Presidential Address 2014

The past presidents, Members of Council, Chief Guest Dr. Carl Wadman, Guest of Honour Dr. Kate Grady, Members of The College of anaesthesiologists of Sri lanka, Ladies and Gentleman.
Thank you very much for your kinds words of introduction.
It is my immense pleasure as the President of the College of Anaesthesiologists of Sri Lanka to present the Past President’s Medal to Dr. Kumudini Ranatunga, who is the outgoing President of the College of Anaesthesiologists of Sri Lanka.
1st slide –
I must thank the College members for electing me as the President – 2014-2016. The College which was started as an association at the General Hospital of Colombo with a few consultants has now expanded into a giant tree of the College of Anaesthesiologists.
I am very proud to be at the helm of the College with such eminent past presidents. I pledge my whole hearted commitment to the wellbeing and expansion of the College. My appeal to the Council is to help me achieve this goal.

Today, we are entering the 3rd decade of our annual sessions. As the new president and the council, what are our challenges for the next decade? How do we achieve these?
Slide – Best Practice
This is our vision and mission ‘’ Best Practice towards Excellence ‘’
Best Practice is a method or technique that has constantly shown results superior to those achieved by other means. In addition, Best Practice can evolve to become even better as improvements are made, achieved and discovered.
We need to identify, implement and monitor the best available evidence in healthcare so that the results are reflected in better patient care and safety.
During the 1styear, we need to get all our practices to meet the best available evidence in perioperative anaesthesia, critical care and pain management throughout the country by all the anaesthetists, regardless of their designation.
With this foundation for Best Practice, we then need to make necessary resources available to all these centers, within the existing financial constraints.
Only then will we be able to achieve our target for the next decade ‘’ Best Practice towards Excellence ‘’

Slide – RCOA building
We all recognize the building in this picture

Slide – 1st page of guideline
This is the Guideline published in 2006 by Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland
Good Practice

A guide for departments of anaesthesia, critical care and pain management

It says in the foreword: 
4th slide – Message
All doctors practising anaesthesia, critical care and pain management have a primary duty to provide the best care of patients that they can, whether they practise as consultants, non-consultants career grade doctors or trainees, and whether in the National Health Service or in the independent sector

It is the duty and the responsibility of all of us that we provide the best possible care for the patients through Best Practice.
5th slide–1st Anaesthesia
Not only now, this concept has been in practice since the origin of anaesthesia more than a century ago and throughout the history of medicine.
The practice of anaesthesia dates back to 1846, when William Morton, first introduced ether at Massachusetts General Hospital USA, where he successfully gave anaesthesia to a patient for the extraction of a tooth; a good example of best practice of anaesthesia at the very beginning.
But it was an English doctor, John Snow in London, who realised there could be different degrees of anaesthesia – a discovery which continues to influence its practice today.
In 1847, James Young Simpson, a Scottish obstetrician, discovered the anaesthetic effects of chloroform.
It soon replaced ether, and led to surgery becoming much more common for small injuries as people did not have to bear the pain.
But its use to relieve pain at childbirth only became widespread after John Snow administered chloroform to Queen Victoria for the births of two of her children.
Chloroform had to be withdrawn due to a death of a girl by the name of Hana losing her life while undergoing a simple operation of toe amputation. The lesson we learnt for adopting the best practice is not to continue with the same drug, but to investigate the cause of death, thereby preventing further deaths; another example of attempting to achieve Best Practice.
Since then numerous trials and research have led to the development of various substances, equipment and procedures for anaesthesia and analgesia.
The cause of death was hypoxia, and it indicated the need for a way of giving both oxygen and gas during anaesthesia. This was the birth of breathing apparatus
7th slide – earliest breathing apparatus
Hewitt (1857 – 1916), was a leading English anaesthetist of his day and an outstanding clinician. He most importantly invented the first apparatus capable of delivering oxygen and nitrous oxide in variable proportions.

“Magill Endotracheal Apparatus”– an anaesthetic machine, was invented by Ivan Magill (1888 – 1986) around the late 1920s to provide an anaesthetic agent to the patient

The practice of local anaesthesia came into light as a part of avoiding complications of general anaesthesia, again an evidence of Best Practice
8th slide – 1st local anaesthetic
Viennese ophthalmologist Carl Koller (1857–1944), rose to the challenge of using cocaine in clinical work. On September 11, 1884 he performed the first surgery using local anesthetic on a patient with glaucoma.

