1. THE FUTURE OF ANAESTHESIA PRACTICE IN THE NEXT DECADES Dr. B. RADHAKRISHNAN, Director & Principal Director & Principal Academy of Medical sciences, Pariyaram, Kannur, Kerala.

2. Anaesthesiology - 1846 Philosophy-Practice Astrology-Prediction Biotechnology Computer Technology

3. We may extinct or We may dominate

4. WTG MORTON-1846 Ether Days Mystery Discovery of Relaxants Developments in to subspecialties

5. STORY I LIKE TO READ How Anaesthesia progressed - status and promotion in India. Travelling through Indian growth - pit falls – Possible cure

6. Growth of ISA in India – reflections of the past - Developments in India – largest democracy - ISA and Anaesthesia service in India Silver Jubilee (72 / 75) Golden Jubilee (97 / 02) Diamond Jubilee (07) 1956 – WFSA 1976 – AARS 1991 – SACA ISA – City / State / Regional Zones Formative years – Conference – CME (1981) – WFSA – Educational programmes Indian Journal of Anaesthesia Change of name – ISA Flag – Emblem (1969) control of society

7. EARLIER DAYS – 1846 AND AROUND UKVsUSA ChloroformVsEther a)Is Anaesthesiology a Medical Specialty? b)If put on professional category, would there be adequate practioners Margin of safety of Chloroform and Ether – Practice difference in UK Vs USA

8. UK developments in Anaesthesia starts early (Snows Anaesthesia research starts in 1847) Snow – Clovor – Hewitt – London Society of Anaesthesiologists (LSA)

9. GREAT EVENTS IN UK – RESPECTABILITY TO THE SPECIALTY Queen Victoria – Prince Leopold – Simpson Napoleon – III- Clover Edward – VIII- Hewitt Develops as individual specialty

10. USA - ATTITUDES TO ANESTHESIA Learning to do by doing Any one was welcome Step child of medical profession Non Medical personals Organizational development till 1915 – was erratic Brooklyn Society New York Society IARS

11. 1970s – (40 Years ago) Ether, Trilene, Ethyl Chloride, Halothane Gallamine, Curaree, Suxamethaonium, Morphine – Pethidine – Analgesics Controlled mandatory ventilation Lignocaine, Bupivaccaine ECG Monitor, Sphygmomanometer, Visual assement

12. 1970s – (40 Years ago) Fasting protocol- Most cruel Postoperative pain relief– SOS Fluids – Sugar/ Salt solution Red rubber tubes – Steel needle – IV canuala ??. Non disposable rubber tubes + clamps Seemed Comfortable – acceptability in Progress

13. 1990s – (20 Years ago) New drugs – Propofol New relaxants – Vecrunonium, Atracurium Isoflrane – Sevoflurane – Desflurane Synthetic Narcotics – Fentanyl

14. Eid Tidal Monitors Lignocaine makes slow exit – Bupivaccaine Electronic Circuts Analgesic Delivery – PCA Pulse Oxymeter, PAP, Capnography Laparoscopic Techniques CT/MRI LMA

15. 2010 – WHERE I AM Dramatic Changes Care giver/ quality in practice Fast track gets settled. Inhalational agents – Sevoflurane, Cycloflurone Newer analgesics – Infusion devices Analgesic Pharmaco kinetics tied to computerized delivery.

16. 2010 – WHERE I AM EEG – Bispectral index (BIS) - EGADS (EEG Guided Anaesthesia delivery System.

17. CURRENT CHANGING SCENARIO 1.Awake intubation No longer street fight/ mandatory preparation Fibre Optic intubation Blind Nasal – Extreme Situtaion Torture – Not permitted – Criminal

18. CURRENT CHANGING SCENARIO 2. Cuff Pressure Saline Cuff Lignocaine Cuff Cuff pressure in adults Cuff in Paediatrics

19. CURRENT CHANGING SCENARIO 3. Line Flushing Over flushing/ Manual flushing Retro grade embolisation of air Saline Volume Continuous flush device RA to SA (6 Cm/3-12 Cm)

20. CURRENT CHANGING SCENARIO 4. Consent Informed Consent – Pre-Op Examination Investigations /consent over telephone Viacarious liabilities – Consent in different situation

21. CURRENT CHANGING SCENARIO Target organ Protection Protect Kidney not urine output. Metabolic Acidosis Treat lactose acidosis – but not with bicarbonate. Damage Control Surgery Damage Control Anaesthesia

22. CURRENT CHANGING SCENARIO Non Technical Skills Improvement for Anesthesiology (NOTECHS) (ANTS-System Hand Book) (University of Aberdeen) Team Work Leadership Professional Behavior Human Performance Cognitive Evaluation in Post operative phase CQM - CQI

23. THE WITNESSED SCENARIO CHANGE – CURRENT GOOD ANAESTHESIA PRACTICE Two tracks of anaesthesia practice - Slow X Fast Extension of service to perioperative care- and perioperative medicine/physician Development of pain management service Post operative pain/ acute pain and chronic pain management fasting protocol.

