Neonatal outcomes are often compromised when a critically ill parturient is transferred to a critical care units managed by intensivists as they have poor insight into the maternal physiology and fetal well-being. And maternal condition is often compromised when mother is monitored in maternal HDU as the staff are less experienced in managing invasive monitoring lines and equipment providing organ supports. Timing and mode of delivery, again plays a very important role in reversing rapidly deteriorating parturient due to pregnancy specific multi-organ dysfunction syndromes like HELLP-AFLP complex and amniotic fluid embolism etc. Hence, there is no “one size fits all” model to provide critical care in obstetric units. A model of authentic multidisciplinary care involving Obstetricians, Obstetric Anaesthesiologists with critical care training, intensivists, fetal medicine, Neonatologists, Obstetric Physicians, concerned subspecialists (Cardiology, nephrology etc.) with an insight in managing pregnant patients is mandatory for giving BEST TO BOTH THE LIVES, the Mother and the Fetus and the new born! Pregnancy specific maternal cardiac arrest resuscitation again is an essential training that the entire unit has to be made aware for better outcomes. Further, the unit should have robust end of life care policies, organ donation protocol and managing brain dead parturient with surviving fetus, when and how long to prolong the pregnancy etc. All these policies have to be backed by sound ethics committee. Lastly, worldwide, there has been a significant decrease in maternal mortality rates; there is, however, evidence that the rate of decline is plateauing, and it is now projected that the maternal mortality rate will be 133 deaths per 100,000 live births in 2030, nearly double the target of the World Health Organization (WHO) sustainable development goals. Unlike in developed nations where critical care admission of critically ill pregnant women is < 2%, 4- 5% of pregnant women delivering in LMICs still need maternal critical care. This is the right time, that Govt make an effort to invest rightfully in providing equality care to critically ill parturients and develop MCC units with good infrastructure and trained personnel in public hospitals having large obstetric load with good referral systems like Hub & Spoke model to achieve WHO sustainable goals. ABBREVIATIONS: APACHE II – Acute Physiological and Chronic Health Evaluation Score SAPS II – Simplified Acute Physiology Score SOFA – Sequential Organ Functional Assessment MEOWS – Modified Early Obstetric Warning Score HELLP-AFLP – Hemolysis, Elevated Liver Enzymes, Acute Fatty Liver in Pregnancy NIV – Non Invasive Ventilation IABP – Intra Aortic Balloon Pump VV ECMO – Veno Venous ECMO VA ECMO – Veno Arterial ECMO RRT – Renal Replacement Therapy
References: 1. Green LJ, Mackillop LH, Salvi D, et al. Gestation-specific vital sign reference ranges in pregnancy. Obstetrics and Gynecology 2020; 135: 653–64. 2. K. Cranfield,D. Horner,M. Vasco, G. Victory and D. N. Lucas. Current perspectives on maternity critical care; Anaesthesia 2023, doi:10.1111/anae.15948 3. Sunil T Pandya, Sai J Krishna. Acute Respiratory Distress Syndrome in Pregnancy. Indian J Crit Care Med 2021 Dec; 25(Suppl 3):S241-S247. doi: 10.5005/jp-journals-10071-24036. 4. Vasco M, Pandya S, Van Dyk D, Bishop DG, Wise R, Dyer RA. Maternal critical care in resourcelimited settings. Narrative review. International Journal of Obstetric Anaesthesia 2019; 37: 86– 95. 5. Sunil T Pandya, Kajal Jain, Anjan Trikha et al. The association of obstetric anaesthesiologists, India – An expert committee consensus statement and recommendations for the management of maternal cardiac arrest. Journal of Obstetric Anaesthesia and Critical care. 2022 | Volume: 12 | Issue : 2 | Page : 85-93 6. World Health Organization. Sustainable Development Goals Target 3.1 ¦ Maternal mortality: By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births. https://www.who.int/data/gho/data/themes/topics/indicatorgroups/indicator-group-details/GHO/maternal-mortality (accessed 29/08/2022).
Dr N G Upul Ranjith MBBS, MD (ANAESTHESIOLOGY) Dr Upul Ranjith graduated from the Faculty of Medicine, University of Ruhuna in 1992. He rendered his service to preventive health sector for 4 years until he changed over to the field of Anaesthesia in 1998. He obtained his Doctorate in Anaesthesiology in 2003 from the Postgraduate Institute of Medicine, University of Colombo and subsequently completed the overseas component of his Postgraduate training in Liverpool and Campbell Town hospitals in Sydney, Australia. He was board certified as a consultant anaesthetist in 2005. Since then he has worked as a consultant anaesthetist in District General Hospital, Hambantota, Base Hospital, Tangalle and is currently attached to the Teaching Hospital, Mahamodara. He further contributes for the undergraduate and postgraduate medical education in the country and his interests are in the areas of obstetric anaesthesia and analgesia.
Anaesthesia & Maternal Mortality Now and Future in Sri Lanka - Dr N G Upul Ranjith Although Sri Lanka has recorded the lowest maternal mortality ratio of 29.5 per 100 000 live births, in South Asian region in 2020, when compared with the high-income countries, it is in fact an alarming rate, which cannot be simply ignored. Focusing on the history of maternal mortality in Sri Lanka it is obvious that documentation of deaths has first started in 1847 and the first record of maternal death ratio of the country which is 2170 per 100 000 live births reports from the year 1881. Then, there has been a significant reduction in the maternal death ratio in the year 1947 and the recorded figure is 1694 per 100,000 live births. Gradually, the death rate has declined until around 20102 and since then the mortality rate has remained static around 30 per 100 000 live births. In the year 2020, there were 89 direct maternal deaths and obviously the direct anaesthetic deaths are extremely rare. However, the role of the anaesthetist in peri-partum care of mothers is extremely important. In 2020, 4 maternal deaths have been reported due to amniotic fluid embolism. Frequently, the diagnosis of amniotic fluid embolism is made when the post mortem findings are negative. Hence, some of these deaths could also be attributed to high spinal block. Therefore, anaesthetists have to be vigilant on the early diagnosis of such cases and prompt management ofsuch complications is vital to prevent deaths. As we are aware, high-income countries have successfully controlled maternal deaths that cause due to direct obstetric causes though the indirect causes still predominates. Although the same scenario was prevalent in Sri Lanka until 2019 the post-partum haemorrhage has again been reported as the leading cause of maternal deaths in the year 2020. As I believe, the maternal mortality can be significantly minimized by taking the following measures. Implementing a multi-disciplinary approach in peri-partum care of mothers and strengthening of maternal near misses reporting and analysis are vital. Further, the proper implementation of Maternal Early Obstetric Warning Score - MEOWS chart, Continuous Professional Development - CPD for staff, strict adherence to guidelines and protocols, auditing of own practices and legalization of abortions will definitely contribute to bring down the maternal mortality rate in Sri Lanka.
