Врач должен обладать взглядом сокола, руками девушки, мудростью змеи и сердцем льва.
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Основные итоги 16th World Congress of Anaesthesiologists, 28 August - 2 September 2016, Hong Kong Convention Centre

Итоги работы

1. A warm welcome from the President

Dr. David Wilkinson WFSA President

A warm welcome from WFSA President Dr David Wilkinson Welcome to this, the ‘Olympic Games of Anaesthesia Congresses’ (held every four years!) to be held at the Hong Kong Conference Centre August 28-September 2 2016. This 16th World Congress of Anaesthesiologists has been organised by the Society of Anaesthetists of Hong Kong on behalf of the World Federation of Societies of Anaesthesiologists (WFSA). The Hong Kong Congress Organising Committee is chaired by Professor Mike Irwin and he and his team have created what will be a truly memorable experience for all those who attend. The variety and depth of our programme this year is, as ever, very impressive. The Scientific Programme, overseen by Tony Gin, is truly innovative and includes plenty of interactions through workshops, problem based learning and poster sessions, as well as lectures from opinion leaders from around the world. Also take a look at the Humanities track which will include music, art, ethics as well as history, including some fascinating session on anaesthesia in the distant past and also how it featured in the works of Shakespeare. In addition to all of the anaesthesiological updates there will be a vast trade exhibition all of which will be housed in the purpose built modern Conference Centre overlooking the busy Hong Kong waterways. Please come along to the WFSA stand, meet the team and take part in our Safe Anaesthesia For Everybody – Today “SAFE-T” Campaign (more on that in upcoming editions of this newsletter). Attendance in Hong Kong offers unique opportunities to explore food, language, customs, architecture and religion in one of the most beautiful harbour settings in the whole of Asia. Many people suggest that there is no longer a great need to attend such meetings nowadays as information can be taken from journals, podcasts, websites and so on. Yet nothing could be farther from the truth in my view. To sit and have coffee with a colleague from Togo together with someone from the Mayo Clinic, USA, another from Tirana in Albania and another from Tegucigalpa in Honduras cannot be replicated by any other means. Friendships are made which last lifetimes, challenges are shared and new ideas can invigorate jaded minds to spur on new research or bring back new methods to demonstrate to colleagues back at home. This can only bring benefits for all our patients. I welcome you to Hong Kong. Look at the opportunities within this programme and please augment the Congress with your ideas and enthusiasm. I hope we will meet, please come and say ‘hello’ to all of the WFSA team if you see us around the meeting.
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2. President Profile
WFSA President Dr David Wilkinson Born in Pontypridd, Wales and the son of a post office worker and a school teacher, David Wilkinson first thought of being a doctor aged just 7 years while battling childhood asthma and meeting many physicians during the course of his treatment. He qualified from St. Bartholomew’s (Barts) Hospital, London, in 1971 and after routine house jobs in medicine and surgery, he set out on his then chosen career of obstetrics and gynaecology. After 6 months of this in North London, he knew it was not going to suit him for the rest of his life. A senior anaesthetist then suggested that he apply for that speciality as an opening was just emerging. He got the job, and has never regretted a moment since. Here we find out more about David. Q: How did you become involved with the WFSA, and what made you want to be a board member and later president? DW: I was very interested in the history of anaesthesia and collected a museum of apparatus at Barts as a trainee and then was asked to take on the role of curator of the Charles King Collection of Anaesthetic Apparatus owned by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). Through a number of posts at AAGBI, I had close contact with the WFSA European Regional Section. I thus became introduced to European activity and eventually stood for Secretary of that and then became President. It was a natural progression then to stand for the WFSA Council, eventually joining as chair of the Statutes and Byelaws Committee. I then spent four years as Assistant Secretary, four years as Secretary and then my existing term as President. None of it was planned, it just all seemed to happen! Q: How important is it for anaesthetists globally to have a World Congress where people can link up in person? DW: I am convinced it is essential. Apart from the science delivered at the lectures and poster displays and the vast array of material on display in the Trade Exhibition there is something very special about meeting and talking to people from so many different cultures and backgrounds, and puts so much of one’s own life in perspective. I call our World Congress the ‘Olympic Games of anaesthesia’. It happens in the same year as the Olympics and it engenders that same camaraderie and excitement that the Olympics create. Q: What have you most enjoyed about your career as an anaesthetist, and how much have things changed over the years? I have really enjoyed the ability to re-invent myself on a regular basis. The fundamental joys of anaesthesia are without equal. To take someone who is naturally moderately petrified of surgery and make them laugh as they go off to sleep, care for them obsessively throughout a procedure, and then return them to recovery and then the ward or home both well and comfortable is so great. It is very rare to get it all right all of the time, but it was always a challenge and a pleasure. I have also enjoyed various research projects on breathing during anaesthesia. This was very satisfying and challenging and resulted in the publication of a series of papers and then the ability to travel to present the results to meetings in Europe and Asia. I then became very interested in ‘day stay surgery’ and designed and ran an American style day surgery unit at Barts, a fantastically innovative and exciting Unit which was opened by the Queen. I then spent a great deal of time travelling and lecturing about this work. And as stated above, my work for AAGBI, RCoA and WFSA has kept me constantly stimulated and motivated over the years. Furthermore, I was always interested in new equipment, new drugs, and new techniques ‒ anything that improved things for the patient. Q: What have been your highlights as WFSA president? DW: I believe I have been a catalyst to change the WFSA out of all recognition. In that process I have been fortunate to watch a series of previous Presidents and officers at work and learn from them. I am surrounded by a Council and Board of the highest calibre who all have added their thoughts and voices to any plan put before them. This has never been a one man show by any stretch of the imagination, and the current state of the WFSA is now a really exciting stepping off point for an even more exciting future. We have gone from having one dedicated individual secretary to an organisation with a Chief Executive Officer and four other permanent staff to take it forward. This has given us appropriate governance and structure which has allowed tremendous development on all fronts. This office development has been mirrored by the dedication of all those volunteers who have given their time and energy working for every one of the WFSA’s committees all of which have extended and developed their remits. We have been able to increase the contributions made by the Board and Council by increasing their regular meetings. The Board has monthly teleconferences and meets face-to-face at least three times a year. The WFSA Council meets face-to-face annually as a complete group, and more often in smaller groupings at regional meetings. There is a much greater sense of participation and contribution than ever before. It has been a very exciting time to be President. Q: What are you looking forward to in this year's programme - I understand that history of anaesthesia is a big interest of yours - how exciting is it to have this type of track in the programme? DW: History has always been part of the scientific programme of World Congresses and I have been an eager contributor to that in the past. This year it has been stretched to encompass a humanities track with input on all the arts including music and painting. I think that this is a huge step forward. Q: What would you like the WFSA to achieve over the next 10 years? DW: I would like to see the WFSA reach financial security in the next 10 years while at the same time making serious progress in providing care for the 5 out of every 7 people on the planet who right now do not have acceptable access to safe anaesthesia and essential surgery.
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The WFSA’s Fund-a-Fellow campaign An estimated 5 out 7 people worldwide lack safe access to anaesthesia today, with shortages in the anaesthesia workforce ‒ especially in low-income and middle-income countries ‒ a major factor. The WFSA’s Fund-a-Fellow initiative is attempting to address this shortage, by providing fellowships to anaesthetists across Africa, Asia, Europe and Latin America. Thanks to the dedication of many WFSA volunteers in these locations, the actual fellowships do not cost anything. However, Fellows are only able to take up these fantastic opportunities if WFSA pays their travel and living expenses, and as such WFSA is appealing to all delegates to donate to their fund-a-fellow campaign.

“By making a donation you will enable more anaesthesiologists from lower income countries to access training and improve outcomes for thousands of patients around the world,” explains WFSA’s Communications Manager Niki O’Brien. “Over a year, a donation of just $100 per month will support a Fellow’s education, travel and accommodation for a full month. So please donate today.”

India, Kenya, Chile and Serbia are among the 13 countries that offer fellowships, with each fellowship lasting between 2 months and 1 year. Dr Christopher Chanda of Zambia was able to complete a Paediatrics Fellowship at the University of Nairobi Hospital, Kenya, working with WFSA volunteer and senior paediatric anaesthesiologist Dr Mark Gacii. Dr Chanda is dedicated to improving paediatric anaesthesia in Zambia and will be one of the faculty introducing the WFSA training course “SAFE: Safer Anaesthesia From Education” courses in Zambia next year. “Zambia has a critical shortage of physician anaesthetists, and especially paediatric anaesthesiologists. The need to increase the number of physician paediatric anaesthesiologists is crucial,” says Dr Chanda. “The relevance of this Fellowship is huge. I might be the only practicing paediatric anaesthesiologist in Zambia which has a population of 15 million, half of which are aged below 15. Since returning to Zambia I have been involved in teaching residents and undergraduate students. Some of the things that I emphasise are preoperative assessment, the need for premedication in some cases, the WHO Safe Surgery Checklist, and regional techniques.” To apply for a fellowship, applicants must be fully trained in anaesthesia in their home country and supported in their application by both their own National Society of Anaesthesia and the chief of their home department of anaesthesia. They must also be returning to their home country to a recognised post, be under 40 years of age and preferably working in a teaching hospital. The courses are intended mainly for young anaesthesiologists from the geographical region near where the course is based. For more information on the programme, see:

  • Training programs
  • Fund a fellow
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    4.Successes and Challenges

    Preview for Monday sessions: WFSA Training Courses: Successes and Challenges Room S421, 830H-1000H Monday 29 August One of the sessions due to take place on Monday morning is on the successes achieved and challenges encountered in the various WFSA training programmes taking place worldwide. The first part of the session will see Dr Wayne Morriss, current Co-Chair of the WFSA Education and Development Committee, giving an overview of these programmes.

    Dr Morriss will refer to The Lancet Commission on Global Surgery, which found that 5 out of 7 people worldwide cannot access safe surgery and anaesthesia. It also found numbers of anaesthesiologists (as well as surgeons and obstetricians) in low-income and middle-income countries (LMICs) need to double over the next 15 years to meet basic surgical demand.

    “Education will be a vital part of the solution,” explains Dr Morriss. “Unfortunately, in resource-poor countries, there are many barriers, including professional isolation, too much clinical work, and very limited resources for education activities.” The WFSA is working with its member societies to address this educational need, and has rolled out educational materials, (e.g. Anaesthesia Tutorial of the Week), short educational courses (e.g. SAFE Paediatric Anaesthesia and SAFE Obstetric Anaesthesia), the WFSA–Baxter Scholarships to allow young anaesthesiologists working in LMICs to attend conferences, and the WFSA Fellowship Training Programmes.

    “Education will be a vital part of the solution”

    The WFSA Fellowship Training Programmes offer 50 positons in 13 countries to allow young trained anaeshtesiologists in LMICs to receive high quality training before returning to a post in their home country. The longest running WFSA Fellowship Training Programme is at the Bangkok Anaesthetic Regional Training Center, Thailand, which began accepting Fellows in 1996. By the end of 2015, 72 young anaesthesiologists had completed a 12-month training attachment. Almost all have returned to their home countries and are still working as anaesthesiologists. Dr Morriss adds: “The WFSA Fellowship Training Programmes aim to not only train clinical experts; they also aim to train leaders and teachers. Many graduates of WFSA programmes are now leading the development of anaesthesiology in their home countries.” The programmes also build professional networks and reduce the isolation that is so common in resource-poor regions. As such, it is clear the benefits of fellowships extend well beyond the Fellow receiving the training. Dr Morriss will pay tribute to the voluntary work and goodwill of the many WFSA volunteers who make Fellowships possible, and encourages people to donate to the WFSA Fund-a-Fellow initiative to enable more Fellowships (which require the WFSA to pay travel and living expenses for the trainee). He says: “WFSA Fellowship Training Programs are incredibly good value and are making a vital contribution to the development of our specialty worldwide.”

    There will also be a presentation by Dr Yoo-Kuen Chan ‒ an obstetric anaesthesia specialist in the Department of Anaesthesiology, Faculty of Medicine, Kuala Lumpur, Malaysia, who will discuss the WFSA sponsored Obstetric Anaesthesia Training in that location.

    "We bravely accepted an invitation to host regular 6 monthly training positions for obstetric anaesthesia to be sponsored financially by WFSA.”

    The University of Malaya Medical Centre is a national referral centre for high risk patients as it is affiliated to the teaching faculty of University of Malaya, the primier university in the country. “There is a state of the art obstetric anaesthesia provision and training for our postgraduate anaesthesia students,” explains Dr Chan. “The unit is run by 2 consultants and 4-5 medical officers who rotate through the unit on a monthly basis. In 2013, we bravely accepted an invitation to host regular 6 monthly training positions for obstetric anaesthesia to be sponsored financially by WFSA.” Dr Chan says the “red tape” or bureaucracy surrounding the initiative were great but not insurmountable – visa clearance, clearance by the Malaysian Medical Council and especially the hospital was challenging. Fortunately, she says this did not detract from the training of the candidates they hosted. She says: “Their academic needs were varied and often had to be closely monitored and appropriately addressed. We highlighted knowledge, skills and attributes that needed improvement.” She concludes: “These trainees were given numerous opportunities to engage in various activities that ultimately transformed them to become a more confident and thinking anaesthesia provider, ready to meet any and all challenges they are likely to face at home. Many have performed far beyond our expectations!” Dr Subramani Kandasamyu will then discuss the intensive care training course in India, before the session is wrapped up by Dr Marc Gacii, who runs the WFSA paediatric anaesthesia fellowship programme at the University of Nairobi, Kenya. East Africa has a combined population of 252.5 million. If the wider East and Central African region is included, the population rises to 350 million, with just under half aged 14 years and under. “Access to safe anaesthesia and pain relief for this segment of the population is a basic human right,” says Dr Gacii.

    “The International Standards for the Safe Practice of Anaesthesia, as adopted by the WFSA, are a huge challenge to achieve with few anaesthesiologists trained and confident in working with children.”

    The Fellowship team works with valued partners such as the Society of Pediatric Anesthesiologists, Smile Train and the University of Nairobi to address these challenges. The fellowship ‒ though based at the main teaching hospital in Nairobi, Kenya ‒ partners with volunteer paediatric anaesthesiologists from leading centres in the world, faith based hospitals and private hospitals to provide teaching and mentorship to anaesthesiologists from the region who are dedicated to improving the standards of paediatric peri-operative patient care. Dr Gacii concludes: “The fellowship aims to continually improve through feedback and re-evaluation, constantly looking out for opportunities to plug gaps in the training through forming new partnerships and strengthening existing ones.”


    1. Profile: Atul Gawande

    Atul Gawande Photo Courtesy Tim Llewellyn

    Atul Gawande, surgeon and author, will be co-presenting this year’s WCA Harold Griffith lecture with Tore Laedral on Wednesday. Dr Gawande currently divides his time between being a practising surgeon at the Brigham and Women’s Hospital, Boston; working on various media projects including new books and recently a film; and also leading Ariadne Labs, a center for health system innovation which he has cofounded at the Brigham and Women’s Hospital and Harvard Chan School of Public Health in Boston. Dr Gawande is one of many voices calling for an end to the global inequity which sees 5 out of 7 people globally lacking access to safe surgery and anaesthesia. In his talk, Dr Gawande will discuss The Lancet Commission on Global Surgery, to which he contributed an accompanying commentary, and detail the work he did as co-editor of the first volume on Essential Surgery to appear in the World Bank’s highly influential compendium, Disease Control Priorities. Working in a diverse team including public health experts, surgeons and economists, the Disease Control Priorities team found that investment in first-level hospital capacity for 44 essential surgical procedures (including C-section, laparotomy, and fracture repair) “is among the most cost-effective health interventions known”, explains Dr Gawande. He will also discuss how the world will ever manage to close the gaps we have in capacity to deliver a service as complex as surgery. “People think that it’s about having enough expertise—anaesthesiologists, surgeons, nurses,” he says. “But it is much more than this—it requires somehow building infrastructure, procurement systems, management. And yet as economies grow, numerous countries have managed to do it.” Dr Gawande will talk about how, looking at places as diverse as his father’s ancestral village in India, South Korea, and his home town of Athens, Ohio, in the USA (which has provided surgery since the 1960s but did not have an anaesthesiologist until 1983). The concerning pattern, he notes, however, is that the growth of surgical capacity repeatedly outpaces the growth in safety and quality for any given region in the world. “The consequences can be devastating for large numbers of patients,” he said. “But this is what the World Federation of Societies of Anaesthesiologists has the capacity to do something about.” Dr Gawande’s work on the WHO Safe Surgery Checklist requires no introduction, however he has advanced this work and is currently completing a WHO-sponsored trial in India on use of a specialist safe surgery checklist for childbirth, as well as following up the work featured in his bestselling book Being Mortal to address the problems facing end-of-life care. A trial Dr Gawande has led on, just completed in Boston, will he hopes be the basis for a published end-of-life care conversational guide which physicians can turn to when they are facing these issues with their patients. He has also worked with US television network PBS to do a film version of Being Mortal, which aired earlier this year. “End-of-life care is relevant to all of us,” explains Dr Gawande. “A large number of our patients are facing the ends of their lives, and we must listen to them. Survival cannot be the only goal – issues must be considered such as where the patient would like to die and whether they actually want to receive certain treatments or procedures that may compromise what little time they have left.” Finally, no profile of Dr Gawande would be complete without mentioning the Lifebox project which he cofounded with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the Brigham and Women’s Hospital and WFSA to provide vital pulse oximeter devices and safe surgery and anaesthesia training to operating theatres in resource-poor countries. He is also the chair of the Lifebox Foundation. “Our work has stressed the recognition of and need for the professional discipline of anaesthesia,” says Dr Gawande. Pulse oximeters are the only equipment based component of the WHO Safe Surgery Checklist, and Dr Gawande describes the Lifebox project as a vital lynchpin that has seen pulse oximeters and training provided to more than 90% of operating rooms in 27 countries to date. “As financing systems in these countries start picking up to address population need, increasing demand and increasing growth, focus must be kept on improving quality. Delivery of safe surgery and anaesthesia requires a system of care, not just the surgery itself.”
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    2. The opening ceremony
    This year’s opening ceremony was a spectacular feast of entertainment and awards. A brightly coloured dragon show started and ended the proceedings and enthralled the gathered delegates. Following this, there were short speeches from WFSA President Dr David Wilkinson, Hong Kong Congress Committee Chair Professor Mike Erwin, and Scientific Programme Chair Professor Tony Gin. With some 600 delegates from 133 different countries, this year’s meeting will be one of the most successful in WFSA’s history. And most must surely have been impressed by the variety and quality of the Opening Ceremony, featuring some beautiful music from pianist Joe Chindamo accompanied by the Salisbury Quartet. And after that, there was even more to enjoy, with international renowned sand artist Hoi Chiu creating sand paintings live on stage. Among his works were a patient on an operating table, and a backdrop of Hong Kong with the WCA logo written across it. Dr Wilkinson also formally launched the WFSA Safe Anaesthesia for Everybody Today (SAFE-T) campaign, aiming to change the horrendous statistics that show 5 people of every 7 worldwide cannot access safe and affordable surgery and anaesthesia. He highlighted that it is not possible for one organisation alone to collect the data needed to drive and influence change, and so the WFSA has launched the Safe Anaesthesia For Everybody – Today “SAFE-T” Campaign to unite individuals, industry and organisations behind a shared mission. Dr Wilkinson also had the pleasure of presented WFSA Awards, including the Presidential Award for Service to Anaesthesiology, the WFSA Distinguished Service Award and the WFSA – Baxter Innovation Awards. There was one emotional moment among the congratulations, with the son and daughter of the late Dr Anis Baraka (Egypt) joining Dr Wilkinson on stage to collect the WFSA Distinguished Service Award on behalf of their father. Lastly, delegates were treated to video featuring a number of familiar faces from WFSA talking about anaesthesia in the future and their hopes for change. Among them was the WFSA Chief Executive Officer Julian Gore-Booth, who said investment in anaesthesia and surgery is always worthwhile, since each $1 invested leads to an estimated $10 in returns. Following the Opening Ceremony, Delegates continued the jovial atmosphere by heading to the Exhibition Hall to enjoy a drink and some light food.
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    3. Enhanced recovery after surgery (ERAS)
    Grand Hall, 0830-1000H Monday

