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.

Anaesthesiology - 1846

Philosophy - Practice

Astrology -

Prediction

Biotechnology

Computer Technology

We may extinct

or

We may dominate

WTG MORTON - 1846

Ether Days

Mystery

Discovery of Relaxants

Developments in to subspecialties

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

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

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

UK developments in Anaesthesia starts early (Snow’s Anaesthesia research starts in 1847)

Snow – Clovor – Hewitt – London Society of Anaesthesiologists (LSA)

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

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

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

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

1990’s – (20 Years ago)1990’s – (20 Years ago)

New drugs – Propofol

New relaxants – Vecrunonium,

Atracurium

Isoflrane – Sevoflurane –

Desflurane

Synthetic Narcotics – Fentanyl

Eid Tidal MonitorsLignocaine makes slow exit – Bupivaccaine Electronic CircutsAnalgesic Delivery – PCAPulse Oxymeter, PAP, CapnographyLaparoscopic Techniques CT/MRILMA

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.

2010 – WHERE I AM2010 – WHERE I AM

EEG – Bispectral index (BIS)- EGADS (EEG Guided

Anaesthesia delivery System.

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

CURRENT CHANGING CURRENT CHANGING

SCENARIO SCENARIO

2. Cuff Pressure

Saline Cuff

Lignocaine Cuff

Cuff pressure in adults

Cuff in Paediatrics

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)

CURRENT CHANGING CURRENT CHANGING

SCENARIO SCENARIO 4. Consent Informed Consent – Pre-Op

Examination Investigations /consent over telephone

Viacarious liabilities – Consent in different situation

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

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

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.

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.

MONITORED ANAESTHESIA CAREMONITORED ANAESTHESIA CARE

(SURGERY UNDER SEDATION(SURGERY UNDER SEDATION)

(Narcotic Sedation/ Anxiolytic

Sedation/ Tranquillizer Sedation/

Anti histamine sedation)

MAC –

Sedative + Anxiolytic + Analgesic

1985 (Mostly Apnoeic, Cyanotic)

MAC in 2000

Midazolam + Alfentanil +

Conversation

MAC in 2010

(Madam are you comfortable?)

FUTURE OF ANESTHESIA AND FUTURE OF ANESTHESIA AND ANAESTHESIA PRACTICE ANAESTHESIA PRACTICE

A) EXTINCT

B) DOMINANT

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

PRACTICE OF FUTUREPRACTICE OF FUTURE

DOMINANTDOMINANTAcute care bedsSurgery – TraumaConventional surgeryPain Management -AggressiveAnaesthesia – Administered and monitored by Computers. Endotracheal intubation - RobotsRegional Anaesthesia – Change in application

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

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.

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

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

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”

THE FUTURE THE FUTURE

Future depends on how far practice of Anaesthesia kept in hands of Anaesthesiologist -

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

c) Adequate understanding to interpret monitor datas and run intensive care situations

THANK YOUTHANK YOUBEST OF LUCKBEST OF LUCK