Anesthesia information management systems have evolved into sophisticated hardware and software systems available as either stand-alone products or part of a hospital's electronic health record system.

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. Anesthesia machines have evolved from simple, pneumatic devices to sophisticated, computer-based, and fully integrated anesthesia systems. Like any other medical device, anesthesia machine also has gone through revolutionary changes along with technological advancements. Anesthesia machine was a simple pneumatic device two decades ago. But, it is a sophisticated electronic device today. Flowmeter is the most important element in an anesthesia machine. The technology is changing to meet the demand for greater reliability, precision, and accuracy. The control of the anesthesia delivery process rests primarily on titration of fresh gas supply and modulation of ventilation via the breathing circuit. The former is adjusted by making changes in mixing of gases in the flowmeter. Anesthesia workstations available today use mechanical flowmeters, electronic flowmeters, or transitional flowmeters.

The market is moving from a conventional anesthesia delivery system to entry-level anesthesia workstations. In next five years down the line, all basic pneumatic devices will be replaced. Availability of advanced and cost-effective technology will drive the anesthesia market. With increased knowledge sharing in recognized forums and decrease in price points, the need for low flow and minimal flow anesthesia even in the entry-level anesthesia machine segment is on the rise. The demand for high-end anesthesia machines with electronic gas mixing, anesthesia gas module, depth of anesthesia will see an upward trend with experienced and well-trained anesthesiologists being recruited even in Tier-II and Tier-III cities.

Indian Market Dynamics

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The Indian anesthesia market showed a growth of 8-10 percent in 2015, over 2014. The major growth came from the super premium and premium segments. However, the mainstay was the mid-tier and value segment, which continued to contribute 63 percent to the market. The performance segment stagnated, whereas the super value declined, yet continued to have its presence.

The government sector had major procurements. These included AIIMS; HLL; SKIMS Medical College and Hospital, Kashmir; NEIGRIHMS (North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences), Shillong; BMSICL (Bihar Medical Services & Infrastructure Corporation) Patna; and NIMS (Nizam's Institute of Medical Sciences), Hyderabad. Equipment was also procured by Narayana Hrudayalaya, Bangalore, for its facilities in Malaysia and Cayman Islands, and Global Hospitals and Apollo Hospitals for their facilities in Central Africa.

2015 was the year of changing trends. The buyer is showing less inclination for refurbished systems and lower-priced imported competitive ones.

In September 2015, BPL Medical Technologies, backed by Goldman Sachs, acquired Penlon Ltd. Penlon is a UK-based, leading global manufacturer of anesthesia systems and vaporizers with worldwide distribution networks.

Global Market Trends

Anesthesia equipment market has had an excellent growth in the recent times. This growth is expected to increase accordingly in the near future. The global market for anesthesia equipment reached USD 6.25 billion in 2014. The market is expected to grow to USD 10.84 billion in 2019 with a CAGR of 11.64 percent for the five-year period, 2014 to 2019. Continuous growth in this market can be attributed to rapid adoption of anesthesia information management systems (AIMS), which have been implemented in an effort to move the industry away from paper-based record keeping systems to more efficient electronic solutions. The establishment of several government-supported national statistical databases is driving this market.

The demand is rapidly increasing with growing safety awareness and technology enhancements in anesthesia machines. Low-flow anesthesia and electronic medical records dominate the current anesthesia market technology, which indirectly leads to lesser significant savings across the healthcare industry. However, rapid advancements in the anesthesia industry make it increasingly difficult for the anesthesiologist to keep up with anesthesia machine technology. Also, the latest anesthesia technology does not come low priced; even the most basic configuration of the equipment can cost a fortune. Decrease in reimbursements provided by governments for medical equipment, and increased availability of after-market service that prolongs the life of a facility's existing equipment are also the challenges involved.

The anesthesia equipment market is basically segmented into two categories, namely, anesthesia devices and on the basis of geography. The anesthesia devices can be divided into different segments based on the type of instrument. These instruments include anesthesia monitors, anesthesia machines, anesthesia masks, and anesthesia accessories. The major players in this market are 3M, Airsep Corporation, AstraZeneca, Bomimed, Carefusion, Johnson & Johnson, Phillips Healthcare, GE Healthcare, and GSK.

Technology Trends

Perioperative monitoring in anesthesia. Minimal mandatory monitoring in the perioperative period has become an integral part of the anesthesia practice. The technologies in perioperative monitoring have advanced, and the availability and clinical applications have multiplied exponentially. Newer monitoring techniques include depth of anesthesia monitoring, goal-directed fluid therapy, trans-esophageal echocardiography, advanced neurological monitoring, improved alarm system, and technological advancement in objective pain assessment. Various factors that need to be considered with the use of improved monitoring techniques are their validation data, patient outcome, safety profile, cost-effectiveness, awareness of the possible adverse events, and knowledge of technical principle and ability of the convenient routine handling.

