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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