Recent anesthesia models have added new ventilation modes and most manufacturers are trying to increase the similarities between their ventilator and anesthesia monitor interfaces.

Today, anesthesia machines are being increasingly incorporated in healthcare systems as they are seen as a key medical apparatus. The goal of anesthesia care is to ensure the safest possible experience for the patient. The advent of ultrasound, better needles, catheter systems, and monitoring has entirely rejuvenated, if not revolutionized, the practice of anesthesia. Anesthesia machines have evolved from simple, pneumatic devices to sophisticated, computer-based, and fully integrated anesthesia systems. The advanced versions of the machines offer higher patient convenience and safety. The anesthesia equipment of today is trending toward a compact ergonomic design for ease of use and surfaces that are easier to keep clean to reduce nosocomial infections. This equipment has integrated cutting edge monitoring that is versatile and customizable to increase diagnostic confidence.

The main improvements in anesthesia equipment over the past 10 years have been ventilation modes that were previously only used in ICUs. These include pressure support ventilation (PSV), synchronized intermittent mandatory ventilation (SMMV), and synchronized mandatory minute ventilation (SMMV) and various derivatives of each mode. The ventilator has ICU quality ventilation across all patient categories and has low flow and minimal flow anesthesia modes to improve anesthetic delivery and reduce financial impact. Recent models have added new ventilation modes and most manufacturers are trying to increase the similarities between their ventilator and anesthesia monitor interfaces.

Indian Market Dynamics

 The Indian anesthesia systems market in 2016 is estimated at Rs. 167.5 crore, with sales numbering 5115. The super-premium segment had excellent sales with teaching institutes making major procurements. This trend is of course one of a kind, and may not be repeated in 2017. The mainstay continues to be the mid-tier and value segments, which together contributed 53 percent to the market in value terms in 2016. The premium and performance segment each have a market share in the 14 percent vicinity, whereas super value contributes 8.6 percent to the market. The buyer is increasingly exhibiting less inclination for refurbished systems and competitively priced imported models.

 The teaching institutes made major procurements, with a preference for the super-premium segment. Major buyers in 2016 included AIIMS; NEIGRIHMS (North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences), Shillong; BMSICL (Bihar Medical Services & Infrastructure Corporation) Patna; Indira Gandhi Institute of Medical Sciences, Patna; and AP Health Corporation, Hyderabad. Mindray had good success in this category.

With increasing competition on price, vendors are shifting to offering products from their Chinese partners, rather than European ones, and also focusing on Tier-II and Tier-III cities.

Global Market

The global anesthesia devices market is estimated at Rs. 52,125 crore in 2016, projected to reach Rs. 90,500 crore by 2021, at a CAGR of 11.64 percent in the period 2016–2021. Anesthesia and respiratory devices, owing to their capability to resolve various environmental and lifestyle induced respiratory disorders are expected to witness substantial growth. Increasing incidences of respiratory illnesses
such as chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are high-impact rendering drivers for this market. Moreover, the increasing geriatric population and rising rates of environmental pollution are key drivers.

Manufacturers are constantly investing and upgrading their product range. Over the past few years, the preference of people has shifted from hospital care to home healthcare services. This has encouraged leading players to introduce varieties of portable medical devices. The availability of a variety of home healthcare devices has propelled the market in the recent past.

The slow adoption rate of AIMS is expected to be a major challenge. However, destinations where the cost of manufacturing anesthesia and respiratory devices is low are expected to offer many growth opportunities to the global market.

Emerging Technology

Technology has been integrated into almost every facet of anesthesia practice, from patient monitors and anesthesia machines to documentation and drug delivery. In the course of a typical day, anesthesia practitioners care for patients using an array of technologies whose sophistication and utility are continually increasing.

Physiologic monitors. Accelerometers, magnetometers, and gyroscopes in consumer devices such as smartphones and activity trackers allow for monitoring various aspects of individuals' daily lives, from exercise to sleep. Medical device manufacturers are exploring the role of wearable devices integrated in physiologic monitors. Research groups are integrating wearable devices and motion sensors in patients' homes to detect cognitive impairment in vulnerable populations, such as older adults. There is potential for growth in this sector, particularly to maximize patient safety on both an inpatient and ambulatory basis. However, the benefits of remotely monitoring physiologic data on an outpatient basis require scrutiny, particularly if such monitoring requires significant time and resources for implementation.

Capnographic analysis. Continuous respiratory monitoring is one of the most essential components of anesthesiologists' vigilance. Minimally invasive monitoring of ventilation is appealing, particularly for settings outside of the operating room. Noninvasive monitors range from oxygen delivery systems with integrated capnography masks to transcutaneous measuring devices. Anesthesiologists often administer 100 percent inspired oxygen to minimize the risk for hypoxemia during periods of apnea, such as during laryngoscopy.

Surgical blood loss monitoring. Monitoring surgical blood loss is fraught with imperfections. Suction canisters may contain blood and other body or irrigation fluids. Visual estimation based on number of sponges and saturation of sponges also is inaccurate. Weighing sponges is time-consuming and may be inaccurate, particularly if there are other body fluids intermixed with blood.

Second Opinion

Advancement in Anesthesia Equipment

 With continuous advancement in technology, anesthesiologists rely on these sophisticated devices to provide safe care to patients and feedback to manufacturers for further advancement of devices.

