Innovative research and technological advancements: Oars of the boat of progress : Indian Journal of Anaesthesia

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Editorial

Innovative research and technological advancements: Oars of the boat of progress

Bajwa, Sukhminder Jit Singh; Kurdi, Madhuri S.1; Malde, Anila D.2

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Indian Journal of Anaesthesia 67(1):p 3-6, January 2023. | DOI: 10.4103/ija.ija_11_23
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“Water loses its purity from stagnation”….

         Leonardo da Vinci

New knowledge needs to flow into any speciality of science to keep it vibrant. The flow of new knowledge starts from original research and observations. Novel research questions are tested in research studies and the results bring to light newer and useful strategies that can be applied in clinical practice. The recent advances in a speciality are portrayed by the contents of the journals of that speciality, some of which are translated into clinical practice.

Postgraduate (PG) students in anaesthesia have to read their textbooks and do clinical work to acquire knowledge. However, textbooks are a compilation of chapters with material taken from published journal articles. They do not really depict the most recent developments in the field. As per the PG curriculum of the National Medical Commission, the students need to be aware of the recent advances pertaining to their speciality. The fourth paper of the theory examination for the degrees of both, Doctor of Medicine (MD) and Diplomate of National Board (DNB) includes questions on recent advances in anaesthesia.[1] Students often complain that there is a dearth of reading material related to this topic. Furthermore, what was recent yesterday, may not remain recent today. Ours is an ever-evolving branch. The consultants in anaesthesia, too, are yearning to know about the recent advances in the speciality and this often makes them start googling. Keeping this in mind, this PG issue of the Indian Journal of Anaesthesia (IJA) is designed with the novel theme of ‘Recent Advances’. The current areas of major progress in different specialities of our subject are discussed elaborately in this issue by academic experts from different parts of our nation. It is beyond doubt that anaesthesiology has progressed from the speciality of ‘wine and opium’ to the current era where a major part of it is driven by technology.

Technology today plays an important role in almost every branch of anaesthesia. Airway algorithms, second-generation supraglottic airway devices, video laryngoscopes, fibreoptic techniques, extubation catheters, transnasal humidified rapid-insufflation ventilatory exchange, and sugammadex and rocuronium for rapid sequence induction have changed the face of airway management and improved patient safety. The use of ultrasound for preoperative airway and gastric assessment sounds the bugle of the supremacy of technology. Checklists are now being used to improve patient safety in perioperative care and improve surgical outcomes. Intraoperative haemodynamic monitoring with 3D echocardiography allows the real-time monitoring of valve function, ventricular filling, and cardiac contractility.[2] Point-of-Care ultrasound (POCUS) is the new magic wand of the anaesthesiologist. The modern anaesthesiologist neither struggles to secure an intravenous line or give a landmark-guided nerve block nor gropes blindly for a difficult lumbar/epidural puncture. He quickly gets the ultrasound probe and smoothly manages the case. From the facilitation of venous cannulation to guiding peripheral nerve blocks, fascial plane blocks, and central neuraxial blocks and predicting intraoperative hypotension with the inferior vena cava collapsibility index, ultrasound is an invaluable asset of the anaesthesiologist.[3-8] In the intensive care unit (ICU) too, the ultrasound plays a major role with its ability to diagnose extravascular lung water in the lungs at an early stage, increased intracranial pressure, conditions such as pneumothorax, pneumonia, and pulmonary embolism and in mechanical ventilation.[9,10]

In addition to ultrasound, the modern anaesthesiologist is equipped with modern tools such as risk prediction tools, models, and indices which can be applied to identify the high-risk surgical patient.[11,12] The postoperative behaviour and outcomes of the patient are thus no longer a suspense to the operating team and the patient’s attenders. Early warning scores, algorithms, and indices help to detect early chances of clinical deterioration in the ICU, in the detection of sepsis, and in the management of postpartum haemorrhage (PPH), eg-The obstetric early warning scores and the shock index have been used to recognise and predict severe haemorrhage and the need for blood transfusion.[13] The role of point-of-care tests to decide perioperative blood transfusion and in the management of PPH has been very beautifully brought out in two articles being published in this issue.[13,14]

Automated processing algorithms such as processed electroencephalography (pEEG) of raw EEG traces provide easy-to-use indices that can monitor the effect of anaesthesia drugs on the cerebral cortex.[15] Their use can optimise anaesthetic management. Propofol has already washed away thiopentone and now the time has arrived when intravenous drugs like remimazolam, ciprofol, and remifentanil are likely to threaten the empire of propofol, midazolam, fentanyl, and alpha-2 agonists. An article in this issue outlines the advances in intravenous anaesthesia including target-controlled infusions with automated closed-loop anaesthesia delivery systems and pEEG.[16]

