Anaesthesiology

1. Overview of the Discipline

From the period of German occupation in 1898 to the early period after Japan replaced Germany in 1914, clinical anesthesia was administered by surgeons. In 1919, an operating room was established with two operating beds. In 1946, the operating room was staffed by 4 nurses, 1 assistant nurse, and 2 sanitation workers, with no dedicated anesthesia personnel. In 1955, a new operating room was built, increasing the number of operating beds to 6. In 1959, a post-anesthesia recovery room was established. After 1960, an anesthesia group was formed, with the first 3 dedicated anesthesia personnel. By 1971, the operating room was separated from the Department of Surgery, and the Department of Anesthesiology was established, including an equipment group and an anesthesia group. The number of dedicated anesthesia personnel increased to more than 10.

At the end of 1990, the operating rooms were moved to the newly completed surgical building at that time. The Department of Anesthesiology became an independent clinical department, the number of operating rooms increased to 16, and the average number of daily operations exceeded 20. In 1999, the operating rooms were renovated, refurbished, and expanded, bringing the total number of operating rooms to 21. At the same time, an anesthesia recovery room was established with 4 beds, and the daily surgical volume increased to more than 30 cases.

The equipment in the operating rooms of the Department of Anesthesiology has become increasingly modernized. By 2006, the hospital had 32 internationally advanced clean laminar-flow operating rooms (including 10 Class 100 rooms). Each operating room was equipped with imported high-end ceiling-mounted pendant systems, imported anesthesia machines and monitoring equipment (with invasive pressure, temperature, and end-tidal CO2 monitoring), syringe pumps, TCI pumps, and other equipment. In addition, there were 4 EEG BIS monitors, 4 anesthetic gas monitors, and 1 blood gas analyzer. The department also had 2 German-made Stokey-Shelli cardiopulmonary bypass machines and 1 American-made fully automated blood cell salvage system (Cell Saver 5), as well as other high-end equipment.

In February 2007, the hospital acquired the former Wanjie Hospital and established the East Campus, which had a total of 8 operating rooms (including 2 obstetric operating rooms). By May 2007, the total number of operating rooms in the hospital had increased to 40, the number of recovery room beds had increased to 15, and the daily surgical volume was 80–100 procedures. In March 2007, the Department of Pain was established on the basis of the former pain clinic of the Department of Anesthesiology, with 12 inpatient beds. In April of the same year, the Anesthesiology Teaching and Research Section was established.

In July 2011, the West Coast Campus opened, adding 21 operating rooms. By the end of 2013, the number of operating rooms in the East Campus had increased to 16, bringing the total number of operating rooms in the hospital to 70. The number of depth-of-anesthesia monitors increased to more than 20, blood salvage devices to 7, ultrasound machines to 2, blood gas analyzers to 4, various video intubation scopes to 6, and fiberoptic bronchoscopes to 6.

The anesthesia recovery room, completed and put into operation in 1999, was the first nursing unit in Shandong Province to operate in accordance with modern standards and specifications. It was equipped with a complete set of internationally first-class monitoring and treatment equipment. It played a major role in ensuring patients’ smooth recovery after surgery, improving anesthesia safety, and accelerating operating room turnover. At present, anesthesia recovery rooms have been established in all operating room units in the three campuses, with a total of 35 beds.

2. Talent Structure

The Department of Anesthesiology has more than 150 anesthesiologists and more than 100 anesthesia nurses. Among them are 17 chief physicians, 21 associate chief physicians, and 15 associate chief nurse specialists. Among the physicians, 27 hold doctoral degrees, 115 hold master’s degrees, and 11 have returned from overseas study. The discipline has 15 master’s supervisors and 2 doctoral supervisors. At present, more than 20 full-time master’s and doctoral students and more than 10 part-time postgraduate students are admitted each year.

3. Professional Characteristics

（1）Management of Difficult Airways

Management of the difficult airway is the most challenging technical problem in anesthesiology and is directly related to the patient’s life and safety. Among the more than 10,000 patients receiving general anesthesia with tracheal intubation each year, more than 200 have difficult airways, including nearly 100 with extremely difficult airways. Therefore, management of the difficult airway has always been a routine component of anesthesia skills training in the department. In recent years, with the development and widespread adoption of anesthesia visualization technology, we have further strengthened the training of physicians at all levels, particularly intensive training during the residency stage. Before beginning independent duty shifts, residents are required to be proficient in the difficult-airway management process and basic skills.

