OCTOBER 16, 1846, marked a dramatic day in the history of humankind, with the first public demonstration of anesthesia (fig. 1A).1If the reduction of human suffering is medicine's primary goal, it could be argued that anesthesiology has contributed more to humankind than any other field of medicine. In its first issue in 2000, the editors of The  New England Journal  of Medicine  published an editorial on a millennium in medicine, in which they presented the 11 most important advances in medicine in the past 1,000 years.2Anesthesiology was, of course, on the list. However, because information was published in chronological order, anesthesiology did not appear first, its rightful position of importance in my opinion. Although none of us can take credit for this advance, we can clearly be proud of our heritage and what we do every day in reducing pain and suffering for millions of people.

Fig. 1.  (A ) The first public demonstration of ether anesthesia was on October 16, 1846. W. T. G. Morton, M.D., is depicted, holding the ether, whereas J. C. Warren, M.D., performed the operation. This painting is by Robert C. Hinckley (1853–1941), used with permission by Boston Medical Library in the Francis A. Countway Library of Medicine. (B ) The Wright brothers first flight on December 17, 1903, at Kitty Hawk, North Carolina. The picture is public domain (http://www.wpclipart.com/world_history/the_hand_of_man/wright_brothers_first_flight; Accessed November 10, 2010).

Fig. 1.  (A ) The first public demonstration of ether anesthesia was on October 16, 1846. W. T. G. Morton, M.D., is depicted, holding the ether, whereas J. C. Warren, M.D., performed the operation. This painting is by Robert C. Hinckley (1853–1941), used with permission by Boston Medical Library in the Francis A. Countway Library of Medicine. (B ) The Wright brothers first flight on December 17, 1903, at Kitty Hawk, North Carolina. The picture is public domain (http://www.wpclipart.com/world_history/the_hand_of_man/wright_brothers_first_flight; Accessed November 10, 2010).

During the past 164 yr, the field of anesthesiology has rapidly progressed, with many developments that have improved the quality and safety of anesthesia care and enabled tremendous advances in the surgical disciplines. During this lecture, I will focus on two “points of inflection” in the field of which I am familiar: the development of noninvasive monitoring of oxygenation (and monitoring standards, in general) and the development of perioperative anesthesia information management systems (AIMS). I believe many of the older members of this audience will agree that there was a significant change in the practice of anesthesiology between 1980 and 1990. I hope to convince you that we are in the midst of another change that will dramatically affect the way we practice in the next decade as we first implement information systems as a routine and then use the data derived from those systems to make another dramatic change in the way medicine is practiced, not only in our field but in other disciplines.

As I review the progress of anesthesiology for greater than the past 150 yr, I see striking similarities in the progress of the aviation industry. This may make even more sense for me. Having a father who was a test pilot and having soloed my first plane at the age of 17 years, I felt a remarkable déjà vu “soloing” my first anesthetic. What do we actually do to patients? (1) We suspend consciousness. (2) We counterbalance painful stimuli. (3) We maintain normal physiology during a planned trauma. (4) We frequently produce nausea and vomiting. We are a lot like pilots. Both of us have a fun job taking people places. We place people in a dangerous situation. We try to make people feel at ease and allay their fears. We really do not provide complete information for consent. If we were to inform the patient of what we actually plan to do to him or her, we would have to tell the patient the following. We will give you a drug that will cause you to stop breathing, and your oxygen concentration will start to decrease. In case you attempt to breathe, we prevent even the slightest possibility of that occurring by giving you a second drug that paralyzes your muscles. Then, during the next critical few minutes, we manage to control your airway and place you “safely” on a ventilator. This is similar to what a pilot would have to say to passengers before starting down the runway. Before the plane takes off, the pilots do not state that the liftoff speed is 180 mph and that if that speed is not reached half-way down the runway the plane will end up in a pile of flames and most likely all will perish. The pilot should also state that during the first few minutes of maximum thrust, if for some reason the plane should lose power, again it will fall to the earth in a pile of flames and most likely all will perish. This type of informed consent, as with detailed information regarding anesthesia, would not help the passengers (or patients) undergo their “flight” at ease. Therefore, neither pilots nor anesthesiologists inform their patients nor passengers with accurate details of what is about to happen. A formal informed consent does not seem necessary because everyone has a general understanding that being up in the air is not safe and could potentially be lethal. The same could be said regarding anesthesia but in a more vague way (i.e. , most patients know that anesthesia is an abnormal state with inherent danger, but the alternative seems much worse).