    This 3-part session on enhanced recovery after surgery (ERAS) will be opened by session chair Monty Mythen, Smiths Medical Professor of Anaesthesia and Critical Care, University College London, London, UK. Professor Mythen will refer to his 2014 paper on this topic published in the Canadian Journal of Anesthesia, which describes the development of ERAS within the UK National Health Service (NHS). A document titled Delivering Enhanced Recovery – Helping Patients to Get Better Sooner After Surgery was published by the UK Department of Health on March 10, 2010. The introduction says: ‘‘Enhanced recovery is transforming NHS elective and cancer care pathways by using a number of evidence-based interventions as a model of care enabling patients to recover sooner following surgery.’’ The first of 3 talks will then be given by Olle Ljungqvist, Professor of Surgery, Örebro University Hospital, and Affiliated Professor of Surgery at the Karolinska Institutet, Stockholm, Sweden. “One focus of my talk will be the importance of the surgeon having a broad overview of the care pathway rather than just focussing on the operation and the technical aspects,” says Professor Ljunqvist. “The surgeon sees the patient first, performs the operation, orders much of the perioperative care elements and is the one to have control of follow-up, and thus has overall responsibility for the patient. It is essential for the surgeon to understand the value of the team around the operation, not least the work done by the anaesthetist and their colleagues in the operating room, but also in the post anaesthesia care unit (PACU).” Professor Ljunqvist will also refer to a paper he has published on this issue in the Journal of Parenteral and Enteral Nutrition. In this paper, he explains that while ERAS was initially developed for colonic resections, these principles are being used in a range of operations, and there is also a continuous update of care protocols as the field develops. He says: “A key mechanism behind the effectiveness of ERAS is the dampening of the stress responses to the surgical insult combined with the use of treatments that support return of functions that delay recovery in traditional care. The article also gives some insights to why the protocols work and reports the effects of ERAS protocols.” He concludes: “The principles of ERAS are gaining ground and spreading into a range of different surgical specialties and procedures with results of similar magnitude as those seen in colorectal surgery. This is not surprising given that the stress-reducing effect of the ERAS protocols is likely to be effective in any kind of surgery, as well as the impact that ERAS has on outcomes and costs.” The second talk on importance of the intestinal microcirculation will be given by Vladamir Cerny, Professor of Anesthesiology and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, and Charles University, Prague, Czech Republic. “The whole intestinal circulation receives approximately 25-30 % of cardiac output, and 70% of blood flow is directed to the bowel,” explains Professor Cerny, who is also President of the Czech Society of Intensive Care Medicine. “Any blood supply insufficiency ‒ occlusive or non-occlusive ‒ leads to tissue hypoxia of the bowel and at the level of microcirculatory network, to its dysfunction.” Depending on its severity and duration, microcirculatory dysfunction may be associated with various clinical symptoms and with increased morbidity and mortality. The clinical features of intestinal microcirculatory dysfunction are nonspecific. In daily practice, direct assessment of intestinal microcirculation is impossible; a specific approach to efficiently target intestinal microcirculation during anaesthesia and/or perioperative period does not exist. Early detection and effective treatment of intestinal microcirculatory dysfunction continues to be a challenge for the anaesthesiologist. Professor Cerny will stress the importance of intestinal macro- and micro-circulation for preventing intestinal ischemia/injury; address the most important clinical factors affecting intestinal integrity during anaesthesia – such as low cardiac output, hypovolaemia and vasopressors; and review the current role of anaesthesia and related areas – such as anaesthesia techniques, fluid management, and perioperative anaemia on intestinal microcirculatory integrity during the perioperative period. He concludes: “The key clinical points for maintaining intestinal microcirculation during anaesthesia ‒ based on current scientific evidence ‒ will be identified.” The final talk in this session, titled “Optimising perioperative care”, will be presented by Mike Grocott, Professor of Anaesthesia and Critical Care Medicine, University of Southampton, and University Hospital Southampton NHS Foundation Trust, UK. “Perioperative medicine is a patient-focused, multidisciplinary, and integrated approach to delivering the best possible health care throughout the perioperative journey from the moment of contemplation of surgery until full recovery,” explains Professor Grocott. He will highlight how perioperative medicine offers a physician-led vision of perioperative care in the 21st century and beyond. It extends the roles of the anaesthetist beyond the operating theatre into the wider hospital and community role and defines care delivery around the patient (as partner or consumer) rather than the care providers. “The value proposition for perioperative medicine is based on the efficient reapplication of current resources, rather than through major new investment,” says Professor Grocott. “All the elements of perioperative medicine have been implemented somewhere, but few if any centres have successfully implemented the complete package of perioperative care.” The successful implementation of the Enhanced Recovery Partnership Programme in England suggests that such projects can be implemented at minimal cost with increased productivity and quality through the application of leadership and quality improvement techniques. Professor Grocott will conclude that perioperative medicine is in many ways a natural development of the ideas central to Enhanced Recovery after Surgery programs with an added focus on the following: -Integration with care outside of the hospital before and after surgery -Standardisation of intraoperative care -Effective use of in-hospital resources in the postoperative period

    Monty Mythen
    Vladimir Ceryn
    Olle Ljungqvist
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    4. Safe anaesthesia for everybody, today
    1045-1215, Convention Hall A
    This session will be focused on WFSA’s SAFE-T campaign which aims to bring safe anaesthesia to the 5 in 7 people worldwide that cannot currently access it. Formally launching the campaign here in Hong Kong, WFSA President Dr David Wilkinson will describe the background to the project, including the WFSA’s International Standards for a Safe Practice of Anaesthesia first produced in 1992 and updated in 2008 and 2010.

    These standards are agreed and adopted by the 135 Member National Societies of the WFSA and are recommended for anaesthesia professionals throughout the world. However, to reach them, it must first be recognised that this is a collaborative effort across governments, industry, civil society and beyond; and also be understood where and why these standards cannot be met. “We must ‘map the gap’ in access to safe anaesthesia and use this data to influence advancement in every hospital, and for every patient,” explains Dr Wilkinson.

    The “SAFE-T” Campaign will unite individuals, industry and organisations behind a shared mission to advance patient safety and ultimately reach these international standards everywhere. The “SAFE-T Consortium” is a global collaboration of industry and patient focused organisations committed to the advancement of patient safety and the International Standards for a Safe Practice of Anaesthesia. There is also the “SAFE-T Network”, a network of individual anaesthesia providers committed to these goals, and together these two groups will drive the SAFE-T Campaign. To sign up and find out more, delegates should visit the WFSA stand.
    There will be 3 other presentations in this session. One will be given by Dr Kurt Samer, the Vancouver-based anaesthetist, pain and intensive care specialist who is also a volunteer member and International Delegate of the Canadian Red Cross. Dr Samer was seconded to the International Committee of the Red Cross (ICRC) -‒ the lead NGO providing humanitarian medical and surgical care in areas of conflict and war ‒in 2014, and he has since completed two 3-month rotations in South Sudan. He says: “This 6 months of experience of providing anaesthesia for urgent trauma surgery in an ultra low resource environment has given me a unique understanding of the challenges of providing quality anaesthetic care in the context of prevailing low resources in developing countries.”
    In his talk, Dr Samer will highlight how WFSA and ICRC can work together to assist those most in need. “Given the ever increasing burden of surgically treatable trauma in less developed countries, there is a need for anaesthesiologists worldwide to volunteer their skills and experience to provide humanitarian assistance,” he says. ICRC, based in Geneva, has been providing surgical care to war wounded combatants since 1864. ICRC and its activities, and the history of the Red Cross movement will be presented. ICRC’s humanitarian activities will be highlighted by Dr Samer sharing his personal story from South Sudan – a conflict zone in one of the least developed countries in Africa. “The realities and challenges of providing anaesthesia and surgery in ultra low resource environments prompted ICRC to partner with the WFSA in a mutual endeavour to set international standards for anaesthetic skills and care, drugs, and equipment to ensure all beneficiaries in less developed countries receive safe anaesthesia,” explains Dr Samer. Through real patient stories, photos revealing the successes of humanitarian anaesthesia and surgery, and relating the life altering effect it had on him, he hopes to interest and motivate anaesthesiologists to volunteer for humanitarian missions, where they will have one of the most rewarding and satisfying experiences possible in a lifetime. In the other talks, Walt Johnson of WHO will present on how WHO and WFSA can address the global crisis on anaesthesia and surgery, and Dr Fizan Abdullah, Lurie Children’s Hospital of Chicago, IL, USA, will give a talk on the G4 alliance, asking why should we work together to facilitate anaesthesia care systems around world?
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    5. Controversies in labour analgesia
    Theatre 1, 0830-1000H This morning’s three-part session on controversies in labour analgesia will be opened by Professor Cynthia Wong, Chair of the Department of Anesthesia University of Iowa Carver College of Medicine, Iowa City, IA, USA. Asking “does neuraxial analgesia affect the progress and outcome of labour?”, Dr Wong explains: “Labour is a complex physiologic process. The mechanisms responsible for the progress of labour are not well understood. The effects of analgesia on the progress and outcome of labour are of concern to anaesthesiologists, obstetricians, and parturients.” She will discuss that neuraxial labour analgesia is associated with a higher rate of cesarean and instrumental vaginal delivery and longer labour. However, association does not necessarily mean causal; her lecture will review the available data on the effect of neuraxial analgesia on the progress and outcome of labour. Dr Wong says: “We will see that randomised controlled trials and impact studies suggest that neuraxial analgesia does not increase the risk of cesarean delivery. However, the data regarding instrumental vaginal delivery are inconsistent and the relationship is likely more complex. Current data suggest that density of neuroblockade is associated with risk for instrumental vaginal delivery. Finally, there is good evidence the neuraxial analgesia causes a longer second stage of labour. However, whether this results in adverse maternal outcomes is controversial.” Professor Marc Van de Velde will then give a summary of the pros and cons of using remifentanil for labour analgesia. “Neural labour analgesia is currently a very effective and safe strategy for labour pain relief. However, some parturients have contraindications to the use of neuraxial analgesia, whilst others do not want to use this form of analgesia,” says Professor Van de Velde, who is Head of the Department Anesthesiology at the Catholic University Leuven and Full Professor at the Leuven University Hospitals, Belgium In the last 2 decades remifentanil patient-controlled intravenous anaesthesia (PCIA) has been promoted as an effective strategy for pain relief. In this lecture, Professor Van de Velde will be discussing the efficacy of remifentanil PCIA compared to other forms of analgesia including other opioids, nitrous oxide and neuraxial blocks. Overall, based on published literature, remifentanil PCIA provides moderate analgesia slightly superior to the opioids and nitrous oxide, but is significantly less effective when compared to neuraxial analgesia. He will also evaluate the safety of remifentanil PCIA. Recent evidence clearly shows that remifentanil PCIA can induce significant respiratory depression in up to 40% of patients. “In several case reports this has resulted in maternal cardiac arrest and bedside resuscitation and perimortem Cesarean section,” concludes Professor Van de Velde. “If remifentanil is used in clinical practice, clear and strict safety protocols including careful respiratory monitoring and uninterrupted midwifery care are of paramount importance. Guidelines on use will be given in the lecture." The final part of the session, on epidural analgesia and fever, will be by Professor Scott Segal, who is Professor and Chair of Anesthesiology at Wake Forest University in North Carolina, USA. Women receiving labour epidural analgesia experience a greater incidence of clinical fever, involving 20-30% of women. Substantial evidence now suggests that the mechanism of epidural-associated fever is most likely sterile (non-infectious) inflammation. “Epidural-associated fever may have significant effects on the fetus and newborn,” explains Professor Segal. “Lieberman demonstrated that babies born to mothers with epidurals underwent evaluation for sepsis four times more often than babies born to mothers electing natural childbirth or systemic opioids.” Other adverse effects related to intrapartum maternal fever include increased need for bag-mask ventilation and increased incidence of otherwise unexplained neonatal seizures. A far more worrisome possibility is that maternal fever may cause neonatal brain injury, including cerebral palsy, neonatal encephalopathy, learning disabilities, and even increase the risk of autism. Professor Segal will conclude that many questions remain: “First, it is far from clear how epidural analgesia is associated with maternal inflammatory fever. Second, it is not known whether epidural-associated fever is specifically associated with brain injury. Third, it is unknown whether epidural-associated fever can be safely blocked. These questions will likely be the subject of intense investigation in the near future.”
    6. Global challenges in obstetric anaesthesia
    Theatre 1, 1400-1530H The global challenges in obstetric anaesthesia will be addresses in a 4-part session on Monday afternoon. The session will be opened by Professor Sunanda Gupta, Founding President of the Association of Obstetric Anaesthesiologists, India, and Head of the Department of Anaesthesiology at Geetanjali Medical College and Hospital, Udaipur, India. She will discuss that the population growth of the planet is almost entirely in the low- and middle-income countries (LMIC) and is associated with an unacceptably high number of maternal deaths. The risk of death from obstetric anaesthesia (OA) is 1.2 per 1000 women undergoing obstetric procedures, accounting for 2.8% of all maternal deaths, 3.5% of direct maternal deaths and 13.8% of deaths following Caesarean section. “Thus OA contributes disproportionately to maternal mortality in LMIC,” says Professor Gupta. “Exposure to general anaesthesia and administration of anaesthesia by non-physician anaesthetists with inadequate formal training are some of the reasons implicated for these maternal deaths.” She will emphasise that a proper curriculum-based training and skill development modules for physicians in rural areas, along with good earnings and proper infrastructure, will solve the serious crunch in anaesthesia services to some extent. She concludes: “To provide safe OA care, urgent interventions are required which include adequate skilled manpower with provisions to update their skills regularly, ample resources, along with relevant guidelines and protocols for each level of care with supervision. Teaching resuscitation skills, ensuring a multidisciplinary team approach and conducting audits with stress on accountability as an ethical concern, will improve the standards of safe OA care in the LMIC.” In the second presentation, Dr Joseph Kiwanuka will discuss the WFSA SAFE Obstetrics Course in Uganda, which he coordinates under the Association of Anesthesiologists of Uganda (AAU). He is also a Lecturer in The Department of Anaesthesia and Critical Care of Mbarara University of Science and Technology, Uganda. About 15% of global births are associated with complications that lead to both maternal and neonatal mortality. Haemorrhage, sepsis and hypertensive disorders of pregnancy are the leading causes of maternal mortality globally. It should be noted that of the estimated 289000 global annual maternal deaths, most occur in LMICs. “Anaesthesia providers have a critical role to play in the management of complications relating to pregnancy and birth,” explains Dr Kiwanuka. “There is a great discrepancy in the availability and training of anaesthesia providers globally between the developing and developed countries. A lot of anaesthetics are provided by non-physician anaesthetists in LMICs. These anaesthesia providers have limited opportunities and resources available to for continuous professional development. This is especially true for those in remote locations.” The Safer Anaesthesia From Education (SAFE) Obstetric Anaesthesia course was piloted in Uganda in June 2011. It has since been taught in other African, Asian and Latin American countries. It is a 3-day refresher course for anaesthesia providers addressing critical aspects of obstetric care and neonatal resuscitation. A trainer of trainees (ToT) course is also conducted to build in country capacity to run further courses. The course emphasises anticipation, recognition, preparation for and management of obstetric emergencies. Different teaching methods like lectures, case scenarios, discussions, videos and skill sessions are used to deliver the SAFE obstetric course content. “The course is monitored using written and skill tests,” says Dr Kiwanuka. “The course also has a follow up at the different work stations where case logbooks are reviewed to see the application of knowledge and skills acquired on the course. Feedback from participants and follow-up has shown that the SAFE obstetric course is very relevant and addresses a critical need in anaesthesia service provision. There is also translation of what is taught into clinical practice.” In the final part of this session, Dr Mauricio Vasco will discuss management strategies using low fidelity simulation to reduce maternal mortality in Latin America. Dr Vasco is Director of the WFSA Fellowship in Obstetric Anesthesia and Delegate for Central and South America on the WFSA Obstetric Anesthesia Committee. He also directs the Center of Simulation, Universidad CES, Medellin, Colombia. “Few countries in the world have decreased maternal mortality as established by the 2015 Millennium Development Goals (MDG’s),” says Dr Vasco. “There are great expectations regarding the new goals set by the Sustainable Development Goals (SDG’s) and Global Surgery 2030 programs and also on how we anaesthesiologists can be involved with such programmes.” Dr Vasco will highlight the strategic alliances made in Latin America by scientific societies involved in the mother and child care: WFSA – C.L.A.S.A – S.C.A.R.E, WHO, PAHO, CLAP, FIGO, FLASOG and the International Confederation of Midwives (ICM). “The aim of such alliances is to reduce maternal mortality using a low fidelity simulators and high fidelity ambient programmes for training in obstetric emergencies according to the needs LMICs in our continent.”
    7. Old anaesthetics – new effect on cancer spread
    Convention hall C, 1500-1630H This session will be opened by session Chair Beatrice Beck-Schimmer, Professor of Anaesthesiology at the University of Zurich and the University Hospital Zurich, Switzerland. She will discuss the role of anaesthesia drugs in cancer and inflammation.
    “Cancer has become an important topic in anaesthesia. While retrospective studies show a beneficial effect of local anaesthetics on tumour survival of cancer patients, evidence is not yet clear as results of large randomised controlled trials are still pending,” says Professor Beck-Schimmer, whose main research interests include perioperative organ protection and nanomedicine in blood purification systems. She says: “Moreover it is not clear if just local anaesthetics or general anaesthesia drugs also impact on cancer cells. Beside the focus of anaesthesia and clinical outcome after tumour surgery in cancer patients, this topic draws also attention because of the relationship of inflammation and the process of cancer development.” As it is well known that local and general anaesthetics in the perioperative phase exert an immunomodulatory effect, the question remains through which mechanism anaesthetics interact with malignant tumours. Professor Beck-Schimmer concludes: “The presentation will give a distinct overview on the possible role of anaesthetics in cancer spread with particular focus on local and general anaesthesia drugs. It will highlight the need of not only clinical, but also basic studies to fully cover this crucial and at the same time fascinating topic.”
    Another part of this session will address the possible role of the mu opioid receptor in cancer growth and metastatis. The talk will be given by Dr Jonathan Moss (Professor in the Department of Anesthesia and Critical Care at the University of Chicago, IL, USA).
    Dr Moss is an expert on the pharmacology of anaesthetic drugs, with a career that has focused largely on side effects of these drugs. He is one of the developers of methylnaltrexone (RELISTOR), the first peripheral opiate antagonist, which is marketed throughout the world to treat opiate induced constipation without affecting pain relief. In a trial completed last year, patients with advanced cancers who took a drug designed to relieve constipation caused by painkillers lived longer and had fewer reports of tumour progression than cancer patients who did not receive the drug, according to results presented at the 2015 meeting of the American Society of Anesthesiologists in San Diego. This is the first study in humans to associate opioid blockade with improved survival. The finding suggests that the drug - methylnaltrexone, approved for use by the United States Food and Drug Administration in 2008 to treat opioid-induced constipation - could play a role in cancer therapy. “The effect of anaesthetic drugs and technique on cancer recurrence has become a major issue in anaesthesia research. While some human data suggest a benefit of regional anaesthesia, we have proposed that the mu opioid receptor may be involved in cancer growth and metastasis and could account in part for some of these observations,” explains Dr Moss. “In order to test this hypothesis we used the peripheral opiate antagonist methylnaltrexone, approved in more than 50 countries to treat opiate induced constipation without affecting pain relief, to block the mu opioid receptor. This lecture reviews the evidence from molecular, cellular, animal and very recent human studies supporting the hypothesis that the mu opioid receptor is involved in cancer growth and metastasis. The implications for perioperative care and pain therapy of cancer patients will be discussed.” The other presentations in this session will be by Dr Antje Gottschalk, University Hospital Münster, Germany, who will discuss clinical and experimental evidence of the effect of opioids on cancer cell spread.