Slide – Cocaine
After Koller’s discovery of cocaine’s local anaesthetic powers, its use spread rapidly, but because it was administered in high concentrations (on the order of 10–30%), practitioners soon began to report its alarming side effects.

As the undesirable effects of cocaine gradually became known, new anesthetic drugs were sought to replace it.

Extensive research by experts in the field led to the discovery of Novocain, followed by lidocaine.

Currently, the pharmaceutical industry continues to explore the development of safer and more effective local anesthetics, in a pursuit that has come a long way since the earliest experiments with cocaine.

Then a came another discovery, the birth of spinal anaesthesia

10th slide – 1st spinal anaesthetic

The first spinal anaesthetic was administered accidentally by J. Leonard Corning, a neurologist from New York in 1885
Corning developed his own spinal needle and introducer, which he described in the New York Journal of Medicine.

Since then, it had given way to develop the technique as an alternative to GA.
Yet, local anaesthesia was not popular due to inappropriate techniques and the side effects of drugs. With time, more knowledge, experience, research, better drugs and techniques, spinal anaesthesia was getting popular and safer.
The introduction of the regional anaesthesia needle was a major breakthrough in 1990s, leading to its development towards Best Practice.
All these developments in history indicate how best possible practice was sought.
11th slide – Polio epidemic
Developments in Critical care into Best Practice
The best example from history was the polio epidemic. All patients with respiratory muscle paralysis needed a way to support their ventilation.

This had led to the development of critical care units with organ support, including better ways of vetilation, incorporating the concept of intensive care into anaesthesia.
Since early 1950s, anaesthesia was a fast developing speciality through various ups and downs, all because of the need to look for what is best for the patient through best evidence.
Development of intravenous anaesthetics, neuromuscular blockers and endotracheal intubations were some of these break-through points.
13thSlide – picture of old Sri Lanka (Ceylon) and Dr Spittell
Where do we stand in the history of anaesthesia?
The first reference to anaesthesia in clinical practice in Sri Lanka is in 1887. The year the Ceylon Medical Journal commenced, they published use of chloroform in surgery.
Until 1898, the house surgeon used to administer the anaesthetic at the Colombo General Hospital. A separate anaesthetist was appointed in 1904, designated as the chloroformist. Dr Joseph De Silva, was a chlroformist and also a Lecturer in anaesthesiology at the Colombo Medical School.
Dr RL Spittell, a Dutch Burgher Surgeon, born in Sri Lanka, had been working in Sri Lanka from 1910 to 1935. He published a book titled ‘A basis of surgical ward work’ covering anaesthetic topics. His beloved wife was the first female anaesthetist in the country.
In 1915 laparotomies are described in which local anaesthesia was preferred to chloroform or ether.
15th slide – Second World War
During the Second World War British Army anaesthetists in Ceylon were probably the first to use the intravenous induction agent — thiopental sodium in Sri Lanka. In 1947 nitrous oxide and Boyle’s apparatus came into regular use.
The neuromuscular blocking agents were used for the first time. Endotracheal intubation became common by that time.
Commencement of cardio-pulmonary bypass surgery was the impetus for the establishment of the country’s first ICU, serving both medical and surgical patients in 1968.
Since the 1970s, the development and practice of anaesthesia in Sri Lanka has been in line with international standards. The patients received the best practice available at the time.
Dr. Anthony Lucas who obtained the Diploma in Anaesthesia from UK in 1935 was the 1st qualified Sri Lankan Anaesthetist. Since then, there had been a steady increase in the number of qualified anaesthetists in the country.
The College of Anaesthesiologists was born in 1971 leading the way to the development of anaesthesia as a special field of medicine in the country.
I am proud to say, today we have around 250 consultant anaesthetists working in the country assisted by 100 postgraduates and many Junior anaesthetists