Dr Helgi Johannsson VICE PRESIDENT ROYAL COLLEGE OF ANAESTHETISTS, UK Born in Iceland, Helgi Johannsson moved to the UK aged 12, and trained at St Bartholomew’s hospital. During his training he undertook an education and simulation fellowship, and became a consultant at St Mary’s hospital in 2007. His clinical interest lie in trauma, oesophagogastric surgery, obstetrics, bariatrics and general all-round anaesthesia, and recently treatment of COVID-19. He was clinical director of anaesthesia for Imperial 2012-2018, was elected onto the Royal College of Anaesthetists council in 2018, and now serves as Vice President. He is Associate Medical Director for medical education at Imperial, and clinical director of anaesthesia for MSI choices. Other interests include social media and medicine, education, music and exercise. He is on twitter as @doctorhelgi
Professor Ramani Moonesinghe I was appointed as a consultant in anaesthesia and intensive care at UCL Hospitals in 2010 and have been a Professor at UCL since 2018. My research focuses on developing and evaluating ways to improve the safety and quality of perioperative and critical care. I lead several research programmes both in the UK and internationally. I was Director of the RCOA’s Health Services Research Centre between 2016 and 2022. I was appointed to my current role for NHS England (NHSE) in 2020 and provided clinical leadership to the NHSE critical care response to COVID19 throughout the pandemic. I now clinically lead NHSE transformation programmes in critical care and perioperative care. These aim to improve access, reduce system- and patient-level inequalities, and improve care delivery and outcomes for patients who could benefit from critical care and surgery. I am married to a very patient and supportive inventor and live in Sussex with him and our adopted children aged 4, 6 and 7. I was awarded the honour of Officer of the Order of the British Empire (OBE) in 2021 for services to anaesthesia, perioperative and critical care.
Dr Bernadette Ratnayake MBBS, DA, FRCA, aFFPMRCA Diploma in Leadership & Management Dr Ratnayake is a Consultant Anaesthetist at Kingston Hospital NHS FT and a Visiting Consultant EOC with special interest in Trauma & orthopaedics, Colorectal and Peri-operative care. She is also the Lead clinician for inpatient pain service and set up and lead the PreOperative Assessment Department while being the educational supervisor to anaesthetic trainees and a consultant appraise and a mentor. National roles: Immediate Past President British Society of Orthopaedic Anaesthetists, UK Member – Research Council National Institute of Academic Anaesthesia (NIAA)Member – Centre for Peri-Operative Care advisory Group 2021 to date AAGBI Working party – Acute Compartment syndrome 2017-20 Co-Author- Royal College CPD matrix for Higher and Sepcialist curriculum for orthopaedic anaesthsia Reginal Roles: Anaesthetic Lead for the SouthWest London Perioperative Care Programme to digitalise the Care Pathway through to early traiging to expedite High Volume Low complexicy operations and identify patients requiring pre-habilitation. Opioid Stewardship – SWL Regional role in NHS England Patient safety Strategy to reduce the harm from High Dose opioid prescribing. Kingston Hospital Roles: Lead clinician for the Inpatient Pain Service: Which provides Education, skills and training in the management of acute postoperative and other inpatient painful conditions. Management acute pain in sickle crises, fracture rib & fracture neck of femur analgesia, functional abdominal pain and acute and chronic back pain and pain in cancer. Formulated guidelines for Acute Pain management, Patient Controlled Analgesia, Epidural and Regional Analgesia, Post-Operative Nausea & Vomiting and Fracture Rib Analgesia.
Founding and Lead Clinician for the Preoperative Assessment Service:2004- November 2015, 2021- to date Our team consists of 12 Specialist Nurse Practitioners, per-operative Matron and 7 Anaesthetic consultants. We pre-assess all patients scheduled for elective surgery, our focus being ensuring fitness for surgery, optimising medical conditions, patient information and therefore eliminating last minutecancellations. Proactive Care for the Elderly Service @ Kingston Hospital: Shared Decision Making MDT pathway:Program for optimisation of our older surgical patients and other high risk surgical patients and shared decision making with other specialties. New Developments in perioperative care The Challenge: The COVID-19 pandemic has had a significant impact on several aspects of global healthcare systems, particularly surgical services. New guidelines, resource scarcity, and an everincreasing demand for surgery have posed challenges, resulting in cancellation of surgeries, with short and long-term consequences for surgical care and patient outcomes. As the pandemic subsides and the healthcare system attempts to re-establish a sense of normalcy, surgical recommendations and advisories will shift. These changes, combined with a growing case backlog (postponed surgeries and regularly scheduled surgeries) and physician shortages pose a significant challenge to Global Healthcare Systems. The need to improve surgical waiting lists and reduce the length of time a patient stays in hospital are currently top priorities for the UK’s health service. Around 10 million people have surgery in the NHS each year and currently, there is almost a years’ worth of activity on waiting lists. 10-15% of surgical inpatients are at an increased risk of poor outcomes and this number is likely to rise due to waiting list delays. Increasing age and co-morbidity means patients are more susceptible to complications which delay discharge, hamper recovery, put stress on social care and increase likelihood of readmissions. The solution: Harnessing the power of excellent, joined up perioperative care (integrated Care Pathways) is a powerful tool in the efforts to address these issues. Focusing on improving care from the moment surgery is contemplated with public health initiatives and supporting patients to exercise, stop smoking and lose weight is a more powerful intervention than many medical therapies in reducing complication rates. Benefits for health providers include reduced cancellations, reduced length ofstay and reduced complications which in turn reduce cost.
Who: The Centre for Perioperative Care (CPOC) is a cross-specialty centre dedicated to the promotion, advancement and development of perioperative care, for the benefit of both patients and the healthcare community. CPOC has forged a strong working collaborative with a core partnership group including patients and the public, other professional stakeholders including Medical Royal Colleges, NHS England and the equivalent bodies in other UK devolved nations. How: CPOC is working to improve the health of people of all ages, at all stages of their surgical journey, by promoting the highest standards of perioperative care. In real terms this means delivering on the following key strategic aims set out to achieve the overall goal. 1.Improving patient outcomes and experience 2.Empowering patients, carers and the public 3.Educating and developing the workforce 4.Influencing policy 5.Promoting research, technology and innovation CPOC has developed a suite of full pathway guidelines on topics including the management of anaemia, frailty and diabetes. CPOC workstreams and are centred around empowering patients by improving shared decision-making practices and focusing on promoting lifestyle modification during ‘teachable moments’ in their perioperative journey. CPOC is supporting the workforce to deliver excellent care for patients by developing a multiprofessional perioperative care curriculum. South West London Health & Care Partnership: Perioperative Care Pathway Programme: Digital Solutions South West London (SWL) Care Partnership was successful in a bid focussed on utilising digital technology to support improvements in the perioperative care pathway in 2021. The integrated care pathway approach use the SWL Elective and Critical Care programme to help deliver changes within the pathway across the High Volume Low Complexity specialities (HVLC) The work on the Perioperative Care Programme is focused on the following areas: 1. Using technology to support the pre operative assessment including the development of pathways to identify low risk patients who require less input or may be suitable to go straight to surgery – streaming ASA 1 patients via patient portal. 2. Implementing electronic consenting within the HVLC specialities- E Consent 3. Using early Triaging to the deliver pre-optimisation of Chronic Health Conditions and deliver virtual prehabilitation pathways in SWL.
References: 1.Delivering plan for tackling the COVID-19 backlog of elective care https://www.england.nhs.uk/coronavirus/delivering-plan-for-tackling-the-covid-19- backlog-of- elective-care/ 2. Cutting the Covid-19 Surgical Backlog through Digital Innovations 31 August 2021: healthInnovation network South London Cutting the Covid-19 Surgical Backlog through Digital https://healthinnovationnetwork.com ›2021/09 3. Elective recovery plan: what you need to know NHS Confederation: 11 February 2022 https://www.nhsconfed.org/publications/electiverecovery-plan-what-you-need-know4. Win-Win for sustainability and Health
Samantha R Warnakulasuriya FRCA MSc MA (Oxon) BMBCh Dr Warnakulasuriya is a consultant in Anaesthesia and Perioperative Medicine and the Quality Improvement Lead for Anaesthesia, at the University College London, Hospital. She is specialising in orthopaedic, bariatric and major cancer surgery. She has an interest in data driven quality improvement and is the QI lead for anaesthesia at UCLH. Her research interests are in high-risk surgery, perioperative anaemia and PROMS. Formerly a Perioperative Quality Improvement Programme (PQIP) Fellow with the Health Services Research Centre, she has ongoing collaborations with the Centre for Perioperative Medicine at UCLH and the NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice at the University of Oxford.