In accordance with the “Guidelines and Procedures for Difficult Airway Management” issued in recent years by the ASA and the Chinese Society of Anesthesiology, and in light of the actual conditions of the Department of Anesthesiology at our hospital, we revised and improved the department’s “Difficult Airway Management Procedure.” We equipped the department with all necessary instruments and devices, including fiberoptic bronchoscopes, specialized laryngoscopes, video laryngoscopes, and fiberoptic nasopharyngolaryngoscopes (SOS Visconi). Through professional lectures, simulation training, and other forms of education, we strengthened physicians’ use of the new equipment at all levels and worked to ensure proficiency in operating methods. In daily work, all anesthesiologists receive training and practical experience in difficult-airway management. From airway assessment, selection of the anesthesia plan, and prevention of unexpected events to determination of emergency plans, every step is designed to ensure that all anesthesiologists can respond calmly when encountering a difficult airway, use their technical skills proficiently, select appropriate anesthesia techniques, and skillfully apply all necessary measures. This ensures patient safety and the smooth performance of surgery, with the ultimate goals of reducing anesthesia errors and improving treatment outcomes.

（2）Invasive Pressure Monitoring

Since cardiac surgery was initiated in the 1980s, the Department of Anesthesiology at our hospital was among the earliest in China to perform invasive arterial and central venous pressure monitoring. In the early 1990s, monitoring techniques for pulmonary artery pressure and cardiac output using Swan-Ganz catheters were subsequently introduced. In recent years, with the increase in complex and critically ill surgical patients, including patients undergoing organ transplantation, cardiovascular surgery, and surgery with multiple preoperative comorbidities, invasive arterial and venous monitoring has gradually become widespread. At present, approximately 30–50 patients require invasive arterial and venous catheterization and monitoring each day. Most procedures in cardiac surgery, spinal surgery, thoracic surgery, neurosurgery, vascular surgery, and hepatobiliary surgery routinely involve invasive arterial monitoring. This has greatly improved patients’ perioperative safety, ensured hemodynamic stability during surgery, and prevented cardiovascular and cerebrovascular events induced by major circulatory fluctuations. Swan-Ganz catheter placement is routinely used for major organ transplantation procedures, such as liver and lung transplantation, and for complex and critically ill cardiovascular surgery, to guide perioperative treatment and achieve satisfactory results.

（3）Patient-Controlled Postoperative Analgesia

In the mid-1990s, our hospital was among the earliest in China to implement PCA postoperative analgesia. In recent years, with the development of multimodal analgesia, the level of postoperative analgesia has continuously improved, clinical outcomes have become more comprehensive, and patient satisfaction has increased year by year. Since 2010, more than 20,000 cases of postoperative analgesia have been provided annually, including intravenous patient-controlled analgesia, epidural patient-controlled or single-dose analgesia, nerve block analgesia, and local anesthetic infiltration. For the management of postoperative analgesia, an acute pain management team was established, led primarily by anesthesiologists and nurses, with participation from ward nurses. Team members visit patients twice daily, in the morning and evening, and record detailed information from each visit, including VAS scores, postoperative complications, and use of the analgesia pump. The information is handed over at the morning meeting, and timely communication is maintained with ward physicians and nurses. When problems such as alarms occur, the physician on duty is contacted immediately for management. Quality management tools are used each month for data aggregation and continuous quality improvement, and patient satisfaction has increased annually. Based on all patient visits, departments with more frequent problems are monitored more closely, including thoracic surgery, hepatobiliary surgery, and obstetrics. Existing problems, such as inadequate analgesia, dizziness, nausea, and vomiting, are continuously addressed. The background infusion rate and PCA dose settings are adjusted promptly. For obstetric patients, formula adjustments are made to address problems with pump infusion caused by the short duration of postoperative intravenous infusion. Through statistical analysis of 2,000 patients receiving postoperative analgesia, 8 formulas were summarized for research on individualized postoperative analgesia. The results are currently being analyzed. The article “Application of Quality Management Tools in Postoperative Analgesia” has been published. The Department of Anesthesiology also organized hospital-wide training for specialized pain nurses and established pain-free wards. Pain assessment is required for every patient, and the Department of Oncology was designated a national model ward for pain management.