Monitoring in anesthesia is a subject of a lot of research and development. Minimal mandatory monitors, that is, electrocardiography
(ECG), noninvasive blood pressure (NIBP), end-tidal CO2, pulse oximetry, and temperature which are universally acknowledged, have now become an indispensible part of the anesthesia practice. Some patients may require additional invasive monitoring, e.g., vascular or intracranial pressure (ICP), cardiac output (CO), or biochemical variables. Over the last two decades, an increased number of medical litigations with subsequent increased attention to patient safety coupled with the advancements in technology have led to enhanced need for improved monitoring. Newer perioperative monitoring techniques include depth of anesthesia (DOA) monitoring, goal-directed fluid therapy (GDFT), transesophageal echocardiography (TOE), neurological monitoring, the advancement in the alarm system, and technological advancement in perioperative pain assessment.

Thriving for effective non-operating room anesthesia. Non-operating room anesthesia (NORA) refers to administration of anesthesia outside the operating room to patients undergoing painful or uncomfortable procedures. These procedures are increasing due to technological developments in medical equipment, proficiency of anesthesiologists, and medically challenging patients. Common procedures include radiology, gastrointestinal imaging, diagnostic/therapeutic interventions, pediatric cardiac catheterization, psychiatric treatment, and dentistry.

Anesthesiologists are frequently asked to provide NORA in these remote locations, but sometimes fail to understand the importance of standards regarding equipment, personnel, and facilities associated with safety. To provide safe and qualified anesthetic care in the NORA, it is important for anesthesiologists to construct a systemic, uniform structure throughout an institute that contains all provisions of all categories of anesthetic care. Such criteria must be applied equally throughout the hospital, not only to ensure patient safety but also to guarantee the safety of healthcare providers. Because anesthesiologists providing NORA are responsible for the safety of the patient as well as their own, these standards should not be neglected. Resorting to standardized monitoring and anesthetic equipment is ensuring maximal patient safety and comfort.

Anesthesia information management system (AIMS). Anesthesia information management systems (AIMS) began as simple automated intraoperative record keepers, the core function of which remains the generation of an automated, continuous electronic anesthesia record that captures and documents the patient's physiologic data (e.g., vital signs) and allows for the manual notation of intraoperative events (e.g., drug administration). Since then, AIMS have evolved into sophisticated hardware and software systems that are currently available as either stand-alone products or part of a hospital's electronic health record (EHR) system; both types offer features to expand their capabilities beyond intraoperative record keeping to enhance other aspects of the perioperative experience. For example, most AIMS allow their users to view patients' previous anesthetic records and preoperative assessment forms. AIMS that are part of a hospital's EHR can retrieve relevant patient information from the EHR and then load that information automatically into the preoperative assessment and intraoperative record.

AIMS have been shown to improve the quality and safety of patient care, and clinical decision support systems (CDSS) are one of the factors that have contributed to these benefits. CDSS have become increasingly integrated into AIMS, and can be grouped into three categories, such as, process of care which involves improving adherence to clinical protocols and guidelines and perioperative antibiotic administration; practice management such as billing, maximizing operating room efficiency, and throughput; and outcome-based decision support like facilitating care that leads to better patient outcomes. CDSS are currently an active area of anesthesia research and development, largely due to their potential to improve patient care and outcomes.

Challenges

The conventional anesthesia machine works well and meets almost all needs. Machine-related morbidity and mortality are usually attributable to human misuse such as, unrecognized breathing circuit disconnection rather than to true equipment failure. Conventional machines are at the end of their evolutionary cycle, however, and the introduction of a new generation of machines is well under way. Next-generation anesthesia machines present many challenges to anesthesiologists in terms of their increased complexity, changed layout and function, and integration of new technologies.

Major unique challenges with NORA include those related to the patient, procedure, and environment. Physicians who are unfamiliar with NORA typically underestimate the fact that patients undergoing procedures involving new and advanced technological equipment are at higher risk.

These patients include pediatrics, geriatrics, and medically challenged patients who are too weak for surgical management but able to obtain some benefit from a procedure. Whether the procedures (or surgeries) performed by NORA are simple or not, each patient should be prepared in accordance with general anesthesia because the sedation can be converted to general anesthesia at any time.

