INTERNATIONAL NEUROANESTHESIA NEWS

Neuroanesthesia and Neurocritical Care in Brazil

Christine Tavares
Cristiane Tavares, MD
Luiz Marcelo Sá Malbouisson, MD, PhD
Luiz Marcelo Sá Malbouisson, MD, PhD
Pedro Martins Pereira Kurtz, MD, PhD
Pedro Martins Pereira Kurtz, MD, PhD
Maria José Carvalho Carmona, MD, PhD
Maria José Carvalho Carmona, MD, PhD

Cristiane Tavares, MD
Neuroanesthesiologist and Clinical Research Physician
Department of Anesthesiology, Surgical Sciences and Perioperative Medicine
Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
Coordinator of the 1st Neuroanesthesiology Specialization in Brazil

Luiz Marcelo Sá Malbouisson, MD, PhD
Associated Professor of Anesthesiology, University of São Paulo Medical School
Supervisor of the Neurocritical Care Unit in the Central Institute of Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil

Pedro Martins Pereira Kurtz, MD, PhD
President of the Brazilian Neurocritical Care Society
Supervisor of the Neurocritical Care Unit in the State Institute of Brain Paulo Niemeyer, Rio de Janeiro, Brazil

Maria José Carvalho Carmona, MD, PhD
Associated Professor of Anesthesiology, University of São Paulo Medical School
Director of Anesthesia Division in the Central Institute of Hospital das Clínicas, University of São Paulo Medical School
Editor-In-Chief, Brazilian Journal of Anesthesiology
Coordinator of the 1st Neuroanesthesiology Specialization in Brazil

Neuroanesthesia is a subspecialty in anesthesiology that is still incipient in Brazil. A selected group of anesthesiologists has been developing this expertise in the last 50 years by working exclusively in neurosurgical teams where greater integration with neurosurgeons and intensive care physicians is possible.1 However, The Brazilian Society of Anesthesiology only created the Committee of Anesthesia for Neurosurgery in 2016.2 In a way, it reflects the country's reality that general anesthesiologists perform most of the anesthetic procedures for neurosurgery and do not follow the patients postoperatively.

According to the Federal Council of Medicine, there were 3,298 neurosurgeons, 23,021 anesthesiologists, and 6,562 specialists in Critical Care in 2018.3, 4 Considering that from the 34,000 neurosurgeries performed per year, there are about 2,400 intracranial vascular microsurgeries and more than 10,000 craniotomies for brain tumor resections,5 procedures that demand the expertise of a neuroanesthesiologist, specialization in this field is highly desirable in the country. Concerning pediatric neurosurgical procedures, the situation is even more critical, with few experienced professionals performing this kind of anesthesia.6

Brazil is a federal republic composed of 26 states and a federal district. It is a continental country with more than 5,000 municipalities and 208 million inhabitants.7 The Constitution of 1988 initiated a process of decentralization and municipalization of health services and introduced the principle of universal access to them, entirely financed by government resources.8 Hence, the Unified Health System (SUS) provides full and free access to the national health system, which seems to be the perfect scenario. However, regional inequalities and disparities between the public and private sectors contradict this idea. Neurosurgical assistance is not equally available for all the patients that need it.5

About two-thirds of the population does not have access to private insurance or health plans and depends exclusively on SUS.9 It is a huge demand to be entirely absorbed by the public health system.

In 2018, there were a total of 668 hospitals with 5,037 beds available for neurosurgical patients across the country, a density of 3.2 beds for each one million inhabitants.9, 10 More than 50% are concentrated in the Southeast and South regions, where there is a capacity to perform neurosurgeries comparable to developed countries.11 On the other hand, there is a lack of infrastructure and a shortage of critical neurosurgical materials and devices in municipalities far from large medical centers, especially in the North and Northeast regions. Neurosurgeons claim that there are not enough conditions and staff for complex surgical procedures and avoid staying there.5 Indeed, the density of neurosurgeons per 100,000 inhabitants varies from 6.82 in cities with more than 500,000 inhabitants to 0.16 in small towns with less than 20,000 inhabitants. The Southeast has a mean density of 2.24, while the Northeast has only 0.9 neurosurgeons per 100,000 inhabitants, which is less than the SOSSUS report's recommendation.5, 12

Concerning education, the National Medical Residency Commission (CNRM/MEC) establishes a period of five years for Neurosurgery and three years for Anesthesiology residencies. Neurocritical Care specialization takes one or two extra years besides the three-years of Internal Medicine or Neurology residencies.4 Once again, the South and Southeast regions concentrate 78 of the 99 neurosurgical residency programs, 27 of which being in the state of São Paulo5, 13 Since the 122 teaching and training centers in Anesthesiology are more spread, and there is high heterogeneity in the distribution of neurosurgery services across the country, many anesthesiology fellows do not have the opportunity to witness complex neurosurgeries. They usually rotate in neuro anesthesia for only four months.14

