Some hospitals have begun to rely on robots instead of doctors to sedate patients, and it could be the tip of the iceberg when it comes to drug delivery in hospitals and clinics. Would you like to have a robot anesthesiologist? Is it safe? Are human anesthesiologists on their way out? We investigated.
GETTING TO KNOW THE ‘BOT
The technical name for robotic anesthesia is “computer-assisted personalized sedation”–CAPS. The FDA approved the first and so far only robot anesthesia device, Johnson & Johnson’s SEDASYS System, in 2013. It administers a powerful anesthesia called propofol into the patient’s bloodstream via an IV.
So far it’s been approved only for colonoscopies and upper endoscopies (colon and digestive tract exams conducted with cameras) in healthy adults. Most hospitals aren’t using it…yet. But it’s most likely coming to your hospital, because it’s cheaper and opens up beds about 20% faster, too. (Whether those savings get passed on to health-care consumers is another story.)
For patients, there are potential benefits with the new robots. Why? It turns out that the choice isn’t primarily between having a trained anesthesiologist versus a robot. It’s actually between having a human-assisted robot sedate you versus having a gastroenterologist or a nurse give you an inferior drug.
Why? Until now, only an anesthesiologist could administer propofol, so gastroenterologists who didn’t want to call in an anesthesiologist every time they did a common procedure such as a colonoscopy often relied on less powerful sedatives such as midazolam.
The problem: Compared with propofol, these other sedatives work more slowly and leave patients feeling groggy longer. Patients need more time to become clear-headed so they can talk to their doctors (and remember the conversation) and safely leave the hospital.
The new robot-assisted system might allow for more colonoscopy and endoscopy patients to get the sedative propofol, which is better for this kind of procedure. You may have heard of propofol because singer Michael Jackson died from an overdose of it in 2009. Yet despite the grim association, many doctors prefer propofol to less potent sedatives in part because of its swift action—it works fast, and patients recover from it quickly.
CAN ROBOTS BE TRUSTED WITH SEDATION?
The SEDASYS system begins with a sedative dose that is calculated based on information that a clinician enters into the system, such as a patient’s weight. The machine then begins to send that dose continuously through an IV into the patient. At the same time, the machine monitors the patient’s blood oxygen levels, heart rate, respiration and blood pressure. If it detects a problem, such as a fall in blood pressure, it alerts the humans in the room (typically the doctor performing the procedure and an assistant of some sort). The computer can reduce the dose of anesthesia or turn off the flow completely, but it can’t increase the amount without a human’s order. This reduces the risk for oversedation from the robot.
Here’s another risk-reducer: Although there is no anesthesiologist present, a health-care professional such as a nurse or doctor must be present and must monitor the SEDASYS system and the patient’s airway. This is a separate individual from, say, the gastroenterologist performing the procedure, and monitoring the patient is his or her sole responsibility. This person must be trained to use the device and trained in how propofol works, how to identify high-risk patients, how to gauge whether the level of sedation is too high or too low (and what to do about it) and how to clear air obstructions and otherwise make sure the patient is breathing well—all sorts of things that we have traditionally relied on anesthesiologists to do to keep us safe.
The system has several safeguards built into it, and it’s potentially more cautious than an anesthesiologist would be. In trials, healthy patients who were sedated using the device had lower occurrences of low blood oxygen levels compared with similarly healthy patients who were sedated with other drugs during colonoscopies and endoscopies. Patients were just as satisfied with SEDASYS as with standard sedation. There were no serious adverse events, and gastroenterologists in the study reported being more satisfied with the sedation they were able to provide with SEDASYS than with the drugs they normally used without an anesthesiologist.
The biggest concern? There were some occurrences of deeper-than-intended sedation with the system in the preapproval studies, although the patients didn’t experience any problems such as shallow breathing as a result. Because of this risk, the FDA added two additional requirements before approving SEDASYS—the human monitor must receive specific training in safe administration of propofol, and an anesthesiologist must be on-call in case of an emergency.
THE ROBOTS ARE COMING, THE ROBOTS ARE COMING
SEDASYS is likely the first of many innovations in semi-autonomous anesthesia administration. The FDA has suggested that the system could be a model for other anesthesia scenarios—beyond GI screenings—and even other medical specialties. According to an article in the Washington Post, researchers at the University of British Columbia in Vancouver are currently testing an anesthesia robot for brain and heart surgeries.
Although anesthesiologists lobbied hard against SEDASYS, they eventually saw the writing on the wall and shifted gears to trying to limit how it can be used and other restrictions. As two prominent anesthesiologists with no ties to the product pointed out in a 2014 editorial in the journal Anesthesiology and Pain Medicine, “While robotic assistance for anesthesia is being rolled out, we can focus on those tasks that humans perform better than computers.”
There doesn’t seem to be any reason to fear the robot. If one gets wheeled into your procedure room before your next colonoscopy, wave.