The anesthesiologist must understand the nature of the procedure, including the position of the patient, how painful the procedure will be, and how long it will last. In addition, prior discussion with the anesthesiologist must include contingencies for emergencies and adverse outcomes. Other staff must be trained to assist or carry out immediate cardiopulmonary resuscitation. Unfamiliar locations, lack of monitoring devices, inadequately trained or insufficient staff, and unavailable medication or equipment in emergency situations places both patients and anesthesiologists at risk.

Various factors that need to be considered with the use of improved techniques in anesthesia are the validation data, patient outcome, safety profile, cost effectiveness, awareness of the possible adverse events, and knowledge of technical principles and ability of the convenient routine handling. So far, there is a lack of substantial evidence if these new improved monitoring techniques have improved patient outcome.

How often these improved monitors are used for a particular indication also varies from institution to institution. Most of the new monitoring techniques have been evaluated to a limited degree. Moreover, the main barrier to research evaluating the patient outcome with these new monitoring techniques includes its non-uniform availability.

Road Ahead

The anesthesia system of the future will have an additional advantage that it would enable automated correction of physiological abnormalities simultaneously, pharmacokinetic-based anesthesia infusion pumps with DOA monitoring or newer ventilators that can automatically adjust the ventilator settings by monitoring lung mechanics. These new monitoring techniques can potentially reduce the element of human error. New and improved monitoring techniques have undoubtedly led to dramatic changes in anesthesia practice.

The technological advances will be increasingly complementary and interoperable, so that anesthesia providers will use EHR-AIMS to document an anesthetic in a patient whose preoperative vital signs and lab values were assessed with his smartphone and a wearable non-invasive monitoring bracelet.

A preoperative airway exam will have been performed using smartphone-based telemedicine. Smart pumps, computer-controlled infusions, and barcode technology have made medication errors negligible, on the rare occasions when such errors occur, sophisticated monitoring systems alert the clinician while also providing patient and medication-specific decision support.

The rapid pace of development of consumer technology has great potential to merge commercial products into anesthesia practice and education. The demand for anesthesia machines is increasing due to increase in surgical procedures that require safe anesthesia equipment. The future will be technologically advanced and user-friendly machines taking into consideration patient safety and lower running expenses. Availability of innovative, accurate, and reliable patient-friendly devices would motivate the institutions to replace their existing basic equipment with advanced anesthesia machines.

P. Gopishankar, Assistant Manager, Design & Development, Skanray Technologies
Industry Speak
Technological Advancements and Emerging Trends in Anesthesia Workstations

In the recent past, anesthesia technology has undergone a major change. Anesthesia delivery, which was purely a mechanical technology with more manual controls for quite some time now, has embraced the latest technological advancements in the field of electronics and software and evolved into a more sophisticated and comprehensive machine. The complete gas mixing, delivery of anesthesia, monitoring of anesthesia gas mixture, breathing system, ventilator, and patient monitoring is taken care of by a single unit called anesthesia workstation. The need for individual functional units and the inherent problem in integrating each of the modules is getting eliminated in the new concept of workstations. {mosimage}

The following technologies signify the changing trends in anesthesia equipment:

Low-flow anesthesia. Low-flow anesthesia with closed breathing system is becoming popular because of its various advantages. It benefits the users by reducing anesthesia gas consumption by up to 70 percent and reducing the concentration of anesthesia gas and nitrous oxide in the operating room.

Digital gas flow meters. The mechanical float-type flow meters used for anesthesia gas mixtures are now being replaced by digital flow meters, which can directly project the gas flow rates on the digital display or on the ventilator screen. The flow values are more accurate than the analog float meters as the flow sensors are temperature- and media-compensated with individual calibration constants stored in each sensor.

Modern circular breathing systems. The integrated circular breathing system minimizes the number of connections and dead space volume, which makes delivery more accurate and reduces leakage to the minimum. The reusable soda lime canisters are getting replaced by disposable cartridge soda lime canisters.

Electronic ventilator. The mechanical ventilators used for anesthesia ventilation are now being replaced by advanced software-controlled electronically driven ventilators, which are compact, smarter, and user friendly. The use of electronic sensors in close-loop improves the accuracy of flow, pressure, and ventilation.

Monitors and peripherals. The modern anesthesia delivery systems are integrated with various monitoring equipment like end-tidal carbon-dioxide (etCO2) monitor, anesthesia gas concentration monitor, and patient monitor to have control on anesthesia delivery and to monitor the patient condition during the procedure. Peripherals like syringe pumps, suction devices, and scavenging units are also a part of the modern anesthesia workstation to make it a complete solution for anesthesia delivery.

The latest technology makes the workstation advanced and user friendly. Precise delivery of anesthesia is possible with the help of these latest technologies. The safety of patient, user, and environment is also addressed in this technological evolution.