Physiological closed-loop controlled devices (PCLC) are an emerging technology that analyzes the specific data to regulate physiological variables by autonomous therapy. They play an important role in reducing cognitive overload, minimizing human error, and enhancing medical care during high workload and high-stress environments like in operating rooms, intensive care, and emergency medicine settings and mass casualties' incidents to ensure adequate and timely therapy delivered automatically.

PCLC devices play an important role in operation theater for closed-loop anesthetic delivery, closed-loop vasoactive drug and fluid delivery, closed-loop mechanical ventilation, and monitoring vitals. The anesthesiologist must consider before using the benefit–risk of devices and evaluate system design, system performance analysis, fault detection, fallback modes, user interfaces, and operational transparency. The closed-loop systems should prominently display whether control is on or off and the controller mode. The closed-loop systems should display a graphic trend of all relevant variables and parameters. Users should be able to monitor and track the input signal and the controller output, and also notify the auditory alarms with descriptive text messages required for safe operation.

The user should always be able to determine what the controller is doing, why it is doing it, and what it will do next. The risk with such devices may be from human error, or artifact in physiologic sensors, for example, invasive blood pressure, electroencephalogram, cardiac output, respiratory gases; and in mechanical sensor systems, for example, flows, pressures, and gas concentrations internal to machines. Still the challenges are related to design, development, and performance evaluation. So, PCLC medical device should be robust, stable, and effective in such an environment.

Dr Sushma Saroa
Anesthesiologist-Department of CT & MRI,
Sir Ganga Ram Hospital

Simulation. Medical simulation continues to play an integral role in education in the operating room. In 2016, consumer devices for consumption of virtual reality content are entering the market. Generating content is also becoming increasingly easy with consumer cameras. Medical simulation and education may benefit from this increased accessibility. Virtual reality headsets range from the cardboard box frames that house a smartphone to sophisticated devices. The virtual-reality industry is just beginning to find applications in the consumer and healthcare markets.

The Road Ahead

Anesthesia machines and the technology behind them have constantly evolved over the years. The machines used today, are completely different from the conventional versions that were based on pneumatic systems. Manufacturers will continuously introduce technological advances in their equipment which focus both on patient safety and efficiency. The integration to the hospital information system is worthy of the initial investment. The advancement of low flow technology and savings on anesthetic agent spend will also be a focus in the future.

The equipment will be easier for the provider to use and will have a low consumption of costly anesthetic agents. Setup, self-checks, and routine maintenance will be fast and simple. Accessibility to patient data and complete clinical information will be at fingertips in one compact ergonomic system that ensures a good return on investment. As these technologies grow older and more commonplace, they will likely become more affordable and more broadly used leading to increased safety and faster patient recovery times.

Second Opinion

Procurement Planning and Budgeting for Anesthesia Services

 Dr Dipankar Dasgupta
Director and HoD,
Anesthesia Department,
Jaslok Hospital and Research Centre,

 Dr Rajani M R
Consultant Anesthetist,
Jaslok Hospital and Research Centre

Procurement plan is a composite decision to buy from the available market with limited resources and a long-lasting functioning. Procurement planning for hospitals is processed by world federation guidelines adopted by a national body of affiliated countries. Medicolegal constraint and safety compel us for uniform adaptation of given guidelines. Procurement planners need knowledge in subject, quality functioning, market dynamics, on spot servicing facility, sense in finance, integrity, and honesty. Planning mainly depends on whether procurement is for new/running/primary health center/district/medical college/service establishment/super specialty/tertiary care hospital.

In India, till 1990, medical college hospitals designed their individual norms of procurement. Global products were not available freely, and were compounded by inadequacy of national manufacturing of medical equipments. Agents used to push products unscrupulously. In 1988 the Prague WFSA conference task force was created for assessing the mandatory needs for anesthesia set-up. In the 1992 world conference at Washingtonmonitors were declared mandatory, dividing the hospitals at three levels covering the remotest hospital to the ultra modern urban center for safe practice in anesthesiology. ISA a member country for WFSA took the challenge and listed requirements at all levels with minimal realistic changes which covered basic to advanced requirements.

In the last six decades, revolutionary changes have taken place in the monitoring system and workstation in anesthesia. Earlier we were monitoring clinically, assisted by sphygmomanometers, ECG, and thermometer. Modernization started with availability of equipment revealing central venous pressure, arterial pressure, pulmonary wedge pressure, haemogram, blood biochemistry, blood gas analysis, blood glucose, and lactate level. Cardiac output monitoring with a pulmonary artery catheter is replaced by pulse pressure analysis and is the latest trend. PICCO, LIDCO, volume view, and cardiac output variations work on principle of transpulmonary, thermodilution, and arterial pressure waveform analysis with continuous cardiac output display. Oesophageal Doppler with transducer at the tip demonstrates constant cardiac function along with thoracic aorta blood flow and is a late additional assistance.

Anesthesiology, critical care, and the dolorology-related appliances procurement plan involve modern equipments tried extensively over the globe, locally available with service guarantee and fitting economics. Work stations should have the monitoring facility of continuous gas flow/temperature compensated vaporizers/displaying hemodynamic data/gas and vapor concentration display/temperature display/anesthetic depth monitor/temperature/neuro-muscular stimulation monitor. Scientific procurement also includes a difficult airway cart including fiber-optic bronchoscope and jet ventilation and hemodynamic resuscitation trolley (defibrillator and pacemaker facility).

High pressure as well as unscrupulous marketing must not influence the minds of personnel. Medicolegal consideration must remain at the back of the mind. Procurement is the hallmark that involves square knowledge, availability, service facility, functioning within available budget, intellect, honesty, and integrity.

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