To bring you an inside look at the newest anesthesia technologies, Outpatient Surgery asked a panel of anesthesiologists and CRNAs to weigh in on 10 of the latest advances. While there was no consensus on any of the devices, anesthesia providers weren't shy about sharing their enthusiasm, skepticism or complaints regarding the products in question. Here's a review of what they said about the technologies to help you decide whether to incorporate them in your facility.

Needle-free jet injectors
Jet injectors, which may resemble a toy gun and be as small as a pencil, deliver medications parenterally, without a needle, before the IV catheter touches the skin. Modern jet injectors blast compressed carbon dioxide to eject medication through a micro orifice at the injection site.

Technology proponents insist the devices eliminate much of the anxiety felt by needle-phobic patients, virtually eliminate the pain associated with an injection or placement of the IV (reports on whether the devices are painless vary) and greatly aid infection control programs.

Anesthesiologist Elemer Zsigmond, MD, a professor of anesthesiology emeritus at the University of Illinois at Chicago (UIC) has long championed needle-free jet injection and needle-free TIVA for children. He says that facilities make back the device costs (depending on the model, they can cost up to nearly $1 per injector, including the loaded syringe) in infection control savings alone. Jet injectors eliminate the costs of purchasing and disposing of the needle and needle container.

UIC's medical center abandoned conventional needle injections three years ago and now does jet injections in all areas of the hospital, from ambulatory surgery to the ER to oncology units that provide chemotherapy. Cedars-Sinai and Seattle Children's' Hospital have studied the UIC model and are switching to jet injection.

Fear of pain in general and - needles in particular - are a lot of patients' biggest worry about surgery, says UIC's Patrick Darby, RN, who has started thousands of IVs with jet injection. "Ninety-nine times out of 100, patients find jet injection painless, although occasionally some say it's uncomfortable," he says.

"I've evaluated such products, and they're iffy at best," says Jeffrey Katz, MD, of Chicago. "They create a pinhole in the skin like any needle and they're not pain free. Some would argue that injecting sterile water is equally painless."

Dr. Zsigmond counters that at UIC, they've used jet injection on more than 120,000 patients, and the injections are painless and they shorten cases, because a painless, fast IV insertion shortens transfer time between pre-op and the OR. "Now that we routinely use jet-injected local anesthesia prior to IV catheter insertion, we've completely eliminated transfer delays, starting surgeries sooner," he says.

Anesthesia Information Systems (AIS)
AIS denotes various information technology systems designed to automate perianesthesia environment management. One system (DocuSys), functions as an IV drug monitor that incorporates digital imaging and barcode scanning and provides real-time information that detects the drug, dose and volume of an IV bolus. It also accepts and displays information from the patient monitors. Another system (Drager's Saturn system) keeps the anesthesia provider connected to medical devices, automatically collecting data.

Michael O'Reilly, MD, MS, works with GE's Centricity information system at the University of Michigan Health System in Ann Arbor. He calls AIS "an indispensable way to do quality improvement because it puts your entire anesthesia practice at your fingertips."

Kerry Gossett, CRNA, who uses the DocuSys system at St. Vincent's Hospital in Birmingham, Ala., recalls how the newly installed system prevented the accidental reuse of a syringe on a second patient. The monitor displayed information that anesthesia had used a syringe on another patient. Upon investigation, staff learned from the scanned bar code that drugs in the syringe had been prepared for the previous case. "Accidental syringe reuse is unfortunately something that happens in clinical reality from time to time, and AIS is a great safeguard against potential patient contamination. In the five months we've used it, we've thwarted accidental syringe reuse on several occasions," he says.

The biggest drawback to AIS is the cost (more than $20,000 for top-end systems). "I'd like to use AIS, but it simply costs too much," says Dr. Marco.

Some providers also find the computerization more of a hassle than a help. "The disadvantages of typing in information and constantly correcting spurious information outweigh the benefits," says Dr. Katz.

"Unless the anesthesia department has a really good information technology program, I don't know if AIS actually improves someone's anesthetic technique or management of the patient," says anesthesiologist Kristin Meyer, MD, of Philadelphia.

