EFFECTS OF MINIMALLY INVASIVE THERAPY ON THE PRACTICE OF ANESTHESIA AND SEDATION

Modern technology and the development of minimally invasive therapy (M IT) are providing a much wider range of therapeutic options, reducing interventional risk and allowing many more procedures to be undertaken as day-cases. Complex health economic issues are involved since the i ncrease in day-case surgery is allowing the expansion of the number an d type of therapeutic procedures without a commensurate increase in co st. The conversion of previously open to closed procedures, particular ly in vascular interventional radiology and some forms of endoscopic s urgery, is allowing a much higher percentage of patients to be managed using only sedation and/or analgesia administered by non-anaesthetica lly trained physicians and surgeons. The need for specialist training has recently been recommended by the College of Surgeons of England, s upported by official representation from the Royal College of Anaesthe tists. However, the high mortality rate from diagnostic endoscopy woul d suggest that there is no room for complacency, and that the public i nterest in terms of quality control and assurance may not be being ser ved. The concept of monitored anaesthetic care, i.e. the continuous pr esence of an anaesthetically trained person in addition to the interve ntionalist, emanates from the USA and France. Much new technology has already been absorbed into the practice of anaesthesia, notably the us e of fibre-optic systems in the airways, 3-dimensional imaging in preo perative assessment, an increasing use of ultrasound to facilitate ner ve blocks, and cannulation procedures. Work in the intrathecal and epi dural spaces using direct vision is now possible. 'Smart' systems for drug administration and automated anaesthesia are being developed, as are improved systems for monitoring and data management. Robotic place ment of regional blocks and cannulation of vessels is also a possibili ty. Much more initial training and subsequent revision and upgrading a nd recertification will be undertaken using virtual reality simulators . The anaesthesiologist will survive but must become the product of be tter, shorter, more focused training, with a wider range of knowledge and skills and above all a more adaptable attitude than is often the c ase at present. It is in the public interest that departments and dire ctorates of anaesthesia are given a central role in training and respo nsibility for the quality of care in units practising minimally invasi ve therapy throughout their institutions where drugs with anaesthetic potential are in use.