the future of anaesthesia practice in the next decades dr. b. radhakrishnan, director &...
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THE FUTURE OF THE FUTURE OF ANAESTHESIA PRACTICE ANAESTHESIA PRACTICE IN THE NEXT DECADES IN THE NEXT DECADES
Dr. B. RADHAKRISHNANDr. B. RADHAKRISHNAN,, Director & PrincipalDirector & Principal
Academy of Medical sciences, Pariyaram, Academy of Medical sciences, Pariyaram, Kannur, Kerala. Kannur, Kerala.
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Anaesthesiology - 1846
Philosophy - Practice
Astrology -
Prediction
Biotechnology
Computer Technology
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We may extinct
or
We may dominate
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WTG MORTON - 1846
Ether Days
Mystery
Discovery of Relaxants
Developments in to subspecialties
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STORY I LIKE TO READSTORY I LIKE TO READ
How Anaesthesia progressed -
status and promotion in India.
Travelling through Indian growth -
pit falls – Possible cure
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Growth of ISA in India – reflections of the pastGrowth of ISA in India – reflections of the past- Developments in India – largest democracy- ISA and Anaesthesia service in India
Silver Jubilee (72 / 75)Golden Jubilee (97 / 02)Diamond Jubilee (07)1956 – WFSA1976 – AARS1991 – SACAISA – City / State / Regional ZonesFormative years –Conference – CME (1981) – WFSA – Educational
programmesIndian Journal of AnaesthesiaChange of name – ISA Flag – Emblem (1969) control of
society
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EARLIER DAYS – 1846 AND AROUND EARLIER DAYS – 1846 AND AROUND
UK Vs USAChloroform Vs Ether a)Is Anaesthesiology a Medical Specialty?b)If put on professional category, would there be adequate practioners
Margin of safety of Chloroform and Ether – Practice difference in UK Vs USA
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UK developments in Anaesthesia starts early (Snow’s Anaesthesia research starts in 1847)
Snow – Clovor – Hewitt – London Society of Anaesthesiologists (LSA)
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GREAT EVENTS IN UK – GREAT EVENTS IN UK – RESPECTABILITY TO THE SPECIALTY RESPECTABILITY TO THE SPECIALTY
Queen Victoria – Prince Leopold –
Simpson
Napoleon – III - Clover
Edward – VIII - Hewitt
Develops as individual specialty
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USA - ATTITUDES TO ANESTHESIA USA - ATTITUDES TO ANESTHESIA
“Learning to do by doing”Any one was welcomeStep child of medical profession Non Medical personals
Organizational development till 1915 – was erratic
Brooklyn SocietyNew York Society
IARS
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1970’s – (40 Years ago)1970’s – (40 Years ago)
Ether, Trilene, Ethyl Chloride, HalothaneGallamine, Curaree, Suxamethaonium, Morphine – Pethidine – Analgesics
Controlled mandatory ventilation Lignocaine, BupivaccaineECG Monitor, Sphygmomanometer, Visual assement
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1970’s – (40 Years ago)1970’s – (40 Years ago)
Fasting protocol - Most cruelPostoperative pain relief– SOSFluids – Sugar/ Salt solution Red rubber tubes – Steel needle – IV canuala ??. Non disposable rubber tubes + clamps“Seemed Comfortable” – acceptability in Progress
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1990’s – (20 Years ago)1990’s – (20 Years ago)
New drugs – Propofol
New relaxants – Vecrunonium,
Atracurium
Isoflrane – Sevoflurane –
Desflurane
Synthetic Narcotics – Fentanyl
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Eid Tidal MonitorsLignocaine makes slow exit – Bupivaccaine Electronic CircutsAnalgesic Delivery – PCAPulse Oxymeter, PAP, CapnographyLaparoscopic Techniques CT/MRILMA
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2010 – WHERE I AM2010 – WHERE I AM
Dramatic ChangesCare giver/ quality in practiceFast track gets settled. Inhalational agents – Sevoflurane, Cycloflurone Newer analgesics – Infusion devicesAnalgesic Pharmaco kinetics tied to computerized delivery.
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2010 – WHERE I AM2010 – WHERE I AM
EEG – Bispectral index (BIS)- EGADS (EEG Guided
Anaesthesia delivery System.
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CURRENT CHANGING CURRENT CHANGING
SCENARIO SCENARIO 1. Awake intubation
No longer street fight/ mandatory preparation
Fibre Optic intubation Blind Nasal – Extreme
Situtaion Torture – Not permitted –
Criminal
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CURRENT CHANGING CURRENT CHANGING
SCENARIO SCENARIO
2. Cuff Pressure
Saline Cuff
Lignocaine Cuff
Cuff pressure in adults
Cuff in Paediatrics
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CURRENT CHANGING CURRENT CHANGING
SCENARIO SCENARIO 3. Line Flushing Over flushing/ Manual
flushing Retro grade embolisation of
air Saline Volume Continuous flush device RA to SA (6 Cm/3-12 Cm)
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CURRENT CHANGING CURRENT CHANGING
SCENARIO SCENARIO 4. Consent Informed Consent – Pre-Op
Examination Investigations /consent over telephone
Viacarious liabilities – Consent in different situation
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CURRENT CHANGING CURRENT CHANGING
SCENARIO SCENARIO Target organ Protection
Protect Kidney not urine output.
Metabolic Acidosis Treat lactose acidosis – but
not with bicarbonate .