Harnessing Quality Improvement in Perioperative Medicine Quality Improvement (QI) aims to improve patient care by applying a systematic approach to design and implement changes. Hospital systems with a clear model for QI are associated with outstandingratings in the UK(1) . National clinical audit (NCA) data highlights current challenges in perioperative care. Increasingly NCAs incorporate quality improvement as an objective (2)with regular feedback to local hospitals. Further data is available with increasing digitalisation of medical records (3) and this should be harnessed for improvement purposes. At a local level, clinicians express a desire for continuous feedback of process and outcome data(4) and significant improvements are made when data is fed back to frontline clinicians (5). Audit and feedback, whilst an intervention in itself, has potential to spark further implementation strategies(4). Whilst reporting of QI projects should be systematic (6), our recent scoping review (7) highlighted lack of systematic collection of reports of perioperative QI. The majority of NCA based QI is in grey literature with a publication bias to positive interventions. Translating this to a local level strategy the questions to ask are: Do you have an overview of what QIis happening in your department? Do you have a record of what interventions have been tried in thepast? What positive interventions have lapsed? Are you using all of the data that you have in order to continuously improve? At our institution we have built a QI infrastructure to support MDT improvement efforts. Using familiar Microsoft 365 tools, this allows tracking of projects over long term period and prioritisation for resource allocation. Together these tools allow a focused approach aligned with departmental strategy and builds ability to sustain projects and institutional memory in the longer term. Requirementsfor QI infrastructure will be common to most institutions with low cost and accessibility being key to acceptability. References 1. CQC. Quality Improvement in Hospital Trusts. Care Quality Commission. 2018. 2. Oliver CM, Hare S. What do perioperative national clinical audits tell us? The evolving role of national audits in changing practice and improving outcomes. BJA Educ. 2019;19(10):334–41 3. Goldacre B, Morley J. Better, Broader, Safer: Using Health Data for Research. A review commissioned by the Secretary of State for Health and Social Care and Analysis. Department ofHealth and Social Care. 2022 4. Springer M v., Sales AE, Islam N, McBride AC, Landis-Lewis Z, Tupper M, et al. A step toward understanding the mechanism of action of audit and feedback: a qualitative study of implementation strategies. Implementation Science. 2021;16(1):1–14. 5. Hu QL, Liu JY, Hobson DB, Cohen ME, Hall BL, Wick EC, et al. Best Practices in Data Use forAchieving Successful Implementation of Enhanced Recovery Pathway. J Am Coll Surg . 2019;229(6):626-632.e1 6. Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards forQUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Qual Saf. 2016;25(12):986–92 7. Wagstaff D, Warnakulasuriya S, Singleton G, Moonesinghe SR, Fulop N, Vindrola-Padros C. A scoping review of local quality improvement using data from UK perioperative National ClinicalAudits. Perioperative Medicine. 2022;11(1):1–11
Professor Richard Langford MBBS, FRCA, FFPMRCA Professor Richard Langford is the Lead Consultant, In-patient Pain Service, The London Clin- ic since 2014 to date. He was the Founding Director of the Pain and Anaesthesia Research Centre at Barts Health NHS Trust and served in the position from 1991 to 2004. Professor Richard Langford was the President of the British Pain Society from 2010-2013 He is having over two hundred publications to his credit which include: BMJ; NEJM; Arthri- tis and Rheumatism; Clinical Pharmacology and Therapeutics; Br J Anaesth; Br J Pain; Anes- thesiology; Eur J Pain; Anaesthesia; Eur J Anaesth
Summary Post-operative pain management has not kept pace with intra-operative management, or the challenges posed by ever earlier discharge and concerns regarding opioid use. Proposals for improvement include: assessing the impact of pain on function, ‘Functional Pain Scores’ and attempts to develop automated algorithm based ‘nociception monitoring’ (as yet of unproven added benefit) rather than a unidimensional pain score; and anticipa- tion of patients’ analgesic requirements for potential analgesia gaps when intra-operative measures are expected to wear off. Regular modified release opioids appeared to address some of these needs, but have raised both individual and societal safety concerns. We have a duty to ensure seamless management of patients discharged soon after surgery, and hence recommendations for analgesia planning, post-discharge supervision and opioid tapering by transitional pain clinics. A major focus has been the search for methodsto deliver peripheral, continuous analgesic action closer to the site of the noxious stimuli, for nerve blockade, and around or within the wound itself. These include a range of new non-opioid methods (already or soon to be available), such as ‘cryoanalgesia’ techniques and extended-release candidates. Two modified release local anaesthetic formulations are authorised, releasing bupivacaine for two and three days respectively. Options still in development will be presented. References Schug SA, Palmer GM, Scott DA et al (2020) Acute Pain Management Scientific Evidence 5th edition. Melbourne, Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine.https://www.anzca.edu.au/safety-advocacy/advocacy/college-publications Accessed December 2020 Pogatzki-Zahn EM et al. Postoperative pain—from mechanisms to treatment. Pain Re- ports.2 (2017) e588 Levy N, Mills P. Controlled-release opioids cause harm and should be avoided in manage- ment of postoperative pain in opioid naıve patients. Br J Anaesth 2019. 22:e86-e90 Srivastava D, Hill S et al. Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom. Br J Anaesth. 2021.126(6):1208- 1216
Dr Ajay Gandhi MD (Pathology) Dr Ajay Gandhi is a Hematopathologist and a Hemostasiologist. Presently he is the Associate Director, Clinical Affairs of Werfen, India and South Asia, and the custodian of the Werfen Academy India. Achievements & Awards: MBBS (Gold Medalist); MD Pathology (Honors) Bhamashah Puraskar for Excelling in field of Medicine in Rajasthan in 2002 Gold Medal, Ministry of Health and Family Welfare, MP for original research work on PBM in 2005 He is the Primary author for the first publication on PBM recommendations from India and the Primary author for the publication on D-dimer best practice recommendations from India. His other key publications in 2021-22 includes Gandhi A, Görlinger K, Nair SC, et al. Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group. J Anaesthesiol Clin Pharmacol. 2021;37(1):3-13. Gandhi Ajay, Ahluwalia Jasmina, Nair Sukesh C, Saxena Renu, Naithani Rahul, Phatale Rajesh, Dayal Nitin, Best Practices In D-Dimer Testing; In COVID-19 and Beyond: Expert Group recommendations. Journal of the Indian Medical Association Vol 119, No 9, September 2021 Special Interests Hemostaseology, Patient Blood Management, Goal directed bleeding management, POC Viscoelastic testing, Anti-platelet drug monitoring
Way forward in Patient blood management - Dr Ajay Gandhi Patient Blood Management (PBM), as science, has reached a significant level of advocacy in terms of evidence; however, as a concept, in terms of policy and practice, it continues to find avenues to establish itself, at least in the developing world. Sri Lanka, as a country and as a pioneer amongst the peer group of nations across South and South-east Asia, has caught the global attention by achieving one of the key WHO millennium goals of reducing Maternal mortality rate. Whereas, it is highly encouraging and inspiring for other peer-group nations, there is still quite a distance to be covered in terms of uniform, multidisciplinary, nation-wide establishment and implementation of PBM guidelines. The inclusion of all concerned stakeholders is especially importantduring the current sociopolitical and economic scenario within Srilanka. My best wishes and commitment towards full support in realising this noble and impactful initiative.
