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COMMENTRY Handheld devices and informatics in anesthesia Prasanna Vadhanan,MD1, Adinarayanan S., DNB2

1Associate Professor, Department of Anaesthesiology, Vinayaka Missions Medical College & , Keezhakasakudimedu, Kottucherry Post, Karaikal, Puducherry 609609, (India) 2Associate Professor, Department of Anaesthesiology & Critical Care. The Jawaharlal Institute of Postgraduate & Research, Dhanvantri Nagar, Gorimedu, Puducherry, 605006, (India)

Correspondence: Dr. Prasanna Vadhanan, MD, No. 6, P&T Nagar, Mayiladuthurai 609001 (India); Phone: +919486489690; E-mail: [email protected]

Received: 02 April 2016; Reviewed: 2 May 2016; Corrected: 02 June 2016; Accepted: 10 June 2016

ABSTRACT Handheld devices like smartphones, once viewed as a diversion and interference in the operating room have become an integral part of healthcare. In the era of evidence based , the need to remain up to date with current practices is felt more than ever before. Medical informatics helps us by analysing complex data in making clinical decisions and knowing recent advances at the point of care. Handheld devices help in delivering such information at the point of care; however, too much reliance upon might be hazardous especially in an emergency situation. With the recent approval of robots to administer anesthesia, the question of whether technology can replace anesthesiologists from the operating room looms ahead. The anesthesia and critical care related applications of handheld devices and informatics along with its possible drawbacks are discussed.

Key words: Informatics; Anesthesia informatics; Anesthesia; Critical care; Devices; Smart phones Citation: Vadhanan P, Adinarayanan S. Handheld devices and informatics in anesthesia. Anaesth & Intensive Care 2016;20(2):209-213 Received: 25 April 2016; Reviewed: 15 May 2016; Accepted: 2 June 2016

INTRODUCTION Table 1: Sources of Information The integration of technology into medicine has made Sources of anesthesia related information the entire process of patient management more efficient, 1. Peer reviewed journals accurate and safer. Complex medical devices are becoming 2. Text books with new editions every few years smaller and robust, and hand held devices have an 3. Conferences and seminars increasing role to play in day to day patient management. 4. Association guidelines (American Society of Anesthesiologists, Hand held devices like smartphones, personal digital Difficult Airway Society etc.) assistants (PDA), informatic devices and handheld 5. National and institutional protocols 6. Pharmaceuticals monographs ultrasound are changing the ways in which anesthesia and 7. Expert opinions, best practice guidelines critical care is practiced. 8. Web based resources (websites of societies like WFSA, Information Overload NYSORA etc.) In this era of evidence based medicine litigation has According to Medline, since 2005 between 2000 to 4000 become an everyday happening. Anesthesiologists completed references are added each day .In 2013 this therefore, need to stay up to date with recent advances amounted to more than 700,000 articles.1 Even within a and practice guidelines. Searching for evidence, appraising specific speciality, it is impossible to keep up with all the and grading the evidence and determining their practical published medical reports.2 With the increasing number applicability needs time and resources. Before internet, the of medical publications, however narrow a speciality field only source of information was textbooks, few journals may be, it is impossible to keep up to date to become an and personal opinion of experts (the least possible level of expert. As of 2014 in and pain medicine evidence), but today the sources of information are vast nearly 118 and 81 journals critical care journals and are shown in Table 1. are being published.3 gThe total number of articles published in these journals amounts to approximately