Implemented properly, however, "the data allow you to predict workload, better prepare you for contract negotiations because you'll know the true case costs and improve your QI," says Alan Marco, MD, MMM, of Toledo, Ohio.

Consciousness Monitors
A vocal minority consider depth-of-consciousness monitoring an indispensable investment that ultimately saves money. Detractors remain unmoved.

"Giving providers peace of mind that they're not overdosing patients is not a cost saving," says Dr. Marco, who says providers should be educated to manage dosages properly without the equipment. "Those who lean on the technology as a crutch can get a false sense of security and rely on the number on the monitor rather than actually assessing the patient."

"The monitors are good for ensuring amnesia during TIVA, but they're worthless for speeding up wake-up times," adds Dr. Katz.

"Intraoperative awareness is so uncommon that using consciousness monitoring for every case is extremely cost ineffective," says Thomas Cutter, MD, of Chicago.

Barry Friedberg, MD, of Corona del Mar, Calif., however, believes that providers who dismiss the technology overlook its true potential. It's a question of using brain activity, rather than spinal cord activity, as the primary monitoring tool, he says: "Once you make that mental leap, you start to see marked differences in reduction of medication during cases, transfer times out of the OR, greatly reduced PACU costs and shorter discharge times."

Anesthesiologist Michael Belinson, MD, of Freeport, Ill., is another believer. "I use it with every patient under general anesthesia and even the occasional sedation case. Overcoming any drawbacks, such as the 15- to 30-second time lag, can be limited by experience," he says.

Nerve stimulators for regional anesthesia
Nerve stimulators have slowly but steadily replaced methods such as paresthesias as a preferred choice for doing peripheral nerve blocks. The American Society of Anesthesiologists conducted a recent questionnaire of 683 anesthesiologists (413 responded). Among those who do regional anesthesia, nearly two-thirds (64.8 percent) report that they use nerve stimulators in their practice.

Nerve stimulators present several advantages over paresthesias, says anesthesiologist Eugene Viscusi, MD, of Philadelphia. Nerve stimulators work with sedated or anesthetized patients, unlike paresthesias. Secondly, paresthesias are unpleasant to the patient ("they can turn the patient into a human pin cushion," says Dr. Viscusi). Lastly, some suggest that nerve stimulators may reduce the risk of nerve damage during regional cases.

Dr. Viscusi says marked improvements in nerve stimulator technology have aided its growth. The needles are better, he says (most providers now use insulated block needles). The stimulators evolved from "non-specific devices into very sensitive instruments that let the provider place the block faster."

For example, Dr. Viscusi generally starts the setting at 3 mA and works his way down to 0.5 mA. The higher you start, the longer it takes to place the block. This, he notes, is often matter of experience and comfort level.

Others echo Dr. Viscusi's views. "The stimulators are indispensable clinical tools, even for experienced providers," says Admir Hadzic, MD, of the New York School of Regional Anesthesia. "They're much more user friendly now, too. For example, there are stimulators that let you adjust the current via a foot pedal, which lets a single provider perform the block uninterrupted."

"I use them and I find them particularly helpful with lower extremity blocks," says Dr. Marco. "But it depends ' For many blocks, you don't need them."

Dr Marco says that there are no clear head-to-head outcome studies that show less nerve injury than with using paresthesias as an end point. Lastly, the special needles for the stimulators add variable costs.

Pathogen-control devices
Anesthesia technologies needn't be high-tech. Take, for example, pathogen-control devices such as suction-containment systems, one of which Pittsburgh-based anesthesiologist Rafael Velez, MD, invented (the Secretion Trapper). It's a single-use secretion-containment device affixed to the OR table. The provider puts the suction tip in the holder arm in between uses. At the end of the case, he leaves the used suction tip (and potentially other disposables, such as the endotrachael tube) in the bag for disposal into the main biohazard waste can.

Dr. Velez says he developed the device based on his OR observations and concerns about anesthesia's role in nosocomial infections. He has little doubt anesthesia has some role to play in these sentinel events, though there has never been a good study showing how many infections are directly anesthesia-related.

