Key Points - Demand for ambulatory surgery increases the importance of anaesthesiology. - Geriatric and neonatal patients have unique needs that must be met by the anaesthesiologist. - The flight of medical talent from the developing world must be addressed urgently.
Dr Florian Nuevo reports on how new surgical procedures and changing demographics are having an impact on anaesthesiology, and how the philippines is coping with the situation.
A number of changes have occured concurrently in the field of surgery and anaesthesia. In the Philippines, the national anaesthesia service faces the challenge of coping with these changes, with minimal resources in terms of modern anaesthesia machines, equipment and monitors. In this article, I will present some areas of particular interest that need further attention from hospital administrators and the healthcare industry.
Extended Ambulatory Surgery
Most surgical patients would like to be treated as ‘day-case patients’. Although outpatient surgery used to be limited to minor surgical procedures, with the development of minimally invasive surgical techniques and advancements in technology, demand for ‘ambulatory surgery’ has soared. Simple lumpectomies, herniorrhapies, hysteroscopies, diagnostic laparoscopies and knee arthroscopies are now done in the ambulatory service.
Potent anaesthetics with a fast onset of action, short duration and no residual effects thus became the order of the day. The anaesthesiologist must review the conduct of anaesthesia so that patients can be safely discharged from the hospital within at least two hours after surgery. The most demanding aspect of all is that the homebound patient must be comfortable and pain-free so that he or she can get by with minimal supportive care.
Some pharmaceutical companies have met this market demand with products such as Propofol, Sevoflurane and Desflurane. These are anaesthetic agents that can facilitate general anaesthesia with fast recovery from drug effects. Remifentanil is a potent opioid analgesic drug, but is not readily available.
Greying Patient Population
Age is no longer a barrier to surgery.Aged patients are most often on multiple medication and suffering from one or two co-morbid illnesses. Geriatric anaesthesia entails more intensive monitoring, even up to the recovery period. Perioperative haemodynamic lability, pulmonary disorders and central nervous system complications are the most commonly associated cause of morbidities, if not mortality. Geriatric medicine is not yet fully developed nationwide in the Philippines. Anaesthesiologists must be able to complement this need for better understanding and management of the elderly surgical population.
Maintenance of normal body temperature is one such important concern in the care of elderly patients. This can easily be overlooked, particularly inside the cold operating room theatres and postanaesthesia care units, because continuous body temperature monitoring is not standard for all procedures.
Air-driven warming blankets, such as the Bair Hugger, are a safe, easy, and efficient way of maintaining normal body temperature. Currently this equipment is scarcely used, even in some tertiary hospitals. Basic management of hypothermia is done by exposure to warm droplights and the use of heavy blankets.
Too Small and Too Young
Patients presenting with neonatal emergencies such as gastroschisis, anoplasty, diaphragmatic hernia and early correction of complex congenital heart diseases under cardiopulmonary bypass, usually have low birth weights, in the range of 2–4kg. For these patients, many technical difficulties are encountered because of the lack of appropriately sized catheters for percutaneous placement of central venous lines and arterial lines. Drug delivery systems should be accurate up to hundredths of a millilitre. Portability of these infusion pumps and monitors during patient transport would also be of great value.
Anaesthesia machine ventilators that can be safely used for controlled ventilation of these neonates are another concern. Temperature control is very important intraoperatively and postoperatively. Radiant warmers are always recommended.
Too Big and Too Heavy
Heavier patients – in the range of 200– 400lb – are often presented, scheduled for bariatric surgery or endoscopic placement of gastric balloons. Because of the rather large sizes of these patients, technical difficulties are encountered in terms of airway management. Even simple things like the appropriate size of blood pressure cuffs and extra-long spinal or epidural needles to facilitate regional anaesthesia can be helpful.
Special operating room tables and transport facilities such as stretchers or wheelchairs suitable for morbidly obese patients must be made available. This is to ensure that the patient’s body and extremities are not inadvertently injured while undergoing treatment. Transferring patients between table and stretcher can also be a problem without the aid of simple devices such as the patient slide board and, of course, extra personnel.
It cannot be denied that the Philippines is currently experiencing problems in the availability of physicians particularly in rural areas. At the root of the problem lies the heightened migration of doctors to countries that offer more remuneration. This is further aggravated by the high demand for nurses in the US and Europe, prompting some physicians to pursue nursing jobs abroad. As a consequence, even young medical graduates leave the country. There are fewer applicants to residency training programmes and fewer applicants to medical schools, but there is a big surge in nursing students.
How are We Coping?
The Philippine Society of Anaesthesiologists (PSA) recognises the need to ensure patient safety in view of all these developments and changing landscapes in anaesthesia practice today. To address this concern, in collaboration with leading pharmaceutical companies, it has strengthened further the continuing medical education programme in anaesthesia through aggressive outreach programmes in the country, such as the Distance Education Programme in Anaesthesiology, which is open to anaesthesiologists who wish to update their knowledge base and upgrade technical skills.
We appeal to hospital administrators to prioritise the upgrading of services and facilities in critical areas like operating rooms, delivery units, and post-anaesthesia care units. During these times of staff shortages among nurses and physicians, there is an exaggeratedd need for more monitoring devices to assist the anaesthesiologists and nurses in their daily work. Industry must collaborate with hospital administrations in working out an affordable finance assistance programme to meet all these needs.