Anaesthesiology and Intensive Care in Lithuania Prof. Juozas Ivaškevičius
Historical facts Present situation Education and trainig The future
VILNIUS L.Lechavičius (1811-1880) W.T.G.Morton 16 th October, 1846 23 rd February,1847 Ether anaesthesia J.V.Simpson 10 th November,1847 21 st December, 1847 Chloroform anaesthesia
12 th of February, 1847, Vilnius Medical Society - A.ADOMAVIČIUS Presentation about ether anaesthesia.
William Stewart Halsted, 1852-1922 The advent of anaesthesia has made it so that any idiot can become a surgeon
1946 Anaesthesia open mask ether anaesthesia only for complicated operations Performed by nurses from surgical department local infiltration anaesthesia Fluid therapy no infusions perioperatively, after operation subcutaneous infusion Statistics up to 50% of patients died because of ileus, 5% of patients died because of acute appendicitis
1955 the first endotracheal anaesthesias were performed 1958 Health Care Ministry introduced incumbency of anaesthesiologist 1961 Spinal anaesthesia 1962 - Lithuanian Society of Anaesthesiology and Intensive Care was founded 1963 the first department of anaesthesiology was opened in Vilnius 1964 postgraduate training of anaesthesiologists was started
1991 Lithuanian Society of Anaesthesiology and Intensive care joined WFSA 1994 Pain Clinic
Hospitals in Lithuania - 2004 80 hospitals Kaunas Medical University Clinics Vilnius University Hospital Santariškių Clinics
Number of Departments in Lithuania - 2004 80 hospitals Anaesthesia departments Intensive care departments 76 79
Number of Anaesthesias - 2004 Total number 210 000 General anaesthesia 147 000 (70 %) Regional and local anaesthesia 63 000 (30 %)
Development of anaesthesiology and intensive care in Lithuania was close related with Vilnius University Faculty of Medicine Kaunas Medical University
ANAESTHESIOLOGY in VILNIUS UNIVERSITY AFTER 1990 Clinic of anaesthesiology and intensive care with 2 centers 5 training Hospitals: 30 192 anaesthesias, 11 080 ICU pts.
Development of Anaesthesiology and Intensive Care in Kaunas Medical University Number of anaesthesias 34 650, 9 030 ICU pts.
Scientific research work 1. Anaesthesia and coexisting diseases. 2. Regional anaesthesia. 3. Cardiac anaesthesia and cardiopulmonary bypass. 4. Sepsis and multiple organ system failure. 5. Enteral and parenteral nutrition. 6. Treatment of acute and chronic pain. 7. Therapeutic apheresis.
Residency Program In compliance with: Lithuanian laws and regulations European Union laws and regulations: Training Guidelines in Anesthesia of the European Board of Anaesthesiology Reanimation and Intensive Care, 2001 European Council Directive 93/16/EEC European Council Directive 2001/19/EC
Anaesthesiologists in Training Vilnius University Faculty of Medicine 27 residents 2005 graduated 10 residents Admitted - 8 residents Kaunas Medical University 36 residents 2005 graduated 12 residents Admitted - 12 residents
Training of Anaesthesiologists Until 2003 1 year of internship, 3 years of residency Now 1 year of internship, 4 years of residency
Residency Program 1 year basics of anaesthesia and intensive care 3 years specialty anaesthesia and intensive care New program more time to spend in intensive care, pain clinic. One credit point 40 hours
Residency Program 176 credits Subject Credits General anaesthesia and pain treatment 40 Anaesthesia for abdominal surgery 12 Anaesthesia for neurosurgery 8 Anaesthesia for thoracic surgery 8 Anaesthesia for orthopedic surgery and trauma 8 Anaesthesia in obstetrics 8 Anaesthesia for pediatric surgery 8 Anaesthesia for vascular surgery 8 Anaesthesia for odontology and surgery 4 Anaesthesia for urological surgery 4 Anaesthesia for cardiac surgery 8 Total for anaesthesiology 116 Treatment of acute and chronic pain 8 Electives 8
Residency Program 176 credits Subject Credits Resuscitation and basics of intensive care 16 Intensive care in abdominal surgery 16 Neonatal and pediatric intensive care 4 Intensive care after cardiac surgery 4 Intensive care in cardiology 2 Intensive care in toxicology 2 Total for intensive care 44
Residency Program Procedures Anaesthesiology Procedures Minimum number of procedures Lithuania Recommended UEMS General anaesthesia 500 500 Spinal anaesthesia 50 50 Epidural anesthesia 50 50 Nerve and plexus blocks 20 20 Total number of anaesthesias 1200 1500
Residency Program Procedures - Anaesthesiology Procedures Minimum number of procedures Lithuania Recommended UEMS Pediatric patients, age < 5 years 30 30 Pediatric patients, age < 1year 10 10 Obstetrics, S.Caesarea 10 10 Epidural for delivery 10 10 Thoracic 16 15 Neurosurgery 15 15 Urology 10 10 Odontology, head and neck surgery 15 15 Orthopaedic endoprostheses 15 15 Day case surgery 30 30 Vascular 10 10
Residency Program Procedures - Intensive Care Minimum Procedures number of Recommended procedures UEMS Lithuania Minimum number pf patients in ICU 50 50 Pediatric patients, age < 5 years 3 3 Pediatric patients, age < 1year 2 2 Respiratory disorder 3 3 Cardiovascular disorder 10 2 CNS problems 2 2 Sepsis 4 2 Renal failure 4 1 Transport of critically ill patients 5 5 Resuscitation 5 5
Residency Program Procedures - Pain Treatment Procedures Minimum number of patients in pain treatment Minimum number of procedures Lithuania Recommended UEMS 50 50 Pediatric patients 5 5 Major surgery 10 10 Thoracic surgery 5 5 Major orthopedic surgery 5 5 Day-case surgery 10 10 Chronic pain 20
Continuing Medical Education (CME) Recertification every 5 years. CME forms Formal CME 120 hours, training at Vilnius University Faculty of Medicine Kaunas Medical University Also publications in scientific journals, lectures, etc.