    1. Profile: Tore Laedral

    Tore Laerdal facilitating the "Helping Babies Breathe" course in Bangladesh

    Having yesterday profiled one of our Keynote Speakers, Atul Gawande, today we meet Tore Laerdal, who will share Wednesday’s Harold Griffith Lecture with Dr Gawande. Tore Laerdal acknowledges he is a little bit different from many of the speakers at this year’s WCA, saying he is not a doctor and not a scientist. However, this has not stopped him becoming fully engaged in issues affecting healthcare, as Chairman of Laerdal Medical, Executive Director of the Laerdal Foundation for Acute Medicine and the founder and leader of Laerdal Global Health. Laerdal Medical is a Norwegian family owned company that since modern lifesaving techniques were developed in 1960, has been pioneering the development of training manikins and patient simulators for acute medicine. Mr Laerdal’s late father Aasmund Sigurd Laerdal founded the family company in 1940, which originally manufactured children’s cards and books, then later toys, including the world famous lifelike “Anne” toy doll. Aasmund Laerdal then began manufacturing medical products not long after saving the then 2-year-old Tore’s life after he had been found face down unconscious in water. Working with anaesthetists and other specialists, the company began manufacturing lifelike manikins, which could be used for training in resuscitation and other medical procedures. Following studies proving the efficacy of using these manikins for lifesaving training, experts in the field recommended that first aid workers of all categories, school children and the general public should be taught resuscitation techniques. The Norwegian Saving Banks Association agreed to donate a manikin to each of the 700 primary schools in the country, and Norway subsequently became the first country to train all school children to be lifesavers. As such, the Laerdal family has been involved in saving lives across multiple generations. In recent years, Laerdal Medical has been an official alliance partner of the American Heart Association and the American Academy of Pediatrics in developing and implementing the simulation-based advanced Cardiac and Advanced Pediatric Life Support courses of these two organisations. Mr Laerdal has also been instrumental in establishing and developing the SAFER Simulation Center with the University of Stavanger and the Stavanger University Hospital in Norway. SAFER organized the European Patient Simulation Congress in 2012, and Laerdal has been awarded honorary membership of SESAM, the European Patient Simulation Organisation. In recent years, Mr Laerdal has turned his full focus to global health challenges, and established Laerdal Global Health, a not for profit company with the sole purpose of providing highly affordable and culturally sensitive training and therapeutic solutions to help reduce maternal and newborn mortality in low resource settings. For this purpose Laerdal Global Health has partnered with USAID, the US National Institutes of Health (NIH), Save the Children, the American Academy of Pediatrics and others in the Survive & Thrive global development alliance. This has resulted in a suite of simulation based Helping Babies Survive educational programs that have been used to train several hundred thousand birth attendants in low resource countries. “In 2008, I saw two newborns dying in front of me during a visit to a rural hospital in Tanzania. I knew there and then that better trained and equipped birth attendants would have had a good chance of saving both of these babies,” says Mr Laerdal. “I realised that, by far the greatest opportunity for successfully applying CPR was on the day of birth. What was needed was a solution that could make lifesaving much easier to learn and remember in low resource settings. This was the foundation of the Helping Babies Breathe program.” A further 6 educational programs have later been created and implemented under the umbrella of the Survive and Thrive Alliance, which which is working with 20 partners across a range of disciplines. The Survive and Thrive alliance was showcased at a United Nations session last month on the Power of Harnessing Public-Private Partnerships to End Preventable Newborn, Child and Maternal Death. “This alliance is well underway to reaching its goal of training and equipping half a million birth attendants by 2020. Imagine if each of them could save one life per year, this would mean 500,000 lives saved,” explains Mr Laerdal. He believes this bold ambition is achievable simply by implementing what we already know works. “This in turn depends on achieving not only the new Sustainable Development Goal (SDG) 3 relating to health, but also other SDG goals for industry innovation, quality education and partnerships. We can develop the medical equipment and educational tools our users need to help them deliver better care, but partners are needed to help develop and implement the programmes. And in this regard we are privileged to be an alliance partner with professional associations of pediatricians, midwives, obstetricians and cardiologists, as well as implementation organisations.” Asked why he has spent so much time in recent years on the work of Laerdal Global Health, Mr Laerdal explains: “Although it does not contribute directly to our company’s bottom line it contributes much to trust among our partners and customers, and motivation among our employees. And the reason I have spent so much time personally on this is because of that terrible moment in Tanzania in 2008 seeing those babies die. That was the day I realised that the greatest opportunity for helping save lives was on the day of birth – both mothers and babies.” Mr Laerdal holds an MSc degree from the Norwegian School of Economics and Business Administration. He has received an Honorary Doctorate in Science from the University in Hertfordshire in the UK. In 2016 he became a Oslo Business for Peace honoree

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    2. Corrections to yesterday's newsletter

    The newsletter editor apologises for these errors in yesterday’s edition:

    The name of Professor Mike Irwin (spelt correctly here), Hong Kong Congress Committee Chair, was spelt incorrectly in the Opening Ceremony report.

    Also, the information regarding the number of delegates should have said: There are some 6,000 delegates from 133 countries at this year’s congress. (The original text said 600)

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    3. Media coverage of the congress

    The congress has been covered by international media on Monday, with a press release titled ‘Study shows i-Pad apps to be as effective as sedatives on children needing anaesthesia, with higher parent satisfaction’ (Poster number PR237) generating multiple stories. The Times (this is blocked by a firewall I have requested the full article - however you can see the Congress is credited near the top) http://www.thetimes.co.uk/edition/news/to-relax-a-child-in-hospital-use-a-tablet-computer-38076jrwm The Times article has been syndicated by The Australian, national newspaper of Australia: http://www.theaustralian.com.au/news/world/the-times/ipad-games-sedate-children-before-surgery/news-story/860a6baa3e6802ec2ab018549d2cc78d The Daily Mail: http://www.dailymail.co.uk/health/article-3762817/iPads-sedate-children-surgery-Computer-games-good-drugs-relaxing-youngsters-operation.html i-news, UK: https://inews.co.uk/essentials/news/tablets-can-effective-pills-lowering-anxiety-children-study-finds/ The Times of India, national newspaper: http://timesofindia.indiatimes.com/tech/tech-news/Apple-iPads-are-as-good-as-sedative-for-kids-before-surgery-Report/articleshow/53906663.cms India.com national news website: http://www.india.com/whatever/apple-ipad-best-sedative-for-kids-before-surgery-1442296/ Business Insider Australia: http://www.businessinsider.com.au/science-says-ipads-can-be-as-effective-as-a-good-sedative-2016-8 News Medical : http://www.news-medical.net/news/20160829/iPad-use-before-surgery-requiring-anaesthesia-effective-in-reducing-child-anxiety.aspx Der Speigel - National Newspaper in Germany: http://www.spiegel.de/gesundheit/diagnose/aengste-vor-operation-ipads-beruhigen-kinder-wie-medikamente-a-1109802.html The Nursing Times: https://www.nursingtimes.net/news/research-and-innovation/apps-effective-as-sedatives-in-children-before-surgery/7010183.article