How this is distributed – 18thSlide
19thSlide – This slide shows Distribution of all categories of ICUs , Intensive care units in the country. Out of 120 ICUs 75% is manned by consultant Anaesthetists
The first pain clinic for the management of chronic pain was established at the General Hospital, Colombo, in the 1980s.
Slide – Landmarks in 1st decade of 21st Century
Let us get back to how Best Practice continued to develop in the rest of the world.
During 1960s and 1980s, anaesthesia was a fast developing speciality due to many discoveries in relation to drugs and equipment.
How did anaesthesia and Critical Care evolve for better patient care during the first decade of the 21st Century?
The most important development is to recognize Critical Care and Pain Medicine as separate specialities.
The Intensive Care Society was formed in 1971 in UK; the first such organization in the world. This was followed by the Critical Care societies from various parts of the world.
In 2010, the Faculty of Intensive Care was formed in UK. These organizations remain committed to developing Intensive Care Medicine, and excellent care as much as possible throughout the world.
In Parallel to that, the Faculty of Critical care of the College of Anaesthesiologists of Sri Lanka was started in 2011 in Sri Lanka.
The Faculty of Pain Medicine was started in the same year showing our commitment to follow the international standards.
Introduction of ultrasound to Anaesthesia and Critical Care was a major step in moving towards better practice.
21st slide – NICE and US + S/E of CV Cannulation
The use of Ultrasound has been shown to decrease all of these side effects. Therefore, NICE guidelines recommended using 2D Imaging ultrasound as the preferred method of both elective and emergency CV cannulation (September 2002 and August 2005).
Since then it has found its way to regional anaesthesia and in critical care giving us the opportunity for excellent care through Best Practice.
The first ultrasound guided regional anaesthesia workshop was done in 2008 in HNSL. The first workshop on Critical Care ultrasound was done in 2012 in Colombo.
All the teaching hospitals in Sri Lanka now have the privilege of having ultrasound machines for Anaesthesia and Critical Care.
This is our way of giving excellent care for the patients, through Best Practice in keeping with international standards.
The concept of the Critical Care Outreach Team has been an excellent way forward in detecting critically ill patients within the golden hour.
The birth of less invasive monitoring techniques is another significant step in monitoring, leading to improved quality of care in the OR and ICU.
The techniques such as PiCCO, Flo-trac and Easophageal Doppler monitoring is already available in our Operating rooms and ICUs

What about communication, how does it help to achieve better patient care?
Slide – Communication
This is an area which was completely neglected in the past and has become one of the most important aspects of patient care in the last decade.
Discussions and information has enabled the patient and the anaesthetist to decide on the best form of perioperative care for a particular procedure. It is the informed consent that should be taken — not “consent’’ for anaethesia.
Communication with relatives of critically ill patients is an important issue for decision making, especially in end of life care and organ donation. The training and experience in these critical situations is an integral part of our curriculum for senior house officers and postgraduates.
In a demanding situation, the ability to communicate with the colleagues, not only with the patient, will help the patient to get the best possible perioperative care.
The changing phase of ‘’Do not attempt resuscitation ‘’ order now reflects more and more communication with patients and relatives, rather than the blanket policy that was generally the case before. The guidelines set by Association of Anaesthetists of Great Britain and Ireland. ‘’DNAR decisions in the perioperative period’’ London 2009, will allow patients to be involved in the decision if appropriate, and be given the relevant information and opportunity. The patient’s autonomy is a much more recognized concept now than in the past
Slide – Pain
Have we given the best care for the patient in terms of pain management, so far?

If you look at current literature reviews, you will find that pain is not a symptom anymore, but a disease in its own right. The current thinking is not only about acute postoperative pain but also persistent postoperative pain which can lead to chronic pain.
Extensive research and clinical evidence has advanced our knowledge of physiology, for example, the Cloning of classical and non-classical opioid receptors and genetic variation of pain have resulted in much better understanding of acute and chronic pain.
The fascinating developments are drugs like gabapentin and pregabalin and use of cannabis in pain. There are many examples that translational research may yield direct clinical benefit to the patient in areas such as metastatic cancer pain.

Slide – Pharmacology
Let us look at pharmacology and therapeutics, — how the Best Practice is achieved in terms of perioperative anaesthesia and critical illness, other than pain.
A major breakthrough was the development of activated Recombinant Factor VII. This wonderful but expensive therapy, if used in the correct situation, would have helped many in need.
One best example of changing practice for better care is perioperative beta blocker therapy which was once highly recommended. Further research followed and then the recommendations changed as the results of POISE, other trials and reviews.
Another best example of changing practice in sepsis and multi-organ failure is the use of activated protein C after ‘’PROWESS ‘’ TRIAL. All of us know how it was thought to be effective in severe sepsis due to its anti-coagulant and anti-inflammatory properties. The ‘’PROWESS-SHOCK trial led to the withdrawal of drugs leaving the critical care physician with an empty feeling of failure.
The most recent therapy which got into controversy because of ‘evidence based medicine’ is volume replacement using HES administration, which leads to increased morbidity and mortality. The controversy over colloid versus crystalloid has continued for years, still without evidence for Best Practice.
These are only few but important examples which most of us are familiar with, in addition to extensive clinical research done on anaesthetic drugs.