Damage Control Surgery Damage Control
Anaesthesia
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CURRENT CHANGING CURRENT CHANGING
SCENARIO SCENARIO Non Technical Skills Improvement for Anesthesiology (NOTECHS) (ANTS-System Hand Book) (University of Aberdeen)Team WorkLeadershipProfessional BehaviorHuman PerformanceCognitive Evaluation in Post operative phaseCQM - CQI
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THE WITNESSED SCENARIO THE WITNESSED SCENARIO CHANGE – CURRENT GOOD CHANGE – CURRENT GOOD ANAESTHESIA PRACTICE ANAESTHESIA PRACTICE
Two tracks of anaesthesia practice - Slow X Fast
Extension of service to perioperative care- and perioperative medicine/physician Development of pain management servicePost operative pain/ acute pain and chronic pain management fasting protocol.
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Blood - Blood products Artificial blood – replacement of human blood , genetic engineering (Crocodile blood/ bacteria ‘E’-Coli)
Xeno transplantation PONV – Prophylaxis Gene Therapy and Brain repairMonitors –Forgiving drugs –Newer Anaesthesia delivery apparatus.
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MONITORED ANAESTHESIA CAREMONITORED ANAESTHESIA CARE
(SURGERY UNDER SEDATION(SURGERY UNDER SEDATION)
(Narcotic Sedation/ Anxiolytic
Sedation/ Tranquillizer Sedation/
Anti histamine sedation)
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MAC –
Sedative + Anxiolytic + Analgesic
1985 (Mostly Apnoeic, Cyanotic)
MAC in 2000
Midazolam + Alfentanil +
Conversation
MAC in 2010
(Madam are you comfortable?)
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FUTURE OF ANESTHESIA AND FUTURE OF ANESTHESIA AND ANAESTHESIA PRACTICE ANAESTHESIA PRACTICE
A) EXTINCT
B) DOMINANT
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PRACTICE OF FUTUREPRACTICE OF FUTURE
EXTINCTEXTINCT-Non-medical Assistants-(Short term course – Promotion)-Promotion by our own tribe-No Anaesthesiologists in Operating Rooms-Anaesthesia will be remotely controlled-ICU’s will be managed by Pulmonary Physician -Blood will be synthetic-No blood Bank
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PRACTICE OF FUTUREPRACTICE OF FUTURE
DOMINANTDOMINANTAcute care bedsSurgery – TraumaConventional surgeryPain Management -AggressiveAnaesthesia – Administered and monitored by Computers. Endotracheal intubation - RobotsRegional Anaesthesia – Change in application
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PRACTICE OF FUTUREPRACTICE OF FUTURE
DOMINANTDOMINANTSimulators in conductNewer drugs - Target pointedBlood transfusion Anaesthesia residency programmeAnaesthesia Machines – Speaking machinesIntellectual base/ linking/ foundation/ care giversOverall developments of medicineSharing of information
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PLANNING THE FUTURE OF PLANNING THE FUTURE OF ANAESTHESIOLOGYANAESTHESIOLOGY
(Dr. Longnecker/ David. E – University (Dr. Longnecker/ David. E – University of Pennsylvania) of Pennsylvania)
Chill winds of competition – Survival
Socio economic situationChanging policies and will power/
PoliticsAwareness and consumer demandScaling of service Demand and supply of Physician +-
future man power need.
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PLANNING THE FUTURE OF PLANNING THE FUTURE OF ANAESTHESIOLOGYANAESTHESIOLOGY
(Dr. Longnecker/ David. E – University (Dr. Longnecker/ David. E – University of Pennsylvania) of Pennsylvania)
Credentialing for systems and Practioners
Visionary departmentsQuality based globally acceptable
medical education – affordable and acceptable
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The future of Anaesthesia – GlobalThe future of Anaesthesia – Global
Until 1940’s – developmentsDiscovery of muscle relaxants Future depends on Social awareness / Social needs / Cost bearingChanges – fast track / slow track – (conventional)Developments Emergence of artificial blood/ gene therapy / new
drugs (SAFE) / biotechnological changes Anaesthesia machines - remote control / voice
control / smart machinesAcute care bedsRobotic interventions / Regional / Requirement of
anaesthetists? / Future monitors – smart monitorsDocumentation –EHR- leasingPatient safety – prime concern
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Future of our ‘tribe’ in IndiaFuture of our ‘tribe’ in IndiaHave we progressed? How far? ‘ 30000/ 14500 ‘Innovation / islands of progressGeneral quality / progress?Practice controllers
Medical Council of India - AcademicNational Board of Examinations - AcademicGovernment of India - ‘Snails Pace’- qualityProfessional Organizations - Quality in education
Teachers and Trainers Predict possibilityReorganization of teachingRemodeling of practice ‘ Quality implementation’Standardization –Mistakes of the past ISA – Organisational pride “ Non -aggressive Saints
of Medicine”
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THE FUTURE THE FUTURE
Future depends on how far practice of Anaesthesia kept in hands of Anaesthesiologist -
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Acceptability and respectability will be ensured when average Anaesthesia Practitioner shows he/she is
a) Understand pathogenesis and possible haemodynamics in any situation, may be able to explain the same
b) Sufficiently skilled in conduct of anaesthesia whether GA/RA/MAC
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c) Adequate understanding to interpret monitor datas and run intensive care situations
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THANK YOUTHANK YOUBEST OF LUCKBEST OF LUCK