The practice of anesthesia doesn't stand still. Neither do the technological advances that offer its providers a better view, safer practices or improved efficiency. Here are some of the new developments that stood out during our visit to the exhibit hall at the American Society of Anesthesiologists' annual meeting in Washington, D.C., in October.

GO LOW FLOW GE Healthcare's Avance CS2 with ecoFLOW gives real-time updates on anesthesia costs.

GE Healthcare
Avance CS2 with ecoFLOW
GE Healthcare's new anesthesia machine, still awaiting the FDA's 510(k) clearance for U.S. sale at the time of the conference, may interest administrators as much as those in the ORs. While electronic flow valves and an advanced breathing system enable precise, digitally controlled gas delivery and ventilation, the "ecoFLOW" application graphically displays the amount — and cost — of the anesthetic agents used and oxygen consumed during surgery.

The whole idea of cost-efficient anesthesia is good, and a significant factor for us right now. There's no way we're going to compromise patient care, but case costs are a pressure. This immediate feedback can assist us in those aims, by showing us how much we can do with low-flow anesthesia.

The big question is: If your anesthesia providers know how much the gas is costing as it's being delivered, will it influence how they practice? The ecoFLOW offers a polite (and optionally visible) reminder that they could go lower, but it's dependent on them to heed those numbers. Dr. Bloom is skeptical, too, about the widespread adoption of virtualized touchscreen controls for gas delivery over the tactile feedback of the mechanical dials and bobbins we trained with.

HANDS ON Dr. O'Neill test-drives Karl Storz-Endoscopy's FIVE scope

Karl Storz-Endoscopy
Flexible Intubation Video Endoscope (FIVE)
As soon as Dr. O'Neill had this scope in his hands, he wanted it for his cases. The lighter handpiece, the equilibrium point, the hand control's nicely ergonomic neutral position (with tactile and audible signals): It's all about the simple pleasures.

This flexible video endoscope has a CMOS video chip at the distal end instead of a CCD chip at the handpiece, as fiber-optic scopes do. A "chip at the tip" means you won't have to suffer through gradually degrading images as the bundled fibers snap, one by one. The scope tip also incorporates LED illumination and a heated lens to eliminate fogging.

Another difference from fiber-optic scopes: Instead of a tunnel-vision view, it shows you a full-screen, rectangular image on the monitor. While this isn't entirely necessary, it is impressive. It's accomplished through the use of a fish-eye lens, which adds a little bit of distortion, but you can get used to it. Listing at $15,000, this scope isn't any pricier than a regular fiber-optic one.

BRIGHT BLADE The LaryngoBloc blade is single use for sterility, and a single piece for strength.

Karl Storz also displayed its LaryngoBloc line of blades for direct laryngoscopy. The blades (available in 6 sizes of Miller and Macintosh) and the long, stubby handles are constructed as a single piece, and the sturdy plastic they're made from can withstand a lot of force without breaking. (The reps challenged us to try.) They're disposable for infection control's sake, except for the fully contained LED insert in the handle, which conveniently illuminates the blade's blind side. You can never have enough light. The individually wrapped blades are $6 each, with a 5-year expiration date.

HOT SPOT Arizant's SpotOn Temperature Monitoring System.

ARIZANT
SpotOn Temperature
Monitoring System
There's a lot of complex electronic and thermodynamic science behind the "zero heat flux" technology that makes this non-invasive monitoring device work, but its advantages are pretty clear. The circular sensor affixed to the forehead travels with the patient throughout the perioperative process, delivering an accurate, consistent and continuous core temperature reading to the output unit or a portable monitor. It eliminates the need for spot-check (and possibly highly variable) temperature readings with different devices. It looks like it would be particularly useful for regional anesthesia patients, who, not being intubated, don't offer immediate access to esophageal temperatures.

We were left wondering, though: Why the forehead? That might be an uncomfortable tether for patients to deal with from pre-op all the way through to PACU. Inconvenient for nurses, too, as we were told that if the sensor peels off, you can't just stick it back on, but have to replace it with a new one. Plus, in the OR, consciousness monitoring and cerebral oximetry sensors demand a fair amount of forehead space. A rep told us that they'd been researching how well the SpotOn sensor worked on the mastoid. Scheduled for a January 2013 introduction, the system hasn't been priced yet. We'll be interested to see if providers adopt this clever improvement on a traditional practice.