Aiming to improve that, we are recruiting fellows for the first Neuroanesthesiology specialization course in Brazil, which is being launched in the largest Latin American hospital complex: Hospital das Clínicas of the University of São Paulo Medical School. It already pursues the most extensive neurosurgical training program, with 20 fellows that run through many subspecialties in four different Institutes. While the Child and the Cancer Institutes are specialized in pediatric and oncologic surgeries, the Central Institute is the reference for urgencies, neurotrauma, skull base, vascular, and spine subspecialties. In the Psychiatry Institute, they rotate in epilepsy, tumors, cranioplasty, peripheral nerves, hydrocephalus, pituitary, pain, and functional neurosurgery. We also have high-skilled teams of interventional neuroradiology, intraoperative neuromonitoring, and two exclusive neurocritical care units. More than 4,500 anesthesia for electroconvulsive therapy and about 3,620 anesthesia for neurosurgical procedures are performed per year in the whole complex.15 In addition to that, we are also working on a partnership with the Brazilian Neurocritical Care Society to improve our fellows' skills concerning pre and postoperative management, EEG, and transcranial doppler. Therefore, we intend to obtain accreditation by the ICPNT and become a vital reference center for Neuroanesthesia and Neuroscience Research in Latin America.

References

  1. Gusmao SS. História da Neurocirurgia no Rio de Janeiro. Arq. Neuropsiquiatr. 2002;60(2-A):333-7.
  2. Brazilian Society of Anesthesiology- Sociedade Brasileira de Anestesiologia [web site  https://sbahq.org/neurocirurgia/2020 ]. Assessed November 10, 2020.
  3. Scheffer M, Cassenote A, Biancarelli A. Demografia médica no Brasil: dados gerais e descrições de desigualdades. v. 1. São Paulo: Conselho Regional de Medicina do Estado de São Paulo; Brasília, DF: Conselho Federal de Medicina, 2011.
  4. Brasil. Ministério da Educação - MEC. Comissão Nacional de Residência Médica- CNRM. Resolução CNRM Nº 02/2006, de 17 de maio de 2006. [website ]. Acessed November 12, 2020.
  5. Sheffer M, Cassenote A. Neurocirurgia no Brasil: perfil dos profissionais e os serviços de saúde. São Paulo: SBN,2019.177p. ISBN 978-65-80681-00-6
  6. Silva MC, Salomao JFM, Zanon N. Historia da neurocirurgia pediatrica no Brasil. Rev. Bras. Neurol. Psiquiatr. 2014;18(2):77-84.
  7. IBGE. Instituto Brasileiro de Geografia e Estatística. Tabelas de estimativas populacionais para os municípios e para as Unidades da Federação brasileiros em 01.07.2018. Available from: <ftp://ftp.ibge.gov.br/Estimativas_de_Populacao/ Estimativas_2018/estimativa_dou_2018_20181019.pdf>. Accessed November 10, 2020.
  8. Buchan J, Fronteira I, Dussault G. Continuity and change in human resources policies for health: lessons from Brazil. Hum Resour Health 9, 17(2011). Access here.
  9. Brasil. Ministério da Saúde (MS). Sistema de Informações Ambulatoriais do SUS (SIA/SUS) [database only]. Available from: http://tabnet.DataSUS.gov.br/cgi/deftohtm.exe?sia/cnv/qauf.def. Accessed November 10, 2020.
  10. ANS. Agência Nacional de Saúde Suplementar. Mapa Assistencial de Saúde Suplementar 2018. Available here. Assessed November 10, 2020.
  11. Brasil. Ministerio da Saude (MS). CNES: Cadastro Nacional de Estabelecimentos de Saúde. Available here. Assessed November 10, 2020.
  12. Zuidema GD. The SOSSUS report and its impact on neurosurgery. J Neurosurg. 1977;46(2):135-144.
  13. Brazilian Society of Neurosurgery- Sociedade Brasileira de Neurocirurgia (SBN) Programa de treinamento da Residência Médica em Neurocirurgia. Available here. http://www.sbn.com.br Assessed November 10, 2020.
  14. Brazilian Society of Anesthesiology- regulamento dos Centros de Ensino e treinamento. Available here. Assessed November 10, 2020.
  15. Neurosurgical Department- Hospital das Clinicas FMUSP. Available here. Assessed November 10, 2020.

Figure 1

Figure 1: Hospital das Clínicas, which includes Central Institute, Psychiatry Institute, Child Institute, and Cancer Institute; the places for activities of the neuroanesthesiology fellows.

Figure 2

Figure 2: Neuroanesthesiology, Neurosurgery, and Neurocritical Care team.

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