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