SCANNED FOR SAFETY The Codonics SLS500i Safe Label System automates medication safety with electronic checks and verifications.

Codonics
SLS500i Safe Label System
Syringe labeling is one of the fundamentals of medication safety. This networked system, designed to complement your drug storage carts or dispensing equipment, automates labeling and verification at the point of preparation and use.

Here's how it works. You log onto the system and scan a bar-coded vial under the laser reader. The system asks you to confirm the drug you're using. You draw the contents of the vial into the syringe and affix the label that the system prints out. The colored label includes the drug, concentration, preparer, preparation and expiration date and time. Before administering the syringe, a scan of the bar-coded label verifies its contents.

The system seems like a good defense against look-alike/sound-alike drugs, mislabeling, inadvertently swapped vials or syringes, and other human errors. It can even assist in patient documentation and inventory tracking. But it should be noted that it doesn't integrate directly with your EHR or AIMS systems. It needs the company's administrative module, which stores the system's drug information and lets your pharmacist input and customize your formulary, to make the connection. The system lists at $10,000.

YOU'RE SO VEIN The VueTek Scientific Veinsite headset reveals the anatomy while leaving your hands free.

VUETEK SCIENTIFIC
Veinsite
BARD ACCESS SYSTEMS
Site-Rite Prevue Ultrasound System
There are ways to locate a vein that don't require much more than your fingertips, but if the technology exists to visualize the vessels beneath the skin, and the results increase proficiency and success over blind sticks, then there's value to it. VueTek Scientific and Bard Access Systems are adding to the vascular imaging field with 2 new devices.

VueTek Scientific's Veinsite is a lightweight headset that uses near-infrared imaging to provide a hands-free, real-time view of veins up to 7mm deep. You see the anatomy through the headset's binoculars. You can also connect the device to a monitor for training purposes. The list price is $5,095.

ULTRASOUND, ULTRA COMPACT The Site-Rite Prevue system from Bard delivers low-cost and portable vascular imaging.

The Site-Rite Prevue Ultrasound System from Bard Access Systems makes ultrasound vascular imaging compact. Its smaller transducer probe uses sterile, single-use hydrogel cartridges (eliminating the need for messy gel application) and a size-adjustable needle guide that angles the needle directly under the beam. The monitor unit isn't much bigger than a smartphone, but presents a wealth of information, including visualization of the surrounding anatomy and gauges to indicate vessel depth, size and orientation in relation to the catheter. It lists at $9,000.

CARDIAC CONDITIONS Edwards Lifesciences's non-invasive cardiac output monitoring system.

EDWARDS LIFESCIENCES
ccNexfin
SURGICAL INFORMATION SYSTEMS
SIS Surgery Dashboard
Surgical anesthesia depends on information, and the more immediate the information, the better. A couple of days before the conference, Edwards Lifesciences acquired BMEYE, the Dutch company that developed the ccNexfin non-invasive hemodynamic monitoring system. It's an impressive technology.

An inflatable cuff wrapped around the middle of a finger uses Masimo's Rainbow SET technology to read a pressure waveform from the artery. From this, the system derives continuous, beat-to-beat blood pressure, oxygen saturation, stroke volume, pulse pressure and other real-time cardiac output parameters. The only way you'd otherwise have this information is by deploying a Swan-Ganz catheter or intra-arterial line, which you wouldn't usually do with surgical patients. The ability to obtain it non-invasively is quite useful, even if the inflated cuff turns a patient's fingertip an alarming shade of purple.

GLOBAL VIEW Surgical Information Systems' dashboard app keeps tabs on cases' progress.

The SIS Surgery Dashboard from Surgical Information Systems offers a similar window on your scheduling and workflow. The interactive application, viewable on a desktop computer at the nurses' station, any workstation with web access or a mobile device, provides status reports on each case, including their scheduled and actual start times, their estimated end times, turnover times, and canceled and add-on cases. This up-to-the-minute snapshot of each OR lets surgical managers use their ORs more efficiently by identifying and addressing problems in scheduling, resource use and overtime. It's a trend we're seeing more of: the possibility that immediate information (delivered through video-game-style graphics) can empower a rapid response to help healthcare providers reach that buzzword, "peak performance." Surgical Information Systems' analytics package, which includes the Surgery Dashboard, has a list price of $60,000. Purchased individually to add on to the analytics system, the dashboard app costs $10,000.

