as OR hospitalists and in research," he says. "The specialty will become less attractive to med school graduates and anesthesia assistants will disappear."

Mr. MacKinnon also expects to see "erosion of the anesthesia care team," as CRNAs expand into independent and autonomous practices. "As the economic belt of health care tightens, all providers will be expected to work to the top of their scope of practice and license," he says. As such, private practices will follow the lead of the U.S. Department of Veterans Affairs, which is proposing to give full practice authority to APRNs. The combined factors will lead to the "dying of all MDA practices," he says.

But the advent of the perioperative surgical home — a team-based model created by anesthesiologists and designed to align with the oft-stated goals of value, patient satisfaction and reduced costs — may add a new dimension to the role played by anesthesiologists. "As all specialties become more production driven, particularly surgery, someone has to do the perioperative management," says Dr. Viscusi. "And that's likely to be anesthesiologists. Who better? We have the best understanding of the perioperative process and outcome drivers. Furthermore, surgeons are less trained and less interested in managing these aspects."

Hospitalists, he says, are likely to take on some added responsibility, "but they have less surgical understanding." Instead, anesthesiologists will likely emerge as the leaders as the perioperative surgical home model advances. "The PACU is no longer the finish line," says Dr. Viscusi. Outcomes will be judged on numerous additional criteria, including chronic pain after surgery, disability-free recovery and incidence of addiction.

Who's to say?
What else can we confidently predict? Only that there's bound to be unpredictability as well. Consider that it wasn't very long ago that Sedasys — the computer-assisted personal sedation system — was, at least many assumed, going to revolutionize anesthesiology. When it finally arrived, there was barely enough time to say hello before it was gone. The future, it seems, has a mind of its own. OSM