Pioneers & Pathfinders: 10 Years of Frontiers in Medicine From T(Ether)ed in-person medicine to Untethered telemedicine

Ata Murat Kaynar^*

• School of Medicine, University of Pittsburgh, Pittsburgh, United States

The last 10 years Dr. Laennec is renowned for inventing the stethoscope, tethering the physician to the patient. 1,2 A couple decades later, Dr. Morton is recognized for demonstrating the effects of ether as a surgical anesthetic. 3 Since the initial publication on the use of ether, the field of anesthesiology had 180 years to evolve experiencing an enormous expansion of the profession beyond the four walls of an operating room. The pre-cordial stethoscope of the anesthesiologist became the tether between the patient and the doctor over the years to assure that the patient was breathing and had a healthy heartbeat under general anesthesia. Over time, this practice evolved into modern monitoring technologies such as pulse oximetry and capnography. [4][5][6][7] Like in any medical field, advancements in technology have made patient monitoring more accessible and standardized while also enabling remote monitoring, reducing the need for direct tethering, the new "untethered" care. The COVID-19 pandemic further accelerated this shift, popularizing telemedicine and other remote care models. 8 While these innovations have improved patient safety and accessibility, they have also distanced physicians from direct patient interaction, reshaping the nature of medical care and the patient-physician interaction as well as trust.In this decennial issue, Pioneers & Pathfinders: 10 Years of Frontiers in Medicine, I would like to highlight manuscripts in anesthesiology and intensive care medicine that broaden our understanding and push the boundaries of patient care yet still maintain that close-knit tethered sacrosanct relation between the patient and the doctor.The pre-operative patient assessment has been studied at the University of Buffalo with high levels of confidence for appropriate risk assessment of patients. 9 These data have been supported by a multi-center survey among members of European and American Anesthesia Society members feeling comfortable using such technologies for perioperative risk assessment. 8 Racial Bias in Pulse Oximetry Measurement 10 : University of Michigan researchers studied two large cohorts of critically ill patients requiring supplemental oxygen therapy. In their analysis, Black patients had nearly three times the frequency of occult hypoxemia that was not detected by pulse oximetry as White patients. Such inherent biases in monitoring highlight the need to study various clinically important variables before widespread use as important clinical decisions are made based on these datapoints.This comprehensive review, published in Pain, has been highly cited for its in-depth analysis of central sensitization theories and its relevance to pain management upon which new therapies are built.Undergoing Noncardiac Surgery. 12 While it is a frequent question to the anesthesiologist to assess and mitigate the peri-operative cardiac event risks, myocardial injury marker-based assessments occur usually after an index event, such an ischemic symptom. Two studies using troponin and high-sensitivity troponins serial measurements suggested that asymptomatic events occur and do correlate -as expected-with the risk for mortality. Featured in JAMA, the first study highlighted the significance of monitoring postoperative troponin levels to predict 30-day mortality in noncardiac surgical patients. Patients with a peak TnT value of 0.01 ng/mL or less, 0.02, 0.03-0.29, and 0.30 or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs without. Similar findings were repeated in a 2017 study published using high sensitivity troponin measurements among a similar cohort of patients. 13 While such tests do suggest a risk for mortality, the clinical question is whether we should implement such expensive tests systemwide requiring further studies.Electroencephalogram Signatures of Loss and Recovery of Consciousness from Propofol. 14 The human experience, consciousness, has its philosophical roots embedded in history and Darwin had theories relating it to the evolutionary tree. 15 The fear of being awake under general anesthesia is not a novel concept and made it to the mainstream media. 16,17 Published in the Proceedings of the National Academy of Sciences, research from the MGH provided insights into the neural mechanisms of anesthesia-induced unconsciousness using the commonly used anesthetic agent, propofol. 14 This descriptive as well as mechanistic work does pave the way for us to have a better understanding of the transitions from consciousness to unconsciousness under general anesthesia.Such EEG signatures in theory could be used to assess other agents or the level of consciousness.Old and frail requiring surgery. 18 In a world, where the population is ageing, sometimes not in a healthy way, further increases the peri-operative risks for patients.and Sevoflurane General Anaesthesia. 19 This study, appearing in the British Journal of Anaesthesia, examined how aging affects brain activity under general anesthesia, offering valuable information for tailoring anesthetic care to older patients.Major Non-cardiac Surgery (ENIGMA-II): A Randomised, Single-blind Trial. 20 Dating back to the time of Queen Victoria of England, nitrous oxide (aka nitrous) had an up-and-down popularity in scientific community, especially anesthesiologists. 21 Published in The Lancet, this large-scale ENIGMA-II trial assessed the safety of using nitrous oxide in general anesthesia for at-risk patients, influencing anesthesia practices worldwide showing its safety in an era, where other anesthetic agents have negative impact on the environment.Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. 22 In this multicenter prospective trial comparing spinal anesthesia vs. general anesthesia for elderly undergoing hip surgery (795 spinal vs. 805 general anesthesia), spinal anesthesia was not superior to general anesthesia in mortality or other morbidity endpoints, including post-operative mobility.Anaesthetic depth and delirium after major surgery: a randomised clinical trial. 23 Another common question posed by the practicing anesthesiologist is the risk for post-operative delirium and the factors leading to this. In this multicenter trial among 655 at-risk patients undergoing major surgery from three countries were assessed for delirium for 5 days postoperatively using the 3 min confusion assessment method (3D-CAM) or CAM-ICU, and cognitive screening using the Mini-Mental State Examination at baseline and discharge and the Abbreviated Mental Test score (AMTS) at 30 days and 1 yr. Patients did not have a diference in the rate of delirium, whether they had a BIS score of 50 or 35. However, patients in the BIS score of 50 group (aka not as deep level of anesthesia), targeting light anesthesia reduced the risk of postoperative delirium and cognitive impairment at 1 yr.As it relates to science beyond the walls of the operating room, the following work was of interest.A Randomized Trial of Protocol-Based Care for Early Septic Shock (ProCESS Trial). 24 This study evaluated protocol-based resuscitation in patients with early septic shock and found no significant difference in mortality compared to usual care, challenging previous early goal-directed therapy protocols. 25 Hydrocortisone plus Fludrocortisone for Adults with Septic Shock (APROCCHSS Trial). 26 This trial demonstrated that the combination of hydrocortisone and fludrocortisone reduced mortality in patients with septic shock, supporting the use of corticosteroid therapy in this population.). 27 The study found that using balanced crystalloids instead of saline reduced the incidence of major adverse kidney events in critically ill adults, influencing fluid resuscitation practices and building further on the earlier work by the ANZICS group comparing albumin to saline. 28 Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit. (SPLIT Trial). 29 This trial is dissecting the impact of various resuscitation fluids as it relates to the risk of AKI. Comparing buffered crystalloid solutions to saline in ICU patients and the group did find no significant difference in the rate of acute kidney injury, contributing to the ongoing debate on optimal fluid choice.Prioritization of Circulation Over Intubation (CAB over ABC). 30 A common observation among intensivist and emergency physicians is that the intubation process and the affiliated induction agents, removal of the sympathetic drive upon relief of the respiratory distress lead to hemodynamic instability. This question has been studied by the group in a multicenter trial and suggests that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries, potentially reshaping trauma resuscitation protocols.Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. 31 As it relates to resuscitation fluid of choice, blood and blood products have fallen out of favor in peri-operative medicine. However this study focusing on trauma patients at risk for hemorrhagic shock showed that pre-hospital use of thawed plasma improved the 30-day mortality as compared to the standard of care challenging the current paradigms.