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

2. Historical facts Present situation Education and trainig The future

3. VILNIUS

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

5. William Stewart Halsted, 1852-1922 “The advent of anaesthesia has made it so that any idiot can become a surgeon”

6. 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

7. 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

8. 1991 – Lithuanian Society of Anaesthesiology and Intensive care joined WFSA 1994 – Pain Clinic

9. Hospitals in Lithuania - 2004 80 hospitals Kaunas Medical University Clinics Vilnius University Hospital Santariškių Clinics

10. Number of Departments in Lithuania - 2004 Anaesthesia departments  Intensive care departments 7679 80 hospitals

11. Number of Anaesthesias - 2004 Total number – 2 10 000 General anaesthesia – 147 000 (70 %) Regional and local anaesthesia – 63 000 (30 %)

12. Development of anaesthesiology and intensive care in Lithuania was close related with Vilnius University Faculty of Medicine Kaunas Medical University

13. 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.

14. Development of Anaesthesiology and Intensive Care in Kaunas Medical University Number of anaesthesias – 34 650, 9 030 ICU pts.

15. 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 work

16. 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

17. 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

18. Training of Anaesthesiologists Until 2003 – 1 year of internship, 3 years of residency Now – 1 year of internship, 4 years of residency

19. 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

20. Residency Program – 176 credits SubjectCredits General anaesthesia and pain treatment40 Anaesthesia for abdominal surgery12 Anaesthesia for neurosurgery8 Anaesthesia for thoracic surgery8 Anaesthesia for orthopedic surgery and trauma8 Anaesthesia in obstetrics8 Anaesthesia for pediatric surgery8 Anaesthesia for vascular surgery8 Anaesthesia for odontology and surgery4 Anaesthesia for urological surgery4 Anaesthesia for cardiac surgery8 Total for anaesthesiology116 Treatment of acute and chronic pain8 Electives8

21. Residency Program – 176 credits SubjectCredits Resuscitation and basics of intensive care16 Intensive care in abdominal surgery16 Neonatal and pediatric intensive care4 Intensive care after cardiac surgery4 Intensive care in cardiology2 Intensive care in toxicology2 Total for intensive care44

22. Residency Program Procedures Anaesthesiology Procedures Minimum number of procedures Lithuania Recommended UEMS General anaesthesia500 Spinal anaesthesia50 Epidural anesthesia50 Nerve and plexus blocks20 Total number of anaesthesias 12001500

23. Residency Program Procedures - Anaesthesiology Procedures Minimum number of procedures Lithuania Recommended UEMS Pediatric patients, age < 5 years30 Pediatric patients, age < 1year10 Obstetrics, S.Caesarea10 Epidural for delivery10 Thoracic1615 Neurosurgery15 Urology10 Odontology, head and neck surgery15 Orthopaedic endoprostheses15 Day case surgery30 Vascular10

24. Residency Program Procedures - Intensive Care Procedures Minimum number of procedures Lithuania Recommended UEMS Minimum number pf patients in ICU50 Pediatric patients, age < 5 years33 Pediatric patients, age < 1year22 Respiratory disorder33 Cardiovascular disorder102 CNS problems22 Sepsis42 Renal failure41 Transport of critically ill patients55 Resuscitation55

25. Residency Program Procedures - Pain Treatment Procedures Minimum number of procedures Lithuania Recommended UEMS Minimum number of patients in pain treatment 50 Pediatric patients55 Major surgery10 Thoracic surgery55 Major orthopedic surgery55 Day-case surgery10 Chronic pain20

26. 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.

27. 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.

28. 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

29. Lithuania 10-11 May, 2003 Referendum about the membership in European Union 64 % came to vote. 90 % said yes.

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

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

32. Lithuanian Statistics - Number of Physicians Country Number of physicians per 100 000 population Lithuania390 European Union 340 UK250 2 nd Baltic Conference of Health Care Policy, September 30 th, 2005 2005

33. Lithuanian Statistics - Number of Physicians in Lithuania Country Number of physicians per 100 000 population Lithuania313 2 nd Baltic Conference of Health Care Policy September 30 th, 2005 2015 Shortage of physicians - 1000

34. Lithuania, Reasons of Shortage of Physicians in Lithuania, 2015 2 nd Baltic Conference of Health Care Policy September 30 th, 2005 Emigration Age Other reasons Critical areas: Anaesthesiology and intensive care Gynecology, obstetrics Ophthalmology

35. 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

36. Licensed Anaesthesiologists in Lithuania 2 nd Baltic Conference of Health Care Policy, September 30 th, 2005 Number of anaesthesiologists age > 60 years – 10 % 10 % have applied for references from Lithuanian Health Care Ministry that are required in EU countries

37. 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”.

38. Inhalation Anaesthesia Agents 29% 12 % 28 % 31 %

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

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

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

46. Local Anaesthethics 16 % 37 % 47 %

47. Anaesthesia Machines  Less than 10 years 57%

48. Anaesthesia Machines  More than 10 years 43%

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

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

51. 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

52. 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

53. Health Expenditures as % of GDP (2004)

54. 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

55. 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

56. Number of ICU Patients - 2004 Number of patients in the ICU 74 200 Mortality in the ICU 6,4 %

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

58. Valuation for ICU Service in Lithuania LevelHoursCost EUR I - I (recovery room) 24 hours60,40 I - II (primary ICU) 48 hours88,44 II level3 days601,73 III level4 days989,88 III-3 level20 days1 day – 354,05