Professor Klaus Görlinger MD Dr. Görlinger is a Senior Consultant for Anaesthesiology, Emergency and Intensive Care Medicine, Haemostaseology, and Pain Therapy. From Dec 1986 to June 2012, Dr. Görlinger worked as a Senior Consultant at the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, Germany, particularly in the field of Trauma, Liver Transplant, and Cardiac Surgery. Since July 2012, Dr. Görlinger is the Medical Director of TEM Innovations GmbH, Munich, Germany, which belongs since 2016 to Werfen. His main field of research is the development and implementation of point-of-care-guided algorithms for goal-directed perioperative bleeding management and patient blood management. He published 107 PubMed-listed publications, numerous abstracts, and book chapters. He has 7,179 citations and a h-index of 44. E-mail: [email protected]
Patient Blood Management - Way Forward -Professor Klaus Görlinger Patient blood management (PBM) is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while promoting patient safety and empowerment.” PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at (1) Screening for, diagnosing, and appropriately treating anaemia (2) Minimizing surgical, procedural, and iatrogenic blood losses and managing coagulopathic bleeding throughout the care (3) Supporting the patient while appropriate treatment is initiated. Key measures of the second pillar of PBM are (1) blood sparing surgical techniques with meticulous haemostasis, (2) the use of cell salvage, (3) the use of tranexamic acid, and (4) advanced individualized and goal-directed coagulation management including viscoelastic testing and the use of coagulation factor concentrates. In severe trauma, postpartum haemorrhage and major cardiac and non-cardiac surgery, transfusion does not stop bleeding and improves outcomes. Here, it is important to stop the bleed as soon and effective as possible without increasing the risk of thrombosis. Using a one-size-fits-all management strategy such as a ratio-based transfusion approach is unlikely to be optimum for all patients, and a more rational decision-making must account for the individual need of each bleeding patient. Accordingly, thromboelastometry-guided bleeding management implements this concept of precision medicine in the second pillar of PBM. Here, ROTEM algorithms follows the concept of administering the right haemostatic drug/interaction in the right dose at the right time and in the right sequence. By using the high negative predictive value of ROTEM for bleeding, inappropriate blood transfusion and haemostatic interventions can be avoided. However, pathologic ROTEM results should only be treated in case of clinically relevant bleeding. Accordingly, ROTEM algorithms must be understood as “Not-to-Do” or “Rule-out” algorithms, which avoid what is not needed. Multiple studies and meta-analyses have proven that this concept is very effective and safe in decreasing transfusion requirements, morbidity, mortality, and health care costs.
Dr. Janaki Dissanayaka MD Dr Janaki Dissanayake, is a consultant transfusion physician presently attached to the Colombo North Teaching Hospital at Ragama. Dr. Janaki Dissanayaka graduated from The Faculty of Medicine, University of Peradeniya Following her internship at Colombo North Teaching Hospital, she joined with the National Blood Transfusion Service as a medical officer of blood bank in the same hospital. She perused her Diploma and MD in Transfusion Medicine from the Post Graduate Institute of Medicine, University of Colombo and completed her overseas training at Canadian Blood services, Vancouver, Canada. As a board-certified consultant transfusion physician, she has worked at Teaching Hospital Anuradhapura and Kalutara prior to her present position at TH Ragama. Dr. Janaki Dissanayaka is a Member of the specialty board in Haematology & Transfusion medicine at the Post Graduate Institute of Medicine, Colombo and hold the post of course Coordinator for Diploma in Transfusion Medicine. She is the immediate past president of Sri Lanka College of Transfusion Physician
Professor Sandro Rizoli MD PhD FRCSC FACS Dr Sandro Rizoli received his Doctor of Medicine and completed a general surgery residency in Brazil. He moved to Canada in 1992 and underwent second residency in General Surgery at the University of Toronto, followed by fellowships in Trauma and Critical Care, and a PhD under Dr Ori Rotstein. I 2002 he joined the university of Toronto, and Sunnybrook Health Services Centre. Dr Rizoli was promoted to Full Professor in 2012. He has over 300 peer-reviewed publications and supervised numerous PhD, MSc, fellows, residents, and students. Dr Rizoli received two endowed chairs: The De Souza Chair and the St. Michaels ‘s & University of Toronto Endowed Chair in trauma Research. Dr Rizoli was the President of the Trauma Association in Canada, the Panamerican Trauma Society and the Chair of the Region XII(East Canada) of the American College of surgeons Committee on Trauma. Presently Dr Rizoli is the Trauma medical Director of the Hamad General Hospital in Doha, Qatar, Editor of JEMTAC Editor – in -Chief of the Panamerican journal of trauma Critical Care and Emergency Surgery.
Pelvic Fractures – Which Pathway? Objective : Summarize the most clinically relevant management principles in pelvic fracture in adults Focus : Anesthesiologists and Intensivists attending the 39th Annual Academic Congress of The College of Anesthesiologists and Intensivists of Sri Lanka (2023) Disclosure : Written by a Trauma Surgeon (general surgeon and intensivist) Overall Trauma is common Trauma remains the most common cause of death and disability among young (below 40 years of age) and working patients worldwide, particularly in middle- and low-income countries Pelvic fracture = death (due to bleeding or associated injuries) + long-term disability Outcome after pelvic fracture depends on appropriate (correct) + timely management – about 1/3 of deaths occur within 6 hours due to inability to control hemorrhage Best management by multidisciplinary team = trauma team + orthopedics + anesthesia Bone fractures Blunt trauma (road traffic and work-related) = pelvic fracture + hemorrhage The pelvic fracture itself (bone fracture) can be mechanically stable or unstable Not all patients with unstable (bone) pelvic fracture have hemodynamic instability “Open” pelvic fractures = fracture communicates with the vagina, rectum, bladder or skin Hemorrhage 1/3 of all patients with pelvic fracture + shock (hemodynamic instability) die Hemorrhage due to pelvic fracture = 85% from venous plexus + fractured bones 15% arterial (including iliac arteries) Principles of management ABCDE principles as per ATLS Chest X-ray + pelvic X-ray + extended FAST (ultrasound) = search for associated injuries Pelvic pain/tenderness on palpation = presume pelvic fracture exists Pelvic fracture + hemodynamic instability (sBP <90mmHg) 1. activate the massive transfusion protocol + administer tranexamic acid + restrict crystalloids + judicious use vasopressors 2. trauma-induced coagulopathy (TIC) is common and worsens hemorrhage 3. TIC (coagulopathy) diagnosis and management best guided by ROTEM (ROTEM protocol) 4. temporary external stabilization a. wrapping sheet around the pelvis b. pelvic binder (commercially available) c. external fixator (anterior or posterior C clamp) 5. do NOT take unstable patients to CT scan (unsafe) 6. unstable patients with positive FAST = OT for emergent laparotomy 7. unstable and negative FAST
