E.Flerov, I.Sablin, O.Broytmann, S.Batchayev, A.Bankov.

The Russian National Research Center of Surgery,
2 Abrikosovsky per., Moscow, 119991, Russia



     According to the on line survey conducted by the Anesthesia Patient Safety Foundation (APSF), the two factors that contributed most to intraoperative adverse events were believed to be inadequate preoperative information/preparation and communication/teamwork errors1. Thus development of electronic medical record and automated anesthesia record keeping systems remains a very relevant task for modern anesthesiology. Even bigger challenge is to ensure compatibility and universal access to the wealth of the acquired anesthesia information. Internet as a common information milieu in combination with new technologies creates the basis for Web integration of anesthesia-relevant information and further advances of anesthesiology, minimizing the “human error” component in the area of patient’s safety in the operating room (OR). In the last century this minimizing of human error was secured through adoption and introduction of the Standards for Basic Anesthetic Monitoring. The 21st century calls for systems for remote patient’s monitoring, facilitating close cooperation between anesthesia provider and specialist/mentor, creating databases jointly accessible via Internet and modern audiovisual telecommunicating tools for physician’s lifelong learning. That contributes to a “second layer of safety”, when specialized anesthesiologist is able to supervise and control via any on-line computer physiologic parameters in real time, together with visualizing the actions of the OR team over web cams. This redundancy compensates for the remaining «human factor» («to err is human»), that can be responsible for the anesthesia-related complications even when all the essential hardware of safety monitoring is in use. The same computer can give the videoconferencing capabilities to the supervisor for his teleconsulting and mentoring role. Work in that promising field at the Russian National Research Center of Surgery has been active since 1997 and is reflected at

Study Goal

     Development and clinical application of a system for the permanent Internet monitoring of patient’s condition, actions of anesthesiologist and surgeon to optimize operating room workflow and to ensure administrative oversight. Piloting of the concept of «remote second safety layer in anesthesia»


Material and Methods

     «Home-grown» paperless automated anesthesia record keeping in 8 operating rooms (cardiac, organ transplantation, abdominal/colorectal surgery, thoracic and invasive radiology) with gathering data on the central server and using the proxi-server that presents information over the Internet. High resolution Webcams (736x480 pixels) controlled over the Internet (Sony SNC-RZ30), four-channel video server Axis 241QA for visualization of performance of surgeons and anesthesia providers, as well as screens of the anesthesia monitors, transesophagial echocardiography (TEE), X-ray and endoscopic equipment with resolution of 768x576 pixels. Videoconferencing using H323 and H320 protocols and peer-to-peer Voice over the Internet Protocol (VoIP) «Skype». Database with over 5000 patient's records, 2400 operated during last four years are accessible and available for mathematical analysis from any computer on the world network. Patient's control and performance monitoring of surgical and anesthesia personnel using any web browser on any stationary computer as well as mobile devices from site



     This technology allows to receive information that constitute anesthesia record in real time as well as access it for the post-hoc analysis on any computer of the world. It is easy to control the computer monitoring protocol, to discover the technical or instrumental errors, to detect periods of suboptimal anesthesia. The chief of service can oversee the situation in the OR during meetings and conferences, using mobile Internet access from laptop , from home during emergency procedures and even via mobile telephone (s. Fig.1, Quadruple OR view on the iPhone, at the end of this text).
     Physician in charge can, without leaving his office, home or even car can monitor the anesthesia provider, give advice and prioritize his/her work, supervising several operating room in parallel with the necessary administrative duties. The comments, remarks, recommendations and diagnostic statements made remotely are recorded in anesthesia record using specifically designed piece of software that identifies the commenting author as well. To diagnose the patient's condition at the distance quality and comprehensivness of data output are of high importance. From that standpoint displaying the hemodynamic and ventilation trends together with two video server images or simultaneous four-windows picture from Axis 241 QA proved to be the best. Combining the «fly on the wall» view of the OR with operating field, trends of computer anesthesia record and screens of hemodynamic and gas analyzing monitors / TEE permitted to detect hemodynamically significant responses secondary to coarse surgical manipulations or changes in preload (leg elevation) that were not recorded by the anesthesia provider in the room. Based on the results of Internet-monitoring it was posssible to diagnose the patinet's condition and provide recommendations to anesthesiologist in the OR. There were two occasions when disconnection of endotracheal tube from anesthesia circuit was diagnosed remotely using this system. Videoconferencing, Skype in particular, provides the leader reliable opportunity for «telemanagement». We successfully tested telemonitoring of anesthesia's depth by Board certified anesthesiologist stationed in Philadelphia, USA.
     Using the system the leading cardiac surgeon follows preparatory stages of the procedure remotely, instructs and consults his team, participates in the TEE study or provided with live X ray images. It is possible to capture video images as digital files to document the key stages of the procedure and create videoclips / podcasts of the operating technique to educate and train surgeons.
     Developed system is succesfully implemented in remote medical graduate and postgraduate education of students, surgeons, anesthesiologists and specialists in intraoperative functional diagnostics. It also permits substantial cost savings over installation of commercially available designated systems for videoconferencing often requiring the presence of dedicated staff to ensure their operability. High quality of visualization of operating field is achieved by remotely controlled via Internet, never turned off Web cams or by simple video server. VoIP Skype combined with high definition camera Logitech 9000 Pro delivers a very clear professor's image to the OR, and cordless headset Plantronics CS60db provides quality audio.



     Developed at the Russian National Research Center of Surgery system of Internet-monitoring provides reliable remote access to control the condition of patient undergoing surgery, as well as performance of anesthesiologist and actions of surgical team. It provides «informational backbone» of the concept of «Real Time Telemedicine in the OR», that is built up in our center and may serve as basis for creating National anesthesia database in Russia. «Real Time Telemedicine» implies formation of the digital operating room, in which all gathered information is available to qualified user via secure Internet access from potentially any computer in the world for review, management and teaching, with using available modern communication technologies like videoconferencing and VoIP videotelephony.



[1] Anesthesia Patient Safety Foundation: accessed 12 Feb 2010


Fig.1 Real Time View of the 4 Operating Rooms on the iPhone