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Anaesthesiology and Intensive Care in Lithuania Prof. Juozas Ivaškevičius Anaesthesiology and Intensive Care in Lithuania Prof. Juozas Ivaškevičius

Historical facts Present situation Education and trainig The future Historical facts Present situation Education and trainig The future

VILNIUS VILNIUS

12 th of February, 1847, Vilnius Medical Society A. ADOMAVIČIUS Presentation anaesthesia. about ether 12 th of February, 1847, Vilnius Medical Society A. ADOMAVIČIUS Presentation anaesthesia. about ether

William Stewart Halsted, 18521922 “The advent of anaesthesia has made it so that any William Stewart Halsted, 18521922 “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 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 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 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 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 76 Ø Intensive Number of Departments in Lithuania - 2004 80 hospitals Anaesthesia departments 76 Ø Intensive care departments 79

Number of Anaesthesias - 2004 Total number – 210 000 General anaesthesia – 147 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 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 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 – 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 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: 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 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 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 – 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 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 Resuscitation and basics of intensive care Intensive care Residency Program – 176 credits Subject Resuscitation and basics of intensive care Intensive care in abdominal surgery Neonatal and pediatric intensive care Intensive care after cardiac surgery Intensive care in cardiology Intensive care in toxicology Total for intensive care Credits 16 16 4 4 2 2 44

Residency Program Procedures Anaesthesiology Procedures General anaesthesia Minimum number of procedures Lithuania Recommended UEMS Residency Program Procedures Anaesthesiology Procedures General anaesthesia Minimum number of procedures Lithuania Recommended UEMS 500 Spinal anaesthesia 50 50 Epidural anesthesia 50 50 Nerve and plexus blocks 20 20 1200 1500 Total number of anaesthesias

Residency Program Procedures - Anaesthesiology Minimum number of procedures Lithuania Recommended UEMS Pediatric patients, Residency Program Procedures - Anaesthesiology Minimum number of procedures Lithuania Recommended UEMS Pediatric patients, age < 5 years 30 30 Pediatric patients, age < 1 year 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 Procedures

Residency Program Procedures - Intensive Care Procedures Minimum number pf patients in ICU Minimum Residency Program Procedures - Intensive Care Procedures Minimum number pf patients in ICU Minimum number of procedures Lithuania Recommended UEMS 50 50 Pediatric patients, age < 5 years 3 3 Pediatric patients, age < 1 year 2 2 Respiratory disorder 3 3 10 2 CNS problems 2 2 Sepsis 4 2 Renal failure 4 1 Transport of critically ill patients 5 5 Resuscitation 5 5 Cardiovascular disorder

Residency Program Procedures - Pain Treatment Procedures Minimum number of Recommended procedures UEMS Lithuania Residency Program Procedures - Pain Treatment Procedures Minimum number of Recommended procedures UEMS Lithuania 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 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 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. 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 % 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) Lithuanian Statistics - Inhabitants (thousands) (1998 -2004)

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

Lithuanian Statistics - Number of Physicians 2005 Country Number of physicians per 100 000 Lithuanian Statistics - Number of Physicians 2005 Country 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 Lithuania Number of physicians Lithuanian Statistics - Number of Physicians in Lithuania 2015 Country Lithuania Number of physicians per 100 000 population 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: 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) 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 % Licensed Anaesthesiologists in Lithuania Number of anaesthesiologists age > 60 years – 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 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 29% 12 % 28 % 31 % Inhalation Anaesthesia Agents 29% 12 % 28 % 31 %

Intravenous Anaesthesia Agents 74 % 15 % 7% 4% Intravenous Anaesthesia Agents 74 % 15 % 7% 4%

Opioids Fentanil 91 % Remifentanil 0, 1 % Morphine 6% Opioids Fentanil 91 % Remifentanil 0, 1 % Morphine 6%

Muscle Relaxants 39 % 26% 21 % 11 % 3% Muscle Relaxants 39 % 26% 21 % 11 % 3%

Local Anaesthethics 16 % 47 % 37 % Local Anaesthethics 16 % 47 % 37 %

Anaesthesia Machines Ø Less than 10 years 57% Anaesthesia Machines Ø Less than 10 years 57%

Anaesthesia Machines Ø More than 10 years 43% Anaesthesia Machines Ø More than 10 years 43%

Artificial Ventilation Equipment in ICU Less than 10 years 64 % More than 10 Artificial Ventilation Equipment in ICU Less than 10 years 64 % More than 10 years 35 %

Yearly Maintenance of the Equipment Performed in departments 89 % Yearly Maintenance of the Equipment Performed in departments 89 %

Lithuanian Society of Anaesthesiology and Intensive Care should play active role in: Propagation of 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 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) Health Expenditures as % of GDP (2004)

Financial Situation in Lithuania Introduction of realistic and proper valuation for anaesthesia requires additional 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 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 Number of ICU Patients - 2004 Number of patients in the ICU 74 200 Mortality in the ICU 6, 4 %

Number of ICU Patients - 2004 47 % 36% 11% 6% Number of ICU Patients - 2004 47 % 36% 11% 6%

Valuation for ICU Service in Lithuania Level Hours Cost EUR I - I (recovery 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