a. consider OT for pre-peritoneal packing + external fixation – followed by arteriography/embolization b. consider going directly to arteriography/embolization 8. if available, consider REBOA (placed on zone III or I) a. followed by CT scan and/or arteriography/embolization b. OR going directly to the OT 9. best management unstable patients in a hybrid OT room (angiography + CT scan) Other considerations Stable patients responding to resuscitation = best evaluation by CT scan (3D reconstruction) Arterial extravasation (blush) on CT scan = may require arteriography/embolization Dropping Hg (even if no “blush” on CT scan) = may require arteriography/embolization 20% patients also have head injury – another 20% chest trauma, 10% intra-abdominal injuries Common associated injuries = urinary tract (hematuria), rectal, vaginal, perineal, spinal/nerve Temporary fracture stabilization (sheet wrap, binder, external fixator) = to realign + stabilize, should be replaced asap Preperitoneal packing = surgical placement sponges for tamponade is NOT universally used Arteriography/embolization indications = active contrast extravasation (blush on CT scan), large retroperitoneal hematoma and/or shock a. growing use worldwide b. requires expertise and availability (expensive) c. part of the treatment – many patients also require surgery and other interventions Open pelvic fractures may require temporary diverting colostomy or ileostomy
Dr. Joachim Schlieber MD Dr Joachim Schliber is a Consultant Anaesthesiologist at the AUVA – Trauma center Salzburg, Austria since 2012. He was the Deputy director and interim director of the Department of Anaesthesiology and Intensive Care of Stolzalpe Hospital, Styria, Austria, 2005 – 2012 Since 2019 he render his services as an Helicopter Emergency service HEMS doctor and is involved in rescue missions by helicopter as an emergency physician. He graduated from Graz University Medical School in 1996, qualified as a general practitioner Austrian Medical Association in 2001 and as an Anaesthesiology and Intensive Care Specialist from Bavarian Medical Association in 2005. He has published many articles specially related to resuscitation science. https://www.researchgate.net/profile/Joachim_Schlieber/publications Dr Schlieber is A Member of the Development Committee Education of the European Resuscitation Council. The vice president of Austrian Resuscitation Council The Medical director of the HEMS base- ÖAMTC Flugrettung –“CHRISTOPHORUS 7”, Nikolsdorf, Tyrol, Austria A member of the Austrian Armed Forces and holds office as an Officer of Military Medical Service Prehospital Emergency Medicine, Resuscitation, Trauma Care
Professor Arnold J Suda Prof. Dr. med. univ. Arnold J. Suda (Austria) AUVA Trauma Center Salzburg, Austria Academic Teaching Hospital of Paracelsus Medical University · Department of Orthopaedics and Trauma Surgery.
Professor Wayne Morriss Dr Wayne Morriss is a practising anaesthesiologist in Christchurch, New Zealand. Dr Morriss is the current President of the World Federation of Societies of Anaesthesiologists and a member of the WFSA Board and Council. He served as Chair of the Education Committee from 2012-2016 and Director of Programmes from 2016-2020. Dr Morriss has been closely involved with the development and delivery of a range of educational programmes, including Essential Pain Management (EPM), Primary Trauma Care (PTC), Safer Anaesthesia From Education (SAFE), and the WFSA Fellowship Programme.
The anesthesia workforce: strengthening our most valuable resource - Prof Wayne Morris The World Federation of Societies of Anaesthesiologists (WFSA) is a unique global alliance of 135 societies representing anaesthesiologists in 150 countries. Our mission is to “unite and empower anaesthesiologists around the world to improve patient care”. We work with member societies to improve availability of anaesthesia, improve patient safety, and protect the wellbeing of anaesthesiologists (www.wfsahq.org). A healthy and well-educated anaesthesia workforce is essential for functioning health systems everywhere. Anaesthesiologists have multiple roles inside and outside the operating theatre and access to safe anaesthesia is a prerequisite for the World Health Organisation’s goal of Universal Health Coverage (UHC). Unfortunately, in many parts of the world, progress on UHC has been delayed or halted because of the COVID-19 pandemic. n 2015, the Lancet Commission on Global Surgery found that 5 billion out of the world’s 7 billion people do not have accessto safe anaesthesia and surgical care when needed.1 A key underlying factor is not enough well-trained anaesthesia professionals. The WFSA published a workforce survey in 2017 which showed massive deficiencies in the global workforce and marked differences between countries. The WFSA Workforce Map is available online (www.wfsahq.org/workforce-map) and now has information for 191 countries, representing over 99% of the world’s population. The map has been a valuable tool during workforce planning discussions and when advocating for increased resourcing for anaesthesia. We recently repeated the survey and updated workforce data will be published before the next World Congress in March 2024. Workforce quality is just as important as workforce quantity. We need to build a resilient, well-trained workforce and encourage our governments to adhere to the WHO-WFSA International Standards for a Safe Practice of Anesthesia.3 Workforce strengthening is underpinned by advocacy, education and working together. First, we need to continue to remind governments, colleagues and patients of our multiple vital roles in healthcare and argue for appropriate resourcing. Wellbeing issues must be addressed in order to build a stable, resilient workforce. Second, we need high-quality, context-appropriate educational programmes. It is vital that we support and train leaders and teachers – the people who will drive change. WFSA educational programmes (see www.wfsahq.org) include fellowships and short subspecialty courses, e.g. SAFE Obstetric Anaesthesia, SAFE Paediatric Anaesthesia, and Essential Pain Management. WFSA also provides a range of online resources that can be used for training and continuing education. Third, we can achieve a great deal by working together. The WFSA has recently introduced a mentorship programme. Conferences, such as the World Congress of Anaesthesiologists, also play an important role in building professional networks.
We will only achieve Universal Health Coverage if there is universal access to safe anaesthesia. Our workforce is our most valuable resource. He aha te mea nui o te ao? He tāngata, he tāngata, he tāngata. What is the most important thing in the world? It is the people, it is the people, it is the people. (Māori proverb) References 1. Meara JG, Leather AJM, Hagander L, et al. The Lancet Commissions Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569-624. 2. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The WFSA Global Anesthesia Workforce Survey. Anesth Analg. 2017;125(3):981-990 3. Gelb AW, Morriss WW, Johnson W, Merry AF. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) international standards for a safe practice of anesthesia. Anesth Analg. 2018;126(6):2047-2055
Dr Gowri De Zylva MD FCARCSI Dr Giowri de Zylva is a Consultant Neuroanaesthetist at King’s College Hospital, London, UK Academic qualifications: MD Anaesthesia Sri Lanka FCARCSI Special interests Functional Neurosurgery and Anaesthesia Anaesthesia for Neuro oncology surgery Awake craniotomy Publications Sri Lankan journal of anaesthesiology Anaesthetic consideration in epilepsy surgery Vol.19(1)2011,pp.53-56 Deep Brain Stimulator Insertion: Whatshould we know as anaesthetist? - Vol.24(1),pp.4-10. Educational Activities Dr Gowri was very much involved in teaching & training post graduate in Sri Lanka and was responsible for many of their MTI training programmes in the UK
Challenges for anaesthesiologist in neuro radiological interventions - Dr Giowri de Zylva The scope of interventional neuroradiology has expanded rapidly. Conditions which were previously untreatable or only amenable to open surgical techniques are now being considered for interventional radiological management. As the complexity and diversity of INR procedures increases, the demand for anesthesia also increases. Anesthesia for interventional neuroradiology is a challenge for the anesthesiologist due to the unfamiliar working environment which the anesthesiologist must consider, as well as the unique neurointerventional components.
