The era of transformation in anesthesia is coming

Author: Yu Buwei is a professor at the Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

China's anesthesia discipline has experienced a period of initial start-up and rapid development, and is now at the crossroads
of the development of the times.
The era of transformation of anesthesia is coming, and this article will discuss
how to face the transformation of the discipline.

1.
Historical Review

Since the founding of New China, the anesthesia discipline in China has gone through 72 years of ups and downs
.
From the 1950s to the 1960s, the establishment of a professional anesthesiology and anesthesiology teaching and research department, to the 1970s to the extensive implementation of acupuncture anesthesia work throughout the country, the Chinese anesthesia department initially completed the creation and layout stage
.
With the popularization of anesthesiology throughout the country, the business work that anesthesiology can carry out basically meets the development needs
of surgical departments such as surgery.

At the same time, the anesthesiology department also undertook all the heavy responsibilities of cardiopulmonary resuscitation and emergency critical rescue, and performed prominently
in the rescue and treatment of the main leaders of the party and the state and the rescue of the wounded during the Tangshan earthquake 。 During this period, the predecessors of China's anesthesia discipline not only kept up with the pace of the development of anesthesia in the world, but also walked in the forefront
of the world in cardiopulmonary resuscitation (chest cardiac compression cardiopulmonary resuscitation carried out by Professor Wang Yuanchang), cerebral resuscitation (comprehensive treatment measures such as deep brain hypothermia, high-dose dehydration, high-dose glucocorticoids, and early hyperbaric oxygen carried out by Professor Li Dexin) and the treatment of large-scale infectious diseases (artificial hibernation therapy carried out by Professor Tan Huiying).

Taking scopolamine as the basic drug to rescue severe shock, treat microcirculation disorders of various organs, including acute lung injury, take nerve block technology as the mainstay, and comprehensively use anesthesia to carry out pain diagnosis and treatment work, all of which have further developed the comprehensive treatment ability of anesthesia science, and have also greatly promoted the development of emergency medicine, intensive care medicine and pain medicine, and formed a new subspecialty of anesthesia, which is the current emergency department, The prototype of critical care medicine and pain department
.
The first emergency department to be established independently of the anesthesiology department, there are still a lot of emergency rescue work began with anesthesiologists to perform emergency endotracheal intubation
.

Subsequently, the Department of Critical Care Medicine was established, and anesthesiologists still undertook a large number of rescue tasks
in the treatment of severe acute respiratory syndrome (SARS) in 2003 and new coronavirus pneumonia (COVID-19) in 2020.
The anesthesiologist risked his life to form an "intubation death squad" for tracheal intubation, and the rescue guidance suggested by anesthesia experts to "mainly hibernate therapy under anesthesia" was applied clinically, so that the rescue work could achieve rapid results
in a short period of time.
The above experience fully explains the historic achievements made by the anesthesia discipline in promoting the development of many medical disciplines in China, and is a glorious tradition
that the doctors of the anesthesia department and the colleagues of the emergency department, critical care medicine and pain department derived from the anesthesia discipline should remember and inherit.

2.
Transformation requires the development of anesthesia disciplines

It has a glorious history and has achieved good results, but with the development of medicine, acute critical care rescue, pain diagnosis and treatment have become the main work of the current emergency department, critical care medicine and pain doctors, and how anesthesiologists respond to the transformation and development of the discipline is worth exploring
.
The author will focus on the paradox of the development of anesthesia science
.
Looking back at history, it can be found that the development speed of anesthesia in China is amazing
.
China, the world's largest developing country, has achieved a leading position among all developing countries (12/1 million) in reducing anaesthesia-related mortality (12/1 million) and close to the level of developed countries in the world (10/1 million
).

China's achievements include the data of anesthesia departments of all medical institutions at the county level and below, in fact, the level of anesthesia development of large hospitals and affiliated hospitals of medical colleges and universities in China's provincial and municipal cities has long been on a par with the level of developed countries in the
world.
Today, when the COVID-19 epidemic is still raging around the world, China's medical treatment level has shown an excellent performance of "thriving": as of the deadline, the total number of deaths of critically ill patients in China is more than 4,600, and the case fatality rate is the lowest in the
world.
The achievement of this achievement mainly depends on the ability and advantages of the Chinese government in all aspects, and it can also suggest that the rescue program of anesthesiologists in China has become one of the
effective methods for successfully treating critically ill patients.