Next, both anesthesiologists and pilots have a flight plan A and plans B and C, should the unforeseen occur. Again, most of the risk is during the takeoff and the landing (i.e. , the induction and emergence); during the flight, both of us look at electronic devices to see where we are. Finally, we both tend to make some people experience nausea and vomiting.

As with pilots, anesthesiologists have short and long flights, with long ones requiring more planning and preparation. We may be flying young “healthy” planes, or we may be flying elderly planes with more “comorbidities.” We may need to fly under extreme conditions. The advances in anesthesiology in improving safety have given us the ability to care for more elderly patients undergoing more complex surgical procedures.

Clinical Decision Support Goes to Fly-by-wire

In 1995, the Airbus 320 was launched as the first fly-by-wire commercial aircraft.42This had long been a requirement for military fighter aircraft to allow them to fly at extreme speeds with high maneuverability and still stay airborne.§§Flying-by-wire refers to the design of the controls of the aircraft; the pilot controls the yoke to guide the plane but that yoke is not connected to any of the ailerons or tabs by mechanics or hydraulics. It is connected to a computer and the pilot uses the yoke to tell the computer which way he or she would like to fly; the computer then processes that information and makes a series of complex changes in the ailerons, rudder, and tabs to make the plane do what the pilot wants it to do. It had become impossible to fly top-performance fighter aircraft safely under the conditions the aircraft was expected to fly. Fly-by-wire has become common on large aircraft (commercial and military). This “driving-by-wire” has crept into the auto industry first with antilock brakes, followed by automatic parking, automatic braking, and crash avoidance systems.43As we use these large clinical databases to develop designer anesthetic plans, it will become too difficult for a practitioner to track those plans for individual patients, with specific comorbidities and medications, undergoing procedures. There will need to be a progression from what we have as pop-up alert decision support to complete an integrated primary flight display and multifunctional display support, as in modern aircraft (fig. 8A). If you think this analogy to the aircraft industry is going too far, look at the cover of the August 2010 issue of Anesthesia & Analgesia , which shows a display for pharmacokinetic modeling in the cockpit of an F-111 aircraft.44The cover description says, “Anesthesiologists are pilots … navigating the patient through profound physiologic trespass … coming to a cockpit near you.”44Early data suggest types of management that are not clinically feasible. Two years ago, Kheterpal published an article45from our institution in which he examined preoperative and intraoperative predictors of postoperative myocardial infarction. One of the findings was that if the median blood pressure measured during 10-min epochs decreased to lower than 60% of the patient's preoperative baseline measurement, the incidence of postoperative myocardial infarction increased.45Calculating the median blood pressure during a 10-min interval continuously in real time during a case and comparing it with 60% of the preoperative blood pressure would be a challenge for even the brightest anesthesiologist. In 2005, Terri Monk, M.D. (Professor, Anesthesiology, Duke University Medical Center, Durham, North Carolina), presented a study reporting the 1-yr mortality related to the area under the curve of bispectral index measurements lower than 45 (cumulative deep hypnotic time).46Measuring the real-time area under the curve would also be challenging. Neither of these calculations would be difficult for the decision-support computer in the AIMS. These types of informatics may aid in our anesthetic plan and, more importantly, assist us in selecting the most appropriate postoperative care plan.

Fig. 8.  (A ) Avionics from a modern aircraft. This is a picture of an avionic screen from a Boeing aircraft that integrates information to provide the pilot with visual alerts, allowing for simultaneous management of the aircraft's integrity, lift, yaw, pitch, air speed, and navigation. Photograph from Integrated Electronic Standby Instrument from Thales Aerospace Division Web site (available at: http://www.thalesgroup.com/aerospace; accessed November 10, 2010). Reprinted with permission from Thales Avionics, Saint-Laurent, Quebec, Canada. (B ) The visual alert system (RiskWatch) is a prototype “avionics” display for anesthesia. It integrates live data from the physiologic monitors, the anesthesia information management system (AIMS), the history and physical (H&P), and the laboratory in a color-coded graphic display. Green indicates normal range; yellow, marginal range; red, abnormal range; and orange, “at risk.” The system shows the heart beating with the heart rate and the lungs inflating and deflating with the respiratory rate. The level (filling volume) within the heart is calculated using continuous I and O calculation based on the patient's weight and nothing by mouth (NPO) time, estimated blood loss (EBL), and fluid resuscitation. Data regarding adequate filling volume are automatically retrieved from systolic pressure variation, central venous pressure (CVP), or pulmonary diastolic if those data are available. (Left ) Characteristics of the case. (Middle ) The moving diagram with each organ system. (Below ) The pertinent laboratories. If any system has risk factors that are derived from the patient's H&P, they are orange. The box on the right is where alerts are displayed. It automatically alerts when any variable is out of a safe range and for presumptive diagnoses of tension pneumothorax and potential malignant hyperthermia. The patient has risk factors for a difficult airway and heart disease (this patient has a pacer). There is a high filling volume (CVP = 24 mmHg) and high potassium concentration. Reprinted with permission (Kevin K. Tremper, University of Michigan, Ann Arbor).