Dr Tumul Chowdhury MD, DM, FRCPC Dr. Chowdhury is a Faculty anesthesiologist at Toronto Western Hospital, University of Toronto, Canada. He is currently Chair of the Neuroanesthesia Section of the Canadian Anesthesiologists' Society. He the co-program director of Neuroanesthesia Program at Toronto Western Hospital. He is an active researcher, clinician, educator and mentor. He has published more than 100 articles. He is an active reviewer for more than 20 journals, and also an editorial board member in Journal of Neuroanesthesiology and Critical Care, Official journal of ISNACC. He has edited two books and authored more than ten book chapters. His main research areas are brain-heart interactions, trigeminocardiac reflex, and anesthesia & brain cancer survival. He has received several grants. Internationally, he is an active member of various committees SNACC (clinical affair committee and trainee engagement committee), WFSA (constitution committee) and Brain-Heart Interactions Society (Secretary). Dr Chowdhury is the Editor-in-Chief of SNACC newsletter. He is a member of the Neuroanesthesia program relations committee of ICPNT and served as a reviewer of various Neuroanesthesia fellowship programs for ICPNT. He is the Board of Director, SNACC and also serves as the Director of Membership and Global Outreach Committee of SNACC.
Fatal love between brain and heart: A block buster story -Dr.Tumul Chowdhury Brain and heart interact in multiple ways, including neural, humoral, biochemical and mechanical. These connections are usually bi-directional. Majority of the research is focused on exploring the brain and heart axis. Some of those known interactions are stress, cardiomyopathy, stunned myocardium, hibernating myocardium and many other cardiogenic responses. Similarly, many brainstem reflexes have been shown to produce these interactions. One of such interactions is known as the trigeminocardic reflex (TCR). This phenomenon is incited by the stimulation of sensory branches of the trigeminal nerve. Common manifestations of TCR include bradycardia, asystole, respiratory perturbations, and G.I. changes. Sometimes the exaggerated form of this interaction can cause severe consequences during the surgery. Therefore, the knowledge of such phenomenon becomes crucial for all perioperative physicians.
Dr Bimal Kudavidanage He obtained MBBS and MD anaesthesiology with special interest in intensive care from University of Colombo, Sri Lanka. Currently working as the consultant anaesthetist and intensivist at the neurosurgical and epilepsy unit of the National Hospital of Sri Lanka. He has done many publications related to critical care and perioperative management. In addition to that many presentations at national and international forums. He is engaged in training post graduate trainees and an examiner for the post graduate examinations. He is an active member of the College of Anaesthesia and Intensive care in Sri Lanka organizing workshops and annual sessions.
Dr Victor Mendis MD. MD. FCARCS. FRCA. FFPMRCA Clinical Lead, Department of Pain Medicine, Mid and South Essex University Hospitals NHS Trust Consultant in Pain Medicine and Anaesthetics, Mid Essex NHS Trust Chairman, Training and Assessment Committee, Faculty of Pain Medicine, Royal College of Anaesthetists, UK Dr Mendis Graduated with a first class degree from the Vinnitsa Medical Academy in Ukraine in 1990 and Obtained an MD Anaesthesia in 1998 from the University of Colombo. He Completed his Specialist Training in Anaesthesia at Barts and The London Hospitals, obtaining the Certificate of Completion of Specialist Training (CCST) in 2005. During his training he undertook a year of Advanced Pain Training in London. He was appointed a Consultant in Pain Medicine and Anaesthetics at Mid Essex NHS Trust in 2005. He was elected as the Regional Adviser in Pain Medicine for London in 2010 and was elected chair of the Regional Adviser’s from 2017-2019. He has been an examiner of the Faculty of Pain Medicine(FPM) since 2014 and is currently the chair of the Training and Assessment Committee of the FPM. He was the recipient of the Bangladesh Friendship award from the Bangladesh Society for the Study of Pain in 2018 for his continued commitment to pain training in Bangladesh. He was a Principal Investigator for a Pan-European drug trial and has many publications to his credit.
Chronic Pain- It’s all in the Head -Dr Victor Mendis, MD, MD, FRCA, FFARCSI, FFPMRCA millions of people globally with a huge impact on the economy. Pain can be categorised as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitised nervous system), all of which affect work-up and treatment decisions at every level; however, in practice there is considerable overlap in the different types of pain mechanisms within and between patients, so many experts consider pain classification as a continuum. The mechanisms underlying chronic pain differ from those underlying acute pain. As pain persists, central nervous system factors play a more prominent role and therefore chronic pain states are understood to be centrally driven. These centrally driven pain conditions are characterised by widespread pain, non-restorative sleep, fatigue, memory problems and mood disorders. In these circumstances, pain is no longer protective. The pain in these situations arises spontaneously, can be elicited by normally innocuous stimuli, is exaggerated and prolonged in response to noxious stimuli, and spreads beyond the site of injury. Central sensitization has provided a mechanistic explanation for many of the temporal, spatial, and threshold changes in pain sensibility in acute and chronic clinical pain settings and has highlighted the fundamental contribution of changes in the CNS to the generation of abnormal pain sensitivity. Chronic pain is complex and many clinicians and patients lack an understanding of treatment options. Some rely on medications alone, and others on the use of costly interventions, despite a limited evidence and this may be spurred by aggressive industry and marketing. Proper access to multidisciplinary services such as physiotherapy and psychology should be in the forefront of managing patients with chronic pain. References Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009 Sep;10(9):895-926. doi: 10.1016/j.jpain.2009.06.012. PMID: 19712899; PMCID: PMC2750819. Phillips K, Clauw DJ. Central pain mechanisms in chronic pain states--maybe it is all in their head. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):141-54. doi: 10.1016/j.berh.2011.02.005. PMID: 22094191; PMCID: PMC3220875. Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021 May 29;397(10289):2082-2097. doi: 10.1016/S0140-6736(21)00393-7. PMID: 34062143. Rethinking chronic pain. Lancet. 2021 May 29;397(10289):2023. doi: 10.1016/S0140-6736(21)01194-6. PMID: 34062132. Chronic Pain is a distressing experience with sensory, emotional,social and cognitive components and affects
Dr S R Thanthulage MD, FRCA, FFPMRCA, FIPP Dr Thanthulage has been a consultant in Pain Medicine and Anaesthetics at Broomfield hospital, UK, since March 2009. He is the local pain medicine educational supervisor at the Broomfield hospital. He graduated as a doctor in 1993 from Rostov State medical institute Russia. He trained at The University Hospital in Colombo and obtained an MD in Anaesthesia in 2001. He completed specialist training in anaesthetics and Fellowship in pain management at Bart’s and The London School of Anaesthesia. He obtained the Fellowship of Interventional Pain Practice in 2009 by examination. Main NHS Hospital Broomfield Hospital, Chelmsford, ESSEX, CM1 7ET, http://essexpainspecialist.com
Vitamin D supplements in Chronic pain management -Dr S R Thanthulage Physicians at The Royal Brompton hospital used Cod liver oil to arrest the progression of tuberculosis in 1848. In the early 19th century, rickets was a common condition in many children. In 1922, the antirachitic factor in cod liver oil was confirmed as Vitamin D. We know now vitamin D is a major steroid hormone essential to overall well-being, and serum vitamin D concentrations are associated with many health conditions. Most of these associations are reported by observational studies, and there is no agreement on the exact supplement dose or the blood concentrations that prevent diseases. Chronic pain is a continuous process that may not necessarily have a confirmed pathological or anatomical diagnosis. However, the long-term lack of vitamin D is one of the known associations with chronic pain. This vital hormone involves many physiological functions besides known effects on calcium metabolism, and it should be one piece of the puzzle needed to help patients with chronic pain. The commonest hesitance among physicians to recommend vitamin D is due to the risk of hypercalcemia and developing kidney stones. Numerous lifestyle factors are involved in developing hypercalcemia and kidney stones; therefore, we should encourage lifestyle adjustment while advising regular vitamin D intake or healthy sunbathing.