This is strong evidence
that the Chinese anesthesia discipline has surpassed the level of Western developed countries in the field of COVID-19 treatment.
The great achievements made in the anesthesia department have gradually changed the industry's views and expectations on surgical risks, and the process of occurrence has become "silent"; The contradiction is that although the death threat of anesthesia process to surgical patients is always present, the high level of development of anesthesia science has made it no longer the most important factor affecting the safety of patients' lives, that is, the safer anesthesia is, the more easily its importance is overlooked
.
The current situation is that some hospitals do not have anesthesiologists present when rescuing critically ill patients, and sometimes the plans proposed by anesthesiologists after they arrive may not be adopted
.

If the work content and specialist opinions of the anesthesia discipline are no longer valued by the health administrative departments, the heads of hospitals and departments, and the majority of medical staff, the development of the discipline will be constrained, and it will not be possible to continue to maintain the original level, and it is not impossible
for the development of the discipline to regress.
This paradoxical problem will become more and more obvious
with the further development of anesthesia disciplines.
The author once went to a tertiary first-class hospital in a northern city to consult a surgical patient, and the patient was determined by the director of the cardiology and respiratory department of the hospital that there was no abnormal cardiopulmonary function, considered no anesthesia risk, and planned surgery
.

After examining the patient's condition, the author believes that the afternoon low-grade fever is caused by the incomplete early debridement surgery, resulting in subcutaneous fat necrosis infection, and it is necessary to perform debridement surgery, completely remove the fat on the retained skin, and then the skin sheet is sutured by tension and pressure
.
The results of the final operation proved the author's judgment, and the dean and director of the department who had previously ignored the opinions of the anesthesiology department also apologized to the author
.
The above events reflect that there is still a big bias in the industry's understanding of anesthesia
science.

In 1989, the former Ministry of Health issued Document No.
12 mentioned that after years of development, the anesthesia discipline has been developed from a medical technology department to a clinical department, and the scope of clinical work covers clinical anesthesia, emergency resuscitation, intensive monitoring and treatment, and pain diagnosis and treatment; The Department of Critical Care Medicine and the Department of Pain have been independently formed, and the document requires that their members must have work experience
in the Department of Anesthesiology.
Therefore, the vast majority of the organizers of the above departments have served as deputy directors of
the anesthesiology department.

To the author's deep regret, the disciplinary nature of anesthesiology is still considered to be a medical technology department
due to the misleading of some media and literary and artistic works.
The development of anesthesia in Taiwan Province in China represents the paradox caused by problems left over from history, and it should also be taken as a warning
.
In the 1990s, an expert with considerable influence in the industry worked as the director of the anesthesiology department at Taipei's Veterans General Hospital, and was praised
for his performance as the leader of the rescue team of the Taiwan regional leader at the time.
In order to promote the development of anesthesia science, the expert proposed the establishment of an anesthesia department in the hospital, but met with huge opposition, so he left his post
in anger.

Since then, the anesthesia community in Taiwan Province has lost its "bellwether" that can be shaken, and the number of anesthesiologists has been reduced from nearly 1,000 at its peak to about 600 at present, and a large number of clinical anesthesia work has been replaced
by anesthesia nurses due to insufficient personnel.
As a result, the death rate directly related to anesthesia has increased significantly, and the development of the discipline has stagnated or even regressed
.
In addition to the social issues mentioned above, anesthesia disciplines will also face the challenge of
artificial intelligence anesthesia devices.
In short, the essence of anesthesia is to adjust the patient from a state of wakefulness to a state
of anesthesia after loss of consciousness.

