Originally published by our sister publication, Anesthesiology News
San Diego—The development of a simulated anesthesia app may help anesthesiologists save both time and money in their practice in the near future.
Researchers at the University of Florida College of Medicine, in Gainesville, said the panoramic, screen-based simulator is particularly adept at assessing the cost of neuromuscular blockade administration, monitoring and reversal, while also considering drug costs and the cost of associated operating room time.
“Given the continued incidence of residual postoperative neuromuscular blockade, along with the fairly recent FDA approval of sugammadex, there is renewed interest in fine-tuning the monitoring and reversal of neuromuscular blockade,” said Samsun Lampotang, PhD, the Joachim S. Gravenstein Professor of Anesthesiology and a professor of urology at the institution. With this in mind, Lampotang, senior author Nikolaus Gravenstein, MD, and their colleagues developed the interactive app, which he said was specifically designed to enable users to practice the administration, monitoring and reversal of neuromuscular blockade.
The app was built in Adobe Director, a now-discontinued authoring platform for multimedia applications, to simulate various anesthesia activities in the OR. Although the app uses only one computer screen to simulate the entire OR environment, users can pan around the entire room.
A range of simulated activities and equipment are represented, including video clips of intubation and laparoscopy. The app also simulates such equipment as a neuromuscular blockade monitor, an anesthesia machine with user-adjustable flow meters and vaporizers, gas analysis (which models breathing circuit dynamics like wash-in and washout), and physiologic monitoring.
Pharmacokinetic and pharmacodynamic parameters from official package inserts were used by the developers to mimic (via compartmental models) a host of related drugs, including sevoflurane, isoflurane, glycopyrrolate, neostigmine, succinylcholine, fentanyl, propofol, rocuronium and sugammadex. These inserts were included in the app as searchable PDF files. The app also displays scrolling time plots of drug concentrations and circuit gas concentrations, both of which respond to such user actions as drug administration, and provide line of sight of future concentrations.
Navigating the Simulation
To help users assess the clinical and financial effects of their actions, the app incorporates an event log, which captures all user actions throughout the simulated case. This tool allows clinicians to go back in time and undo mid-case events, and even make a different decision without restarting the scenario. The models then forecast relevant parameters for each new user interaction for up to three hours. Finally, a scrolling time line gives users the opportunity to jump forward and backward in time, either to skip periods of inactivity or to undo a previous action. It is this kind of functionality, Lampotang explained, that allows users to see the potential costs and savings inherent in using a particular neuromuscular blockade reversal strategy.
Using an innovation the researchers call a “taxi meter,” the app also displays the cost of the procedure on a minute-by minute basis. Using a baseline OR cost of $100 per minute, it illustrates the financial impacts of clinicians’ decisions, such as the time to complete recovery from deep neuromuscular blockade.
“This is where sugammadex shines,” Lampotang said during his presentation at the 2021 annual meeting of the American Society of Anesthesiologists (abstract A1040). “Using a typical simulated patient, we assume that a drug like rocuronium will take considerably more than 40 minutes to clear out of the patient’s system on its own. Using neostigmine or glycopyrrolate, that drops to approximately 20 minutes. But if you use sugammadex, you’re going to reverse the patient in a minute or two. So you’ve saved 18 minutes, which we calculate as an immediate savings of $1,800.”
The app, which was also presented at the 2022 Society for Technology in Anesthesia annual meeting, is ultimately much more focused on helping clinicians practice neuromuscular blockade and its reversal than on optimizing practice patterns. The researchers verified the app by comparing the output of each model with its source material, such as the package insert. It was found that drug concentrations, clinical durations and recovery times on the app matched these materials. Anecdotally, anesthesiologists who used the app said its output matched their clinical practice.
“Our goal in developing the app was not to optimize practice patterns around neuromuscular blockade, but to offer our clinicians more experience,” Lampotang explained. “So in that sense, there was no agenda. Now that we know it mimics actual practice, though, clinicians can use it to see the effects of their decisions.”
The researchers are exploring the possibility of repurposing the app to include the carbon footprint of each item or consumable used during an anesthetic. A six-minute video of the app can be viewed at bit.ly/3LFutj0.
Ratan Banik, MD, PhD, an assistant professor of anesthesiology at the University of Minnesota Medical School, in Minneapolis, and the co-creator of an iPhone app that assesses the train-of-four ratio, said he believes the simulator’s ability to assess the various aspects of neuromuscular blockade is unique.
“Typically we use simulation to work on critical conditions like cardiac arrest, difficult intubations and other life-threatening situations,” he said.
Banik added that this characteristic helps fill a void in the simulation world, and will likely improve clinical practice. “Many clinicians have a hard time grasping the concept of quantitative neuromuscular blockade because these devices are unavailable at many institutions. Even when they are available, we tend to use them only for research purposes,” he said. “So if we can teach people through a simulated environment, all the better.”
—Michael Vlessides
Banik and Lampotang reported no relevant financial disclosures.
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