Dr. Amal Indika Withanage M.B.B.S; M.D Anesthesiology Advanced life support instructor, European resuscitation council Consultant anaesthetist with special interest in critical care Dr. Amal Indika Withanage has served as consultant anesthetist for 11 years. He commenced his carrier as a consultant form District General Hospital, Monaragala, where he got actively involved in ALS training for medical and nursing officers. Later he was selected as an instructor to European resuscitation council (ERC). During his tenure at the Provincial General Hospital (PGH), Badulla, he commissioned the simulation center, and conducted regular Intermediate life support (ILS) training programs. Later, he continued his training activities at Teaching Hospital (TH) Kegalle and TH Ratnapura. He restructured the ALS programme at TH Ratnapura following the ERC simulation teaching methodology. With a group of medical and engineering professionals, Dr Vithana, developed a low cost rhythm generator. It has more options of operation when compared to existing products. He has also contributed to ICU developments at PGH Badulla and TH Ratnapura. He had been playing key role at opening the 3rd ICU which was named as COVID ICU by that time. He is interests are in development and incorporating IT knowledge to patient management and ALS teaching.
Challenge the crisis- Value added ECG rhythm generator - Dr. Amal Indika Withanage Generation of different ECG rhythms is an essential requirement in simulated teaching. Currently designed rhythm generators are expensive, either manually operated with visible wires or fixed inside manikins to work wirelessly. It can be designed to operate wireless, either to place inside or outside of manikin. With mobile phone installed commanding software, it gives more selection of ECG waves and sequence of events. User friendly software keeps instructor at ease, retaining attention at other teaching targets. It had marked acceptance by ALS instructors. More effective, less costly rhythm generator is expected to expand the ALS teaching width, depth and chances.
Dr. J. M. Ramitha Jayasundara MBBS, MD Anaesthesiology Dr Ramitha Jayasundara presently serves as a consultant anaesthetist with special interest in Intensive care at the District General Hospital at Monaragala, Sri Lanka. In addition to his clinical duties he is also attending to the administrative activities of the hospital as an acting Director to the Hospital. Academic qualifications Board certified Consultant Anaesthetist with special interest in Intensive care MD Anaesthesiology Professional activities Regional representative of Uva province of the COAISL Member of the Patient safety and quality improvement committee of the COAISL Special academic interest Teaching, administration and quality improvement Project of extensive caring of ICU patients’ relatives at ICU DGH- Monaragala in May 2020 Innovation of locally made patient transfer boards and sheets for the first time in Sri Lanka in April 2021 Actively contributed to the innovation of first ever adjustable rehabilitation chair in Sri Lanka April- May 2021 Project of construction of proper rest rooms for theatre staff in March-May 2021 Project of “perioperative caring of patients’ relatives” for the first time in Sri Lanka 2021-2022
Perioperative Family care –Beyond conventional anaesthetist: Project of Perioperative caring of patients’ relatives - Dr Jayasundara JMR 1 , Sujeewa JA 2 1 Consultant anaesthetist, District general hospital-Monaragala, Sri Lanka 2 Chief special grade nursing officer, District general hospital-Monaragala, Sri Lanka An operation is a major occurrence in a person’s life and is often accompanied by fear, distress and lack of hope, which can lead to physical and emotional exhaustion of the patient as well as the relatives. Patients’ relatives need to adapt to various problems of patients in order to provide effective physical, psychological and emotional support. Family centered care is an approach for planning and delivering health care based on partnerships among patients, families, healthcare providers and hospitals. Most of the western countries move towards family centered care targeting better outcome. However, there is no universal model orsystem to address the concerns of patients' relatives particularly during perioperative period. This project was designed to improve family and patients’ satisfaction during the perioperative period and enhance the recovery of patients by active participation of relatives. The project was consisted of development of infrastructure and landscaping to conduct interactive sessions with patients’ relatives on weekdays, while providing physical and psychological support. Hence bridging communication gap between patients’ relatives and healthcare providers in the district general hospital Monaragala situated in one of the most rural districts in Sri Lanka. Moreover, this was the first project focusing mainly on role of anaesthesia and anaesthetists during perioperative period in Sri Lanka. It happened to overcome a unique set of obstacles including allocating funds, developing infrastructure and landscaping, designing an attractive programme and improving awareness due to unfamiliar nature to the most, amidst covid pandemic and economic crisis.
Professor Dileep De Silva BDS(Peradeniya), MSc (Colombo), MBA (Colombo), MD -Com Dent (Colombo), PhD-Health Management (UK), AIB (Sri Lanka), FCMA(UK), FRSPH(UK), FDS RCPS(Glasgow) Dileep De Silva is the Chair Professor of Community Dentistry at the Faculty of Dental Sciences, University of Peradeniya. By profession he is a Chartered Banker, Cost & Management Accountant and a Specialist in Health Finance and Health HR. He holds BDS(Peradeniya), MSc (Colombo), MBA (Colombo), MD -Com Dent (Colombo), PhD-Health Management (UK), AIB (Sri Lanka), FCMA(UK), FRSPH(UK), FDS RCPS(Glasgow) Being a National Apex Award winner, he has had 25 years of working experience in the Ministry of Health, before joining the University. He was the National Focal point for Health Accounts and Health HR in the Ministry of Health.
