Looking for a more compact monitor? Or new nerve stimulators for pain management? Or for more options for handling difficult airways? Equipment for it all - and more - was on display at the 2004 meeting of the American Society of Anesthesiologists in Las Vegas in October. I combed the exhibit hall's more than 230 vendors to find the products that are new since last year. Here's what I thought would most interest you.

Airway management
Difficult-airway products were among the neatest on display.

• Endoscope-intubator in one. The C-Trach (a combination endoscope-intubation device) drew quite a crowd to LMA North America's booth. The device, due out in mid-2005, features a monitor for viewing the trachea right on top of an LMA, which can help make intubating difficult airways faster.
• Trach tube with flexible tip. Medline's EndoFlex endotracheal tube lets clinicians rapidly and safely adjust the tip of the tube into position for a variety of difficult-airway situations. An attachment lets you bend the tube's flexible tip (eliminating the need to use a stylet for intubation), adjust the tube and place it exactly where it needs to be in the patient to find the trachea and establish an airway.
• Intubating laryngeal airway. Mercury reps presented the CookGas ILA (intubating laryngeal airway) as easier to place than an LMA because of its oval-shaped top that prevents fold-over or flip-flopping. With a keyhole-shaped airway, you can fit up to a size 8.5 ET tube, and you don't need to buy special ET tubes for use with the ILA. It's reusable and autoclavable up to 40 times, they say.
• Next-generation LMAs. A full line of new laryngeal mask airways will soon hit the market from Nellcor/Tyco. Disposable and in eight incremental sizes, these vary from first-generation LMAs in three ways, says the company. First, the inflation line isn't in the airway; it's in the wall of the shaft. It also runs across the top of the dome, preventing rollover. Second, an epiglottic shelf/barrier prevents the epiglottis from closing off the airway. Third, there are no bars, so you can easily pass a suction catheter.
• Image capture. Want to be able to capture images of difficult cases? The PortaView LF intubation fiberscope and the PortaView LF-V videoscope with the CCD chip at the tip let you take pictures and zoom in on the fly intraoperatively via the control handle, says Olympus. I found the picture quality to be very good. Everybody (laparoscopic and orthopedic surgeons and anesthesiologists) can use the same camera box on several different scopes. The PortaView lists for $25,000 to $28,000.
• Video laryngoscope. Karl Storz has added a battery light source to its video laryngoscope, maintaining bright light while making the semi-rigid telescope for intubation more portable. I found this easy to use. With the picture up on the OR monitor, you don't even have to put your head down to intubate - you can see it in front of you. Reps say many compatible blades are available.

Patient warming
Can less be more? Maybe so.

• Head heating. Cincinnati Sub-Zero's Head Wrap, which insulates against heat loss while infusing heat, gives you as much body access as possible. A new Patient Vest is also available.
• Hot water pads. KC Healthcare's Patient Warming System consists of a control unit and disposable, hydrogel, non-slip pads that are applied to the patient's body. Because water is pulled instead of pushed through the pads (negative-feed, which means better water flow), reps say you get better perfusion and need to cover only 20 percent of the patient's body to effectively warm.

More ways to monitor

• Portable BIS monitoring. Aspect Medical's BISx takes the company's BIS monitoring technology and puts it in a hockey-puck-sized device that can be plugged into several compatible monitors by other manufacturers, including Philips, Drager and Datascope. The result is portable BIS monitoring, which in light of the JCAHO Sentinel Event Alert regarding anesthesia awareness might be worth a look. (See "Anesthesia Awareness: Your New Malpractice Risk?" on page 10)

Aspect's pediatric-specific sensors, which run on the company's XP platform, are due in early 2005.