Slide – Recovery
Latest evidence of Best Practice – enhanced recovery which provides an excellent means of good practice for best patient care
Improvements in the quality of care, outcomes, patient expectations, experience, and efficiency with reductions in unnecessary lengths of stay, have been highlighted by organisations that have embedded the pathway into day to day practice.

Finally, what has given us the way for better care for patients?
Slide

It is audit and clinical trials and research

The research into molecular biology and identification of glycocalyx and formation of oedema has upgraded the understanding of sepsis and its current management.

Research into Genetic variation of pain and neuplasticity of the nervous system explains why some patients develop chronic pain while others do not.

One other good example of changing towards best practice is perioperative fluid therapy.

The ultimate goal of IV fluid administration is optimizing the patient’s haemodynamic status, so that the tissue perfusion closely matches the metabolic demand.

The focus has shifted from a fixed-dose approach based on static measurement towards titration of fluid therapy guided by dynamic indices of fluid responsiveness. From the inspiration of the work by Shoemaker and colleagues’ – ‘’Goal directed fluid therapy’’ – to novel individual patient based fluid therapy, was the driving force in developing minimally invasive haemodynamic monitoring techniques and indices.

There is continuous debate and research concerning both the amount and the type of fluid for various clinical situations.

I should not forget to mention the work by the Scottish Epidemiologist Archi Cochrane’s approach for evidence based medicine resulting in the Cochrane Collaboration which marked the 20th anniversary last year. The Cochrane anaesthesia review group founded in year 2000 had done a number of notable reviews, which resulted in better patient care in anaesthesia and critical care. Few of these are protein C in sepsis, BIS monitor in awareness, timing of tracheostomy in critically ill, and use of goal directed treatment.

I request all my colleagues to make use of these valuable resources in the promotion of excellence in their research and clinical practice.

Clinical audit

Clinical Audit is a quality improvement initiative undertaken individually or within the departmental teams. When conducted appropriately, they have clear value and importance to improve the local practice.

We need to encourage this practice in all the hospitals where consultant anaesthetists are available to guide the juniors.

Each anaesthetic department needs to undertake at least two audits a year, change or improve their practice accordingly, and re-audit to evaluate the changes. This will make a huge difference towards better patient care.

What is the challenge for research and clinical trial during the next decade?

It is now clear that extrapolation data from animals to humans is not the best since animal models do not mimic clinical conditions or the time course of human disease.

When it comes to audit and research for Best Practice, it is a long walk that never ends. As often happens, when we think that the destination was reached, it is found that other destinations beckon, and there is more walking to be done.
In that context, it may not be the Best Practice but better practice towards excellence in patient management that matters.

Slide

How do we continue our Best Practice and improve patients’ care further?
How to improve our training towards Best Practice?

Our trainees are our future as mentioned by Prof Rowbothom – Chairman National Institute of Academic Anaesthesia)
This is how it should be
1.On line continuing medical education

2.Introduction of CPD system where what is learnt from audit and research can be translated to better practice

3.Simulation Training

It has been shown that simulator based training can enhance the transfer of technical and non-technical skills in to clinical practice, and effectively support the changes of attitude and behaviour. This applies to trainees of all levels of experience; single candidates and for teams. Simulator based training may facilitate the improvement of quality of care and patients safety.

In that context we started our 1st workshop on simulation training during this Annual Sessions.

4.Critical incident reporting system

Critical incident reporting was first used in anaesthesia in 1978.
It is now a common practice in almost all hospitals, generally shared only at a local level.
In order to share and expand learning more widely at a national level, we need a system which offers opportunity to report and read by the others.

We will establish a system reporting and learning that can be done by a National Reporting system through the College Website. The reports will be analysed regularly and the learning points will be fed back to the system. This will
promote the academic process in anaesthesia.

5.Multi-professional and multi-speciality engagement in patient management

There is evidence based improvement in patient care if the required other specialities are involved at the right time

Ladies and Gentleman
I have attempted to summarize, with difficulty, how Best Practice works towards the excellent care for the patients as it has always been.

It is the undoubted responsibility of all of us to maintain it at all times and continue for the future though our trainees and junior anaesthetists.

Finally, may I emphasise to all anaesthetists that the council is here to serve you. We are always grateful to those who come to us with views and suggestions for improvement.
Ladies and Gentlemen
I would like to thank everybody who helped me to make this event a success. Special thanks goes to Dr Gayanie Senanayake who was the live wire through out this event. My staff at the college Himasha, Surani and Sunethra.
And Last but not least my son Chamira, Hashani my daughter Upamali who did a wonderful job as the compeer and my husband who supported me right through out