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12,000 in anesthesiology and 10,000 in critical care 2. In making decisions based on ’ clinical annually. This implies that even if a trainee manages to parameters and as a database of best practices from read and assimilate information from 40 articles per day reliable sources. This is called HDSS or Health for five days a week, he or she can only cover half the Decision Support Systems. Intelligent medical published articles that year and additional 22,000 articles informatics should be able to mimic the thought would have assimilated by that time. Literally we are process of an expert .10 living in an era of information overload. 3. In Telemedicine.Telemedicine is the ability to Information from Patients diagnose and treat remotely. This is the basis of tele-ICU and tele . Patient data can lead to information overload as well. As and laboratory parameters are increasing it Anesthesia related informatics systems are known as becomes difficult for the human mind to process them Anesthesia information management system or AIMS. and arrive at a clinically relevant diagnosis. Human mind Most of the features of the AIMS can be accessed by can adequately process four variables only at one time. hand held devices. Companies like McKesson, Stanford 4 A patient in an intensive care unit can generate up to Anesthesia informatics provide integration of the 236 variables,5 hence it is possible to miss relevant data informatics systems with hand held devices. Some of the that can help in diagnosis and management. On the other practical uses of AIMS are shown in Table 2. hand, such excess of information can lead to diagnostic errors and neglect of relevant data. Therefore instead Table 2. Use of informatics in Anesthesia of just raw data in the form of investigation reports Practical uses of AIMS and clinical parameters, we need computers to process • Storing patient data, automatic recording of intra operative them with appropriate algorithms and provide us with vitals and events clinically relevant hypothesis/diagnosis that best explains • Calculating drug dosages and infusion rates the raw data.6 • Predicting possible drug interactions based on patient’s Human Errors medications Fatigue and mood of the had been shown to • Diagnosing light anesthesia and unstable blood pressures influence his/her decision making in patient management. • Reminders for drugs (e.g. insulin, DVT prophylaxis, Emotion can play a role in decision making, and studies antibiotics) in both psychology and economics have demonstrated • Scheduling and reserving post-operative beds 7 human fallibility in everyday decision making. A • Decision support involving multiple patient factors. stressed physician is more likely to deviate from standard protocols with or without his knowledge. Physicians tend to talk less, prescribe and refer more when they are Handheld Devices and Internet stressed and in a negative mood.8 Informatics can help in reducing such events by constantly alerting the physicians Another major application of handheld devices is whenever a deviation from protocol is noted and thereby accessing internet for information. Most AIMS devices preventing litigations.9 provide integrated internet access. Medical Informatics E Learning is a concept where computers and networks are used to provide online educational materials and Medical informatics can be defined as a complex science . Modules rich in multimedia teaching that integrates relevant theories, design methodologies, and files and discussions and feedback create a virtual knowledge of best practices drawn from various cognitive, classroom. It is also referred to by other terms: online computational, informational, organizational, and other learning, computer-assisted-learning, or Web-based expert knowledge domains.10 It involves synergistically learning. E Learners have demonstrated increased collecting, storing, organizing, manipulating, using, retention rates and better utilization of content.11 Other and disseminating clinical-based and health-related advantages are that the learner can control the pace, information. Handheld devices can be used to utilize the timeliness of content and sequence of learning. Interactive numerous benefits of medical informatics at point-of- learning enables users to manipulate variables and observe care. outcomes, for example drug kinetics. Several societies and There are three major areas where informatics is used in associations offer eLearning modules on various topics, anesthesia and critical care. which can be accessed from handheld computers as well. In a randomized trial, residents scored high on post 1. As a tool for electronic record keeping and retrieval.

210 ANAESTH, PAIN & INTENSIVE CARE; VOL 20(2) APR-JUN 2016 commentry module knowledge assessment after a regional anesthesia book are providing a platform where case discussions can E Learning module and all participants reported a be carried out with peers. Videos of procedures can be preference for web based learning.12 watched, and calculation of drug dosages and infusion rates can be done. Podcasts where digital media files can For the practicing anesthesiologist, the need to stay up to be downloaded and watched later helps in understanding date in current concepts and guidelines is being felt more complex concepts with ease. Podcasting uses RSS (Rich and more. The need to retrieve reliable and clinically site summary) format to broadcast audio or video files relevant data rapidly at the point of care has made few from Web sites to portable players, allowing physicians institutions to employ perioperative librarians dedicated to access educational materials at point of care. In a solely to this purpose. survey among anesthesia residents 60% used podcasts While accessing information from the internet, the mainly for procedural videos.16 AIMS manufacturers like pitfalls should be borne in mind. The source, reliability, McKesson and Metavision provide applications meant and time of publishing should be noted. Most patients for smartphones connectivity. and even some health care professionals believe that Other out of the box usages of smartphones has been any information from the World Wide Web is reliable. reported. Age appropriate videos shown to children For example, the quality of drug information from before induction has been shown to allay anxiety, a Wikipedia continues to be inconsistent, and clinicians technique nicknamed iphone induction.17 The high may inappropriately rely upon it. 13 Like all other definition cameras of iPod touch have been used as a low medical literature, information from Web sites should be cost remote monitor.18 The accelerometer (the hardware evaluated and compared to prior knowledge, new studies, that orientation and motion of the device) has and current recommendations.14 been used to accurately measure 15 degree tilt during To avoid pitfalls, appropriate databases (PubMed, Embase, Caesarean sections 19 and as a monitor for neuromuscular CINAHL, Scopus, Cochrane database, DARE etc.) should junction,20 where the fade can be demonstrated accurately be used for searching with appropriate key words, filters as a graph. and Boolean operators. A step by step guide for searching evidence on internet was published by Stillwell et al, in Smartphone Medical Applications (Apps) 2010. 15 A lot of anesthesia related applications are available for smartphones. Ready reckoner for calculating drug doses, Handheld Devices endotracheal tube sizes, normal laboratory values are As technology advances, we have smaller devices capable available. Pharmacokinetic models like procalculator are of doing more and more. Remote monitoring via a hand some of the apps worth mentioning. The accuracy of data held devices in real time is possible. The hand held device of these applications cannot be guaranteed and should communicates with the server wirelessly via Bluetooth not be relied upon to replace our knowledge. Several drug (range- 10 -20m), WLAN (70-100m), Internet, or newer databases are also available. A review of the smartphone protocols like Zigbee. apps for paediatric anesthesia was published in 2012.21 Ultrasound devices have become hand held, enabling FDA encourages development of mobile medical apps greater mobility and ease of use. Most require the image to enable health care professional’s access relevant to be transferred to a computer for proper processing information. It is estimated that more than 500 million and reporting. At least three manufacturers are currently smartphone users will be using a medical application by marketing handheld USG devices. Vscan by General 2015, and by 2018, 50% of all smartphone and tablet users Electricals, Mobisante US and Signostics. (3.4 billion) will be using a medical related application.22 Epocrates, a leading software for health professionals Smartphone as a Medical Device is being used by more than half of US doctors for Apart from accessing internet and AIMS, the smartphone accessing information on drug dosing, interactions and has found several uses in our day to day practice. Since insurance information,. On 2015, FDA released guidance 2010, smartphones have virtually replaced personal digital for implementing regulations for certain devices and assistants or PDAs. applications.22 Soon we will have FDA approved medical apps, subjected to regulations. Today, a smartphone has the ability that a personal computer had few years back. The huge storage capacity, Hazards of Handheld Devices fast processing speed and enables them to store 1. Distraction: Handheld devices especially smartphones entire textbooks or rather libraries. Most journal articles can distract health care providers especially when used can be accessed anytime and social media sites like face in operation theatres and critical care units. Slagle and