• More versatile sensors. Conmed has added Nellcor-compatible sensors to the handheld Dolphin Voyager and Dolphin 2150 pulse oximeters. The Voyager is a platform that can be added to any Windows-based pocket PC device you furnish; the 2150 is a self-contained portable machine. When the sensor is on the patient, you can see perfusion, heart rate and SpO2 to the nearest tenth, and you can see wave forms on your pocket PC with the Voyager program. The Voyager lets you save the data under the patient name and upload it to your main computer system later. These seemed handy and easy to use in the recovery room; reusable or disposable sensors are available.
• New line of monitoring products. Drager launched an entire line of Infinity patient-monitoring products that includes the Kappa XLT and the Trident. The Kappa XLT is a split-screen, single-use patient monitor that lets you view expanded monitoring arranged according to clinical context on one side of the screen, with real-time vital signs and continuous trending on the other. The Trident is a plug-and-play pod, similar to the BISx, that adds neuromuscular transmission monitoring. This indication of muscle relaxation helps you judge the state of the patient's neuromuscular blockade.
• Measuring disorder. GE Healthcare has added a new parameter, the Entropy, to its monitors. Entropy is a measure of disorder in the system. The parameter tracks cortical activity, which is linked to wakefulness and ability to respond to stimuli: If you're awake, your cortical activity will be high and readings will be disordered, and you'll have high entropy; the more asleep you are, the more regular your EEG (cortical activity), the lower the disorder and the lower the entropy. Entropy measures in real time EEG and EMG, so the reading is individualized (not a library of historical data, as is the case with BIS), which could let you better tailor anesthesia administration.
• Four-pound monitor. Invivo's M8 is the newest addition to the Escort line of monitors. This small, lightweight version will soon include end-tidal CO2 and one invasive pressure monitor (making it more complete), as well as the standard multi-lead ECG, non-invasive blood pressure, respiration, SpO2 and temperature. M8 weighs four pounds and has a five-hour battery life, making it portable between the OR and recovery. It lists for about $5,000.
• For spot-check monitoring. Masimo's Rad 5 is a portable pulse oximeter that incorporates Masimo's SET technology for better readings during motion and low perfusion. The patient can wear the same sensor as in the OR for quick checks in recovery, which is nice if you're moving patients through quickly and don't want to spend time connecting and reconnecting them. The Rad 5's rubber edges protect it in case it's dropped.

Data management systems
Three new anesthesia platforms were on display.

• Central networking. Datascope's Panorama patient monitoring network is a central platform that puts the readings from both wireless bedside and wireless ambulatory monitors in one place. You can capture, print and archive real-time patient data. It seemed easy to expand to other departments, a bonus if you're in a hospital-based OR.
• Piece of the pie. An addition to the 3-D Anesthesia line, Drager's Apollo Anesthesia Platform is a modular workflow station that is the digital delivery component. It's suitable for low-and minimal-flow anesthesia, says the company, and lets you retain ventilation parameters when switching modes. The idea is to make anesthesia quicker, safer and more precise.
• Many monitors, one platform. The Windows-based IntelliVue platform from Philips is modular in design (you just plug in modules to add features). It lets you network your monitors (across the IntelliVue line) so you can view all patient-monitoring information in one place. If you want to standardize your monitors, IntelliVue lets you customize according to departmental needs.

Lock up scrubs, supplies

• Carts with electronic locking systems. Staff pass the chip (which can be put on the ID card they already carry) over a sensor, and Blue Bell Medical's carts unlock, recording the user, time and date to a central database. Pass the chip over the sensor again, and the cart locks and stamps the time and date. If you suspect someone of stealing anesthesia supplies, or if someone has been fired, you can immediately deactivate the chip from the database (on your office computer). You can even activate a chip with a time limit; for example, if you have a visiting anesthesiologist, you can activate the card for just five hours.
• Keeping scrubs secure. Do scrubs have a tendency to walk out of your facility? The Pyxis Scrub Station IC is a possible solution. To get new scrubs, you have to enter a password and deposit dirty ones. What I like about it is that all the scrubs are arranged by size, so you don't have to dig through them on the traditional four-tier shelf, making a mess while you get frustrated looking for the ones you want.
• Custom dispensing stations. Everything you do results in a paper trail with the Anesthesia Workstation from Omnicell. Once the physician selects a patient and enters his password, all drawers open - as opposed to only being able to open one at a time - making access more convenient. This workstation anticipates the barcoding of all supplies and drugs that's impending; you scan each item you take out, which then appears on the monitor and is captured for printing for post-case reconciliation. You can custom-configure the workstation for actions such as documenting doses and requiring an additional witness password.