MINI MONITOR Mirador Biomedical's Compass confirms your catheter insertions.

MIRADOR BIOMEDICAL
Compass Vascular Access
It's unfortunate but true that we're still capable of making mistakes. But sometimes tragedy is the mother of invention. This point-of-use, digital pressure monitor, designed for central venous catheter insertions, can guard us against accidentally entering an artery. The device — a version of which is available for epidural insertions — is attached to a needle and syringe, which are inserted and aspirated. The display screen shows a continuous pressure reading to confirm the insertion site, and a guidewire port ensures accurate placement. There are other ways to detect pressure, but this is brilliant engineering and an elegant solution. It's expensive, though. The single-use device costs $35, and we usually spend $35 on the entire cath kit. If it were included in a manufacturer's cath kit without significantly increasing the price, it's a sure bet we'd buy that kit and use the mini-monitor every time. We urged the reps to strike a distribution deal to arrange this.

MORE COOL ANESTHESIA PRODUCTS

New Thinking on Monitoring, Warming and Infusing

Masimo's finger clip

• Masimo's familiar finger clip may soon be sending pulse rates, blood oxygenation stats and perfusion indexes to the screens of Apple's popular mobile devices. The company is awaiting FDA approval on a version of the sensor with cables that incorporate a circuit board programmed with SET monitoring technology and a plug that fits the jacks of iPads, iPhones and iPods.

Philips's HeartStart XL+ (left) and HeartStart FR3.

• Covidien's Nellcor Bedside Respiratory Patient Monitoring System ($4,500) is a portable device with a color touchscreen that captures and displays adult, pediatric and neonatal pulse rates and SpO2 numbers to signal potential respiratory complications. Its network connectivity and modularity make upgrades and added parameters easy.

• Two new automatic external defibrillators from Philips Medical Systems can double as portable patient monitors. The HeartStart XL+ ($9,200) turns on as a patient monitor, with a 3-lead ECG, pulse oximetry and non-invasive blood pressure readings, but can be used as a defibrillator. The HeartStart FR3 ($3,300), ruggedly designed for emergency responders, turns on as an AED but can be overridden for use as a patient monitor.

• Augustine Temperature Management and Medline Industries introduced warming solutions for the smaller set. Because covering pediatric bodies limits surgical access, adequately warming children can prove difficult. Augustine has adapted its Hot Dog electric blankets into a head-wrap and underbody warmer ($5 to $7 per patient), and Medline's PerfectTemp is designed to replace your existing table pad with a pressure-reducing warming mattress ($12,000).

• Hovertech, known for its Hovermatt patient transfer device, demonstrated how its recently FDA-approved HT-Wedge can assist in the endotracheal intubation of obese patients. The inflatable positioner angles up the head and chest, and is reusable after a disinfecting wipedown.

• Balloons are the state of the art in local anesthetic infusion pumps. Three companies — Ambu, B. Braun and LMA North America — highlighted pain pumps built with elastomeric reservoirs. Each disposable pump is latex- and DEHP-free, in a range of sizes, with variable dispensing rates and on-demand bolus dosing. Ambu's ACTion pump ($125 to $450) is an easy-to-fill bag with a dial activator. B. Braun's Symbios GOBlock pump (housed in a rigid plastic shell) is available in selectable flow and fixed rate versions. LMA North America's AutoFuser (with a rounded plastic container that's easily filled through a front port) features parallel bolus for uninterrupted infusion during patient-controlled dosing.

Civco's Infiniti Plus

• By now there's little question that ultrasound guidance is the way to go when administering continuous peripheral nerve blocks. The manufacturers of infusion components are still improving on the process, though. Infiniti Plus from Civco Medical Solutions is a needle-guide system that snaps on to the end of the ultrasound transducer to enable accurate block placements. (The starter kit with reusable bracket costs about $345 to $445. A box of 24 guides costs $200.) Pajunk's SonoPlex needles ($12.50 to $15) are imprinted with triangular "cornerstone" reflectors to increase their ultrasound visibility, even at steep insertion angles. And the Teleflex Arrow FlexBlock non-stimulating catheter resists kinking and occlusion to evenly distribute the anesthetic agent.

— David Bernard