FEATURED ARTICLE

Current Status of Neurosurgical Anesthesiology in China

Nan Lin*, Yan Li*, Haiyun Wang†, Ruquan Han*, Guolin Wang†
*Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
†Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, PR China

Ruquan Han, MD

Nan Lin, MD

The Brief History of Neurosurgery and Neuroanesthesia in China
China’s neurosurgery led by the pioneers eg. professor Yicheng Zhao etc., was established in 1950s. Neurosurgery in China develops rapidly and has shifted from traditional anatomical model to modern functional model with the notion of maximum resection under minimizing brain function impairment. Neurosurgical anesthesiology plays a vital role in advancing neurosurgery development in China through popularizing the multimodal monitoring, brain protection and postoperative pain control. The innovative technologies and concepts spreading rapidly in China effectively improve patient outcomes through protecting brain function during perioperative period. 

In 1993, the first China’s national neurosurgical anesthesiology conference was successfully held in Beijing hosted by Beijing Tiantan Hospital, Capital Medical University. Since then, the training program of neuroanesthesia and brain protection provides theoretical and practice courses with core knowledge and new concepts to subspecialty practitioners every year.

In 2007, the branch of neuroanesthesia in Chinese Medical Association was established with committee members who come from different areas of China and are representatives of neurosurgical anesthesiologists in their regions.

Since the first Tiantan International Neurosurgical Anesthesiology Symposium (TINAS) was held in 2009, TINAS has become the influential platform in China for clinicians and researchers in neuroaneasthesia and related disciplines to exchange their experiences and accomplishments.

National Survey of Neuroanesthesia in 2017
Recently, a national survey has been conducted in terms of neuroanesthesia clinical practice, education, and research situation. The survey collects data from 290 hospitals which has neurosurgical service from January to December in 2017. The surveyed hospitals locating in 31 provinces, municipalities and autonomous regions include 209 level-one public hospitals, 75 level-two public hosptials, and six private hospitals. Due to uneven distribution of health care reasource, the hospitals with neurosurgical service concentrate mostly in developed and densely-populated cities in the east part of China, eg. Beijing, Shanghai, Tianjin, Hangzhou, Guangzhou. Hospitals in large cities attract quite a number of patients from small-scaled cities where medical resource is poor.

Among the hospitals with neurosurgery specialty, Beijing Tiantan Hospital has 450 beds. There are total of 25 hospitals which has over 200 neurosurgical beds. In 2017, the total neurosurgical cases in China is 255,453. The types of neurosurgery and number of neuroanesthesia cases are tabulated as follows.

The prevalence of acute stroke in China is 136-441 per 100 thousand population which is the highest in the world, with mortality reaching high to 94-137 per 100 thousand. However, in the past, very few patients were provided timely endovascular treatment due to the lack of knowledge and manpower. The less involvement of anesthesiologist rendered the treatment and patient safety unsecured. With the fast health care development, the importance of anesthesia care in endovascular treatment has been increasing realized. Now, 77.6% of surveyed hospitals provide interventional treatment service, where anesthesiologists participate in the treatment to provide general anesthesia or monitored anesthesia care (MAC) to improve perioperative safety in 200 hospitals (97.8% (220/225)).

The application of navigation and neuroimaging technics promotes the quality of surgical care. Intraoperative multimodal monitoring has also been widely used in China. Intraoperative neuro-monitoring including transcranial Doppler, neurophysiological monitoring, regional cerebral oxygen saturation were conducted in 72.8% hospitals. Awake craniotomy with the total number of 1,247 in the entire year were performed in 64 hospitals. Awake-awake-awake technique was used in 34.6% of awake craniotomy cases, while 65.4% cases were done with sleep-awake-sleep technique.

Postoperative pain occurs in 46%-78% patients after craniotomy. However, postoperative pain management is not optimistic and needs further improvement. More than half of hospitals (182/290) seldomly provide postoperative pain control service to neurosurgical patients. The main method of pain management is patient-controlled intravenous analgesia. some patients received scalp nerve block or incision infiltration. Intraoperative blood salvage was used mainly in closed brain trauma, cerebral aneurysm, arteriovenous malformations, and benign meningiomas in 74.5% of the hospitals.

Neuroanesthesia Subspecialty and CME
There is no accurate statistics of numbers of neurosurgical anesthesiologists in China due to lack of an independent neuroanesthesia society in China. Neuroanesthesia as subspecialty is recognized only in 37% of hospitals even in the level-one hospitals. It is estimated that the number of neuroanesthesiologists is only 2021. The lack of neuroanesthesia subspecialty in national wide limits the quality of perioperative care and it needs to be improved.

During the standardized first-phase residence training (three years), it requires residents to complete a two-month rotation in neurosurgical anesthesia and to participate no less than 60 neuro cases. During the second-phase training (two years), residents are supposed to choose one or more subspecialties in their hospitals to continue the rest part of training. Unfortunately, the second phase is not implemented well. Only those in big neurosurgical centers gain better training in neuroanesthesia subspecialty.

To improve the quality of neuroanesthesia in general, the diverse continued medical education (CME) is provided by neuroanesthesia centers, eg. Beijing Tiantan Hospital and Shanghai Huashan Hospital. Anesthesiologists from other hospitals can apply for visiting and working in these centers for three to six months where they are trained in neuroanesthsia. Courses in the training programs and conferences are open to all doctors. Besides, the online course is a new emerging mode where experts are invited to deliver lectures and answer questions. Nevertheless, there is still a long way to go to standardize and enhance neuroanesthesia subspecialty training in China. 

Neuroanesthesia Research and Future
One of the advantages in China’s healthcare is rich in clinical cases due to huge population. It is relatively easy to integrate resources and to lead middle- and small-scaled hospital to implement multicenter clinical trials. For some uncommon cases, a national database will be of great clinical value. China Neuroanesthesia Clinical Research Collaboration will be established to share cases and to promote translational study, and finally to guide clinical practice in 2018. In this year’s survey, 76.6% (222/290) of hospitals are interested in establishing this collaboration and willing to join in.

As one of the important parts in the world, China’s neurosurgical anesthesiology keeps pace with the time, transitioning from intraoperative care to perioperative medicine. In the year of 2018, TINAS was officially renamed as Tiantan International Neuroscience in Anesthesiology Symposium to emphasize the importance of perioperative neuroscience that is rapidly developing in China. Enhancing multidisciplinary collaboration and communication in clinical/basic neuroscience research, delivering cutting-edge concepts and techniques in perioperative medicine are our future directions and goals.