ANESTHESIA IN 2025: WHAT’S CHANGED IN 25 YEARS?

Author: Richard Novak, MD

The Anesthesia Consultant

A quarter-century into the new millennium, how much has anesthesia changed? During the years 2000-2025 the world transformed in remarkable ways. In 1999 we lived without:

• Smartphones
• GPS mapping and directions in our phones
• Digital photography and video cameras in our phones
• Social media
• Television streaming services such as Netflix
• AI
• Electric cars
• Drones

Surely the field of anesthesia has evolved and changed during these same years. But has it? Let’s look at ten ways in which anesthesia changed or stayed the same, and whether the specialty is better off as a result:

1. Anesthetic drugs. A typical general anesthetic in 1999 included intravenous midazolam as the premed, propofol as the induction agent, fentanyl as the narcotic, and rocuronium as the muscle relaxant. Antiemetic agents included ondansetron and dexamethasone. Inhalation maintenance anesthesia was sevoflurane plus or minus nitrous oxide, and intravenous maintenance anesthesia was a propofol infusion. In 2025 these drug regimens are largely unchanged. I review medical records from around the United States on a regular basis, and the general anesthetic techniques today aren’t significantly different than they were in 1999.
2. Electronic Medical Records (EMR) in the operating room. In the 1990s we were documenting all anesthesia care with pen on paper. Today hospital anesthesia medical records are recorded into computer software. The result has been a mixed bag. The electronic record of intraoperative vital signs is a more accurate database than the previous handwritten grid of vital signs, but the actual input of medical information into the EMR by MDs and RNs is tedious and slow, requiring typing into various repetitive screens. Copying of previous notes is widespread, and lengthy computer-generated histories and physicals lack any attention to brevity or to the pertinent positives and negatives we learned in medical school. A three-hour anesthetic/surgery generates 500+ pages of EMR documentation for future healthcare providers to plow through if they want to learn what happened. A better model of anesthesia EMR in the future is inevitable, likely to be authored by an anesthesiologist/software engineer.
3. Ultrasound-guided regional blocks. Ultrasound-guided regional blocks are commonplace in orthopedic cases, with the benefit that patients feel less pain during surgery and less pain following surgery. Like a carpenter with a hammer who must find a nail, it seems many orthopedic anesthesiologists with an ultrasound machine must find a nerve to block, even for surgeries that are not very painful. And there’s risk to peripheral nerve blockade that’s rarely discussed verbally with patients preoperatively—that roughly one in 3000 patients will have permanent nerve damage following their elective/optional ultrasound-guided regional block.
4. Omnicell/Pyxis machines. The addition of automated drug supply cabinets in the operating room was a significant advance over the Sears Craftsman carts we used previously. The tracking of narcotic doses administered, wasted, and returned is simplified and more reliable.
5. Videolaryngoscopy. The video laryngoscope is the crown jewel medical device advance in anesthesiology over the past 25 years. In the 1990s we struggled with direct laryngoscopy, backed up by fiberoptic laryngoscopy, to perform difficult intubations. With videolaryngoscopy we can now see around corners and place endotracheal tubes more quickly and with more ease.
6. Sugammadex. Sugammadex was a marked advance in the reversal of neuromuscular paralytic medications, far faster and more dependable than our previous regimen of reversing paralysis with neostigmine/glycopyrrolate.
7. Quantitative neuromuscular monitoring. In 2023 the American Society of Anesthesiologists recommended quantitative monitoring over qualitative neuromonitoring, to avoid the complication of residual neuromuscular blockade. It remains to be seen how many hospitals/surgery centers will purchase these new quantitative monitors, how many anesthesia professionals will use the devices, or whether this change will affect any important change in anesthesia outcomes.
8. PubMed/digital medical libraries. One can now access the abstract of any published medical literature on PubMed.com.  This is a tremendous advance in medical education and research. In the 1990s one would have to physically travel to a medical school library, read through a search catalog, walk through the book stacks, locate the journal you were seeking, and then photocopy the article you were looking for. Today you can type your keywords into PubMed and the information will flow into your computer or smartphone. In addition, if you’re on the faculty of a medical school, the entire medical library can be accessed digitally and nearly every textbook can be viewed on your computer screen. Medical education is a lifelong process, and PubMed/digital medical libraries have vastly improved our ability to stay current.
9. Private equity purchases of anesthesia practices. Private equity groups have moved into the medical fields and purchased anesthesia practices from senior anesthesia partners willing sell their group. The senior anesthesiologists profit with a bolus of money as they transition out of the group. The group’s  future is set up with lower salaries for the junior anesthesiologists, as that income is skimmed off as profit for the investors. A JAMA Network study in 2020 found that one out of three anesthesiologists have been acquired in a private equity physician practice buyout. Private equity has led to higher patient costs and lower care quality—a JAMA study in 2022 found that prices increased 26% when anesthesia companies backed by private-equity investors took over a hospital outpatient or surgery center. Another study published in JAMA found that private equity-backed hospitals may have worse quality of inpatient care. Per Becker’s ASC Review, “Findings like this could contribute to physicians’ wariness toward private equity.”
10. Hospital subsidies for anesthesia groups. Over 80% of hospitals are paying stipends—some in the millions of dollars—to entice anesthesia groups to serve their hospital 24/7. Hospital difficulties in acquiring anesthesia staffing are due to: a) the current shortage of anesthesiologists and certified registered nurse anesthesiologists; b) poor payor mix in hospitalized patients—many hospital-based anesthetics are insured by Medicare, which pays at a rate of 33% or less of commercial insurance reimbursement; and c) increased demand for anesthesia services, as the number of daily anesthetizing locations in the United States is at an all-time high. As a result, more than 80 % of hospitals pay monthly/yearly monetary stipends to their anesthesia groups to keep them tied to the medical center. Without these valuable subsidies, hospital anesthesia staffing in America would be inconsistent and chaotic.

Twenty-five years.

Ten topics, as I see them.

Stay tuned for the next quarter century . . .