Even so, airway secretions can contaminate the OR. At the very least, cleanup adds to OR turnover times. " There's usually no good place to put the suction tip in between uses. We've all had it slip and fall on the floor," he says.

Dr. Velez says devices such as his and Medical Device Group's Suction-tip Holster (which also contains the suction tube) are links in a chain of error-prevention strategies providers should institute to reduce nosocomial infection risks. "Suction-tip containment goes along with wearing gloves even for non-sterile procedures and safe needle practices," he says.

Several providers tell Outpatient Surgery they would consider such pathogen-control devices if they were readily available and reasonably priced.

"They're definitely a good idea," says Brian Kirkpatrick, CRNA, of Seattle. "I also wonder if perhaps anesthesia couldn't just rig up something similar in-house. But perhaps if you do a cost analysis of the materials and set-up time for each case, it may prove simpler just to order the commercial product."

Dr. Velez, whose device retails for about $75 for a box of 50, claims it represents a relatively minor investment compared to the cost of treating even one nosocomial infection.

Improved pulse oximetry
Anesthesia providers almost universally agree that pulse oximetry is an extremely valuable monitoring tool. "Not to exclude the importance of EKG and the blood pressure cuff, but the pulse oximeter is the one monitor you'd choose if you could only have one monitor in the OR," says Adam F. Dorin, MD, MBA, of San Diego, Calif.

The monitors, however, are notorious for being disturbed by movement, equipment "chatter" and arterial occlusion from blood pressure cuffs (if the cuff has been on the same side as the pulse oximeters). They can also produce false desaturation reports during patient movement and cold-induced peripheral vasoconstriction (which diminishes perfusion to the extremities).

Manufacturers continually refine pulse oximetry equipment to make it less sensitive to interference. Providers evaluate based on these criteria:

• SpO₂ sensitivity (detecting true desaturation),
• SpO₂ specificity (absence of false alarms),
• sensor clip placement and provider preference (finger, toe, earlobe, forehead),
• equipment drop-out rates and missed monitoring events,
• impact of motion,
• effect of low perfusion, and
• independent research on clinical efficacy.

In all, says Dr. Dorin, "most providers are very satisfied with the quality of the newer machines, but the interference is still a fact of life."

Pediatric anesthesia devices
In addition to pediatric versions of bread-and-butter devices, such as child-size masks, there are technologies geared specifically to doing pediatric cases. Once example is the PediSedate headset, which is in the final stages of its clinical trials, and should be available to facilities in 2004, according to its inventor, anesthesiologist Geoffrey Hart, MD, of Boston.

The device, which looks like a toy, is a real-time respiratory monitoring device and anesthetic gas (such as nitrous oxide) infusion snorkel. The non-pharmacological benefits, he says, set the device apart from other monitors and induction masks. Dr. Hart's device attaches to a Nintendo Game Boy or compact disc player. While the child plays video games or listens to music, the anesthesia provider begins the anesthetic. Later, during emergence monitoring, the game or CD player can be reattached.

Dr. Hart says the device can be used for anything from dental surgery to shorter outpatient ENT procedures. It also can be incorporated into moderate sedation procedures. For example, it may ease the child's anxiety and make starting an IV easier (combining sevofluorane and fentanyl anesthesia). Non-anesthesia providers, such as radiologists, also can use them.

None of the providers contacted by Outpatient Surgery have seen Dr. Hart's device first hand, but several knew of it. "It sounds like an interesting product if you do a high volume of pediatric cases," says Mr. Kirkpatrick, who often works in an ASC that does many pediatric ENT cases. "The psychological benefits to the kids and their parents could be a difference maker in why they'd purchase it."

Mr. Kirkpatrick says such a product could gain a foothold in children's hospitals, with pediatric oral surgeons and in outpatient ENT centers. However, he adds that budget constraints may limit the interest except in facilities with very high pediatric volumes.