P. Gopishankar
Assistant Manager, Design & Development,
Skanray Technologies

Aditya Kohli, Director-Marketing & Sales, Allied Medical Limited
Industry Speak
Paradigm Shift in Demand for Anesthesia Workstations

The last decade has witnessed a paradigm shift in the demand for anesthesia workstations. Having a good reliable anesthesia workstation with temperature-compensated anesthesia vaporizers and in-built ventilation has now become the new norm. We are witnessing increased number of customers upgrading from existing boyles-type basic anesthesia machines to quality anesthesia workstations packed with safety features.

Our range of workstations is designed in such a manner as to offer a range of customizable features to suit varied budget requirements depending on the customer needs without compromising on safety standards of the equipment.

The safety features offered by anesthesia workstations are at a huge advantage and substantially minimize chances of any accidental incidents during anesthesia. All our workstations are equipped with a twin station manifold for mounting two selectatec-type temperature-compensated anesthesia vaporizers with interlocking safety, an anti-hypoxic system, an inbuilt integrated ventilator with direct switching controls from the circle absorber system, and integrated patient alarms.{mosimage}

The display screens are offered in a series of sizes and touch/non-touch variants to meet varied customer requirements. The ventilators offer a choice of ventilation modes comprising CMV - continuous mandatory ventilation, PCV - pressure-controlled ventilation, SIMV - synchronized intermittent mechanical ventilation, and manual ventilation modes. The advanced versions offer an addition of PSV - pressure support ventilation, SIMV - synchronized intermittent mechanical ventilation with pressure/flow triggers, and spontaneous mode of ventilation.

The workstations are offered with our Meditec Pisces vaporizers, which are suitable for delivering Halothane, Isoflourane, Enflurane, and Sevoflourane anesthetic drugs. The vaporizers offer a drug delivery range starting from 5 to 8 percent and come with a choice of drug-filling options. The vaporizers are accurate, precise, and designed to compensate for variance in temperature and flow.

The workstations are offered with a choice of monitoring options starting from basic monitoring of ECG, NIBP, SP02, RESP, and dual temperatures. The monitors offer a number of upgradeable features such as EtC02 monitoring, anesthetic gas monitoring, invasive blood pressure, cardiac output, depth of anesthesia monitoring, and many others used for advanced anesthesia monitoring.

Aditya Kohli
Director-Marketing & Sales,
Allied Medical Limited

Dr Anil Kumar Jain,MD & Vice-Chairperson, Dept. of Anesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, New Delhi
Second Opinion
Essentials of Safe Anesthesia

Over the last two decades, anesthesiology, a medical sub-specialty, has evolved as a complex, technology-driven clinical service provision for surgical patients. Safety of anesthesia depends on accurate measurement and delivery of anesthetic agents (intravenous or inhalational) to maintain consistently adequate depth of anesthesia. Anesthetic delivery runs through a controlled system for preservation of environment as well as economical use of costly anesthesia drugs. In order to achieve this online, continuous concentration measurement of anesthetic agents, oxygen, and gases (nitrous oxide) is required. For humidification of anesthesia gases, accurate, and safe heat-and-moisturizer exchangers (HME) are utilized. HME helps in maintaining the water content of the respiratory tract during administration of general anesthesia, thereby preserving the core body temperature.

An automatic workstation, which administers anesthesia by monitoring depth of anesthesia, patients hemodynamic, and autonomic responses to pharmacological anesthesia state, is the need of the hour. Record and audit of all events during anesthesia gives us the opportunity to improve anesthesia performance and enhance patient safety.

Transesophageal echocardiography has added greatly to direct monitoring of the cardiac function in real time. There is significant progress seen in fluid monitoring (fluid responsiveness) in surgical patients. Accurate and effective in all clinical situations, this monitoring is suitable for further reinforcement of safety in vulnerable patients. Ancillary equipment for airway management like fiberoptic laryngoscopes with mounted video scopes were universally required for each and every OR, tubes which are atraumatic having an endotracheal portion which is hard when in vitro but soft in vivo, are specially desired to lower tracheal friction and related morbidity. Operation tables, which are suitable for more than 350 kg weight, with easy maneuverability, soft mattresses, and extra-strong maneuverable arm supports, are still not available.

Electrocautery remains a concern for patient safety and should be more than 100 percent safe. Auto-select servo cautery that selects the power and switches of defective and faulty earth plate application, adds to electrical safety in the midst of potential for fire in the operation theater.

Dr Anil Kumar Jain
MD & Vice-Chairperson,
Dept. of Anesthesiology, Pain & Perioperative Medicine,
Sir Ganga Ram Hospital, New Delhi


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