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    4. Live report from Monday: Identifying high risk elderly patients - what can be done?
    Dr Stacy Deiner was the host and speaker for a lively interactive session on Monday afternoon, the subject of which was identifying high risk elderly patients. Dr Deiner is Associate Professor of Anesthesiology, Neurosurgery and Geriatrics & Palliative Care, Department of Anesthesiology at the Icahn School of Medicine at Mount Sinai, New York, USA.
    The session discussed a number of issues in this field, including the American Geriatrics/American College of Surgeons recommendations for preoperative assessment of the elderly patient, which Dr Deiner describes as comprehensive but also a ‘little ambitious’. This is because they rely on the physician, anaesthetist, geriatric medicine specialist, and perhaps other members of the healthcare team being in regular contact with each other and the patient, which is very often not the case. for guidelines see: https://www.facs.org/~/media/files/quality%20programs/geriatric/acs%20nsqip%20geriatric%202016%20guidelines.ashx The session also looked at the Checklist for Optimal Preoperative Assessment of the Geriatric Surgical Patient, which includes screening them for depression, functional status, history of falls, nutritional status and history of postoperative delirium. Dr Deiner also covered the much discussed term ‘frailty’, saying frailty has been defined in several different ways. The most common are either phenotypic frailty (Fried et al) or deficits accumulation (Rockwood et al). “Frailty is not a death sentence but it is a significant risk factor for most major surgery in terms of postoperative mortality and morbidity,” she says. Put another way, Dr Deiner suggested thinking of 2 patients with the same age and comorbidities, yet one is highly functional and independent yet the other is struggling a lot more – the difference between two such people is what frailty is meant to measure. In an ideal world, frailty in elderly patients and other risk factors before an operation would be picked up in a preoperative clinic setting long before the actual operation. This would give time for the patient to take on more physical activity if possible, change their diet, be treated for mental health issues, or whatever other help they need to improve their chances of a successful operation. However, if this assessment is taking place 24-48 hours before the operation (as most are), then it is hard to do things other than those that can be changed immediately, such as polypharmacy. The group also passionately discussed the problem of lack of ownership of patients once the initial perioperative period is over. Dr Deiner said the USA generally regards up to 48 hours as the perioperative period, and it is unclear who has responsibility for patients after this. One delegate described the 3-months post-operative period as “the deep dark period that no-one wants to take responsibility for”. Dr Deiner added that up to 1 year post-operation is a crucial period which is vital for successful recovery of the patient. She gave the example of hip fracture patients, saying one recent US study had found that 40% of these patients had not ventured outside alone in the one year following their surgery (yet before their fracture were completely independent). Also among the many subjects discussed in this session is what to do when your preoperative screening detects a problem. Dr Deiner said you should talk to the patient and their family and perhaps manage their expectations of surgery. For example, those with pre-existing cognitive decline are likely to deteriorate further following surgery, perhaps returning to their baseline state within a year. A frank discussion must be had to ensure patients are aware of what they may face after their surgery. Finally, Dr Deiner discussed that in current postoperative delirium guidelines, the most important point for anesthesiologists is about avoidance of polypharmacy and Beers list medications, awareness of depth of anaesthesia, and optimisation of pain control with addition of nonopioids/regional anaesthesia when possible. See http://www.journalacs.org/article/S1072-7515(14)01793-1/fulltext for these guidelines
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    5. Awake Craniotomy: for seizure surgery, for tumour surgery
    Theatre 2, 1045H-1215H This 4-part Tuesday morning session will be chaired by Professor Hari Dash, Director and Head of Anaesthesiology and Pain Medicine at the Fortis Memorial Research Institute, Gurgaon, India, and will delve into the fascinating topic of awake craniotomy, looking at its use in both seizure surgery and tumour removal. Resection of lesions in eloquent areas of the brain represents a significant clinical challenge for the neurosurgeon and neuroanaesthesiologist. To preserve neurological integrity, many of these lesions are best resected while the patient is awake. An awake patient can provide instant neurological feedback during the resection of the lesion, which improves the chances of complete resection, without leaving a neurologically devastated individual. Unfortunately, lack of patient cooperation, pain, and airway problems are among the major impediments to the wider use of awake procedures. To unravel the evidence-based practice of anaesthetic management during awake craniotomy, four eminent individuals from around the world will speak at this symposium. They will discuss the historical aspect of awake craniotomy, anaesthetic management, neuropsychological / functional / cortical mapping, and paediatric awake craniotomy during this session. They are Dr Adrian Gelb (USA), Dr Ari J Katila (Finland), Dr Pirjo Manninen (Canada) and Dr Girija P Rath (India).
    The first presentation will be given by Dr Adrian W Gelb, Distinguished Professor, Department of Anaesthesia & Perioperative Care, University of California San Francisco, and will cover the history and indications of these procedures. Awake craniotomy can be divided into 2 types – 1) keyhole approaches such as deep brain stimulation (DBS), endoscopy and 2) large craniotomy used for tumour and epilepsy resection.
    “Serendipity has played a crucial role in the development of DBS,” explains Professor Gelb. “An injury to a small cerebral blood vessel in the 1950s, and unintentional high frequency stimulation in the same region 30 years later made it clear which part of the brain could be stimulated to reduce tremors in Parkinson’s Disease. DBS is used predominantly for Parkinson’s and dystonias, but is also increasingly being tried for other disorders including obsessive-compulsive behavior, depression, and obesity.” Awake craniotomy for epilepsy and tumour surgery was extensively used in the first half of the 20th century, largely because of concerns about the safety of anaesthesia. This “opportunity” led to studies and publications by Penfield, Boldrey, and Rasmussen from Montreal, which mapped the parts of the brain responsible for movements and sensation (homunculus). “Awake craniotomy is used today for tumours or epilepsy foci that are close to eloquent regions, that is the language, or motor areas of the brain,” says Professor Gelb. “Such an approach results in safer, more extensive tumour resection, and better outcomes for patients.”
    The second talk will be given by Dr Ari J Katila, Senior Staff Anaesthesiologist at Turku University Hospital, Turku, Finland, who will discuss anaesthetic techniques regarding awake craniotomy, including scalp block, airway management and monitoring.
    “Awake craniotomy is one of the neurosurgical interventions where the neuroanesthesiologist certainly has to be on their toes at all times,” says Dr Katila. “One has to know thoroughly the medications used and have a plan B ready in case of unexpected reactions (such as contradictory restlessness or agitation). Plan B is utterly important to bear in mind particularly when open airways and sufficient breathing are in question. The anaesthesiologist must have experience in vast and various methods of securing the airway – particularly in an emergency situation while the patient’s head is pinned in a head frame and airways are accessible only from the front. How can you monitor adequate breathing in real time? Come to the session and find out!” Dr Katila concludes: “I will encourage the audience to start using scalp blockade, a safe, easy to perform and effective technique to enhance patient comfort perioperatively. Not only in awake craniotomy, but also in other cranial vault procedures this technique can give the patient a smoother recovery with less discomfort and pain.”
    Dr Pirjo Manninen, Associate Professor at the Department of Anaesthesia, University of Toronto, Toronto, Canada, and Consultant Anaesthesiologist at Toronto Western Hospital, will deliver the third session on the subject of neuropsychological/functional and cortical mapping during awake craniotomy.
    She says: “The purpose of an awake craniotomy is to allow for the ability to perform mapping of brain function: localisation of focus of epileptogenic activity in patients with epilepsy with electrocorticography without effects from anaesthesia; and also identification of areas of eloquent brain function (speech, language, motor, sensory) in patients with epilepsy or tumours close to or in areas of eloquent brain function to allow for aggressive resection of the lesion but avoiding neurological injury.” She concludes: “The role of the anesthesiologist is critical in providing good conditions for mapping: an alert, cooperative awake patient, and the absence of the influence of anesthetic agents.”
    The final talk of this series will be by Dr Girija Prasad Rath, Additional Professor, Department of Neuroanaesthesiology & Critical Care, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Dr Rath will be discussing paediatric awake craniotomy, a surgical practice which presents unique challenges, and about which there is considerably less knowledge and experience among the anaesthesiology community.
    “Awake craniotomy with intraoperative electrical brain mapping is considered to be a reliable method for minimising the risk of permanent neurologic deficit during surgical excision of lesions near the eloquent cortex,” says Dr Rath. “It is, however, mainly practiced in adults, and reports of awake craniotomy in children are limited.” The mental and psychological immaturity of a child is the main hindrance to allowing them to undergo awake neurosurgery. Although few clinicians suggest the lower cut-off age to be 10 years, the youngest child who has undergone and awake craniotomy procedure is reported to have been 9 years old. “Co-ordinated psychological preparation of the child during preoperative period, by the team of neurosurgeon, neurophysiologist, neuropsychologist, and neuroanaesthesiologist, is the key to ensuring the success of this procedure,” concludes Dr Rath. “Most of the paediatric case series highlight the importance of awake-asleep-awake (AAA) technique for anaesthesia management, however, other authors suggest that dexmedetomidine sedation, along with a regional scalp block might be a reasonable alternative for the provision of conscious sedation, particularly in adolescents.”
    6. Technology outside the operating room
    Convention Hall A, 0830H-1000H One of the Tuesday morning sessions will look at the use of technology outside the operating room. The opening presentation will be by Dr Alain Kalmar, staff anesthesiologist at Maria Middelares Hospital, Ghent, Belgium, in scientific affiliation with Groningen University Hospital, The Netherlands. Dr Kalmar is also a past member of the ESA Scientific Subcommittee on Equipment, Monitoring, and Ultrasound.
    As an anaesthetist and biomedical engineer, his interests are in haemodynamic and cardiopulmonary resuscitation (CPR) optimisation, medical devices, and physiological signal analysis. Dr Kalmar works in close collaboration with anaesthesia department of Groningen University in The Netherlands, the Emergency Department of Antwerp University Hospital, Belgium, and the Engineering Department of Ghent University, Belgium. In the management of cardiopulmonary collapse, there is an increasing automation of both ventilation and chest compression. Automated ventilation provides intermittent intrathoracic positive pressure, to optimise oxygenation and ventilation. Automated chest compression provides chest compressions to induce cardiac output. Currently, both devices are operated independently, largely neglecting individual differences in cardiopulmonary interaction. Attempts to individually optimise both chest compressions and positive pressure ventilation will have to take into account the interaction between both interventions. Two major types of chest compression assist device exist, with variable effects on the “cardiac pump” and “thoracic pump”, as the two principal driving forces for cardiac output during CPR: direct sternum compression, versus compressing the entire thoracic cavity. Dr Kalmar will describe a promising strategy to study these interactions and, based on the advanced analysis of pressure waveforms measured in the endotracheal tube as input for iterative algorithms, enable individual optimisation of the ventilation and compression devices. In addition, he will show how the same hardware has been used to develop a device which permits fast determination of the endotracheal tube location (oesophageal vs tracheal) after intubation, with a very high reliability.
    Professor Hartmut Gehring, Directive Senior Resident at the Department of Anaesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein, Campus Lübeck and University of Lübeck, Germany, will deliver the second talk of the session on anaesthesia equipment and MRI. He acts as a quality management representative of the department, and leads the anaesthesiological service in the area of diagnostic and interventional procedures.
    “Anaesthesia services outside of the OR cover an increasingly wide range of activities, especially in the interventional area, such as stroke therapy,” says Professor Gehring. Magnetic resonance imaging (MRI) is characterised by the presence of a permanent, invisible, and very strong static magnetic field. This limits any anaesthesiology work to what can be performed with the small number of MRI-compatible devices and tools that are currently available. “The rapid development of MRI technology is leading to a wide gap between those anaesthesiology services which can be delivered in practice, and the possibilities that would open up with the development of a wider range of MRI-compatible equipment. Unfortunately, the historically small market for devices of this type means that development efforts in the field have often been slow and rudimentary,” says Professor Gehring. Due to the shift to more intense magnetic fields of 3 Tesla or more in newer MRI machines, as well as the increasing demand for their use in interventional and intraoperative applications, there is an urgent requirement for the rapid adaptation of these technologies in the anaesthesiology environment. “The greater awareness of the existence of this market is leading to an increasing number of devices being made available which meet the standards of the professional associations, as well as the necessary safety requirements,” concludes Professor Gehring. “I will outline the current status of the anaesthesiologic workplace and how it fits in with the demands of the clinical management of an MRI suite.” The final presentation of the session will be given by Dr Thomas Fuchs-Buder, Professor of Anaesthesia at the University of Lorraine, Nancy, France, who will outline the equipment needed during procedural sedation.


    1. The Harold Griffith Lecture: Preview
    Grand Hall, 1045-1215H This year’s Harold Griffith Lecture will be shared between keynote speakers: Atul Gawande, surgeon and author, and Tore Laerdal, Executive Director of the Laerdal Foundation for Acute Medicine, founder and leader of Laerdal Global Health, and Chairman of Laerdal Medical. Mr Laerdal will refer to Sunday’s Opening Ceremony, in which David Wilkinson highlighted WFSA’s opportunity for collaborative initiatives, such as the G4 Alliance and the SAFE-T programme. Dr Wilkinson also presented the Laerdal Foundation as one of the two initial Global Impact Partners for WFSA. This makes the title of Mr Laerdal’s talk this morning, Partnering for Saving Lives, very timely. Mr Laerdal will review the Utstein Formula for Survival, on how medical science is dependent on educational efficiency and good local implementation to translate into improved patient outcomes. He will also discuss three collaborative initiatives for better implementation: collaboration with WFSA, the establishment of a new Global Resuscitation Alliance and the programmes of the Survive & Thrive alliance for saving lives at birth in low resource settings. In his talk, Dr Gawande will discuss The Lancet Commission on Global Surgery, to which he contributed an accompanying commentary, and detail the work he did as co-editor of the first volume on Essential Surgery to appear in the World Bank’s highly influential compendium, Disease Control Priorities. Working in a diverse team including public health experts, surgeons and economists, the Disease Control Priorities team found that investment in first-level hospital capacity for 44 essential surgical procedures (including C-section, laparotomy, and fracture repair) is among the most cost-effective health interventions known. He will also discuss how the world will ever manage to close the gaps it has in capacity to deliver a service as complex as surgery. Following the presentations, Dr Wilkinson will moderate a discussion between the speakers with audience participation.
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    2. Updated profile: Tore Laerdal

    Tore Laerdal facilitating the "Helping Babies Breathe" course in Bangladesh

    Today we meet Tore Laerdal, who will share the stage in today’s Harold Griffith Lecture with surgeon and author Atul Gawande.

    Tore Laerdal acknowledges he is a bit different from many of the speakers at this year’s WCA, being neither a doctor or a scientist. However, this has not stopped him becoming fully engaged in issues affecting healthcare, as Executive Director of the Laerdal Foundation for Acute Medicine, founder and leader of Laerdal Global Health, and Chairman of Laerdal Medical.

    In the opening session on Sunday, David Wilkinson highlighted WFSA’s opportunity for increased impact through collaborative initiatives such as G4 Alliance and the SAFE-T programme. He also presented the Laerdal Foundation as one of the two initial Global Impact Partners for WFSA. This makes the title of Mr Laerdal’s talk today ‒ Partnering for Saving Lives ‒ very timely.

    Q: You represent a family company with a special history?

    TL: Yes, my father started the company in 1940, by making children’s books, and continuing with toys of wood and later in plastics. He introduced a very realistic toy doll with stitched hair and sleeping eyes in the early 1950s, and then changed to life-size dolls for training the general population in lifesaving, following the breakthrough of modern lifesaving techniques around 1960.

    Q: I understand there was also a personal event that influenced the change from toys to medicine?

    TL: Well yes, although I do not personally remember much of that. When I was two years old, my father saved me at the very last moment from a near drowning. That experience no doubt added to his motivation to helping train the population at large to be lifesavers.

    Ever since that time, Laerdal has focused on CPR manikins and patient simulators, as well as therapeutic equipment for resuscitation. The company has helped WFSA publish and widely disseminate three editions of its landmark CPR manual authored by Peter Safar, and has furthermore become an official alliance partner of the American Heart Association and the American Academy of Pediatrics in developing and implementing the Basic and Advanced Cardiac Life Support, as well as the Pediatric Life Support courses of these two organisations.

    Q: More recently, you have spent nearly all of your time on the needs of low resource settings. Why?

    TL: During a visit to rural hospitals in Tanzania in 2008 I saw several newborns dying right in front of me that no doubt would have had a very good chance of surviving with a better trained and equipped birth attendant. I came to realise that in spite of the important role CPR is playing in prolonging the last breath of life for victims of cardiac arrest, an even greater potential is found in helping patients take their first breath of life, by saving many of the newborns dying from birth asphyxia or being classified as stillborn while still having a beating heart during labour. And saving a newborn statistically saves 70 years of life compared to about 10 years for a cardiac arrest victim.

    For this reason Mr Laerdal established Laerdal Global Health, a not for profit company with the sole purpose of providing highly affordable and culturally sensitive training and therapeutic solutions to help reduce maternal and newborn mortality in low resource settings. He subsequently partnered with USAID, the US National Institutes of Health (NIH), Save the Children, the American Academy of Pediatrics and others in the Survive & Thrive global development alliance. This has resulted in a suite of simulation based Helping Babies Survive and Helping Mothers Survive educational programmes that have been used to train several hundred thousand birth attendants in low resource countries.

    A further 6 educational programs have later been created and implemented under the umbrella of the Survive & Thrive Alliance, which is working with 20 partners across a range of disciplines. The Survive & Thrive alliance was showcased at a United Nations session last month on the Power of Harnessing Public-Private Partnerships to End Preventable Newborn, Child and Maternal Death. “This alliance is well underway to reaching its goal of training and equipping half a million birth attendants by 2020. Imagine if each of them could save one life per year, this would mean 500,000 lives saved,” explains Mr Laerdal. He adds: “I am delighted to see the strong emphasis on global health at this conference, and look forward to collaborating with WFSA in the further development and dissemination of the SAFE-T programme.”

    Mr Laerdal serves as Chairman of the Board of two external research foundations in Norway. He holds an MSc degree from the Norwegian School of Economics and Business Administration and is an honorary member of several professional associations, including the American Academy of Pediatrics, and the European Patient Simulation Organization SESAM. He has received an Honorary Doctorate in Science from the University of Hertfordshire in the UK and is also a 2016 Oslo Business for Peace Honoree.

    For more information on the Survive & Thrive Alliance, see: https://surviveandthrive.org/Pages/default.aspx

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    3. Media coverage of the congress

    There has been further media coverage on Tuesday, with a press release titled ‘5-year study reveals patients operated on at night twice as likely to die as patients who have daytime operations’ (Poster number PR601) generating stories. i-news UK https://inews.co.uk/essentials/news/patients-likely-die-operations-night/ Daily Express, UK: http://www.express.co.uk/news/uk/704952/patients-more-than-twice-as-likely-to-die-night-operation-surgery-World-Congress-hong-kon There was also more coverage of ‘Study shows i-Pad apps to be as effective as sedatives on children needing anaesthesia, with higher parent satisfaction’ (Poster number PR237) Huffington Post: http://www.huffingtonpost.com.au/2016/08/28/ipad-as-effective-as-sedatives-for-children-before-surgery/ SBS (national TV channel, Australia) https://www.sbs.com.au/news/article/2016/08/30/night-surgery-doubles-risk-death-study

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    4. Highlights from Tuesday: Acute Medical Pain

    A three-part session on Acute Medical Pain was opened yesterday by Dr Ammar Salti, Consultant Anaesthesiologist and Pain Specialist, giving a presentation on burns pain. Dr Salti is currently the Head of Regional Anaesthesia and Pain Medicine at Sheikh Khalifa Medical City (SKMC), United Arab Emirates, and also the chairman of NYSORA Middle East (Abuu Dhabi 2015-2016).

    “Burn pain is the most difficult form of acute pain from any type of etiology,” said Dr Salti. He explained that pain has a dynamic evolution, both centrally and peripherally, with many factors influencing pain perception. Consequently there is a need for a clear therapeutic plan to deliver treatment that is “dynamic and flexible enough to cope with the facets of background, breakthrough, procedural and post-operative pain” – treatment directed by ongoing pain assessment.

    Opioid analgesics provide the backbone of pain control for burns patients – giving an excellent range of potencies, duration of actions and routes of administration. However, Dr Salti explained: “They can have clinically relevant side effects and have been implicated in hyperalgesia. As such there is increasing recognition of the benefits of the addition of NMDA receptor antagonists such as ketamine and gabapeninoids to opioids for pain control, as well as the usefulness of non-pharmaceutic methods for some patients.”

    Dr Salti said that an environment where pain is given a high clinical priority is invaluable, this presentation being based around practical guidance and examples for all health professionals. He concluded by recommending the “addition of pain specialists as an integral part of the burns multi-disciplinary team”.

    In another presentation Professor Stephan A Schug focused on best practice in acute pain. Professor Schug is a Professor of Anaesthesiology and the Chair of Anaesthesiology in Pharmacology at the University of Western Australia, and Director of Pain Medicine at Royal Perth Hospital. He is also currently a Visiting Professor at the Department of Anaesthesiology and Intensive Care at the University of Münster, Germany.

    Professor Schug discussed the strong evidence base for the benefits provided by multimodal analgesia – the combined use of multiple analgesic medications or techniques with different mechanisms or sites of action. He explained that the use of appropriate combinations produces synergistic effects and improved analgesia, leading to reduced dose requirements and side effects. Current evidence supports the use of paracetamol, NSAIDs, coxibs, alpha-2-delta modulators, ketamine, and clonidide in multimodal analgesia, along with local anaesthetics, both systemically and via regional anaesthesia techniques.

    Also gaining importance, said Professor Schug, is the use of some of these medications in preventive analgesia – whereby medications show a longer effect on pain than pharmacological parameters such as half-life would suggest. “This benefit is currently being shown, for example, by local anaesthetics and ketamine, and could lead to a reduction of persistent post-surgical pain,” he concludes.

    In the other presentation in this session, the acute sickle cell crisis was covered by Dr Dave Otieno, Past President of the Kenya Society of Anaesthesiologists.

    Note: The current evidence in acute pain management has been recently summarised in the fourth edition of the document ‘Acute Pain Management: Scientific Evidence’ by the Australian and New Zealand College of Anaesthetists (ANZCA) and its Faculty of Pain Medicine (FPMANZCA); it can be accessed at http://fpm.anzca.edu.au/Resources/Publications and ordered in print from the College office.

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    5. Highlights from Tuesday: Teaching in difficult circumstances
    This 3-part session on Tuesday morning was opened by Mark Newton, Professor of Clinical Anesthesiology based mostly at Kijabe Hospital, Kenya, and also Vanderbilt University, Nashville, TN, USA, where he is Director of Vanderbilt International Anesthesia.
    He discussed how the surgical rate per 100,000 population in sub-Saharan Africa has improved from 281 in 2004 to 595 in 2012; however, at this rate of change, it would take a further 100 years to reach the hypothetically high enough rate of 5000 per 100,000 population to meet basic population demand. Currently, 78% of people globally (5 in 7) have no access to safe anaesthesia or surgery; this is projected to fall to 73% by 2035, yet in actual numbers this means 6.2 billion people will be without access in 2035. The goal of an average 20 surgeons, anaesthesiologists and obstetricians per 100,000 population also remains a distant goal – this would require an extra 1.27 million of these professionals by 2030, requiring an 11-fold increase in trainees entering medical school. Dr Newton talked of the challenges facing his own hospital north of Nairobi, in Kenya, and their drive to persuade all visiting educators to commit to at least two years with the hospital. Multiple countries, both within Africa and high-income regions, send trainees to Dr Newton’s hospital for training as educators. He discussed the importance of the faculty at host institutions driving the teaching programme and ensuring all educators and trainees are gaining maximum benefit and experience. Key components of successful development of teachers discussed included identifying possible teachers early, even before their anaesthesia training; encouraging potential teachers; extending their knowledge to a deeper level, providing advanced education programmes; clinical and didactic tools for teaching, supervision by senior educators and feedback, and making education of these ‘next educators’ a priority in hospital, despite the very heavy clinical workload. This backbone has been the key to building successful training programmes in Kenya, South Sudan, and Somaliland (part of Somalia).