Fig. 8.  (A ) Avionics from a modern aircraft. This is a picture of an avionic screen from a Boeing aircraft that integrates information to provide the pilot with visual alerts, allowing for simultaneous management of the aircraft's integrity, lift, yaw, pitch, air speed, and navigation. Photograph from Integrated Electronic Standby Instrument from Thales Aerospace Division Web site (available at: http://www.thalesgroup.com/aerospace; accessed November 10, 2010). Reprinted with permission from Thales Avionics, Saint-Laurent, Quebec, Canada. (B ) The visual alert system (RiskWatch) is a prototype “avionics” display for anesthesia. It integrates live data from the physiologic monitors, the anesthesia information management system (AIMS), the history and physical (H&P), and the laboratory in a color-coded graphic display. Green indicates normal range; yellow, marginal range; red, abnormal range; and orange, “at risk.” The system shows the heart beating with the heart rate and the lungs inflating and deflating with the respiratory rate. The level (filling volume) within the heart is calculated using continuous I and O calculation based on the patient's weight and nothing by mouth (NPO) time, estimated blood loss (EBL), and fluid resuscitation. Data regarding adequate filling volume are automatically retrieved from systolic pressure variation, central venous pressure (CVP), or pulmonary diastolic if those data are available. (Left ) Characteristics of the case. (Middle ) The moving diagram with each organ system. (Below ) The pertinent laboratories. If any system has risk factors that are derived from the patient's H&P, they are orange. The box on the right is where alerts are displayed. It automatically alerts when any variable is out of a safe range and for presumptive diagnoses of tension pneumothorax and potential malignant hyperthermia. The patient has risk factors for a difficult airway and heart disease (this patient has a pacer). There is a high filling volume (CVP = 24 mmHg) and high potassium concentration. Reprinted with permission (Kevin K. Tremper, University of Michigan, Ann Arbor).

During the next decade, as these data provide more specific decision care plans that are automatically derived when the patient's preoperative comorbidities, medication, procedure, and intraoperative response data are entered, some might suggest that this is the ultimate in “cookbook medicine.” I would say, absolutely! I would suggest that all the best chefs use books, all engineers I know use books, and people who are looking out for the welfare of their patients should also use all the decision support available. Figure 8Bis an attempt at an “avionic screen” for the management of an intraoperative patient. We designed this with the help of the Engineering School at the University of Michigan and incorporated many of the aspects of general anesthesia care and teaching, calculated on a real-time basis.47The heart and lungs move in real time from the physiologic monitor; the estimated cardiac filling is determined by continuous input and output calculations, unless there is an invasive monitor. It highlights organ systems at risk, alerts you when physiologic data are in marginal or dangerous range, and is programmed to detect immediate events (e.g. , malignant hyperthermia and tension pneumothorax). When I have demonstrated this to anesthesiologists, they have said “with this type of support, anyone could provide anesthesia,” and I would say, “with this type of support, anyone could provide safer  anesthesia.” I have also heard people remark that this type of support is trying to put us out of a job. My response would be that, despite the fact that the Airbus 320 flown in US Airways Flight 506 in New York had electronic decision-support capabilities, I think all of the passengers would agree they were happy to have Captain Chesley B. “Sully” Sullenberger and copilot Jeffrey Skiles at the front of the plane when the birds hit the fan.∥∥

I would like to acknowledge Jenny Mace (Faculty Staff Associate, Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan) for her extensive assistance in developing this lecture and manuscript, especially for her efforts in finding the historical photos, which I feel added greatly to the presentation.

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