New for pain management

• Catheter needles. The Stimuquick nerve-block needle used in conjunction with the Stimucath continuous nerve-block catheter from Arrow International can stimulate the nerve through both the needle and catheter. BD has added a 20-gauge notch needle (22 and 24 are already available) that will be on the market in early 2005. The notch is meant to help keep you from advancing the needle too far into the vein. International Medical Development has a new spinal needle called the Gertie Marx, which has raised side-port indicators to enhance feel when positioning it. A line of stimulating catheters embedded electrodes called Polymedic were on display by Quality Medical Needles. Representatives say the design reduces the chance of nerve injury from the catheter. Stryker is also marketing Polymedic brand needles for France-based Te Me Na.
• Nerve locators/stimulators. Kimberly-Clarke/Ballard's Pain Management System uses radiofrequency to perform standard RF, pulsed RF and intradiscal nerve lesioning procedures. Life-Tech's Stimprobe is a hand-held cutaneous stimulating probe used with the company's Ezstim II for nerve mapping. An audible indicator means you don't have to be glued to the display. An updated laser nerve locator, the Sabre Source, was on display by Minrad. The device mounts on the C-arm and lets the physician turn off the X-ray and use the crosshairs to determine the subcutaneous target; it's accurate to /- 1mm from 1 meter. Sonosite's Titan is a hand-carried mobile ultrasound system for finding and stimulating nerves for needle placement. Being able to see the fluid engulf the nerve might lead to faster blocks with less drugs used. The system lists in the mid-$20,000s to low-$30,000s, according to company reps. Stryker is marketing another Te Me Na product, the Polystim, a radiofrequency nerve stimulator with three stimulation intervals and five current frequencies.

Take-home pain control

• At-home removal. A disposable infusion pump for continuous nerve blocks will soon be available in BBraun's nerve-block trays. Its reservoir houses about a three-day bolus independent of the line for the regular basal rate. The patient can take out the elastomeric pump without seeing a doctor.
• See it. Breg's disposable 3200 and 4200 models sport the company's flow indicator feature, which allows for visual verification that the medicine is flowing. Patients sent home with the spring-loaded pump can see the drip in the pump for themselves, helping prevent untreated post-op pain and a trip to the physician, only to find out the pump is working just fine. The combined drip/bolus devices list for $100 to $175.
• On-the-skin relief. Cosmo Health's Cosmo-TENS (transcutaneous electrical nerve stimulator) PF990 offers wireless, drug-free post-op pain control. You apply the butterfly-shaped patch to the point of use, and a small, battery-operated unit attached to the patch produces high- and low-frequency electrical stimulations for pain relief. Treatment lasts up to 33 minutes. The patches are disposable and replaceable; the PF990 is FDA-approved for self-application.
• Recorded data. The electronic, programmable Ambit (Ambulatory Infusion Therapy), a smaller version of Sorenson Medical's PCA, comes in both reusable ($500 list) and disposable ($250) models; the reusables create a history, tracking the number of patient uses and the number of patient-controlled boluses dispensed. I like the historical-data feature on the reusables; JCAHO wants you to track patient pain on a scale of 1 to 10, and a good way to do so is to look at the number of boluses patients require.

Capital equipment
Only one entry of note here: Philips' BV Pulsera C-Arm, which boasts lower-dose radiation than previous models. I liked the picture quality on this machine. The C-Arm features rotating anode power and extended rotation, and includes an integrated software server in the work station trolley, letting you import to the OR images from other imaging systems in your facility. It lists for $120,000 to $140,000.

From the show floor to you
If you couldn't make it out to the ASA this year, or even if you made it, but were too busy with all the educational programs, panel discussions and scientific posters to work your way through the exhibit hall, I hope you'll find this rundown useful in making purchasing decisions for your facility.