Cardiac anaesthesia has its share of advancements with the growing application of regional nerve blocks, artificial intelligence (AI) including perioperative echocardiography, and evolving anaesthetic strategies for minimally invasive cardiac surgery.[17] The intraoperative use of imaging, the resurgence of ketamine, regional anaesthesia in neurosurgery, the management of awake brain and spine surgery, anaesthesia for functional neurosurgery, and neurological malignancies are some major advances in neuroanaesthesia.[18] The speciality of critical care is now being revolutionised by the fast-expanding indications of POCUS, newer tools in functional haemodynamic monitoring, use of biomarkers in diagnosis and therapy, analgosedation, the comeback of colloids such as albumin, newer modes of mechanical circulatory and respiratory support and newer antimicrobials.[19]

Robot-assisted laparoscopic surgery is commonly done nowadays. Nonetheless, ambulatory robotic surgery is a new area that is evolving and its indications are growing fast. Newer intraoperative ventilation strategies and multimodal analgesia play an important role in improving patient outcomes in these cases.[20]

The role of anaesthesia in minimally invasive foetal surgery, open mid-gestation foetal procedures, and ex-utero intrapartum treatment procedures is very important and our understanding of these procedures and expertise in their management is steadily improving. This has been elaborately explained by the authors in an article on recent advances in anaesthesia for intrauterine and foetal surgery in this issue of the IJA.[21]

Several strategies that have been already established clinically in the west are now being tried out in our country, but are facing difficulties in implementation. Enhanced recovery after surgery (ERAS) is one such strategy and is now a topic of interest for researchers and clinicians.[22] The concept of ERAS and its implementation in the fields of onco-anaesthesia, caeserean section and paediatric anaesthesia has been elegantly touched upon in the articles in this issue.[13,23,24] ERAS protocols are now being followed even in transplant surgery such as renal and liver transplants.[25] The advances in transplant anaesthesia are thus proceeding in parallel with the advances in surgical techniques, improved understanding of immunology and rapidly developing laboratory research.

It is said that education is the backbone of development. Training our young PG students means preparing the future generation of consultants. The advances in anaesthesia and critical care have not spared the field of anaesthesia education. The implementation of the new competency-based medical education curriculum is a good move in this regard and this has been very elaborately described in another article on teaching and training in anaesthesia in this issue.[26]

It is clear that most of the advances in anaesthesia are directed toward improving the safety of the patient and improving patient comfort, satisfaction, and quality of life postoperatively.[27] There is a huge potential for further developments in technology that can aid perioperative care in this direction. As discussed in an article in this issue, advances in AI, telemedicine, and blockchain technology are attempting to improve perioperative care.[28]

The physics of mechanical ventilation is one area that most anaesthesiologists including PG students struggle to understand. A unique article in this issue attempts to help understand the concepts and the dynamics of the equation of motion. The authors have taken great pains to explain the exponential process in lucid terms and with the help of mathematical concepts.[29]

Today, the anaesthesiologist is a physician in the operation theatre, in the critical care unit, and also in the pain and palliative care clinic where all types of pain are dealt with. Early integration of palliative care into oncology is now being practised, wherein the patient is referred to a palliative care clinic soon after the diagnosis of advanced cancer. Chronic pain affects more than 30% of persons in the world and can affect their quality of life. A personalised, multidisciplinary, multimodal approach is adopted nowadays for its management. Two articles being published in this issue describe the newer concepts and developments in pain management and palliative care.[4,23]

The race for advancement using technology is fast progressing; however one has to remember that the risks and benefits of technological advancements are two sides of the same coin. Technological advancements should always be directed toward improving patient safety and the quality of perioperative healthcare. They should not harm the patient and should always serve as an adjunct and never as a substitute for clinical judgment. Cutting-edge research and new therapeutic tools or innovations should be adequately disseminated throughout the world. The medical fraternity is currently witnessing amazing advances including the development of next-generation messenger ribonucleic acid (mRNA) vaccines, drugs like inclisiran which can reduce low-density lipoprotein levels, and an injectable (once-weekly) dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide receptor agonist that can control blood sugar and reduce glycosylated haemoglobin levels in type 2 diabetes mellitus.[30] Genome editing, integrating genomics into clinical management, and predicting cardiovascular comorbidities in patients with hypertension with the help of AI are now the new kids on the block in the research arena. Gene expression occurs early following surgery. Modulation of this expression can accelerate postoperative tissue repair. Furthermore, the effect of different anaesthesia techniques such as general anaesthesia and regional anaesthesia on gene expression profiles can indicate the stress and toxicity produced by the techniques. This is currently being studied by researchers.[31]

The world of anaesthesia and critical care is steadily witnessing great innovations. At this juncture, we should remember that it is research that leads to advancements. Hence, all of us need to partake in the research process and savour the various flavours of research, be it the statistics of quantitative research or the richness and depth of qualitative research. Meanwhile, one cannot help but wonder……. what will be the next technological breakthrough in anaesthesia and critical care?

REFERENCES

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