Alex

Anaesthesiology in Russia When Dr Joseph Eldor has offered me to write a short essay , giving an impression about anaesthesiology in Russia, I has immediately agreed without any fluctuations. However with the first steps I met with some insurmountable difficulties. I realised that any statistical data on anaesthesiology were practically absent in available literature. Accepted this fact with sadness I has decided to limit this report with the description of anaesthesiology in a large general hospital, assured that these particularities can be extrapolated on anaesthesiological service as a whole. I live and work in Saint-Petersburg. This is one of largest and very beautiful ( except winter seasons) cities of Russia. The city with the population of six millions is situated on both sides of Neva river which falls into the Baltic Sea. Conditionally city can be divided into four areas. In the centre of each area are located several big ( 1-1.5 thousand beds) general hospitals, that round-the-clock admit patients delivered on emergency evidences. In 1975 s a Health Care Ministry of the USSR issued a package of documents, which before 1990 defined a structure of anaesthesiological service in Russia. Some of them did not lose its actuality even nowadays. In accordance with these documents: 1 ...ICU on 6-15 beds is organizined in hospitals on 500 beds ( surgical beds must be not less than 70). 3. ... ICU on 20-25 beds must be organized on each 500,000 inhabitants in cities with population more than 0.5 million. 4. ...staff of ICU is planned in accordance with the following schedule: 6 beds- 1 round-the-clock post of physician, 2 nurses and 1 junior nurse. ... the salary of anaesthesiologist is 15% above than the salary of physician or surgeon. To become an anaesthesiologist one has to graduate a secondary school ( 10 years), medical university( 6 years), residency ( 1 year) and pass 3-4 months specialisation on the chair of anaesthesiology in Postgraduate Medical Academy. Once in five years anaesthesiologists are obliged to pass 2-3 month refreshment courses in Postgraduate Medical Academy. The level of qualification of anaesthesiologist is defined by three categories ( II, I and high). Anaesthesiologist can pretend on the first category, if his length of service is not less than 8 years. In science we use two main scientific degrees- a candidate of medical science and doctor of medical science. Rank of doctor of medical science enables to get a job as a professor and head of the chair in the medical university. Three medical journals on problems of anaesthesiology/intensive care are published in Russia: «Anaesthesiology- Reanimatology», « Intensive therapy», « Methods of efferent therapy». That the reader got an impression about the structure and work of anaesthesiologists in Russia I describe a routine activity of the department of anaesthesiology/intensive care in our hospital. This is 1000 beds university affiliated hospital. In 20 beds department of anaesthesiology/intensive care work 28 doctors, 58 nurses (29 anaesthetists) and 18 junior nurses. Since branch of anaesthesiology and intensive care are united in one department the doctors work in shifts- 3 months as anaesthesiologists and 3 months as intensivists. Several years back department of anaesthesiology/intensive care included in itself the branch of CCU on 8 beds and anaesthesiologists treated patients admitted to CCU after MI or implantation of pacemakers. Today branch of CCU is incorporated in the structure of department of cardiology with the stuff of cardiologists who got 3 months training course in anaesthesiology. The structure of patients that are admitted to ICU is the following: traumatic shock -30% , elective surgery - 20%, acute surgical diseases- 30%, misc.- 20% (poisoning with alcohol substitutes, stroke, etc.) Saying about methods of anaesthesia ,they are determined not only by existing standards but mainly by financial situation in each particular hospital. The most widespread method of anaesthesia is endotracheal anaesthesia with neuroleptics, fentanyl and nitrous oxide. The operations on upper limbs are fulfilled under interscalene anaesthesia. Epidural blockades with combination of clonidine, morphine or tramadol are mainly used as a component of postoperative analgesia. Simultaneous operations on organs of thoracic and abdominal cavity ( pancreatoduodenal resection + lung resection + liver resection etc.) in patients with advanced cancer and supposed intraoperative massive blood loss are accomplished under total intravenous anaesthesia (kalypsol or sodium oxybutiricum + fentanyl with inhalation of 100% oxygen) + regional anaesthesia. In lung surgery we use continuous regional retropleural blockades as a component of anesthesia and postoperative analgesia. With the aim to reach broncholitic and analgesic effect we use retropleural blockades in patients with heart ischemic diseases after MI or bronchial asthma. In patients with respiratory failure of various origin ( e.g. ARDS) apply HFJV with PEEP. Always use HFJV when weaning patients from respirator. In patients with endotoxicosis of various origin methods of extracorporeal detoxification are routinely used ( ultraviolet blood irradiation, hemoperfusion, plasmafiltration, plasmapheresis, methods of indirect electrochemical oxidation, ductus lymphaticus drainage, acute hemodialysis etc.). The degree of endotoxicosis is determined by the level of middle molecular weight compounds. Thus, ten-folds increase in serum the level of middle molecular weight compounds is an indication to use extracorporeal methods in septic patients with MOF. It is appropriate to say that extracorporeal detoxification methods are very popular in Russia. We have an experience in treating patients with autoimmune diseases, hypertoxic form of schizophrenia, Landry,s paralysis with VV hemoperfusion through activated charcoals. Patients with acute hemorrhagic pancreatitis are treated with combination of hyperbaric oxygen, catheterization of A.coeliaca with infusions of the drugs with antiprotease activity , drainage of thoracic duct. In general anaesthesiology/intensive care as the whole medicine in modern Russia experiences essential difficulties that are conditioned by shortness in financing ( less than 3% from national budget). Hope to survive this temporary hard period.