24. Blood-Blood products Artificial blood – replacement of human blood, genetic engineering (Crocodile blood/ bacteria E-Coli) Xeno transplantation PONV – Prophylaxis Gene Therapy and Brain repair Monitors – Forgiving drugs – Newer Anaesthesia delivery apparatus.

25. MONITORED ANAESTHESIA CARE (SURGERY UNDER SEDATION (SURGERY UNDER SEDATION) (Narcotic Sedation/ Anxiolytic Sedation/ Tranquillizer Sedation/ Anti histamine sedation)

26. MAC – Sedative + Anxiolytic + Analgesic 1985 (Mostly Apnoeic, Cyanotic) MAC in 2000 Midazolam + Alfentanil + Conversation MAC in 2010 (Madam are you comfortable?)

27. FUTURE OF ANESTHESIA AND ANAESTHESIA PRACTICE A) EXTINCT B) DOMINANT

28. PRACTICE OF FUTURE EXTINCT -Non-medical Assistants -(Short term course – Promotion) -Promotion by our own tribe -No Anaesthesiologists in Operating Rooms -Anaesthesia will be remotely controlled -ICUs will be managed by Pulmonary Physician -Blood will be synthetic -No blood Bank

29. PRACTICE OF FUTURE DOMINANT Acute care beds Surgery – Trauma Conventional surgery Pain Management-Aggressive Anaesthesia – Administered and monitored by Computers. Endotracheal intubation - Robots Regional Anaesthesia – Change in application

30. PRACTICE OF FUTURE DOMINANT Simulators in conduct Newer drugs- Target pointed Blood transfusion Anaesthesia residency programme Anaesthesia Machines – Speaking machines Intellectual base/ linking/ foundation/ care givers Overall developments of medicine Sharing of information

31. PLANNING THE FUTURE OF ANAESTHESIOLOGY (Dr. Longnecker/ David. E – University of Pennsylvania) Chill winds of competition – Survival Socio economic situation Changing policies and will power/ Politics Awareness and consumer demand Scaling of service Demand and supply of Physician +- future man power need.

32. PLANNING THE FUTURE OF ANAESTHESIOLOGY (Dr. Longnecker/ David. E – University of Pennsylvania) Credentialing for systems and Practioners Visionary departments Quality based globally acceptable medical education – affordable and acceptable

33. The future of Anaesthesia – Global Until 1940s – developments Discovery of muscle relaxants Future depends on Social awareness / Social needs / Cost bearing Changes – fast track / slow track – (conventional) Developments Emergence of artificial blood/ gene therapy / new drugs (SAFE) / biotechnological changes Anaesthesia machines - remote control / voice control / smart machines Acute care beds Robotic interventions / Regional / Requirement of anaesthetists? / Future monitors – smart monitors Documentation –EHR- leasing Patient safety – prime concern

34. Future of our tribe in India Have we progressed? How far? 30000/ 14500 Innovation / islands of progress General quality / progress? Practice controllers Medical Council of India - Academic National Board of Examinations - Academic Government of India - Snails Pace- quality Professional Organizations - Quality in education Teachers and Trainers Predict possibility Reorganization of teaching Remodeling of practice Quality implementation Standardization – Mistakes of the past ISA – Organisational pride Non -aggressive Saints of Medicine

35. THE FUTURE Future depends on how far practice of Anaesthesia kept in hands of Anaesthesiologist -

36. Acceptability and respectability will be ensured when average Anaesthesia Practitioner shows he/she is a) Understand pathogenesis and possible haemodynamics in any situation, may be able to explain the same b) Sufficiently skilled in conduct of anaesthesia whether GA/RA/MAC

37. c) Adequate understanding to interpret monitor datas and run intensive care situations

38. THANK YOU BEST OF LUCK