DOES MEDICINE NEED ACADEMIC ANESTHESIOLOGY? Colin J.L. McCartney MBChB PhD FRCA FCARCSI FRCPC Professor and Chair, Department of Anesthesiology University of Ottawa
1. Colin J.L. McCartney MBChB PhD FRCA FCARCSI FRCPC Professor
and Chair, Department of Anesthesiology University of Ottawa
2. Describe three key medical advances made by
anesthesiologists Discuss advances in regional anesthesia and pain
medicine in the last ten years Highlight key areas where uOttawa
anesthesiologists can advance medical practice in the next ten
years
3. Anesthetists have made major contributions to medicine in
the last 150 years Many surgical advances related to advances in
anesthesia 230 million major surgical procedures worldwide each
year Perioperative morbidity and mortality remains unacceptably
high Chronic pain after surgery in 10-50% of individuals Many known
beneficial treatments remain underutilized Lots of work to be
done!
4. Miller RD 2009: Rovenstine lecture
5. Science of anesthesia: John Snow, ether and father of
epidemiology Neuromuscular blockade: Harold Griffith
Multidisciplinary pain clinics: John Bonica
6. BMJ 2007: 11300 readers polled on most important medical
advance since 1840
7. BMJ 2007: 11300 readers polled on most important medical
advance since 1840 Anaesthesia ranked as 3rd most important John
Snow (1813-1858): British physician and anaesthetist. Father of
epidemiology.
8. Developed scientific basis of anesthesia Anaesthetist to
Queen Victoria for last two children First epidemiologist Cholera
and the Broad Street pump Rickets
9. Harold Griffith 1894-1985 MD, McGill University 1922 Chief
of Anesthesia, Montreal Homeopathic Hospital 1923 Recruited by
Frank McMechan,Wesley Bourne and Ralph Waters and IARS to help
advance anesthesia Innovator of tracheal intubation (34FG urinary
catheters!) First used Curare for muscle relaxation in anesthesia
in 1942 with resident, Dr Enid Johnston Mentor of Dr. J.
EarlWynands
10. CMAJ February 1944
11. John J. Bonica 1917-1994 Understood the multidimensional
biopsychosocial nature of pain Authored or edited 41 books
Published 274 scientific articles
12. Descartes 1645
13. John J. Bonica 1917-1994 Understood the multidimensional
biopsychosocial nature of pain Developed the first
multidisciplinary pain clinic at University ofWashington in 1961
Organized first international pain symposium in 1973 and helped to
develop IASP
14. AKA Johnny BullWalker Light heavyweight champion of Canada
in 1939 and world champion for six months in 1941
15. Virginia Apgar Neonatal resuscitation Peter Safar
Resuscitation JW Severinghaus Blood-gas analysis John Lundy
Transfusion Medicine John Bonica Pain Management
16. Use of PNBs: Improvements in ambulatory anesthesia
Ultrasound: Improved efficacy and less complications Perioperative
outcomes research: evidence of changes in morbidity and
mortality
17. Orebaugh SL et al RAPM 2012
18. RDBCT 40 patients USG ISB Posterior approach 5 vs 20 ml
0.5% ropivacaine Standard GA Primary endpoint: Phrenic block at 30
min Secondary: Postop pain, Oxygen saturation, spirometry
19. 0% 20% 40% 60% 80% 100% Diaphragmatic paralysis 30 min post
block Diaphragmatic paralysis 60 min post surgery 95.8% 91.7%
20. 0 1 2 3 4 5 6 7 8 30 min post surgery 60 min post surgery
120 min post surgery 12 hrs post surgery 24 hrs post surgery Pain
score
21. Group 1: Low volume (5ml) Group 2: High volume (20ml)
Adverse Outcomes 0/20 8/20 Horners syndrome: 3 Hoarseness:3 Severe
respiratory distress:1 Persistent hiccups:1
22. BMJ 2000
23. Reduced postoperative pain, opioid consumption, adverse
effects No difference in blood loss orTE events No difference in
mortality
24. 400 hospitals between 2006-10 Data from primary hip/knee
arthroplasty Subgrouped by anesthetic technique 30 day morbidity
and mortality data Anesthesiology 2013
25. 382,000 patients 25% neuraxial Neuraxial associated with
less mortality, length of stay, in-patient morbidity Anesthesiology
2013
26. Faster discharge due to better pain control and less side
effects Safer more effective techniques with ultrasound Emerging
evidence of morbidity and mortality benefits of neuraxial
techniques for major joint arthroplasty
27. Faster discharge but significant pain at home Ultrasound
beneficial but training lags evidence Emerging evidence of
morbidity and mortality benefits of neuraxial techniques for major
joint arthroplasty but only 25% patients receive benefit
28. Medical education scholarship: more effective training
throughout medical careers Perioperative medicine: bench to bedside
Pain Medicine: training and research
29. Stem cell therapy299 CJA 2014; 61: 299-305
30. Potential uses of MSC therapy: Ventilator induced lung
injury Pulmonary hypertension Infectious acute lung injury Sepsis
Trauma Burn injury Lalu M et al 2014
31. Prediction and prevention of perioperative morbidity and
mortality Optimizing functional outcome Prevention and reduction of
chronic pain after surgery
32. Pearse RM et al Lancet 2012
33. CPET can help predict outcome after major colonic
surgery
34. 198 patients having major colonic surgery CPET variables
are associated with postoperative morbidity Prehabilitation,
consideration of alternative approaches and modified perioperative
management may alter risk
35. Much research to be done in pain medicine Mechanisms Which
treatment and when? Translation of knowledge to practice Transition
from acute to chronic pain Classification of chronic pain
Neuropathic pain
36. Chronic pain remains a major societal issue Huge under
provision of chronic pain services Only 12-14 specialty fellowship
training positions available annually across Canada Fragmentation
of care and approaches to care Lack of knowledge translation Opioid
addiction and opiophobia are barriers to good pain management
37. Pain Medicine now a recognized subspecialty program at
Royal College Anesthesia is primary parent specialty Specialty
committee predominantly anesthesiologists (analogous to UK and
Australia) Dr. Catherine Smyth MD PhD has been a leader in this
initiative
38. Anesthesia and anesthesiologists have led key advances in
medicine in the last 150 years Many questions remain that may have
huge impact on the way we teach and practice medicine in the future
Anesthesiologists are keen to collaborate with colleagues to answer
these questions and improve care for patients locally, nationally
and internationally
39. A discipline not continually engaged in an active and
imaginative program of research is dead, and will not advance, and
will probably deteriorate in general standards and efficiency. Kitz
and Biebuyck 1970s DOES MEDICINE NEED ACADEMIC ANESTHESIOLOGY?
40. Anesthesiologists have made major contributions to advances
in medicine As Anesthesiologists we need to think how we can
contribute to medicine and not just anesthesia At uOttawa we can
make major academic contributions to education, perioperative and
pain medicine