The role of anesthesiologists has expanded beyond the intraoperative environment, with the recognition that they have much to contribute in everything from optimizing surgical outcomes to combating the opioid epidemic.
Maxime Cannesson, MD, PhD, the Ronald L. Katz, MD, Chair of the UCLA Department of Anesthesiology and Perioperative Medicine, spoke about recent developments in anesthesiology and future directions for the field.
Historically, anesthesiologists practiced in the operating room. But over the past decade, our role has moved toward perioperative medicine — taking care of the surgical patient before and after surgery, and outside of the hospital as well. That includes preoperative optimization; it includes critical care management; telemedicine; and it includes management of acute and chronic pain. If you look at surgical outcomes, the operating room — where we provide the most acute care — has been the safest place in the hospital, to a large extent due to the patient-safety role anesthesiologists have played. To address postoperative morbidity, we are now applying the expertise we have developed intraoperatively, in close collaboration with surgeons, primary care physicians, nurses and the entire multidisciplinary team.
Certainly, the opioid crisis is at the forefront. To minimize exposure to opioids during and after surgery, our pain physicians have developed an arsenal of what we call multimodal analgesia. Many of the new state-of-the-art medications allow us to manage pain without exposing patients to any opioids. It’s more complicated for patients who have chronic pain before they come for surgery, so we have developed a pre-op pain prehabilitation clinic, where we begin taking care of these patients to optimize their pain management before the surgery starts. For chronic pain, we want our department to be involved with the whole Los Angeles community, not only in our clinics in Santa Monica and Westwood. Over the past few years, we have developed a community practice for chronic pain, and now we have clinics throughout Los Angeles.
COVID-19 has affected every department at UCLA, but clearly anesthesiology has been one of the most affected because we are on the frontline of the management of COVID-19 patients. Our clinicians have been exposed to the risks associated with COVID-19, and I am extremely grateful and proud of their efforts. For pain management, what’s been most impressive is to see all of our chronic pain physicians move to telemedicine so quickly — changing their practice and continuing to serve their patients in that way. Independent of the treatment of chronic pain, our department was a leader in telemedicine for preoperative assessment — seeing patients before surgery to assess their health and risk. Because we had this experience before, we’ve been able to quickly implement telemedicine for our pain physicians.
Our department currently has four main research themes, each of which is supported by a strong foundation of basic and clinical research infrastructure: cardiovascular research; neuroscience, mechanism of anesthesia and pain; organ-protection research; and biocomputing and health informatics. We have a lot of research focusing on the use of functional MRI to understand the mechanism leading to postoperative cognitive dysfunction. We also have a large research program focusing on understanding how anesthesia works on the brain, because we still don’t know exactly why some of the drugs we use induce unconsciousness. That’s a big part of the research in anesthesia — to understand what is consciousness and what is unconsciousness, as well as what the experience of pain means.
I think the major innovations in our practice are going to be along three main domains. The first is the way we deliver care. Whereas it used to be extremely siloed, the care process is becoming much more integrated as physicians and specialists work together independent of their specialty, focusing on the patients more than on the specialty, moving from a physician-centered practice to a real patient-centered practice. For anesthesiologists, it means being fully integrated in the care coordination of the surgical patient. The second is going to be new medications. Anesthesiology has always been associated with the development of new drugs, and we are going to see medications that will have less impact on the physiology than they have today. Postoperative cognitive dysfunction is one of the key complications of anesthesia, and that’s something that we are going to improve in the next 10-to-20 years through new drugs. Medications for pain management are also going to change dramatically. Hopefully, we’ll have new substitutes for opioids, so that we can treat pain without the risk of triggering addiction.
Finally, new technology is going to help us improve patient safety, both during surgery and in the perioperative setting. We are a data-rich specialty, and we are increasingly moving toward precision medicine in the acute care setting. We will be able to stratify our patients better, predict which ones are at risk of developing complications, and then have some prescriptive analytics that will tell us what to do to avoid the complications we want to avoid or to achieve the outcome we want to achieve.