    In the second presentation, Dr Orawan Pongraweewan of Siriraj Hospital, Bangkok, Thailand, discussed her experiences teaching trainees in the Bangkok Anesthesia Regional Training Center (BARTC), which provides WFSA fellowships. A total of 8 centres across the region, including paediatric centres, are involved in the programme.

    Dr Pongraweewan said that English speaking was a big issue for the programme, since all teaching is delivered in English, not Thai or other languages. However, in the past many trainees were arriving in the past with inadequate English skills; the programme has since introduced an English telephone interview for all potential trainees, so that everyone who arrives is at a good enough standard. She also said that some trainees, especially from colder climates in Bhutan and Mongolia, struggled to adjust to the warm Thai weather.

    She provided details of the 12-month training programme structure, saying that simulation and directly observed skills were very important components. She also discussed refresher courses that are held in different countries around the region, and the hospital visits that can reveal some endemic problems, for example one operating room in Cambodia had three operating tables in the same theatre, which can lead to mix-ups and errors. She ended by appealing to delegates to donate to WFSA’s Fund-a-Fellow initiative, which provides living and travel expenses for fellows.

    The final talk was given by Dr Zeev Goldik, the President of the European Society of Anaesthesiology (ESA) and Head of the Post Anaesthesia Care Unit, Carmel Medical Centre, Haifa, Israel. Dr Goldik’s talk was on ‘Teaching on the run - teaching in a busy hospital’.

    He asked the audience to imagine (as many of them probably easily could) – a busy day, with a busy preoperative assessment clinic, requiring seeing a patient every 10 or 20 minutes. The clinic must start at 9 and if lucky you finish at 12. You have another commitment at 2pm. Then you remember you have four trainees with you. “You need time to brief, and this could delay the clinic by up to 30 minutes,” says Dr Goldik. “You also want to allow the students to do certain things, such as allocate them to part of the consultation, and observe a particular skill such as physical examination.” The lack of time can leave the doctor (educator) thinking they have done a bad job in their clinic and a bad job as a teacher. He also talked about the imbalance between what the teacher does and what the student does, leading to the conclusion that traditional training is hard to maintain in modern hospital settings. “We have to move into different doctrines of teaching,” he says. He discussed the Israeli Department of Health’s Gold Guide of Teaching, saying teachers need to be available, look over the shoulder of their trainees, teach on the job with professional conversations, and provide regular feedback. In his comprehensive talk, Dr Goldik discussed the range of barriers than can prevent quality teaching, including difficult trainees, personality mismatches and other factors. He concluded by saying “Effective supervision develops medical professionalism and contributes to improved patient safety, better health outcomes and faster acquisition of skills by trainees. Health systems must commit to provide the human and financial resources necessary to provide effective supervision.” A lively question and answer session followed the session.
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    6. Global oximetry and Lifebox: now and then
    Grand Hall, 1345-1515H

    A session about the Lifebox initiative will take place this afternoon, with four speakers discussing this project which aims to provide operating theatres in developing countries with vital pulse oximeter devices to improve the safety and quality of anaesthesia and surgery.

    The first presentation will be by Dr Iain Wilson, former President of the Association of Anaesthetists of Great Britain and Ireland (AAGBI), which was a key partner in launching the Lifebox project. He will give a talk titled ‘why an oximeter?’. “The pulse oximeter is the simplest and most essential monitoring tool to help the anaesthetist to ensure anaesthesia is safe. It became common in clinical practice in 1980s, transforming the safety of anaesthesia ‒ yet many operations worldwide are still performed without it,” explains Dr Wilson, who is a Consultant Anaesthetist at the Royal Devon and Exeter NHS Foundation Trust, UK. He will highlight that the Lifebox Pulse Oximeter can be delivered anywhere in the world for just US$250, and highlight the initiative’s fantastic achievements to date: more than 13,500 Lifebox devices sent to 100 countries, and an estimated 10 million patients who have received safer anaesthesia and surgery thanks to the project.
    The second invited speaker is Joe Kiani, Founder, Chairman and CEO of Massimo Corporation, the global medical technology company credited with revolutionising pulse oximetry. His talk will address the history and future of oximetry.
    Before pulse oximeters, a patient’s oxygenation could only be determined by arterial blood gas – a measurement that required sample collection and processing, typically, by a laboratory. “Given the need for more rapid information, anaesthesiologists had to check for visual cues like the colour of a patient’s lips,” says Mr Kiani. “The pursuit of noninvasive oxygen measurement dates back to 1935, but it wasn’t until the invention of pulse oximetry in 1972 and commercialisation in 1981, that continuous and noninvasive monitoring of oxygen saturation became available for day to day use.” Unfortunately, pulse oximeters were unreliable during patient motion and low perfusion and clinicians were forced to live with the consequences – excessive false alarms as high as 90%, inaccurate data and an inability to obtain data on the most critical patients. In 1995, Masimo introduced the Signal Extraction Technology (SET®) Pulse Oximeter, the world’s first measure through motion and low perfusion pulse oximeter. With SET, clinicians were able to not only get reliable measurements when other pulse oximeters failed and virtually no false alarms, but use SET pulse oximetry to reduce retinopathy of prematurity in the neonatal intensive care unit, screen for critical congenital heart disease in newborns and monitor active patients in the post-surgical wards at risk of hypoxaemia. Looking to the future, Mr Kiani says: “With rainbow multi-wavelength technology, pulse oximeters continue to advance and oxygen saturation will give way to oxygen content and we will have access to measurements like oxygen reserve index, carboxyhaemoglobin, methaemoglobin, total haemoglobin and an index to guide fluid administration. With power and size reduction, SET Pulse Oximeters for smartphones, like iSpO2, will allow clinicians in countries with very little resources to finally gain access to clinically useful pulse oximetry. “

    The third speaker, Dr Rob McDougall, is Deputy Director of Anaesthesia and Pain Management at Royal Children’s Hospital, Melbourne and has been involved with the WFSA, in various roles, since 2000. He assisted with the development of the Lifebox education materials and has helped coordinate the introduction of Lifebox to a number of countries in the Asia Pacific region.

    In his talk ‘Lifebox challenges and solutions’, Dr McDougall will discuss how the Australian Society of Anaesthetists has assisted the introduction of Lifebox across Asia Pacific region, with local national societies of anaesthesiologists from the Mongolian Steppe to the remote islands of Tonga. “Each project has required a different approach,” he says. “This talk will examine some of the challenges faced and facing Lifebox in our region, including what has worked and what has not worked so well. Issues covered include needs analysis, distribution, the challenges of customs, education and follow-up.” He will also highlight how the Australian Society of Anaesthetists, the Australian and New Zealand College of Anaesthetists, the New Zealand Society of Anaesthetists and Interplast Australia & New Zealand have recently joined forces to form Lifebox Australia and New Zealand. “This new entity will bring together a number of ongoing Lifebox project in the Asia Pacific region and allow greater capacity for new projects,” he concludes. In the final presentation, Dr Sandra Izquierdo (Universidad Francisco Marroquín. Facultad de Medicina, Ciudad de Guatemala, Guatemala) will discuss the work of Lifebox in Guatemala and the unique issues and challenges encountered there.
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    7. Perioperative Stroke
    Convention Hall B, 13.45 - 15.15

    In this session, chaired by Dr Deepak Sharma, University of Washington, Seattle, WA, USA, the panellists will discuss the implications of perioperative stroke for anaesthesiologists, specifically the treatment goals of ischaemic and haemorrhagic stroke. Dr Sharma is a Professor and Division Chief of Neuroanaesthesiology and Perioperative Neurosciences at the University of Washington. He is also Chair of the Education Committee of the Society for Neuroscience and Anesthesiology and Critical Care (SNACC).

    The panel is SNACC affiliated, and all the panellists are renowned experts in this field. “Perioperative stroke is a rather uncommon and under recognised complication – yet occurs at much higher rates after non-neurological surgery than most anaesthesiologists think,” says Dr Sharma.

    It can be ischaemic (embolic or thrombotic) or haemorrhagic. Prompt recognition of change in neurological status is critical, and has to be followed by rapid neuroimaging to identify the type of stroke to facilitate appropriate treatment. The panellists will examine the epidemiology and prevalence of perioperative stroke and the risk factors for the condition, discussing the medical, interventional radiological and surgical treatment options, their indications and the associated risks and benefits. Possible etiologies and evidence based strategies to prevent stroke after cardiac and neurologic surgeries will be discussed, with analysis of these potential strategies (including vasopressor / inotropic choices) and haemodynamic goals. Firstly, Dr Ruquan Han, from China, will present ‘perioperative stroke – more common than you think.’ This will be followed, in the second presentation, by Dr Andrew Kofke who will discuss the implications of haemorrhagic stroke for anaesthesiologists.

    Dr Kofke has been Director of Neuroanaesthesia at the Universities of Pittsburgh and West Virginia, USA, and is currently the Director of Neuroscience in Anaesthesiology and the Critical Care Programme at the University of Pennsylvania, USA.

    “Stroke is the third leading cause of death and leading cause of disability,” says Dr Kofke. “Of all strokes, 9% are due to intracerebral haemorrhage (ICH). Such patients frequently require management by anaesthesiologists in the operating room or intensive care unit.” Dr Kofke will discuss the various issues that must be dealt with by anaesthesiologists regarding ICH. He will begin with a discussion on ICH expansion, and the ongoing concerns regarding identifying and dealing with a spot sign on imaging, and other factors that might support ICH expansion. He will go on to discuss the role of blood pressure management, saying: “Studies vary on periclot ischaemic penumbra and the role of blood pressure management in fostering ischaemic injury versus clot expansion and the data on providing the correct blood pressure. Population based data are not very clear.” The management of ICH related to anticoagulants will also be discussed. “Patients often arrive with ICH due to or exacerbated by anticoagulant or antiplatelet drugs,” explains Dr Kofke. He will review issues of ICH with concurrent use of these medications, for example Coumadin and Heparin. The presentation will then focus on the risks of aggressive vs passive management of hyperglycaemia – as both high and low glucose may worsen ICH. Finally the multiple options for surgical interventions for ICH will be discussed.

    The third presentation, by Dr Chin T. Chong, will discuss the particularly high risk of perioperative stroke for patients undergoing cardiac and neurological surgery. Dr Chong is a Senior Consultant and the Head of the Neuroanaesthesia Service in the Department of Anaesthesiology, Intensive Care and Pain Medicine in Tan Tock Seng Hospital, National Healthcare Group in Singapore.

    “Perioperative stroke significantly increases perioperative morbidity and mortality, disproportionately more than stroke outside the context of surgery,” says Dr Chong. He will consider frequently asked questions in perioperative stroke management, with regard to the mechanisms of perioperative stroke in cardiac and neurological surgery, the risk factors, the types of procedures that are especially susceptible to stroke risk and what risk modification strategies can be implemented and the role of neuroimaging in the management of perioperative stroke. He concludes: “My presentation will provide an evidence-based review of these questions and comments on potential preventative measures in the management of these patients.”

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    8. Building bridges in paediatric anaesthesia
    Theatre 1, 13.45 – 15.15

    This 3-part session will be opened by Professor Fauzia A Khan, Professor of Anaesthesia at Aga Khan University, Karachi, Pakistan.

    Professor Khan will focus on the need to strengthen research capacities in low- and middle-income countries (LMIC), where there are multiple barriers to research, including a lack of basic research skills, resources and infrastructure ‒ and a lack of mentors. “Anaesthesia in particular has a problem as it has issues of insufficient man power to deal with clinical workloads as well as unavailability of basic equipment,” explains Professor Khan. Bigger health issues like infectious diseases dilute what meagre research funds are available and there are difficulties getting anaesthesia research results into prestigious journals.

    Professor Khan will suggest a ‘multipronged’ approach to decrease the research gap between LMIC and developed nations, with roles for national societies and colleges, regional meetings, digital technology and the development of centres of excellence. Whilst the research models of developed countries need not be replicated all the time, Professor Khan says: “LMIC should develop their own models for their own needs and generate solutions to local problems. Developed nations can assist via collaborations, project funding and publishing of research. The strengthening of research capacity in LMIC is a powerful, cost-effective and sustainable means for improving health care.”

    In the second presentation Dr Mark Gacii will discuss the challenges faced in paediatric anaesthesia in Kenya. Having worked in both adult and paediatric cardiology and general paediatric anaesthesia for 15 years, Dr Gacii currently lectures in the Department of Anaesthesia in the University of Nairobi. He is also a Coordinator of the recently introduced WFSA Paediatric Anaesthesia Fellowship programme.

    The estimated population of Kenya is 46 million, with some 42% aged under 14 years. Skilled and trained anaesthetists are needed to manage the issues of this unique age group, including diseases requiring both invasive and non-invasive diagnostic procedures, congenital and acquired surgical conditions, trauma and burn injuries. This burden is high, says Dr Gacii, yet Kenya has only 12 specialist paediatric anaesthesiologists. “Other provision comes from physician anaesthetists, clinical officers and nurse anaesthetists – many of whom are not comfortable with children,” he explains. Additional problems include a lack of facilities, including anaesthetic equipment, supplies and drugs. “This is a particular issue for peripheral hospitals, where facilities to care for very sick children are often not available,” says Dr Gacii. “Long distances, a lack of transport, and demand for beds makes transfer to more equipped centres problematic.” Solutions to improve this outlook that Dr Gacii will discuss include the establishment of a WFSA Paediatric Anaesthesia Fellowship, to enhance training both in Kenya and the East African region, as well as courses such as SAFE Paeds, strengthening continuous medical education, and coming up with guidelines and policies.

    In the third presentation, Dr Isabeau Walker will describe the SAFE paediatric anaesthesia course. Dr Walker is a consultant paediatric anaesthetist at Great Ormond Street Hospital NHS Foundation Trust, London, UK. She is also a trustee of both the Association of Anaesthetists of Great Britain and Ireland (AAGBI) Foundation and the Lifebox Foundation, and will finish her second term as Chair of the WFSA Publications Committee this year.

    SAFE paediatric anaesthesia, explains Dr Walker, is a 3-day ‘off the shelf’ short course that supports the adult learner via a range of educational tools including short lectures, small group discussions, and skills and video demonstrations, alongside a ‘robust monitoring and evaluation programme.’ Written by specialist paediatric anaesthetists from the UK, Canada, the US and Australia, and piloted in Great Britain, Ireland, and Uganda in 2014, the course has now been run in 6 countries with more than 200 anaesthetists trained.

    In addition, the course is supported by a train the trainer course, with 40 specialists now trained as trainers. “Bridges are being formed between specialists and non-specialists, between anaesthetists from around the world, and between providers in cities and in rural areas,” concludes Dr Walker. “The aim of all is to improve outcomes for children undergoing anaesthesia and surgery.” A fourth presentation, ‘From USA to Africa’, will be given by Mark Newton, Professor of Clinical Anesthesiology based mostly at Kijabe Hospital, Kenya, and also Vanderbilt University, Nashville, TN, USA, where he is Director of Vanderbilt International Anesthesia.


    1. Profile: Dr Bisola Onajin-Obembe

    Dr Bisola Onajin-Obembe is the chair of the African section of the WFSA, and until her career break in 2015 was a Consultant Anaesthesiologist at the University of Port Harcourt Teaching Hospital and Assistant Professor of Anaesthesia at the College of Health Sciences of the University of Port Harcourt, Nigeria.

    Here we get to know more about Bisola, including her WFSA work.

    Q: Tell us a little about you and your areas of specialism?

    BO-O: In my role at Port Harcourt, I was head of department of anaesthesiology and my most recent role was head of the anaesthesia team for paediatric, maxillofacial and ear, nose and throat surgeries. I love airway management, which these specialties have in common. I have always been interested in areas where strong teamwork is required.

    Both my parents are from Ondo Town in Ondo State (western part of Nigeria) but they moved to live and work in Lagos in the early 60’s. I was born and raised at Ikeja, mainland Lagos. I studied medicine at the Obafemi Awolowo University, Ile-Ife (former University of Ife) and I graduated in 1988. The peaceful and quiet life of the university campus at Ife contributed to my love for semi-urban cities.

    Q: What made you choose medicine and anaesthesiology as your career?

    BO-O: I wish I could say that my love for medicine made me choose it as a career but it was actually my mother’s choice! I wanted to be an architect so that I can create and build beautiful homes. Therefore, I tried to fail out of medicine to go study architecture. But I did not like the taste of failure so I buckled up, completed the medical school with an intention to look for something more exciting to do!

    Marriage was the next adventurous thing to do! So I got married in 1989 to my husband, Bunmi Obembe who worked for an oil and gas company in Port Harcourt at that time. I had my first son, Daniel in 1990 and within the first five years of marriage, we had lived in Nigeria, France and Holland! Living in Europe was super until I had enough of being a housewife and as soon as we got back to Nigeria, I started residency in anaesthesiology. Then I had two more sons Samuel (1996) and David (1998). My family has been very supportive.

    For me, anaesthesiology was a specialty that can support a lot of movement and travelling and if my family needed to move again or relocate, I would still have my skills. I therefore completed my residency in anaesthesia between 1995 and 2001 at the Lagos University Teaching Hospital, Nigeria and was conferred with Fellowship of the West African College of Surgeons (FWACS). During my residency training, I was blessed to experience a year abroad which I spent mostly at the Hillingdon Hospital, Middlesex, UK. I was supervised by Dr Andrew Thorniley and this gave me an invaluable international exposure in anaesthesia.

