What is the future of anesthesiology?

1. © U N I V E R S I T Y O F U T A H
ANAESTHETISTS: THE NEXT GENERATION
HARRIET W. HOPF, MD
PROFESSOR OF ANESTHESIOLOGY
INTERIM ASSOCIATE VICE PRESIDENT FOR FACULTY
UNIVERSITY OF UTAH
@HARRIETHOPFMD

2. © U N I V E R S I T Y O F U T A H H E A L T H ,
BUT HOW?

3. © U N I V E R S I T Y O F U T A H
THE NEXT GENERATION
@ ANZAC # ELC19KL

4. © U N I V E R S I T Y O F U T A H H E A L T H ,
ANÆSTHETISTS: THE FOUNDING GENERATION
• J. Ellis Gillespie (1918-1970)
– Served in WWI, WWII
– 1918: MBBS
– 1949: Diploma of Anæsthetics
– 1951: Founding Signatory,
Faculty of Anæsthetists, Royal
Australasian College of
Surgeons
@ANZCA #ASM19KL
https://anzca.online-exhibition.net/fellows/home/john-ellis-gillespie/

5. © U N I V E R S I T Y O F U T A H
FUTURE BECOMES PRESENT
• Big ideas of the founding generation are
central principles of current generation
– Research
– Education / Training
– Standards of Practice
• How do we build on their vision?

6. © U N I V E R S I T Y O F U T A H
ASSESSING WHERE WE ARE AND WHAT IS NEXT

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WHAT WAS ON GILLESPIE’S RADAR SCREEN?
https://www.woodlibrarymuseum.org/history-of-anesthesia/
A&A, BJA
Sux
STP
Ether
Cuffed ETT
Halothane
J-R
Studies on mortality
Isoflurane
Propofol
Closed Claims Database
US for blocks
ANZCA Clinical Trials Network
Pulse oximetry
IPPV

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WHAT WAS ON THE RADAR SCREEN IN 1980-2000?
Better drugs: NMBA, vapor,
PONV, analgesic, hypnotic
Better monitors: O2, CO2, echocardiography, depth
Better Airway management and devices
Patient Safety
Outcomes: Cardiac, SSI, Mortality

9. © U N I V E R S I T Y O F U T A H
WHAT IS ON OUR RADAR SCREEN TODAY?
Ondansetron
Sugammadex
TIVA
Videolaryngoscopy
Big Data
Wellness
POCUS
Consciousness /
Depth of Anesthesia
Echocardiography
Patient Safety
NORA
Pain
ICU
Equity
Prehab

10. © U N I V E R S I T Y O F U T A H
WHAT IS ON OUR RADAR SCREEN TODAY?
Ondansetron
Sugammadex
TIVA
Videolaryngoscopy
Big Data
Wellness
POCUS
Consciousness /
Depth of Anesthesia
Echocardiography
Patient Safety
NORA
Pain
ICU
How can we lead anesthesia- and
healthcare- into the future?
Reduce the public health /
environmental impact of
perioperative medicine
Personalize anesthetic
management to improve
outcomes
Equity
Prehab

11. © U N I V E R S I T Y O F U T A H
WHAT IS ON OUR RADAR SCREEN TODAY?
Ondansetron
Sugammadex
TIVA
Videolaryngoscopy
Big Data
Wellness
POCUS
Consciousness /
Depth of Anesthesia
Echocardiography
Patient Safety
NORA
Pain
ICU
How can we lead anesthesia- and
healthcare- into the future?
Reduce the public health /
environmental impact of
perioperative medicine
Personalize anesthetic
management to improve
outcomes
Equity
Prehab

12. © U N I V E R S I T Y O F U T A H
PERSONALIZED MEDICINE
• Single Nucleotide Polymorphism (SNP)
– Stable genetic variation present in a population with >1% frequency
– Human genome has 3 billion base pairs, 20-25K functional genes
– SNP every 300-500 base pairs (0.1% variation)
• Pharmacogenomics already part of practice
– Variable duration of Succinylcholine from SNPs in butyrylcholinesterase
– N-acetyltransferase SNPs: Different rates of metabolism of drugs / ADRs
– Commercial test to predict response to warfarin based on SNPs
– Trastuzumab: effectiveness requires expression of HER2 receptor
https://www.cochrane.org/CD006242/BREASTCA_efficacy-and-safety-of-trastuzumab-in-metastatic-breast-cancer
Hopf, HW. Crit Care Med, 31:S518-23, 2003.

13. © U N I V E R S I T Y O F U T A H
PERSONALIZED ANESTHESIA: THE FUTURE
• Use genomic / proteomic / epigenetic / gene
expression data to:
– Inform large clinical trial design
– Customize anesthetic choices
• Requires combination of availability of individual
genetic information, new ways to mine &
interpret big data, & big trials

14. © U N I V E R S I T Y O F U T A H H E A L T H ,
AVAILABILITY OF GENETIC INFORMATION
• HapMap: catalog of common
genetic variations
(http://hapmap.ncbi.nlm.nih.gov/)
• Cancer Genome Map:
(http://cancergenome.nih.gov/)
• Utah Population Database
(https://uofuhealth.utah.edu/huntsman/
utah-population-database/)
https://www.genome.gov/about-genomics/fact-sheets/Sequencing-Human-Genome-cost

15. © U N I V E R S I T Y O F U T A H
ANESTHESIA, THE ENVIRONMENT, & PUBLIC
HEALTH
• U.S. Healthcare industry:
• 8% of GHG
• 5.9 million tons solid waste/year; ~1/3 from OR
• Public health effects of environmental impacts of healthcare
industry about equal to impact of medical errors
• Lancet Commission on Health and Climate Change:
– Climate change is a “medical emergency” and “greatest global
public health opportunity of the 21st century.”
Chung & Meltzer, JAMA 302 (18): 1970-2; 2009
Eckelman & Sherman PLoS ONE 2016; 11: e0157014
Eckelman & Sherman Am J Public Health 2018; 108:S120-S122

16. © U N I V E R S I T Y O F U T A H
ANESTHETIC CHOICES MATTER
Sherman et al. Anesth Analg 2012;114:1086–90)

17. © U N I V E R S I T Y O F U T A H
VIEW SUSTAINABILITY AS A PATIENT SAFETY
ISSUE
• Encourages evaluation of environmental impact as
part of clinical management decisions
• Allows evaluation of cost-effectiveness of infection
control measures and incorporation into
reusable/disposable decisions
• Reorients drug and device development process to
incorporate sustainability

18. © U N I V E R S I T Y O F U T A H
THE NEXT GENERATION
• The next generation will bring these ideas and
innovations onto the radar screen
• Current leaders must ensure that they have the
training, resources, time, creativity, and vision
to succeed
https://academic.oup.com/bja/article/119/suppl_1/i1/4638461

19. © U N I V E R S I T Y O F U T A H
WHAT IF THEY ARE TOO SUCCESSFUL?
• What if the next generation’s innovations make
anaesthetists obsolete?
• Good on us. That is the ultimate success.
• And since we’re leaders, would you like us to
fix something else?