Prof. Juozas Ivaškevičius Anaesthesiology and Intensive Care in Lithuania.

Prof. Juozas Ivaškevičius

Anaesthesiology and Intensive Anaesthesiology and Intensive

Care Care

in in LithuaniaLithuania

Historical facts

Present situation

Education and trainig

The future

L.Lechavičius (1811-1880)

W.T.G.Morton 16th October, 1846

23rd February,1847

Ether anaesthesia

J.V.Simpson 10th November,1847

21st December, 1847

Chloroform anaesthesia

VILNIUS

12th of February, 1847,

Vilnius Medical Society -

A.ADOMAVIČIUS 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 - 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 - 2004Hospitals in Lithuania - 2004

80 hospitals

Kaunas Medical University Clinics

Vilnius University Hospital Santariškių Clinics

Number of Departments in Lithuania - 2004

Anaesthesia departments

Intensive care departments

7676 7979

80 hospitals

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 Development of anaesthesiology and intensive care in Lithuania was close related within Lithuania was close related with

Vilnius University Faculty of Medicine

Kaunas Medical University

ANANAAESTESTHHEESIOLOGY in VILNIUS UNIVERSITY SIOLOGY in VILNIUS UNIVERSITY AFTERAFTER 1990 1990

Clinic of anaesthesiology and intensive care with 2 centers

5 training Hospitals: 30 192 anaesthesias, 11 080 ICU pts.

Development of Anaesthesiology and Development of Anaesthesiology and Intensive Care in Kaunas Medical Intensive Care in Kaunas Medical

UniversityUniversity

Number of anaesthesias – 34 650, 9 030 ICU pts.

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.

Scientific research workScientific research work

Residency ProgramResidency Program

In compliance with: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 Anaesthesiologists in Training

Vilnius Vilnius UUniversity Faculty of niversity Faculty of MMedicineedicine

27 residents2005 graduated 10 residentsAdmitted - 8 residents

Kaunas Medical UniversityKaunas Medical University

36 residents2005 graduated 12 residentsAdmitted - 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 CreditsGeneral 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 CreditsResuscitation 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 ProgramProcedures - Anaesthesiology

Procedures

Minimum number of proceduresLithuania

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 ProgramProcedures - Intensive Care

Procedures

Minimum number of proceduresLithuania

RecommendedUEMS

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 ProgramProcedures - Pain Treatment

Procedures

Minimum number of procedures

Lithuania

Recommended

UEMS

Minimum number of patients in pain treatment

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 MedicineKaunas 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

LithuaniaLithuania

10-11 May, 2003Referendum about the membership in European Union

64 % came to vote.90 % said yes.

Lithuanian Statistics - Inhabitants Lithuanian Statistics - Inhabitants (thousands) (thousands) (1998-2004)(1998-2004)

3549,3

3524,2

3499,5

3481,3

3469,1

3454,23452,6

3400

3450

3500

3550

1998 1999 2000 2001 2002 2003 2004

Lithuanian Statistics - Number of Births Lithuanian Statistics - Number of Births (1998-2004)(1998-2004)

37019 36415

34149

3154630153 30598 30419

25000

35000

45000

1998 1999 2000 2001 2002 2003 2004

Lithuanian Statistics Lithuanian Statistics - Number of - Number of PPhysicians hysicians

CountryCountry Number of physicians Number of physicians per per 100 000 population100 000 population

LithuaniaLithuania 390 390

European Union European Union 340340

UKUK 250250

2nd Baltic Conference of Health Care Policy, September 30th , 2005

20052005

Lithuanian Statistics Lithuanian Statistics - Number of - Number of PPhysicians in Lithuaniahysicians in Lithuania

CountryCountry Number of physicians Number of physicians per per 100 000 population100 000 population

LithuaniaLithuania 313 313

2nd Baltic Conference of Health Care PolicySeptember 30th , 2005

2015

Shortage of physicians - 1000Shortage of physicians - 1000

Reasons of Shortage of Physicians in LithuaniaLithuania, , 2015

2nd Baltic Conference of Health Care Policy September 30th , 2005

EmigrationAgeOther reasons

Critical areas:Critical areas:

Anaesthesiology and intensive careGynecology, obstetricsOphthalmology

Number Anaesthesiologists in Number Anaesthesiologists in LithuaniaLithuania

Year 1996 – 576Year 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 Licensed Anaesthesiologists in in LithuaniaLithuania

2nd Baltic Conference of Health Care Policy, September 30th , 2005

Number of anaesthesiologists age > 60 years – 10

%

10 % have applied for references from Lithuanian

Health Care Ministry that are required in EU

countries

Number Anaesthesiologists in Number Anaesthesiologists in LithuaniaLithuania

Enough according to WSFA Enough according to WSFA recommendations – 1,9 recommendations – 1,9 per 10000 pop.per 10000 pop.

Shortage of anaesthesiologists in some Shortage of anaesthesiologists in some rural hospital rural hospital

Some foreign countries do not include Some foreign countries do not include doctors working in intensive caredoctors working in intensive care

Possible problem in future – “brain Possible problem in future – “brain drain”.drain”.

Inhalation Anaesthesia Agents

0 10 20 30 40

Halothane

Izoflurane

Sevoflurane

N2O

N2O

Sevoflurane

Izoflurane

Halothane

29%

12 %

28 %

31 %

Intravenous Anaesthesia Agents

0

10

20

30

40

50

60

70

80

Thiopental Propofol Ethomidate Others

Thiopental

Propofol

Ethomidate

Others

74 %

15 %

4 %7 %

Opioids

Fentanil 91 %

Remifentanil 0,1 %

Morphine 6 %

Muscle Relaxants

26%

39 %

0

5

10

15

20

25

30

35

40

1

Sux

Atracurium

Cisatracurium

Mivacurium

Pipecuronium

26%

39 %

3 %

11 %

21 %

Local Anaesthethics

Lidocaine

Bupivacaine

Other

16 %

37 %

47 %

Anaesthesia Machines

Less than 10 years

57%57%

Anaesthesia Machines

More than 10 years

43%43%

Artificial Ventilation Equipment in ICU

Less than 10 years

64 %64 %

More than 10 years

35 %35 %

Yearly Maintenance of the Equipment

Performed in departments

89 %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)

1310,9

7,7

5,3

0

2

4

6

8

10

12

14

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 - 2004Number of ICU Patients - 2004

Number of patients in the ICU

74 200

Mortality in the ICU

6,4 %

Number of ICU Patients - 2004

0

5

10

15

20

25

30

35

40

45

50

ICU I - 1 ICU I - 2 ICU II ICU III

ICU I - 1

ICU I - 2

ICU II

ICU III11%

47 %

36%

6%

Valuation for ICU Service in Lithuania

Level Hours Cost EUR

I - I (recovery room)

24 hours 60,40

I - II (primary ICU)

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