(4) BIS-Monitored TCI Combined Anesthesia

The combined or multimodal use of anesthetic agents has become an important technique in modern anesthesiology and has been a routine anesthesia technique in the Department of Anesthesiology at our hospital for many years, with successful application in surgery across various specialties. This includes intravenous combined anesthesia and intravenous-inhalational combined anesthesia, also known as “balanced anesthesia.” Combined anesthesia plays a highly important role in improving anesthesia quality, refining the art of anesthesia, ensuring patient safety, and reducing medical costs. The combined use of medications not only maximizes the pharmacological characteristics of each anesthetic agent, allowing them to complement one another, but also reduces the doses of the various agents and their corresponding adverse effects, making clinical medication use more scientific and rational. Intravenous-inhalational combined anesthesia is a typical form of balanced anesthesia. It fully reflects the respective advantages of intravenous and inhalational anesthesia and represents the elevation of anesthesia technology to the level of anesthetic art. In recent years, with the development of anesthetic agents and monitoring technology, and in combination with clinical research, we have implemented propofol target-controlled infusion combined anesthesia under BIS monitoring to investigate the interactions among anesthetic agents from a clinical perspective. The research results were assessed by experts as reaching an internationally advanced level and received the Shandong Provincial Science and Technology Progress Award. This significantly improved the technical level of combined balanced anesthesia at our hospital, bringing it to an advanced level nationally and improving the quality and safety of anesthesia. In 2012, more than 20,000 cases of combined balanced anesthesia were completed, all with favorable outcomes.

(5) Intraoperative Autologous Blood Transfusion

In 1993, the Department of Anesthesiology at our hospital was the first to implement acute normovolemic hemodilution autologous blood transfusion in patients undergoing cardiovascular surgery. In 1994, we introduced mainland China’s first fully automated autologous blood salvage and reinfusion device (Cell Saver 4) and began performing intraoperative autologous blood reinfusion. In recent years, because the blood supply has been far from sufficient to meet the clinical demand for blood, the performance of surgery and the rescue of critically ill patients have been affected, and Qingdao has also frequently experienced “blood shortages.” Therefore, in recent years, the Department of Anesthesiology at our hospital has intensified its autologous transfusion efforts, increased the number of blood salvage devices, and strengthened technical training through educational courses, enabling more anesthesiologists to master this technology. At present, all residents in the Department of Anesthesiology with more than three years of experience are proficient in acute normovolemic hemodilution autologous blood transfusion and operation of the blood salvage device. Consequently, the number of cases involving intraoperative blood reinfusion has increased significantly, with a substantial rise compared with previous years. By August 2014, the Department of Anesthesiology had 7 blood salvage devices, and the monthly volume of autologous blood reinfusion exceeded 20,000 ml. As the surgical volume continued to rise, both the number and volume of allogeneic transfusions decreased significantly, effectively alleviating the pressure on Qingdao’s blood supply. This produced significant social and technical benefits and received broad recognition and high praise from the community.

(6) Anesthesia for Off-Pump Coronary Artery Bypass Grafting

On the basis of successfully providing anesthesia for coronary artery bypass grafting under cardiopulmonary bypass in the 1990s, we began independently providing anesthesia for off-pump coronary artery bypass grafting in 2000. The annual number of cases increased from 30–50 initially to more than 200 in recent years, with the oldest patient being 84 years old. Intraoperative blood salvage is routinely performed. One-half of the surgical patients do not require allogeneic blood transfusion. Critically ill patients routinely undergo Swan-Ganz catheter monitoring and transesophageal echocardiography, greatly improving the level of anesthesia management and monitoring, enhancing surgical outcomes, and placing this practice at an advanced level nationally.