    I was also blessed to have gained some regional exposure at the Service d’Anesthésie Réanimation, Centre National Hospitalier et Universitaire de Cotonou (CNHU), Republic de Benin from July to August, 2011. I was sponsored as a Fellow of the West African Health Organization for professional and linguistic exchange programme within the Economic Community of West African States (ECOWAS). I worked with Drs Martin Chobli and Eugene Zoumenou.

    Q: Tell us about your role with WFSA and as chair of the Africa Regional Section.

    BO-O: My role as chair of ARS was divinely orchestrated. I happened to be at the right place, at the right time with the right attitude – helping to make things happen. Getting involved started with my nomination to the board of ARS by the then president of Nigerian Society of Anaesthetists (NSA), Prof Eniola Elegbe. This was at the 4th All Africa Anaesthesia Congress (AAAC) in Kenya, in 2009. Prior to that, I was alternate delegate at the World Congress of Anaesthesiologists (WCA) 2008 in South Africa. I attended the meetings with the NSA president, Dr Niyi Oladapo. Over the years, I found myself helping out leaders who needed my help.

    My involvement in WFSA moved up a notch when I became the interim ARS executive secretary/treasurer at the WCA 2012 held at Buenos Aires. Prof Arthur Rantloane, ARS former President emailed the information I needed for the role since there was no handover. I am therefore a product of the African proverb, “it takes a village to raise a child” having been mentored by many people.

    I see my role in WFSA more like an African anaesthesia ambassador and a participant that fills the gaps. I try to show up for meetings, listen, learn, ask questions, and be a vital voice for African anaesthesia. I represented the WFSA, as a Bellagio Commissioner of The Lancet Commission on Global Surgery in March 2015. I also represent the Nigerian Society of Anaesthetists as a Permanent Council Member of the Global Alliance for Surgery Obstetrics, Trauma and Anaesthesia Care (G4 Alliance). I believe that to be a positive influence, we must be involved. Many decisions that were made, up until recently, have been without much input from anaesthesia globally and African anaesthetists particularly. I am glad that this is changing.

    I have also played a role in closing the communication gap between English speaking and French speaking nations in Africa basically because I speak conversational French. I continue to work to achieve a level of friendship that will encourage networking. I believe we ought to be able to collaborate within and across regions in Africa and learn a lot from one another. The diversity in Africa can become our main strength.

    Q: Do most African nations now have a national society, and what can WFSA do to help those that do not?

    BO-O: To date, we have 30 national member societies in Africa. The WFSA has created awareness of anaesthesia and they are committed to the formation of national societies. To be a national or regional society member of the WFSA, there must be at least 5 physician anaesthetists within a country or 5 within a region. The minimum number of anaesthetists was reduced from 10 to 5 by WFSA to encourage inclusiveness. It is also possible for a group to form a subset within the region. For example, Société d'Anesthésie et de Réanimation d'Afrique Noire Francophone (SARANF) is a subset society made up of 6 French speaking African countries. The WFSA encourages information sharing and training and therefore sponsors facilitators to attend national conferences and workshops.

    Q: One of your talks at this WCA is on African patient safety initiatives. What kinds of things will you cover?

    BO-O: My talk on African patient safety initiative takes a lead from Farmer and Mukerjee’s statement that the delivery of safe surgery and anaesthesia is a reflection of the “staff, stuff, space and systems”. The importance of the WHO Safe Surgery Checklist, Lifebox, hand washing and many initiatives locally, nationally and internationally have been well documented. I will present the “staff” and what we can learn from the origin of physician anaesthetists training in West Africa, as well as the initiative taken by the surgeons in West Africa. Lessons learnt and opportunities for improvement will be examined because human resources are the backbone of any health care delivery system.

    Q: The AAAC will soon be every two years instead of every four. How important is that meeting to African anaesthesiologists?

    BO-O: The AAAC is the Olympics of anaesthesia in Africa just the way the WCA is to the world. The majority voted at the last AAAC in Cairo, Egypt that we meet more often to sustain the momentum. A lot of changes occur in four years and African anaesthetists want to be current. Although hosting a large regional meeting requires a lot of work, we need to define the direction and framework that we want our meetings to take. The ideal situation is to have strong national societies in Africa that are self-sufficient and able to host their own annual meeting. Mark your calendars for the 6th AAAC at Abuja, Nigeria from 20 to 24 November, 2017. And please visit the ARS booth V113.

    Q: What are your aims for the rest of your career?

    BO-O: I will continue to advocate for anaesthetists to take the lead and play a more strategic role in developing our profession. I have an interests in strategic leadership and change management and I am doing an executive PhD program at the International School of Management, Paris. This could lead me anywhere!

    Q: Are there any other sessions that you are looking forward to at this year's congress?

    I look forward to the Education and Development track and the Safety and Quality track. It will be interesting to listen to various views on global surgery and anaesthesia. I will spend time networking and hope to meet with national Presidents of member countries of ARS and other regions.

    Thank you Bisola, and we hope you are enjoying the Congress.

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    2. Information on today's play and concert performance

    ‘Do You Know Me?’ Theatrical Play & Performance of ‘Hush 11: Luminous’

    Planned performances on September 1 in Theatre 2 – HKCC from 14:00

    The Hush Foundation (Hush) in collaboration with renowned Australian playwright, Alan Hopgood, presents “Do You Know Me?”. A collection of short plays with a basis on Aged Care, “Do You Know Me” touches on a range of difficult topics including the end of life and understanding, extension of life through medical intervention and caring for the aged.

    Providing an innovative way to engage the audience in discussion about the experience of care and the importance of partnering with patients and families, the performance is followed by a discussion forum with the audience, facilitated by Hush founder, Dr Catherine Crock.

    With a planned performance on Thursday 1 September at 14:00pm in Theatre 2, this provocative play aims to improve communication between staff and residents by illustrating that every person has a story to tell.

    Following the performance of ‘Do You Know Me?’, notable Australian composer and musician Joe Chindamo will perform a number of classical piano pieces from ‘Hush 11: Luminous’ at 16:00pm in Theatre 2. Inspired by illustrious classical composer, Wolfgang Amadeus Mozart, ‘Hush 11: Luminous’, features thirteen tracks of re-imagined classics especially curated for the hospital setting to reduce anxiety during high stress situations.

    Be whisked away on a musical pilgrimage through 18th century overtures and symphonies and discover the work Hush is doing to transform the culture of healthcare. See what it can do for you and your hospital or medical institution.

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    3. Media Coverage of the Congress
    There was more coverage of ‘Study shows i-Pad apps to be as effective as sedatives on children needing anaesthesia, with higher parent satisfaction’ (Poster number PR237). TIME Magazine USA: http://time.com/4472306/its-official-ipads-are-sedatives-for-kids/ Newsweek USA: http://www.newsweek.com/ipads-work-sedatives-calm-children-494499 CBS News local, USA: http://pittsburgh.cbslocal.com/2016/08/30/study-ipad-as-good-as-sedative-at-calming-kids-before-operations/ CTV News Canada: http://www.ctvnews.ca/health/touchscreen-tablets-as-effective-as-sedatives-for-pre-surgery-anxiety-in-children-study-1.3050021 News.com.au (national Australian news site) http://www.news.com.au/national/breaking-news/ipads-work-like-a-sedative-presurgery/news-story/dced70ddccc13c2c8b24a47b37cb7540 There has also been further media coverage on Wednesday of ‘5-year study reveals patients operated on at night twice as likely to die as patients who have daytime operations’ (Poster number PR601) Medscape: http://www.medscape.com/viewarticle/868160
    4. Highlights from Wednesday: The Harold Griffith lecture with Tore Laerdal and Atul Gawande

    WFSA President Dr David Wilkinson had the pleasure on Wednesday of introducing not just one but two keynote speakers who shared the stage in an enthralling session. First up was Tore Laerdal, Executive Director of the Laerdal Foundation for Acute Medicine, founder and leader of Laerdal Global Health, and Chairman of Laerdal Medical, all based in Norway. He gave a fascinating history of the company, including on how his father had saved him from a near drowning as a 2-year-old, and how he developed life size dolls for children and later full sized manikins to help train Norwegian healthcare workers and the general public (including schoolchildren) in lifesaving techniques.

    He talked of a key moment in his own career: during a visit to rural hospitals in Tanzania in 2008 where he witnessed two newborns dying, he realised better trained birth attendants and equipment could have saved their lives. Having spent much of his previous career on the importance of preventing people having their last breath of life through lifesaving after cardiac arrest, Mr Laerdal saw the potential of helping babies take their first breath of life, by saving many of the newborns dying from birth asphyxia or being classified as stillborn while still having a beating heart during labour. And saving a newborn statistically saves 70 years of life compared to about 10 years for a cardiac arrest victim. Some 1 millions babies wrongly classified as stillborn (they have a beating heart during labour) are among those children under 5 years old dying unnecessary, preventable deaths. Mr Laerdal discussed the vital one-minute window that follows birth in terms of the traffic light colours red, yellow and green. Although most babies are born in the green low danger zone, for those in the yellow zone there is only around a minute to solve their breathing problems before they deteriorate into the red zone and die. For this reason Mr Laerdal established Laerdal Global Health, a not for profit company with the sole purpose of providing highly affordable and culturally sensitive training and therapeutic solutions to help reduce maternal and newborn mortality in low resource settings. In the years that followed, Laerdal Global Health has joined with USAID, the US National Institutes of Health (NIH), Save the Children, the American Academy of Pediatrics and others in the Survive & Thrive global development alliance. This alliance has developed and implemented multiple programmes to save the lives of mothers and babies. “This alliance is well underway to reaching its goal of training and equipping half a million birth attendants by 2020. Imagine if each of them could save one life per year, this would mean 500,000 lives saved,” explains Mr Laerdal.

    Dr Gawande discussed the enormous task facing medicine in deploying its vast modern capability – including several thousand different procedures and drugs ‒ to every town and person in the world. He discussed his own roots in the town of Athens, Ohio, and also his father’s upbringing in a village in rural India, where much of his family still lives. He discussed the economic development that has gradually improved living standards in India, allowing some people to afford private health insurance and driving the development and expansion of hospital services in the biggest town nearby. He also mapped out how public health services had developed in the village, with an anaesthetist from the area returning to work there 7 years ago after his father’s health problems exposed the lack of local capacity. By working with his wife (an obstetrician) and working on a mix of private and public cases, vital services were being provided while at the same time making his clinic financially viable. Dr Gawande discussed his role in the developing the WHO Safe Surgery Checklist, and his role as Chair of the Lifebox Initiative, which distributes vital pulse oximeters (the only equipment based component on the list). Among the 13500 Lifeboxes so far distributed to 100 countries worldwide, 3 have gone to the new clinic in his father’s old village to boost the safety of anaesthesia and surgery there. He also discussed how the world will ever manage to close the gaps we have in capacity to deliver a service as complex as surgery. “People think that it’s about having enough expertise—anaesthesiologists, surgeons, nurses,” he said. “But it is much more than this—it requires somehow building infrastructure, procurement systems, management. And yet as economies grow, numerous countries have managed to do it.” However the concerning pattern, he noted, is that the growth of surgical capacity repeatedly outpaces the growth in safety and quality for any given region in the world. “The consequences can be devastating for large numbers of patients,” he said. Procedures that might have a 1% mortality in high income regions can see 3-20% rates in middle income countries. He referred to the horrific case in an Indian hospital where many women died from sepsis related complications after what should have been a simple tubal ligation operation, due to inadequate hygiene and sterilisation equipment and practices. Dr Gawande also discussed his work around The Lancet Commission on Global Surgery, of which he was a co-author and detailed the work he did as co-editor of the first volume on Essential Surgery to appear in the World Bank’s highly influential compendium, Disease Control Priorities. Working in a diverse team including public health experts, surgeons and economists, the Disease Control Priorities team found that investment in first-level hospital capacity for 44 essential surgical procedures (including C-section, laparotomy, and fracture repair) is among the most cost-effective health interventions known.

    Following the talks, Dr Wilkinson presented both speakers with the Harold Griffith Award, and also paid tribute to their communication skills, saying that part of the problem the medical community faces in dealing with the lack of access to safe surgery and anaesthesia is the problem it has in actually communicating the nature and size of the problem to the world. The speakers then posed for photos with delegates.

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    5. Global anaesthesia workforce expansion
    Room S421, 1400-1530H This 4-part session on Thursday will be opened by Dr Bisola Onajin-Obembe, President of the African Section of WFSA, who will discuss the findings of The Lancet Commission on Global Surgery.

    “A key finding of the Commission, published in 2015, is that 5 billion people lack access to safe, affordable, surgical and anaesthesia care when needed,” says Dr Onajin-Obembe. “Most of these people reside in the poorest regions of the world.” She adds 93% of the population in sub-Sahara Africa and 97% of the population in South Asia do not have access to safe and affordable surgery and anaesthesia compared with 3.6% of the population who do not have access in high income countries (HIC). The global workforce estimate in low and middle-income countries (LMICs), shows that 12% of the specialist surgical workforce (surgeons, anaesthetists, obstetricians) practice in Africa and South East Asia, regions which contain a third of the world population, and where the workforce is most affected by the shortage and maldistribution. “The main constraints to essential anaesthesia in LMICs are obvious, but the hard facts show us how critical the anaesthesia workforce is to the success of any healthcare programme,” concludes Dr Onajin-Obembe. “The anaesthesia workforce is the full responsibility of specialist anaesthetists. To reduce the morbidity and mortality associated with low workforce density, we need to find solutions to make surgery and anaesthesia available, affordable, timely and safe.”

    The second presentation will be by Dr Peter Kempthorne, who will discuss mapping of the anaesthesia workforce. Dr Kempthorne is a paediatric anaesthetist working in Christchurch (affiliated to the University of Otago), New Zealand. He has an interest in the planning of how to provide equity of access to quality paediatric anaesthesia and surgery throughout a country. In the past he was a WFSA Executive Committee Member representing Australia, New Zealand and the Pacific. He also ran the WFSA website for many years.

    “At the 2004 World Congress of Anaesthesia in Paris, I was given the task of counting and characterising the providers of anaesthesia for the world and to present this at the WCA in South Africa in 2008,” explains Dr Kempthorne. “After this initial success it was later decided to turn this into a continuing information gathering process. With the expansion of the WFSA secretariat in London a fresh start was made during 2015-2016 with an online survey return to make it easier.” Over 88% of the world population from 109 countries has now been documented providing information about who makes up the half million that provides anaesthesia for 6.4 billion. Dr Kempthorne says: “It has also revealed the huge gulf between those adequately provided for by over 30 providers of anaesthesia per 100,000 people to those who are served by less than 0.02 per 100,000.”

    The third presentation, on task sharing in Benin, will be given by Professor Eugene Zoumenou Faculté des Sciences de la Santé – Cotonou, Benin. He will highlight that the number of physician anaesthetists in French-speaking Africa is about 370; and non-physician anaesthetists number around 4000. The ratio of physician anaesthetists is 0.16 per 100,000 population, compared with 1.5 in Maghreb and 15 in France.

    Non-physician anaesthetists are nurses or midwives who have carried on with a 3-year specific anaesthesia training program. They are trained for all types of general anaesthesia and spinal anaesthesia. In Benin, only 22 physician anaesthetists are practicing in the 5 major cities. Wherever there are no anaesthetist doctors, non-physician anaesthetists may practice alone. Therefore, non-physician anaesthetists are managing over 80% of anaesthesia cases in the country. In every hospital where there is an anaesthetist doctor, the latter is the chief of anaesthesia department, who is responsible for all patients’ preoperative assessment and the choice of anaesthesia techniques. The chief is not systematically involved in the intraoperative anaesthetic management of patients, although he will take care of particularly difficult patients and any perioperative complications. “There can be conflicts between physician and non-physician anaesthesists, including leadership conflicts, excessive delegation of power, lack of communication and the pretension of some non-physician anaesthetists to consider themselves a doctor and omitting the actual doctor from decisions,” explains Professor Zoumenou. The Cotonou program, a Benin-Belgium cooperation created since 1996, has seen over 100 anaesthetists doctors graduate from 13 French speaking African countries. Over 180 non-physician anaesthetists have also graduated from the Benin Nurse Anaesthetists Programme. “We must continue because where there is no doctor or nurse anaesthetist, anaesthesia is practiced by a non-graduated health care worker, ” concludes Professor Zoumenou.
    In the final presentation, Dr Jannicke Mellin-Olsen, one of the two newly elected Presidents of WFSA, will discuss task sharing in high-income countries. Dr Mellin-Olsen is based at Baerum Hospital, Oslo, Norway, doing clinical work in many fields of anaesthesia, critical emergency and intensive care medicine. She has a particular interest in patient safety, education and workforce issues.
    The presentation will describe several models of how anaesthesiologists practice in cooperation with nurses and other providers in Europe. There will be special focus on the Scandinavian/Norwegian model, which has evolved from a nurse anaesthetist only model into the physician anaesthesiologist led model based on the flexible anaesthesia team. “This development was welcomed and encouraged by the nurse anaesthetists who were relieved to get rid of some responsibility,” explains Dr Mellin-Olsen. “There is always a physician in charge of every anaesthetic, but not all anaesthetic procedures require the same team set-up. This flexible model ensures safe anaesthesia for all patients.” She adds: “There is remarkably little tension between the professional groups, and anaesthesiology is among the most popular and prestigious medical specialties in the country. Countries vary in culture and tradition, so no model can be transplanted to another country without adaptation, but this team approach could inspire other countries to look into alternative models.”
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    6. Ketamine
    0830-1000H Room S221 This morning’s 3-part session on ketamine will be opened by Philip Peyton, who will give a talk called understanding ketamine pharmacology. Dr Peyton is Associate Professor, Dept of Surgery, Austin Hospital and University of Melbourne Head of Research, Dept of Anaesthesia, Austin Health Melbourne, Australia.