Infusion pumps
Pain management pumps, especially the programmable, patient-controlled variety, have become indispensable tools for treating post-op pain, especially after orthopedic, general, obstetric/gynecological, plastic and podiatric surgeries. Most providers believe the devices benefit patients, but not all are satisfied with the state of the technology.

"The quality still varies widely. A lot of models, quite frankly, are poorly designed and are horrible to program," says Dr. Marco, who mentions a study that showed a 100-fold difference between the most and fewest button presses users needed to program different pumps.

Providers say they base their verdict on each pump on three key factors: reliability of the drug delivery profiles, the flexibility to customize treatments to specific cases and the ease of programming to set or modify treatments.

A University of Toronto study published earlier this year estimated that about 650 patients die annually due to programming errors with pain pumps. The study suggested that the control panel used to set medication levels be redesigned to make dosage programming less prone to error and the devices more sensitive to catching such errors.

In all, providers deem the technology an important and valuable perioperative tool. "There are several really good and reliable infusion pump models on the market but a lot of the others still need to be overhauled and idiot-proofed," says Mr. Kirkpatrick.

Airway management devices
Until fairly recently, difficult airway management cases presented a major hurdle that often contraindicated outpatient surgery, especially in freestanding facilities. Everything changed as the equipment got better. Most providers tell Outpatient Surgery they are very pleased with the array of airway management tools available to them and call these devices key factors in the explosion of outpatient surgery.

Many providers tend to stick to the basics of modern airway management equipment. "Under most general anesthesia scenarios, you'll need only the mask, a good fiber optic laryngoscope, intubation capability and LMAs of different sizes," says anesthesiologist Nitin Shah, MD, of Irvine Calif.

Dr. Shah and several other providers say the LMA (laryngeal mask airway) greatly enhances their airway management capabilities with patients who can be spontaneously ventilated, because the device aids placement of an endotracheal tube in a difficult airway. There are also so-called fast-track LMAs, which guides providers to place a special endotracheal tube and is removed once the tube is placed.

"The biggest advantage of using LMA is that it stays outside the larynx, so you don't have to manipulate the vocal cords, which are the deepest point of airway stimulation," says Dr. Shah.

Dr Shah adds that while LMAs usually comprise an effective airway management arsenal, several other technologies have become valuable in recent years:

• COPA (cuffed oropharyngeal airway). Marketed as an alternative to mask airways and LMAs, it is designed to help the patient breathe spontaneously through it. You cannot intubate a patient with a COPA.
• Light wands. These devices, available in pediatric and adult sizes, assist endotracheal-tube placement.
• Special laryngoscopes. Popular alternative designs to standard fiber optic scopes include the Bullard laryngoscope (a rigid instrument with a blade designed to match the patient's anatomic airway) and the Wu scope (a flexible scope with a tubular, rigid blade).

Cox-2 inhibitors
Providers cite the much-hyped and advertised COX-2 inhibitor drugs as an important recent tool in preventive, multimodal pain management. Like standard non-steroidal anti-inflammatory drugs (NSAIDs), they work synergistically with low-dose opioids to provide powerful analgesia but, unlike traditional NSAIDs, you can administer them before surgery without increasing the risk of perioperative bleeding.

"Traditional NSAIDs and COX-2 inhibitors appear to be safe overall for treatment of acute pain. The difference is that because they do not inhibit platelet aggregation and produce less GI toxicity, you can use COX-2 inhibitors even when traditional NSAIDs are contraindicated," says Dr. Katz.

However, he adds, there is no hard-and-fast distinction between the clinical functions of the two COX-2 isoforms, because COX-2 inhibitors can also adversely affect the kidneys, cardiovascular and reproductive systems.

"They're not a wonder drug," says Dr. Marco. "For most patients, there's really no difference between the standard NSAIDs and the Cox-2s."

Convincing the skeptics
Anesthesia providers are creatures of habit and skeptics by nature, says Dr. Velez. And they are constantly bombarded with new devices and technologies claiming to offer major benefits to their patients. "It's very hard to convince people in my profession to change what they're used to doing," he says. "The hardest part is getting your foot in the door, but thereafter, it's hard to argue with the logic behind many of these technologies."