(7) Anesthesia for Removal of Tracheal Foreign Bodies

Tracheal foreign bodies commonly occur in children aged 1–3 years. Obstruction of the trachea or main bronchus by a foreign body causes varying degrees of hypoxia. The difficulty of anesthesia lies in the fact that the depth of anesthesia is difficult to control, and respiratory depression or bronchospasm can easily occur during surgery, aggravating the child’s hypoxia. Most hospitals perform the procedure while the child is awake or under general anesthesia without spontaneous respiration, which is both painful and unsafe for the child. Since the early 1980s, the Department of Anesthesiology at our hospital has achieved excellent results using slow induction with maintenance of spontaneous respiration under general anesthesia, supplemented by adequate topical anesthesia. Approximately 300 anesthetics for tracheal foreign-body removal are administered each year. Patients come from across eastern Shandong, extending westward to the counties and cities of Weifang.

(8) Low Central Venous Pressure Combined with Acute Normovolemic Hemodilution for Liver Surgery

The greatest risk of hepatic lobectomy is major hemorrhage. How to reduce intraoperative blood loss and avoid complications associated with blood transfusion remains a major clinical challenge. After hepatic inflow occlusion, the amount of bleeding is determined mainly by central venous pressure. If central venous pressure can be controlled at a low level while maintaining safety, intraoperative blood loss can be significantly reduced. After successful induction of anesthesia, central venous and radial arterial catheterization is performed. While blood is withdrawn through the central venous catheter, an equal volume of crystalloid and colloid solutions is infused. During surgery, strict fluid management is used to control central venous pressure at 0–5 cmH2O. Acute normovolemic hemodilution is used to controllably reduce central venous pressure. By combining the advantages of the two techniques, blood loss and allogeneic blood transfusion during partial hepatectomy are effectively reduced. At present, 90% of patients undergoing partial hepatectomy at our hospital do not require allogeneic blood transfusion, and intraoperative blood loss is controlled at less than 200 ml in most patients. This achieves the goal of blood conservation in the true sense and reduces the risks of liver surgery.

(9) Day Surgery at the West Coast Campus

Day surgery originated in developed countries in Europe and North America. It refers to a safe and reliable surgical model in which selected patients meeting specific indications are admitted, undergo surgery, receive brief postoperative observation and recovery, and are discharged within one to two working days, without staying overnight in the hospital. The day surgery operating rooms at the West Coast Campus have advanced operating room conditions and equipment, more professional anesthesiologists with extensive anesthesia experience, more comprehensive medical care procedures, and a more complete postoperative follow-up system. This greatly reduces patients’ hospitalization costs and length of stay.

4. Medical Technologies

As the Department of Anesthesiology of a large tertiary general hospital, our clinical subspecialty structure is comprehensive and includes cardiovascular anesthesia, thoracic surgery anesthesia, organ transplantation anesthesia, pediatric anesthesia, obstetric and gynecologic anesthesia, burn and plastic surgery anesthesia, ophthalmic anesthesia, otolaryngologic anesthesia, oral and maxillofacial surgery anesthesia, and more than 10 other subspecialties. Each subspecialty has a physician with a senior professional title serving as its team leader. Depending on the workload undertaken by each subspecialty, 3–6 core members are assigned, consisting of associate chief physicians and attending physicians. The anesthesiologists in each subspecialty have extensive clinical experience and capabilities in managing subspecialty anesthesia and corresponding critical and difficult cases. In particular, they have accumulated extensive experience in difficult-airway management, invasive pressure monitoring, postoperative analgesia, and combined balanced anesthesia. In 2015, more than 81,000 inpatient surgical anesthetics were administered, including more than 1,200 cardiac surgeries and more than 500 da Vinci robotic surgeries. The department also assisted all hospital departments with resuscitation and performed more than 1,000 tracheal intubations and deep venous catheterizations.

5. Research and Education

In recent years, the department has undertaken 5 National Natural Science Foundation of China projects, more than 20 provincial- and ministerial-level scientific research projects, multiple clinical pharmacology trial projects and multicenter research projects, served as chief editor or associate chief editor of more than 10 books, and published more than 60 SCI papers.