Economic Crisis and Health: Sri Lankan scenario - Professor Dileep De Silva Sri Lanka had a limited fiscal space to enhance its health expenditure even before COVID pandemic and economic crisis.Overthe yearstotal health care expenditure was about 3.5% of GDP while the government’s contribution was around 2%. Moreover, out of the government budget only 8% was spent on health. However, Sri Lanka has achieved strong health outcomes over and above what is commensurate with its income and health expenditure levels Following the ongoing economic crisis in Sri Lanka, World Bank and International Monetary Fund are negotiating relief packages and these could include cost-cutting measures and restricting the services, while increasing the government income. These strategies could adversely impact a health system that has an outstanding record of achievements, achieved by providing free health care for all through the robust State Heath system. Given the above context; this lecture will give a bird’s eye view on Health care settings Health HR issues Rising out of pocket expenditure Over reliance on laboratory investigations. Development of appropriate cost-effective protocols: day surgeries Strengthening primary health-care services and an appropriate referral system
Dr Mike Swart MB BS, FRCA, EDICM, FICM Dr Mike Swart MB BS, FRCA, EDICM, FICM Consultant in Anaesthesia, Intensive and Perioperative Medicine: Torbay Hospital, Torquay, Devon. Joint National GIRFT (Getting it Right First Time) Clinical Lead for Anaesthesia and Perioperative Medicine. Royal College of Anaesthetists (London) College Council member. Previously advisor on Anaesthesia for the NHS Enhanced Recovery Programme and Royal College of Anaesthetists joint Clinical Lead for Perioperative Medicine. Clinical interests: Shared Decision Making with patients considering high risk surgery, Cardiopulmonary Exercise Testing (CPET), Enhanced Care (Level 1.5 postoperative care), Global Health and Perioperative Medicine. [email protected] [email protected] telephone for WhatsApp +44 7595 251532
GIRFT – Getting it Right First Time – Recommendations for day surgery - Dr Mike Swart Getting It Right First Time (GIRFT) is a national programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking, and presenting a data-driven evidence base to support change. The programme undertakes clinically-led reviews of specialties, combining wide-ranging data analysis with the input and professional knowledge of senior clinicians to examine how things are currently being done and how they could be improved. GIRFT is part of an aligned set of programmes within NHS England. The programme has the backing of the Royal Colleges and professional associations. https://gettingitrightfirsttime.co.uk GIRFT started with orthopaedic surgery in England in 2012 and then expanded into 25 medical specialties and 15 surgical specialties. Chris Snowden from Newcastle and myself were appointed GIRFT National Clinical Leads for Anaesthesia and Perioperative Medicine in 2018. We managed to visit over half the NHS England hospitals or Trusts that managed more than one hospital (74 out of 140) when Covid 19 hit the UK in early 2020. At these visits we had data on day surgery rates, length of stay and readmissions after surgery. In addition the hospitals filled in a questionnaire on their anaesthetic and perioperative practice. We then published a report on Perioperative Medicine based on these visits in 2020. The report looked at three pathways: Day Surgery, In Patient Elective Surgery and Emergency Surgery. https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/09/APOM-Sept21i.pdf During Covid it soon became clear there would be a huge backlog of patient awaiting elective surgery. GIRFT started to work on promoting the concept of high volume low complexity surgery procedures that could be operated on as day cases. Our expectation from the national data on day surgery rates and high performing hospitals 80-85% of elective surgery could be on a day case pathway. To help improve high quality day surgery we joined up with the British Association of Day Surgery (BADS) and the Centre for Perioperative Care (CPOC) to produce a day surgery best practice guide. https://bads.co.uk https://cpoc.org.uk https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2020/10/National-Day-Surgery-DeliveryPack_Sept2020_final.pdf https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2020/09/NDSDP_appendices_final.pdf In 2023 we are restarting our hospital visits virtually with new outcome data on day surgery rates and readmissions.
Dr Nicholas Levy MBBS FRCA Dr Nicholas graduated from the Royal Free Hospital in 1993 and undertook anaesthetic training in the Central London School of Anaesthesia. In 2003, he was appointed as a Consultant Anaesthetist at the West Suffolk Hospital. As a medical student, and then as a trainee, Nicholas saw that the surgical patient with diabetes was exposed to unnecessary surgical harms. He then joined forces with other likeminded individuals and co- created the pathway that promotes modification of diabetes medication. This then facilitates shorter length of stay, day surgery, and less iatrogenic complications. He has subsequently been involved in co-authoring every national guideline about perioperative management of diabetes. Consequently, he was asked to be the lead anaesthetist for the official UK national guidance that was published in March 2021. More recently he co-led the guidelines for the peripartum management of diabetes
What is new and why? Perioperative care in Diabetes Perioperative management of the surgical patient with diabetes - Dr Nicholas Levy Diabetes is the most common metabolic disorder. In the UK about 6-7% of the population have diabetes. However, since obesity levels are rising and obesity is both a risk factor for T2 DM and other conditions, about 20% of the UK surgical population have diabetes. In Sri Lanka the prevalence in the community is about 10%, and it can only be assumed that the prevalence of diabetes in the surgical population is at least 20%. The surgical patient with diabetes is at higher risk of morbidity and mortality and has longer length of hospital stays. Modern techniques can now reduce this. In 2011, the first national UK guidance on the perioperative of diabetes was published. This adopted the Enhanced recovery after Surgery (ERAS) principle of having a care pathway. Essentially, this principle has led to surgical patients with diabetes having two care pathways that run in parallel. One for the surgical condition, and the other for the medical condition. This concept is now being replicated for surgical patients with other co-morbidity. eg anaemia and frailty. The critical component is the preoperative clinic. The preoperative clinic is vital for two main reasons. Firstly, for identifying patients that should have their diabetes optimised before surgery, and secondly for counselling patients who are deemed fit for surgery on how to manage their diabetes medication preoperatively. Perioperative manipulation of diabetes medication often obliterates the need for intravenous insulin infusions, and the harms associated with them, and means that patients with diabetes are no longer denied day surgery/ ambulatory surgery. This has major benefits for the patient, the patient’s control of diabetes, and the wider healthcare economy. The management of the surgical patient can be improved further by preventing harm from Hypoglycaemia Hyperglycaemia Hospital acquired diabetic ketoacidosis Drug administration and prescription errors Learning objectives Diabetes is the most common metabolic disorder Diabetes is a modifiable risk factor for perioperative morbidity and mortality Harm can be mitigated by preventing the following: o Hypoglycaemia o Hyperglycaemia o Hospital acquired diabetic ketoacidosis o Drug administration and prescription errors Day surgery facilitates prevention of harm The VRIII is associated with harm, and when possible, diabetes should be managed by manipulation of pre-existing medication. References Barker P, Creasey PE, Dhatariya K, Levy N, Lipp A, Nathanson MH, Penfold N, Watson B, Woodcock T. Peri‐operative management of the surgical patient with diabetes 2015. Anaesthesia. 2015;70:1427-40. Centre for perioperative care (CPOC). Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery. Updated December 2022. Available from https://cpoc.org.uk/sites/cpoc/files/documents/2022-12/CPOC-DiabetesGuideline-Updated2022.pdf
Professor Simon Howell Professor Simon Howell is a clinical academic in the University of Leeds. He is the Lead of the Division of Gastroenterology and Surgical Sciences in the University of Leeds. He is an Editorial Board Member of the British Journal of Anaesthesia and a past Chairman of the Vascular Anaesthesia Society. He is an applicant or co-applicant on active research grants totaling over £3 million. His current research interests include perioperative myocardial injury, frailty in the surgical patient, and the perioperative management of the patient with diabetes.
Blood Pressure-What is the Target- Why? - Prof Simon Howell Hypertension is one of the most important treatable causes for population morbidity and mortality. The aim of chronic blood pressure management is life-time cardiovascular risk reduction whilst the concern of the anaesthetist is perioperative blood pressure management. However, hypertension guidelines set the context for the perioperative management of blood pressure. Historically elective surgery in patients with poorly controlled blood pressure has been postponed. There is little evidence to suggest that lowering blood pressure preoperatively reduces risk. In 2019 the international Perioperative Quality Consensus multidisciplinary working group published a set of consensus statements and recommendations on preoperative blood pressure. These suggest that there is no evidence to identify a specific blood pressure value above which would alter the decision whether to proceed with surgery. Preoperative low-blood pressure may be more of a concern. Observational data suggest a significant association between preoperative hypotension and increased mortality in patients aged over 65 years. Recent publications emphasis the importance of avoiding intraoperative hypotension but there is no universal consensus on thresholds to guide blood pressure management. A pragmatic approach isto maintain a systolic arterial pressure of over 100 mmHg and a mean arterial pressure over 60 mmHg. Preoperative blood pressure may also be used to guide intraoperative blood pressure management targeting intraoperative blood pressures of 10% or 20% of baseline. In summary, there is there is clear evidence of an association between intraoperative hypotension and adverse outcome but little data to demonstrate that specific strategies or targets for the management of intraoperative blood pressure improve outcome. The anaesthetist is therefore constrained avoid intraoperative hypotension but manage individual patients on a case-by-case basis.