1. 1. Colin J.L. McCartney MBChB PhD FRCA FCARCSI FRCPC Professor and Chair, Department of Anesthesiology University of Ottawa
2. 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. 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. 4. Miller RD 2009: Rovenstine lecture
5. 5. Science of anesthesia: John Snow, ether and father of epidemiology Neuromuscular blockade: Harold Griffith Multidisciplinary pain clinics: John Bonica
6. 6. BMJ 2007: 11300 readers polled on most important medical advance since 1840
7. 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. 8. Developed scientific basis of anesthesia Anaesthetist to Queen Victoria for last two children First epidemiologist Cholera and the Broad Street pump Rickets
9. 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. 10. CMAJ February 1944
11. 11. John J. Bonica 1917-1994 Understood the multidimensional biopsychosocial nature of pain Authored or edited 41 books Published 274 scientific articles
12. 12. Descartes 1645
13. 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. 14. AKA Johnny BullWalker Light heavyweight champion of Canada in 1939 and world champion for six months in 1941
15. 15. Virginia Apgar Neonatal resuscitation Peter Safar Resuscitation JW Severinghaus Blood-gas analysis John Lundy Transfusion Medicine John Bonica Pain Management
16. 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. 17. Orebaugh SL et al RAPM 2012
18. 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. 19. 0% 20% 40% 60% 80% 100% Diaphragmatic paralysis 30 min post block Diaphragmatic paralysis 60 min post surgery 95.8% 91.7%
20. 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. 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. 22. BMJ 2000
23. 23. Reduced postoperative pain, opioid consumption, adverse effects No difference in blood loss orTE events No difference in mortality
24. 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. 25. 382,000 patients 25% neuraxial Neuraxial associated with less mortality, length of stay, in-patient morbidity Anesthesiology 2013
26. 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. 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. 28. Medical education scholarship: more effective training throughout medical careers Perioperative medicine: bench to bedside Pain Medicine: training and research
29. 29. Stem cell therapy299 CJA 2014; 61: 299-305
30. 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. 31. Prediction and prevention of perioperative morbidity and mortality Optimizing functional outcome Prevention and reduction of chronic pain after surgery
32. 32. Pearse RM et al Lancet 2012
33. 33. CPET can help predict outcome after major colonic surgery
34. 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. 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. 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. 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. 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. 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. 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
41. 41. cmccartney@toh.on.ca @colinjmccartney