This change, in addition to making the patient no longer feel pain, so that the surgeon can successfully complete the operation, more importantly, through the work of the anesthesiologist, to ensure the safety
of the patient's life throughout the perioperative period.
This is manifested in changes in all indicators that reflect the patient's
vital signs.
If all vital signs of the patient remain stable from wakefulness to anesthesia until the completion of the operation, the probability of his life safety is guaranteed
.
The strength of computer technology is precisely to maintain a set of systematic indicators to work
smoothly.

As long as the work experience of anesthesiologists in the past is set and the limited range of vital signs and indicators is set, a set of anesthesia automatic control system
can be initially built.
This threshold is not as high
as imagined.
From this point of view, the anesthesiology department may even become the first department
in the hospital to achieve full artificial intelligence management.
At that time, the anesthesiology department will no longer be a department with tense personnel and continuous overwork and death of doctors, and the work scene of the anesthesia department will also undergo subversive changes
.
Whether a large number of anesthesia medical staff are prepared for the risk of being transferred again is worth thinking about
.

3.
Discipline development ideas

The author believes that the anesthesia discipline is currently facing many crises and potential risks, and although it may not have a greater impact on every anesthesiologist for a period of time in the foreseeable future, all challenges need to be studied and countermeasures
are proposed before they become a reality.
This is not a worry, "Li Ji Zhongyong" said: "Everything is desired, not predetermined", in order to explore the development of
anesthesia science.

3.
1 Continue to strengthen the publicity of the attributes of the Department of Anesthesiology with a straight face

Although it is difficult to immediately reverse the misconceptions that have been formed in society, we should still face the difficulties and continue to carry out the publicity work
that "anesthesiology belongs to the clinical department".
In the past few years, although a lot of efforts have been made at the level of societies and associations, the actual results are still limited
.
Therefore, this must be a long-standing and persistent work for all anesthesiologists, not giving up hope
at any one key point.
The spark of a spark can burn the plains, and perseverance will be beneficial
.
I hope that many of the leading figures in this discipline can play their own abilities
in their respective positions.

3.
2 Be innovative and actively expand the operating room business and anesthesia treatment business of the anesthesiology department

The operating room business is mainly comfortable medical work
.
The anesthesiology department should maximize patient safety, alleviate patient pain, and improve patient comfort for the purpose of expanding from painless endoscopy, obstetric delivery analgesia, painless abortion, etc.
, to the whole disciplinary field, including oral analgesia, pediatric sedation analgesia, cardiac catheterization analgesia, urological sedation analgesia, and home analgesia of cancer patients
。 The anesthesia treatment business is an urgent need for the anesthesia department to expand
.
The so-called anesthesia treatment refers to the work
of anesthesiologists who, under the guidance of anesthesia theory, apply the unique drugs, instruments and equipment of anesthesiology to directly treat stubborn and refractory diseases in various disciplines through a complete anesthesia process.
We must fully realize that this is an innovative and critical step for anesthesia departments to truly step out of the operating room and integrate into clinical departments, and hospitals with the capacity should take the lead in this work
.

3.
3 The future has come to usher in the era of artificial intelligence in anesthesia science

At present, the anesthesia drug robot automatic drug delivery system, anesthesia technology robot auxiliary operating system, and anesthesia evaluation and diagnosis robot automation system are the three pillars of artificial intelligence in anesthesia discipline, and a number of emerging technologies have been applied to clinical anesthesia work, and have huge room for
development.
With the development of science and technology, the comprehensive promotion and application of artificial intelligence in anesthesia disciplines is no longer out of reach
.
We should face the challenges of the anesthesia discipline in the era of artificial intelligence with a positive attitude, not only through technological updates to rationally adjust the ratio of personnel, but also to promote the medical staff of anesthesiology to strengthen their sense of innovation and improve their ability to innovate to promote the high-quality development
of the discipline as a whole.

The above statement is purely a personal foolish opinion, hoping to attract the attention and thinking
of the majority of anesthesia colleagues through throwing bricks and stones.
If more useful discussions and actions can be sparked on this basis, it will surely become one of the great blessings for
the development of anesthesia science.

Source: Yu Buwei.
The era of transformation of anesthesia is coming[J].
Shanghai Journal of Medicine,2022,45(03):137-139.