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CURRICULUM VITAEName : dr. Nabin Dhakal
EDUCATION:Onomichi General Hospital, Onomichi, Hirosima Prefecture, Japan3 months advance training in pain management, November2010 Hasanuddin University, Makassar, South Sulavesi, IndonesiaMD in Anaesthesiology, Intensive Care and Pain ManagementMay 2010 Kuban State Medical Academy, RussiaM.D equivalent to M.B.B.S2000 June
Acute Pain Services in NepalDr Nabin Dhakal
Consultant Anesthesiologist
Total population 26,620,8091 beds/ 3, 833 populationGeneral people less aware of Anesthesiology and
pain management, literacy<50%Anesthesiologist society formed just 2 decades agoNot all hospital have anesthesiologist & pain
physician“Pain Management” is given least important in
Many Hospital
Current Scenario of Nepal
Some Facts about health sector of NepalHealth facility under MoHP(Minestry of Health & Population) in %1. Total Health Institutions under MoHPHospitals(Central, Regional, Sub-regional, Zonal and District) Health Center Primary Health Center (PHC)Health PostSub-Health PostAyurvedic Health Institution
4396945
201699
3104293
2. Total Hospital Beds 6944Health manpower under MoHPDoctors Nurse/ANM Paramedic/Health AssistantVillage Health WorkerMCHWAyurvedic PhysicianBaidhya
145711637749131903985394360
Health Volunteers Female Community Health Volunteer including Trained Traditional Birth Attendants
63326
Development In 1933,First medical doctor to give anesthetics
regularly, B.B Singh Pradhan.In 1955 he obtained first formal training in
anesthesiology(one year in India) In 1976 B N Shrestha first anesthesiologist to work
outside capital cityInformally trained three doctor due to acute shortageTill 1984 only 7 anesthesiologist for 80 surgeons In 1985 started diploma in anesthesiology with
assistance from university of Calgury Canada.
Training and development of Anesthesia started from 1985.
1985- There were only 7 Anesthesiologist as Diploma in Anesthesia(1 year training)
Among them 30-40% left the country. In 1986 annual anesthesiology symposium
was introduceIn 1987 Society of Anesthesiologist of Nepal
founded
Development
Development (Contd…)2005- 43 were trained as DA and other 19
completed MD In AnesthesiaNow Just about 135 anesthesiologistOnly 1 Anesthesiologist for 197191
population at present.Anesthetic drugs, only few Nepalese
manufacturer, still highly dependent to India and foreign drugs.
No anesthesiologist with super specialization in Pain Management.
4 University have 3 years MD Anesthesiology programs including pain and Intensive care.
Institute of medicine(Kathmandu)National Academy of Health sciences(Ktm).BPKIHS(Eastern part of Nepal)Kathmandu University (Ktm)
Current situation
Shortage of AnesthesiologistDue to political instability anesthesiologist
concentrated in Capital cityOnly few anesthesiologist had training in pain
abroad.Heavy work loads & Lack of adequate recoursesPoor understanding and reporting from health
staff.No multidisciplinary acute pain services.B and B Hospital, frist to start first Pain Clinics but
by orthopedics department.
APS in Hospitals of Nepal
Causes of under development of APS in HospitalsShortage of manpower including
anesthesiologist Brain Drain problemLow per capita income USD$540 i.e low
income groupLeast developed countryLiteracy rate 56.6%(also include people able
to read and written without formal education)Many people even out of reach of basic
primary health care.Frequent changes in policy making bodies.
Current practiceAt present majority of hospital in Nepal is practicing traditional postoperative pain which is managed by surgeon (surgeon-based)
Intramuscularly(I/V or IM) usually opioid
Prescribed by the surgeon Administered by the nurses Given as per needed.
Adverse outcome of poorly managed APSThe Patient suffers
MI, dysrhythmiasThromboembolic, pulmonary (atelectasis,
pneumonia)
Psychological: Needless suffering Anxiety, Depression, Fatigue
Development of chronic painIssue of basic human rights.
Provision of Institute Formation of APS
1. Anesthesiology-Based APS
Introduced by B. Ready in US, 1988
2. Nurse-Based APSIntroduced by N. Rawal in Sweden,
1991
AMDA Hospital Damak NepalEstablished on 1992 as N G ORegistered as 75 beds but capicity of 115 bed.Also an educational instituteProvides services in the cities of 810696 peoplePatients also come from near by cities>1.5
millionHigh patient flowLess recourses, heavy work load
Facts and few achievement’s
Society more aware of their right proper pain control
Pain emerging as fifth vital signReduce the hospital stayBalance between patient safety and effective
analgesic modalities(Limit s/e avoid complication)
Anesthesiologist being held accountableMake it cost effective as well
Growing needs of APS
Just two Anesthesiologist for pain managementSimilar to Nurse-based APS started from February
2011.Painless delivery was introduce from March 2011.Heavy work loads, average 400 operation /month.Lack of recoursesPoor understanding and reporting about health
staff.No multidisciplinary acute pain services.
APS in AMDA Hospital
Pain Assessment Tools
In Adults: Self Report Measurement Scales, such as Numerical Scales
Post operative Pain is our goal at present.
Acute burn injury painAcute medical painAcute labour painAcute pain management in emergency
departments
Specific Target Clinical situations
patient with Epidural catheter for post operative pain
Laparotomy
APS Modalities in AMDA Hospital1. Combination of NSAID + opioid
For patients without epidural catheter Intermittent NSAID IV + Week opioid Continuous opioid IV (drip / syringe pump) NMDA antagonist: Ketamin
2. Combination of LA+ opioid For patients with epidural catheter Intermittent OR with syringe pump
PCA & PCEA : currently not available
• Psychological interventions• TENS• Acupuncture(1st hospital in Nepal to
introduce Acupuncture by Anesthesiologist)
• Physical Therapies
Non Pharmacological Techniques
Epidural Analgesia ( Continuous Lumbar or Thoracic Epidural Catheter Placement)
Spinal Analgesia using long acting as well as short acting Opioid.
Peripheral Nerve block(single Shot only)
Intervention Management in AMDA Hospital
Single model
high dose causes High Side effectMultimodel apporach
Current practice
Analgesia
Analgesia Side effect
Side effect
is additive or synergistic analgesia, side-effects profiles are different and of small degree
Patients satisfaction, (appreciation and comfort)
Early discharge of patientsReduce the pain of patientsCost effective
Results
Formation of pain chapter as national priority of Nepal.
Pain Management strategy update and future direction
Provide continuing education of hospital staff and patients
Add technician for offering around the clock service
Upgrade to new Approach and Technique
A way to go
THANK YOU