Continuing Medical Education (CME) CME forms Nonformal CME 80 hours, Local conferences held by medical university or faculty together with scientific society Conferences abroad, etc.
Continuing Medical Education (CME) Government should ensure 70 % of the finances for CME. The other part doctor himself, employer, company, etc. Financial difficulties to go to conferences abroad
Lithuania 10-11 May, 2003 Referendum about the membership in European Union 64 % came to vote. 90 % said yes.
Lithuanian Statistics - Inhabitants (thousands) (1998-2004) 3550 3549,3 3524,2 3499,5 3500 3481,3 3469,1 3454,2 3452,6 3450 3400 1998 1999 2000 2001 2002 2003 2004
Lithuanian Statistics - Number of Births (1998-2004) 45000 35000 37019 36415 34149 31546 30153 30598 30419 25000 1998 1999 2000 2001 2002 2003 2004
Lithuanian Statistics - Number of Physicians Country 2005 Number of physicians per 100 000 population Lithuania 390 European Union 340 UK 250 2 nd Baltic Conference of Health Care Policy, September 30 th, 2005
Lithuanian Statistics - Number of Physicians in Lithuania 2015 Country Number of physicians per 100 000 population Lithuania 313 Shortage of physicians - 1000 2 nd Baltic Conference of Health Care Policy September 30 th, 2005
Reasons of Shortage of Physicians in Lithuania, 2015 Emigration Age Other reasons Critical areas: Anaesthesiology and intensive care Gynecology, obstetrics Ophthalmology 2 nd Baltic Conference of Health Care Policy September 30 th, 2005
Number Anaesthesiologists in Lithuania Year 1996 576 Year 2002 634 (all licensed) Year 2005 683 (all licensed) Lithuanian Society of Anaesthesiology and Intensive Care Year 2002 384 members Year 2005-505 members
Licensed Anaesthesiologists in Lithuania Number of anaesthesiologists age > 60 years 10 % 10 % have applied for references from Lithuanian Health Care Ministry that are required in EU countries 2 nd Baltic Conference of Health Care Policy, September 30 th, 2005
Number Anaesthesiologists in Lithuania Enough according to WSFA recommendations 1,9 per 10000 pop. Shortage of anaesthesiologists in some rural hospital Some foreign countries do not include doctors working in intensive care Possible problem in future brain drain.
Inhalation Anaesthesia Agents N2O 29% Sevoflurane Izoflurane Halothane 12 % 28 % 31 % N2O Sevoflurane Izoflurane Halothane 0 10 20 30 40
Intravenous Anaesthesia Agents 80 70 74 % 60 50 40 30 20 10 15 % 4 % 7 % Thiopental Propofol Ethomidate Others 0 Thiopental Propofol Ethomidate Others
Opioids Fentanil 91 % Remifentanil 0,1 % Morphine 6 %
Muscle Relaxants 40 35 30 25 20 15 10 5 0 39 % 39 26% 26% 21 % 11 % 3 % 1 Sux Atracurium Cisatracurium Mivacurium Pipecuronium
Local Anaesthethics 16 % 47 % Lidocaine Bupivacaine Other 37 %
Anaesthesia Machines Less than 10 years 57%
Anaesthesia Machines More than 10 years 43%
Artificial Ventilation Equipment in ICU Less than 10 years 64 % More than 10 years 35 %
Yearly Maintenance of the Equipment Performed in departments 89 %
Lithuanian Society of Anaesthesiology and Intensive Care should play active role in: Propagation of modern methods of anaesthesia and intensive care Training and CME of anaesthesiologists Play active role in Health Care Ministry, influencing legal background, financial decisions, etc. Increase international partnership
What we have today? Lithuanian Norm of Medicine Anaesthesiologist reanimatologist Resuscitation standards Anaesthesia safety standards are being prepared Valuation of ICU service, pain treatment Partnership with foreign organizations
Health Expenditures as % of GDP (2004) 14 12 13 10,9 10 8 6 4 2 7,7 5,3 0 USA Germany England Lithuania
Financial Situation in Lithuania Introduction of realistic and proper valuation for anaesthesia requires additional funds from State Patient Fund Difficult to expand the range of modern anaesthesia techniques
Financial Situation in Lithuania There is no valuation for anaesthesia service in Lithuania Prices for anaesthesia is included in the price for surgery Prices for pain treatment are currently announced
Number of ICU Patients - 2004 Number of patients in the ICU 74 200 Mortality in the ICU 6,4 %
Number of ICU Patients - 2004 50 45 40 35 30 25 20 15 10 5 0 47 % 36% 11% 6% ICU I - 1 ICU I - 2 ICU II ICU III ICU I - 1 ICU I - 2 ICU II ICU III
Valuation for ICU Service in Lithuania Level Hours Cost EUR I - I (recovery room) I - II (primary ICU) 24 hours 60,40 48 hours 88,44 II level 3 days 601,73 III level 4 days 989,88 III-3 level 20 days 1 day 354,05