    Dr Peyton says: “Ketamine is a drug with many unique features and a pharmacology distinct from other agents used in anaesthesia and pain medicine, which has created both excitement and controversy regarding its current and potential place in clinical practice.” He will be reviewing what is understood about its mechanisms of action, dose response relationships, and its interactions with other anaesthetics and analgesics, in particular opioids. He says: “We will also look at the evidence for its associated effects on neuroinflammation, chronic pain, delirium and mood and discuss the implications for its use in the perioperative period and the need for further research.” Dr Peyton will also discuss concerns about how ketamine’s recreational abuse have prompted international calls for its withdrawal. This comes at an unfortunate time, as there is increasing interest in its other potential therapeutic effects on chronic pain and postoperative delirium, which are now recognised as common and serious postoperative complications, as well as a possible emerging role in management of severe treatment-resistant depression. “Much research still needs to be done to properly define the value of ketamine and its importance in clinical practice before any decisions about the future availability are made.”

    The second presentation will be by Dr Susilo Chandra, Department of Anesthesiology and Intensive care unit, Cipto Mangunkusumo Hospital, University of Indonesia, Jakarta, Indonesia.

    He will suggest that the indications for ketamine may have to be revised based on current knowledge. The separation of the enantiomers S(+) and R(-) has revealed the S(+) enantiomer to be a potentially valuable drug for modern IV anaesthesia. “S(+) ketamine has been found to be a very potent and effective anaesthetic with less prominent side effects (more rapid emergence from anaesthesia and fewer unpleasant psychotomimetic emergence reactions) than racemic ketamine,” explains Dr Chandra. “Its recent commercial introduction on the European market may lead to widespread use and will undoubtedly provide much insight into its pharmacological properties and indications ‒ ketamine may have neuroprotective and even neuroregenerative effects.” Some commentators are reserved or even skeptical, while others see the results obtained thus far more positively and even propose new indications. Although many issues (such as time of administration and dose) remain to be resolved, the preponderance of evidence favors a neuroprotective action. Dr Chandra suggests that inconsistencies among studies probably arise from the complexity of the injury cascade initiated after brain injury. “It seems likely that neither racemic nor S(+) ketamine will be clinically successful if used as sole therapy; only when used in combination with other drugs and treatments can secondary injury be effectively limited,” he says. “It seems confirmed that ketamine does not increase intracranial pressure when the blood pressure is controlled and mild hypocapnia is achieved.” Thus, the contraindication for ketamine use in neurosurgical patients is only a relative one, and when further preclinical and clinical studies confirm a neuroprotective effect of the compound, ketamine and, more likely, S(+) ketamine may well find a place in the neuroanesthesiology drug cupboard. Dr Chandra concludes: “Finally, the analgesic properties of small-dose ketamine have been rediscovered. Current data strongly suggest that the preemptive administration of ketamine can have profound effects on postoperative analgesic requirements with minimal risk and side effects. This provides the anaesthesia practitioner with another useful tool in the management of perioperative pain. Another new indication is the use of ketamine on preventing opioid-induced acute tolerance and in major depressive disorder.” In the final presentation, Dr Jason Nickerson from the Centre for Global Health, University of Ottawa, ON, Canada, will discuss challenges to availability of ketamine.
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    7. Current Controversies
    Theatre 1, 1400H-1530H Thursday 1 September One of the sessions taking place on Thursday afternoon will discuss a number of current controversies in paediatric anaesthesia. Dr Oliver Bagshaw, Consultant in Anaesthesia and Intensive Care at Birmingham Children’s Hospital will deliver the opening talk about spinal anaesthesia.
    The second presentation, entitled ‘What about blood pressure?’, will be by Dr Justin Skowno, Senior Staff Specialist in Paediatric Anaesthesia, and Senior Clinical Lecturer, University of Sydney.
    Blood pressure is one of the most frequently monitored, yet misunderstood metrics that anaesthesiologists have. Dr Skowno points out that: “There is no current consensus on adequate targets, despite a century of practical paediatric anaesthesia. Despite a wealth of information regarding physiology that we measure during an anaesthetic, children still continue to suffer cerebral hypoperfusion and brain injury during surgery and anaesthesia.” This talk will fill the gaps in the audience’s knowledge, and hopefully give attendees an idea of what anaesthesiologists as a speciality can do to improve the safety of the anaesthetics given to children.
    The third presentation of the session will be delivered by Professor Robert Sümpelmann, specialist in paediatric anaesthesia and paediatric cardiac anaesthesia, and senior physician at the children’s hospital of the Hanover Medical School in Germany since 1994.
    His main research interest is in the area of fluid and volume replacement, massive transfusion, cardiocirculatory monitoring, management of cardiopulmonary bypass and fast-track anaesthesia in children. He is the author or co-author of more than 80 papers in peer reviewed journals, as well as numerous book chapters. Professor Sümpelmann is also an active member of the German working group for paediatric anaesthesia. Professor Sümpelmann’s talk will cover controversies in perioperative fluid management, including the dosing and composition of crystalloid solutions, the addition of glucose, and the use of natural or artificial colloids. As he states: “An inappropriate infusion therapy may lead to deleterious iatrogenic acid- base- electrolyte and glucose disorders causing cerebral edema, metabolic imbalances, hyperosmolar coma, shock or fluid overload.” Professor Sümpelmann will present safety-focused and proven guidelines favouring short pre- and postoperative fasting times, isotonic balanced electrolyte solutions (BS) with 1-2.5% glucose for intraoperative maintenance infusion, BS without glucose for fluid replacement, artificial colloids for volume replacement, and BS with 5% glucose for maintenance infusion in postoperative or non-surgical child patients.
    The session will be wrapped up by Dr Norifumi Kuratani, Anesthesiologist-in-Chief at Saitama Children's Medical Center, Saitama, Japan, who will talk about the various issues relating with emergence delirium (ED) in paediatric anesthesia.
    ED immediately after extubation is a difficult problem in routine pediatric anaesthesia. Dr Kuratani will emphasise that no single factor can explain why excitatory emergence occurs in paediatric patients. The surgical pain can be an indispensable risk factor, but complete analgesia cannot guarantee happy anaesthesia wake-up, as shown by MRI anesthesia studies. The growing volume of clinical evidence consistently shows that the choice of anaesthetics can be a highly significant modifiable factor in ED. The use of sevoflurane for the maintenance of anaesthesia is a significant risk factor for causing ED in high-risk paediatric patients. In contrast, intravenous anaesthesia techniques using propofol are associated with lower incidence of ED. Dr Kuratani says: “The use of sedatives to prevent ED might result in unexpected delays in anaesthesia recovery, and might cause airway obstruction during the recovery phase. Anaesthesiologists who care for children should be aware of the risk of ED and should consider methods to prevent ED in order to provide high-quality anaesthetic care for their young patients.”


    1. Profiles: our newly elected WFSA Presidents

    Dr Gonzalo Barreiro

    During Monday’s General Assembly, two new Presidents of WFSA were elected. Dr Gonzalo Barreiro, from Uruguay, will serve as President from the end of this meeting until 2018; Dr Jannicke Mellin-Olsen, from Norway, will then take over from 2018-2020.

    Here we learn more about our new Presidents, starting with Dr Barreiro.

    Q: Where do you work?

    GB: I am based at the Sanatorio Americano, Montevideo, Uruguay, where I am Chief of Anaesthesiology Cardiac surgery. I was born and raised in Montevideo.

    Q: What made you choose medicine and anaesthesiology as your career?

    GB: I wanted to do medicine since I was child! At the end of my studies I had to make a choice, and I chose anaesthesiology. I was in two minds, as I also wanted to be a cardiologist, however but I loved, and still love emergencies, resuscitation and the operating theatre Q: Tell me a little about your role with WFSA, and how you became involved with the Federation?

    GB: My former Professor of Anaesthesia, Dr. Martin Marx recommended me for the Safety Committee and I fell in love! After that, I was elected as Latinoamerican representative, Deputy Secretary and Secretary. This all means being in the WFSA since 1992! Q: How excited are you to become the new WFSA President, and what are some of things you would like to achieve in the role?

    GB: This is a great honour and a great responsibility. This ia a team effort and hard job, both Presidents (Janicke Mellin-Olsen and I) will work very closely in tandem, and there are great colleagues within the Board, Council and Committees who will work with us during the next 4 years. I guess that the challenges for the next term are two: advocacy strategies and to unify all the efforts deployed worldwide in order to avoid duplication and overlapping of efforts. Q: How important is it to gather the World's anaesthesiologists together in a meeting like this?

    GB: More than 135 countries are represented, and I think that the most important experience is to feel how similar our desires and expectations are concerning safe anesthesia. Q: One of your talks is on WFSA and Lifebox - taking the partnership forward for patients. What do you think are the next steps for the Lifebox project, and how much of a difference has the initiative made in developing countries?

    GB: Lifebox is a spectacular initiative and has made the difference in many places. I guess that working together with a cheap portable monitor kit with a pulse oximeter, capnograph, gases monitoring and noninvasive blood pressure could be the second Lifebox which will enable a almost complete monitoring kit in resource poor countries. Q: What are your aims for the rest of your career?

    GB: To begin to retire from clinical practice, to work all these 4 years for the WFSA, and then to be at home with my wife and a dog (at last!).

    Thank you Gonzalo, congratulations on your election as President and we hope you have enjoyed the meeting.

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    2. Profiles: our newly elected WFSA Presidents

    The second elected President is Dr Jannicke Mellin-Olsen from Norway, who will serve as President from 2018-2020.

    Q: Tell us a little about you?

    JM-O: I work in a hospital outside Oslo, Norway, not far from where I was born and raised. In my department, everybody has to do "everything", meaning that I work in the operating theatres, intensive care unit and in obstetric anaesthesia. I am also much involved in critical emergency medicine, patient safety, ethics and education.

    Q: What made you choose medicine and anaesthesiology as your career?

    JM-O: I had a brother who was born with severe malformations and died as a baby. My parents had to spend time with him in the hospital while I was looking after my little sister. He died after a medical error, so already as a 4-year old, I learnt that doctors should always listen to parents and to their gut feeling. I had become fascinated by hospitals and wanted to be a nurse. At that time very few females went to medical school in Norway. But my mother pointed out a female doctor in the neighbourhood, and my destiny was set and I never looked back.

    I did not want to enter a narrow speciality pathway, but get a broad base first. I did general practice, clinical pathology and was the first Norwegian female doctor to complete military services before entering into anaesthesiology. As a student, I liked physiology most, but I did not realise that anaesthesiology was more than squeezing a bag and big ICU charts that I would never understand. I had to serve in a war zone in Lebanon to understand what anaesthesiology is about.

    Q: Could you tell us a about your role with WFSA?

    JM-O: For the four last years, I have served as the Deputy Secretary, which in some ways has been a role to create yourself. Lately, I have been involved as the WHO liaison, working on how to implement the WHA Declaration on Patient Safety in Anaesthesiology to improve the service to those 5 out of 7 billion people in the world who do not have access to safe anaesthesia and surgery.

    We have been lobbying to avoid ketamine becoming a restricted medicine all over the world. I am also the liaison to ICRC. Before that, I was a member of the Education committee for 8 years, the last 4 as the chair. This was particularly meaningful, as I got to know so many colleagues around the world, all trying to improve their own competence to become better anaesthesia providers. I cooperated closely with those colleagues that run the training centres. It is inspiring to see how we all - from high, middle and low income countries - are sharing, working together to improve our services, irrespective of race, religion and nationality.

    Q: How important is it to gather the World's anaesthesiologists together in a meeting like this?

    JM-O: This is very much linked to the answer above. There are many congresses in the world, many of high scientific standard and with many nationalities attending. The WCA is different in the sense that it "belongs to all of us". It gives us a unique opportunity to meet and interact with colleagues from every corner of the world. In addition, for the WFSA, it is particularly important, as it is when we have the General Assembly with elections and with meetings that set the course for the next four years.

    Q: One of your talks is on task sharing in high-income countries - how effectively do you think this is being implemented in your native Norway and other HIC, and how essential is task sharing in all countries to help with the anaesthesia workforce shortage?

    JM-O: I would not have been an anaesthesiologist had I not worked in a country where the flexible anaesthesia team is not the way we work. We respect each other's roles and team members work very well together, and in our setting, it is perfect. Some other HICs do not have that tradition and culture. We cannot ignore culture and history, and no system can be transplanted from one country to another. But we can always learn from other ways of doing it. The view of WFSA and my view is that anaesthesiology is a medical speciality, meaning that doctors should lead the service. But that is not possible in every corner of the world today. In some situations, patients will be faced with the option of having less than optimal service or none at all, and then it becomes more complicated. And not only doctors, but also nurses and other health providers are in shortage, so task shifting is no quick-fix. But we cannot let perfect be the enemy of the best feasible. So we must continuously aim at the perfect, realising that it will take some time to get there.

    Q: The Helsinki Declaration - what is the latest news on this, how many countries are now signatories?

    JM-O: Not only countries, but everyone involved in health care are invited to sign the Declaration. The interest to sign and support it has been impressive. Please look at the map below to see how far we have come. The real challenge is not to sign a paper, but to implement what you commit to. We need to work together to implement the Declaration on regional, national and local levels.

    Q: What are your aims for the rest of your career?

    JM-O: I hope to be active in my clinical role and in my department. In addition, I want to contribute on a national and international level. I have gained so much experience over the years that I would like to share, but in addition, I am learning more all the time, and that is very inspiring.

    Q: Which tracks and sessions have you enjoyed at WCA?

    I have been co-chair of the Education and Development track, and all these sessions are interesting to me. So are the patient safety sessions and so many others. It is hard to choose. The Harold Griffith symposium was a highlight.

    I have enjoyed meeting many colleagues and sharing experiences over this week. I encourage everyone to be actively networking and utilising the opportunities that only the World Congress can provide to you.

    Thank you Jannicke, and congratulations on your election as President.