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Weinger 23 note that with the introduction of electronic University(2011).28 Similarly a remote anesthesia patient care information, the opportunities and allure of maintenance system McSleepy 29,(developed by Intelligent electronic non-patient care activities, e.g., web surfing, in Anesthesia) can maintain anesthesia are increasing. A ‘no personal internet use policy’ and by automatically adjusting the infusion rates of drugs restricted use by personnel can be the only solution. Most bases on three patient parameters(Depth of via anesthesiologists view their mobile phone as a saving EEG, Analgascore for pain, and muscle relaxation with device rather than a life threatening one. phonomyography). 2. Interference: Can handheld devices cause electromagnetic Sedasys, a computer assisted personalized device or radiofrequency interference with sensitive medical got FDA 30 approval in 2013 to administer sedation equipment like and pace makers? Most of and titrating based on the clinical parameters the anecdotal reports were seen with cardiac monitors24 for and , “where an anesthesia and pacemakers. Initially a one-meter rule was proposed professional is immediately available”. This implied by Irnich et al25, which suggested restriction of mobile anesthesiologist need not be present all the time during phone use to greater than 1 meter from equipment, and it the procedure. FDA issued a recall of the device on 2015 still holds good. However, such interferences are not seen and the manufacturers discontinued it. with modern mobile devices with low electromagnetic The future of handheld devices holds much promise, and interference, and medical equipment by FDA regulations, judicious usage helps us in early and accurate diagnoses, should be immune from interference in fields of up to evidence based management of patients and accessing 7 V/m within the frequency range of 450–1000 MHz. 26 reliable information from our finger tips. Like all 3. Infection: Mobile devices have been shown to harbour technology, the ultimate result lies in the way it is used. numerous pathogens, including MRSA, coagulase However, caution should be exercised in relying negative staphylococcus aureus and kleibsella. After solely upon these devices and software and hardware the use of mobile phones, 38 out of 40 anesthetists malfunction can prove life threatening, as exemplified by had bacterial contamination on their hands, some were the Therac-25 incident where lethal doses of radiation was human pathogens.27 Frequent wiping of mobile surfaces administered accidentally due to an error in the software. with antiseptics and using antiseptic covers has been Any advance in technology should be properly used with recommended. Avoidance in sensitive areas like ICU, caution and should not be used to replace the basic motto transplant theatres etc seems to be prudent. of anesthesiology – eternal vigilance. Future Conflict of interest: None declared by the authors As technology improves, devices will get small, robust and versatile. Remote anesthesia is now a possibility. A Authors’ Contribution: PV – Concept, Literature search; AS – remote system, Keplar Intubation system Manuscript preparation, Proof reading. has been developed by Thomas Hemmerling, McGill

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