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    3. Highlights from Thursday: Disasters and intensive care medicine
    “Hospital drills: the most effective way of preparing for a disaster” was the opening presentation in yesterday’s session, given by Professor Hulya Turkan, who is based at the Department of Anesthesiology and Reanimation, Gulhane Military Medical Faculty, Ankara, Turkey.
    In her talk, she said that drills clarify responsibilities, but are complex to put together. She said each of the individual parts or ‘building blocks’ of a drill must first be performed on their own, before putting the whole drill together. Discussion based exercises should come first, followed by operation based and functional exercises using simulation. A full scale drill of course involves everything you would expect in disaster: including setting up a triage system, dealing with transportation, lack of power, and unsafe buildings. “After taking all the steps one by one for 8 months, we were ready for a full scale drill,” said Professor Turkan. "Soldiers, with appropriate make-up to create mock injuries, acted as patients in the drill. The scenario was a 7.1 magnitude Earthquake, and alarms sounded just as they would in real life. Different evacuation techniques were practised, as it was assumed there was no functioning elevator. These included using rope to lower patients strapped to beds from high up floors, and special vacuum mattresses to help move others.” Staff set up a special area for children who may have been orphaned by the disaster and thus were alone; and outside the hospital away from the building structures there were multiple prefabricated huts in which essential medical supplies were stored to allow continued functioning of the hospital if its main buildings are badly damaged. “Following the drill, we surveyed all participants,” says Dr Turkan. “The process raised awareness of potential disasters, motivated preparation, improved employee responsibility, and decreased fatalism and disregard. We need to keep our preparedness updated to ensure we are ready for anything.”
    The second presentation on the 2015 Nepal Earthquake was given by Professor Shyam Maharjan, Department of Anesthesiology and Intensive care, Kathmandu Medical College, Sinamangal, Kathmandu, Nepal.
    On April 25, 2015, there was 7.8 Richter scale earthquake with violent thrust type movement killing around 9000 people, injuring 22000 and leaving 9 million people homeless. “The worst hit areas were Kathmandu and surrounding districts, with the epicenter some 150 kilometers west of Kathmandu,” said Professor Maharjan. He added: “Most of the hospitals in Kathmandu were not quake resistant and tall buildings though not collapsed, had multiple cracks and we had to evacuate all inpatients, including ICU and postoperative cases, to the ground floor and the open parking area. We managed the cases in temporarily erected places including an operation room for surgical and orthopedic cases. Surgical ICU was run on ground floor emergency room and neuro ICU/theatre were on first floor with easy access to open ground ‒ this was possible only after government engineers had confirmed the building, although cracked, was not in danger of collapsing.” Although catastrophic, Professor Maharjan said his team was prepared, since his hospital, like most of the other tertiary hospitals in Nepal, have a disaster management team and were doing mock drills frequently. “Triage with red, yellow and green tags was done on open ground and the patients were managed accordingly,” he says. “We had a total 1887 disaster cases in my hospital, 1292 managed in emergency, 595 admitted, 260 needed surgery and 62 needed ICU care. Management was done according to emergency Mass Critical Care Taskforce and WHO hospital emergency response checklist guidelines.”
    The final session was by session Chair Professor Charles Gomersall (Chinese University of Hong Kong) who discussed recommendations from the Taskforce for Mass Critical Care, which include an oversight system for care in these situations and a process that should be informed by the most up-to-date information.
    However, it is hard, says Professor Gomersall, to get anyone (including politicians) to sign up to something that will restrict triage and subsequent ICU care to the very sickest who are unlikely to survive. Indeed, how is unlikely defined? Is a 1 in 100 chance of survival unlikely? 1 in 1000? Even with these odds, relatives would expect that the person still be treated in many cases. Even when doctors think that care should be given to those who get most benefit, Dr Gomersall’s talk underlined how difficult this is in practice. He discussed the importance of using triage protocols rather than judgement alone, and having an appeal system where doctors can challenge the protocol if they believe a particular patient or patients are not being dealt with fairly. Patients with severe respiratory failure should be included in triage protocols, and also those with hypotension that cannot be treated with fluid therapy. Patients with a life expectancy of one year should not routinely be included. However, Dr Gomersall said it is impossible to predict survival in many circumstances, as even seriously injured or ill patients can sometimes survive without mechanical ventilation or other ICU care. He also noted that different ICU provision in different countries can modify these protocols – for example in Germany, which has very high ICU bed provision.
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    4. Burnout Among Anaesthesiologists
    Theatre 2, 0830-1000H The sensitive issue of burnout among anaesthesiologists will be featured in one of Friday's sessions. The first talk, originally to be given by Dr Pratyush Gupta, will now be given by second speaker Miodrag Milenovic. Dr Gupta, a specialist in professional wellbeing among his other interests as Associate Professor of Anaesthesia at Indraprastha Apollo Hospital, New Delhi, was to give an overview of the factors leading to burnout, but sadly could not attend due to personal circumstances.
    About 45% of the worlds’ population, and 58% of those above 10 years of age belong to the global workforce, sustaining both their economies and societies. Their occupational wellbeing is of utmost importance, but 30-50% of workers report exposure to hazardous physical, chemical, or biological conditions, as well as experiencing psychological overload. This can result in stress symptoms and reduced working capacity. How close a worker then gets to burnout depends on their individual capacity to handle stress. Dr Gupta’s slides will discuss Weingology (the science of studying well-being at work), a positive work-life balance, and factors leading to burnout among anaesthesiologists in particular. Although it is tempting to feel that workload is the primary cause of burnout, it may not be so in all cases. He proposes that tackling burnout can more effectively be achieved by a move away from a negative stress model, towards one of positive job engagement. This will be followed by a presentation from Dr Miodrag Milenovic, University of Belgrade School of Medicine, on how the signs of burnout can be recognised by both anaesthesiologists, and by their colleagues within healthcare organisations. Anaesthesiologists perform a highly responsible and stressful job, whose work and decisions directly affect the treatment, recovery, and quality of life of their patients. Studies have shown that anaesthesiology is one of the most stressful specialties in medicine, and its practitioners may be at increased risk of burnout. Burned-out anaesthesiologists may exhibit higher rates of job turnover, relationship breakdown, incidence of substance abuse and addiction, suicidal ideation, and face reduced life expectancy. It is vitally important for anaesthesiologists and their employers to understand burnout, and to be aware of its symptoms and signs. Departments as well as societies with large numbers of burned-out anaesthesiologists may become resigned, stagnant, and visionless. Patients are then in danger of receiving poor quality, or even life-threatening care from those burned-out staff. Dr Milenovic specialises in the epidemiology and public health impact of these phenomena. His experiences while practicing anaesthesia and intensive care medicine in a highly competitive university department led him to recognise the issue of burnout among academic professionals. The widespread occurrence of the problem, as well as the potential severity of its effects inspired him to study a PhD in the subject. Dr Milenovic has recently published research conducted in association with every university anaesthesiology clinical department in Belgrade, representing almost half the members of the Serbian Association of Anaesthesiologists and Intensivists (SAAI).
    Dr Lize Xiong, President-elect of the Chinese Society of Anaesthesiology (CSA), and Professor in Anaesthesiology, Xijing Hospital, the Fourth Military Medical University, Xi’an, China will deliver the third presentation – a Chinese perspective on burnout that discusses the particular challenges faced by that nation’s anaesthesia practitioners.
    In 2015 there were more than 40 million operations conducted in China, but only around 80,000 anaesthesia practitioners. The shortage of anaesthetists has led to a gap between the enormous workload and demand for their services, and their ability to address that need. Dr Xiong and his colleagues carried out two surveys on the well-being of anaesthetists, the results of which were overwhelming. 42% of those surveyed admitted to feeling burned-out in the face of pressure from high patient expectations, overwork, and conflict with patients. China is already acting on this issue, with the government Health Care Reform initiative promoting the diversion of patients away from top hospitals, towards community ones instead, and it is hoped that salaries for anaesthetists will increase in the near future. The CSA is encouraging staff to participate in training programs and research to strengthen their feelings of self-worth. The Society is also improving its communications and public outreach to make anaesthesiology a more attractive and respected profession among the Chinese public. It is hoped that this approach will boost recruitment, increasing the number of anaesthesia practitioners at both the doctor and nurse level, that China vitally needs.
    The final presentation of the session will be on preventing burnout, presented by Dr Roger Moore - anaesthesiologist in the Electrophysiology laboratories at the University of Pennsylvania, and Chair of the Board of Directors of the Anesthesia Quality Institute.
    Dr Moore will discuss specific protocols, policies and methods for alleviating and controlling the factors that lead to burnout in anaesthesiologists. The WFSA Committee on Physician Wellness has taken a leadership role in bringing anaesthesiologist’s attention to this problem. The next step is to have National Societies embrace these concepts and initiate policies that provide support for beleaguered physicians. Many National Societies have taken active and effective steps in this regard. The next layer of intervention is at the hospital level. Care for the caregiver programmes, with an eye on providing support for at-risk anaesthesiologists, are essential. The loss of a patient intraoperatively, especially if due to a medical error, imposes a tremendous stress on the anaesthesia practitioner. There need to be hospital and anaesthesia department protocols in place to help the affected physician through this troubling time. The final level for preventing burnout is for individual physicians taking his/her health concerns seriously. Getting sufficient sleep, eating well, learning methods to deal with stress, taking the time to enjoy hobbies, and having a social support network, are all essential components of a healthy and happy life.
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    5. Shakespeare and Medicine
    Rooms S222-223, 0830-1000H A treat is in store for those delegates still here for this final day of the Congress, with two experts discussing Shakespeare and medicine. Dr Barbara Kennedy, Visiting Lecturer at the University of Brighton, UK, will cover ‘Shakespeare and Anaesthesia’.
    Dr Kennedy’s area of expertise is in medical humanities particularly in the Renaissance. Her doctoral thesis examines how music was used therapeutically in two distinct ways in the early modern period; namely, through the use of performed music accompanying the healing process itself, and as ‘speculative’ music, the latter providing a philosophical model for understanding the interplay of music with the body, mind and soul. “Generations of audiences and readers have marvelled at the remarkable depth of Shakespeare’s knowledge of the human body,” says Dr Kennedy. “His plays and poems indicate his interest in how the body and mind interact; how they function when healthy, or malfunction when disturbed or ill.” This year marks four hundred years since the death of Shakespeare, arguably the greatest figure in English literature, and while many of his literary allusions remain abstruse, his work remains contemporary since his understanding and imaginings of the human condition remain relevant and vivid today. “But what of anaesthesia and Shakespeare, and does his body of work have any relevance for this modern branch of medicine?” asks Dr Kennedy. “The growing trend in interdisciplinary relationships, and in particular, the field of medical humanities, presents an opportunity to explore the often complex relationship between the humanities and medicine; what were the medical conditions like in Shakespeare’s time, and where does he source his medical knowledge from? This talk aims to present how his work references the complexities of twentieth century anaesthesiology.” In the other talk, Kathryn McGoldrick (Professor Emerita of Anesthesiology, New York Medical College, Westchester Medical Center Valhalla, NY, USA) will discuss ‘Medicine through the ages: Shakespeare and the four humors.’
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    6. Research Fraud
    Theatre 1, 1300H-1430H Friday 2 September This Friday afternoon session will focus on the damaging issue of research fraud, which can include the omission or falsification of results, failure to secure the correct ethical approval, and the manipulation of data.
    The session will begin with a talk on ‘Funny numbers: Random variation or phony data or statistical malpractice?’ by Dr Nathan Pace, Professor of Anesthesiology at the University of Utah, Salt Lake City, Utah, USA.
    Dr Pace currently acts as a statistical consultant on experimental design and analysis for students, residents, fellows, and faculty of the Department of Anesthesiology, having been a faculty member since 1976. He is an MStat level applied statistician, and a University of Utah Champion for the Multicentre Perioperative Outcomes Group (MPOG), and for the planning of epidemiological investigations based on high resolution electronically maintained anesthetic records and hospital electronic health records. He has also fulfilled the role of Author, Editor, Statistician, and Coordinating Editor of the Cochrane Collaboration Anaesthesia, Critical & Emergency Care Review Group since 2001. As Dr Pace points out: “Funny numbers are the results of randomised controlled trials (RCTs), observational studies, and systematic reviews that seem ‘too good to be true’. That is too extreme, too unlikely, too smooth, etc.” While there are a number of possible explanations that might explain such results, including startling and important new discoveries, Dr Pace cautions that: “Other possibilities include deliberate fraud in research reports, failure to publish negative results, improper application of statistical methods, and misinterpretation of statistical test results (the P value problem).” His talk will highlight a few examples in the anesthesia and general medical literature, as well as suggest some possible remedies.
    The second talk will be delivered by Dr John Carlisle, a consultant in perioperative preparation, anaesthesia & critical care at Torbay Hospital, Devon, UK, who has a particular interest in the detection of data fabrication and fraudulent research. He has published a number of papers in journals, and chapters in books on these subjects.
    Dr Carlisle works as an intensivist in the Torbay Hospital intensive care unit, as well as in the preoperative assessment clinic. His work covers the areas of preoperative assessment, anaesthetics, and intensive care, and has led to his main areas of interest: long-term survival, including his own; perioperative probabilities of harm and benefit; cardiopulmonary exercise testing and evidence-based medicine including systematic reviews. He is an editor for the journal Anaesthesia, and for 11 years was an editor and author for the Cochrane Anaesthesia Review Group. He has contributed to evidence-based guidelines for the European Societies of Anaesthesiology and Intensive Care Medicine. He is also an author for Oxford Handbooks of: anaesthesia; day surgery; and vascular surgery. The session will conclude with a talk from Dr Steve Schafer, Professor of Anaesthesiology, Perioperative and Pain Medicine at the Stanford University Medical Center on the subject of ‘How Journals Manage Research Fraud’.

    Итоги закрытия.

    1. Closing ceremony

    A happy and celebratory atmosphere was enjoyed by all at yesterday’s closing ceremony, which was full of amusing (and short!) speeches, and some fantastic entertainment provided by Czech musician Mrs Jitka Hosprova, who enthralled the audience with three varied classical compositions.

    Professor Mike Irwin thanked all involved with the congress, paying tribute to Professor Tony Gin for his hard work on the scientific programme and Dr Chi-Wai Cheung for his work on the organising committee.

    He also paid tribute to outgoing WFSA President Dr David Wilkinson, who then took to the stage himself to offer his own set of thanks. Dr Wilkinson thanked Professor Irwin, Professor Gin and Dr Cheung for their impeccable skills putting the Congress together, and to the board and council who have worked so hard to take the WFSA to where it is today. A special mention was given the WFSA Secretariat – also known as the ‘dream team’ – of Julian, Eva, Aaliya, Niki, and Giselle.

    It was then time to welcome the next Presidents of WFSA: Dr Gonzalo Barreiro (Uruguay) and Dr Jannicke Mellin-Olsen (Norway). Dr Barreiro had planned to let ladies go first, but Dr Mellin-Olsen had already told him: “Age before beauty!”. Both gave speeches looking to the future of the WFSA, committing to working with colleagues worldwide to advance the Federation.

    The venue for the 2024 Congress was announced as Singapore, before Professor Karel Cvachovec, the Chair of the next Congress in Prague 2020, showed a video of Prague and gave an entertaining speech telling delegates, among other things, how much beer that they can get for their money compared to other European countries! Mrs Hosprova then wowed the crowd with her fantastic viola performance before the ceremony closed and the delegates were wished a safe journey home.
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    2. WFSA Abstract Poster Competition

    Professor Tony Gin (Chinese University of Hong Kong and Chair of the Scientific Programme at WCA) and a panel of colleagues had some very tough choices to make to choose the winners of this year’s WCA Abstract Poster Competition.

    The winners and runners-up are below. Note, some categories did not select winners, and categories had one, two or three prize winners as decided by the panel.

    Category: Ambulatory


    Dr Aliza Mohamad Yusof, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Malaysia.


    Xia Yan, Hong Kong University Shenzhen Hospital, China.

    Category: Anaesthesia and cancer


    Dr Elizabeth Nyakundi, Mater Misericordae Hospital, Nairobi, Kenya.

    Category: Arts and Humanities


    Professor Kim Turner, Queen’s University, Kingston, Canada

    Category: Circulation


    Dr Michael Lukins, Monash Health, Melbourne, Australia.


    Professor San-Qing Jin, the Sixth Affiliated Hospital, Sun Yat-sen University. Guangzhou, China.


    Professor Zheng Guo, Shanxi Medical University, Taiyuan, China.

    Category: Education & development


    Dr Shirsti Shah, Nick Simon Institute, Kathmandu, Nepal.


    Dr Camila Lyon, Vanderbilt University, Nashville, Tennessee, USA.


    Alexander Villafranca, University of Manitoba, Winnipeg, Canada.

    Category: Neuroscience


    Professor Kwok Ming Ho, Royal Perth Hospital, WA, Australia.


    Yen-Mie Lai, VU University University Medical Centrer, Weesp, Netherlands.


    Professor Anatoly Martynyuk, University of Florida, Gainesville, FL, USA

    Category: Obesity and Sleep Medicine


    Dr Daniela Godoroja, Ponderas Hospital, Corbeanca, Romania.

    Category: Obstetric


    Dr Nidhi Bhatia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh India.


    Dr Kerry Litchfield, NHS Greater Glasgow and Clyde, Scotland.


    Dr Jill Boyle, Vanderbilt University School of Medicine, Nashville, TN, USA.

    Category: Paediatric


    Dr Francoise Nizeyimana, University of Rwanda, Kigali, Rwanda.


    Professor Woosuk Chung, Chungnam National University Hospital, Daejeon, South Korea.


    Dr Yasuhiro Kogure, National Center for Child Health and Development, Tokyo, Japan.

    Category: Pain


    Dr Armeana Zgaia, Oncology Institute, Cluj-Napoca, Romania.


    Dr Phua Hwee Tang, KK Women's and Children's Hospital, Singapore.


    Kelly Baxter, University of Washington School of Medicine, USA.

    Category:Perioperative medicine


    Professor Young Chul Yoo, Yonsei University College of Medicine, Seoul, South Korea.


    Dr Anair Beverly, Brigham and Women's Hospital, Cambridge, MA, USA.


    Professor Wolf Stapelfeldt, Saint Louis University, Saint Louis, MO, USA.

    Category: Pharmacology


    Dr Jingxia Meng, Peking Union Medical College Hospital, Beijing, China.


    Dr Yong Beom Kim, Gil Medical Center, Gachon University, Incheon, South Korea.

    Category: Professional Practice


    Professor Liana Maria Tôrres de Araujo, Federal University of Bahia, Salvador, Brazil.

    Category: Regional Anaesthesia


    Professor Suman Arora, Postgraduate Institute Of Medical Education & Research, Chandigarh, India


    Dr Juan-Pablo Cata, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.


    Dr Arani Pillai, Royal Perth Hospital, WA, USA.

    Category: Research & publication

    1st prize, HKD$800, PR525: The quality of reporting in pharmacokinetic studies of analgesics and sedatives delivered for more than 24 hours in adult intensive care patients: a systematic review.

    Andrew Tse, The Chinese University of Hong Kong, China.

    Category: Respiration & airway


    Dr Aliza Mohamad Yusof, Universiti Kebangsaan Malaysia Medical Centre, Malaysia.


    Dr Håkan Björne, Karolinska Universitetssjukhuset Solna, Stockholm, Sweden.


    Dr Atsushi Fujiwara, Osaka Medical College, Takatsuki, Japan.

    Category: Safety and Quality


    Dr Maryrose Osazuwa, National Hospital Abuja, Nigeria


    Dr Santosh Sharma, Sahid Ganga Lal National Heart Center, Kathmandu, Nepal.


    Dr Gerald Nyakatawa, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.

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    3. Safe anaesthesia to everybody – today (SAFE-T)
    This session was focused on WFSA’s SAFE-T campaign which aims to bring safe anaesthesia to the 5 in 7 people worldwide that cannot currently access it. Formally launching the campaign here in Hong Kong, WFSA President Dr David Wilkinson described the background to the project, including the WFSA’s International Standards for a Safe Practice of Anaesthesia first produced in 1992 and updated in 2008 and 2010.

    These standards are agreed and adopted by the 135 Member National Societies of the WFSA and are recommended for anaesthesia professionals throughout the world. However, to reach them, it must first be recognised that this is a collaborative effort across governments, industry, civil society and beyond; and also be understood where and why these standards cannot be met. “We must ‘map the gap’ in access to safe anaesthesia and use this data to influence advancement in every hospital, and for every patient,” explains Dr Wilkinson. The “SAFE-T” Campaign will unite individuals, industry and organisations behind a shared mission to advance patient safety and ultimately reach these international standards everywhere. The “SAFE-T Consortium” is a global collaboration of industry and patient focused organisations committed to the advancement of patient safety and the International Standards for a Safe Practice of Anaesthesia. There is also the “SAFE-T Network”, a network of individual anaesthesia providers committed to these goals, and together these two groups will drive the SAFE-T Campaign.

    Copyright © Красноярская региональная Ассоциация анестезиологов и реаниматологов, г. Красноярск
    Разработчики: Россиев Д.А. | Россиев Д.Д. - 2010