Newsletter July 2020: Editorial - We work together, but how close?

Gabriel M. Gurman, MD

Chief Editor



The current COVID-19 pandemic demands, once again, a serious review regarding the shortage of anaesthesia manpower. The tremendous increase in the number of ventilated patients created a situation in which more anaesthesiologists have been assigned to the intensive care units leaving other professional tasks, at least partially, uncovered.

But the shortage of anaesthesiologists is a perennial problem.

Put simply, five billion people all over the world do not have access to safe, affordable surgical and anaesthesia care when needed (1).

True, this worrying reality is much more evident in lower-income countries (as in Africa, where the number of anaesthesiologists per 100,000 population is less than one {2}). Still, in various places in Europe, the situation is not at all ideal. A survey published in Portugal in the year of 2018 indicated that that country needed more than 500 anaesthesiologists to face the current daily needs in the operating room and outside it (3), and Portugal is not alone in this situation.

A WFSA global anaesthesia manpower survey published in 2017 (4) reported that 77 countries (out of the 153 which provided information) had less than 5 physician- anaesthesia providers (PAP) per 100,000 inhabitants.

ESA Doctor and nurse

This reality is evident, but the solutions to solve it are too many, and this means that we did not reach, yet, the best proposal for dealing with the issue.

It would be just too simple to decide that more can be done to increase the number of medical school graduates, and in the same time to improve our everyday activity to recruit more physicians to our speciality (5). This permanent task is obvious, but there are a lot of obstacles, among them economical and psychological, which reduce the chance of success in a short period.

This is why many countries created large groups of nurses, who are implicated in the anaesthesia activity in the operating room and beyond.

The “champions” in this direction are the United States. There, the nurse anaesthetist (NA) profession has already existed for more than a century (6), established and evolved before the medical speciality of anaesthesiology (7). Already by 1988, some 20,000 active NAs were in charge of more than 60% of anaesthesia procedures administered annually  (8). Besides, 20% of the NAs that year administered anaesthesia without the collaboration of an anaesthesiologist. Today it seems to be an irony, but 40years ago, if a NA needed specific advice regarding his/her (anaesthetised!) patient’s condition, it could be offered only by the surgeon involved in the case.

The situation today in this subject is even more complicated. Some reports (9,10) refer to the organisation in the USA of specific courses for NAs to get qualification for using ultrasound to guide intravenous line placement or practical lessons on peripheral insertion of central venous catheters.

In Europe, the situation is somewhat different. Despite the specific and clear differences all over the continent regarding the role of the NA in daily practice, one can easily distinguish some bright general patterns in this regard.

In the year 2010 in Europe, even though 14 countries already recognised the profession of NA (11), anaesthesia could be delivered only under the responsibility of an anaesthesiologist (12).

A survey published in 2018 (13) offered a look into the mode of the NAs’ role in the operating rooms in Europe, in comparison to the USA. Besides the category of “circulation nurse” (who can be asked to help the anaesthesiologist during induction, maintenance or emergence of anaesthesia), European countries employ anaesthesia nurses, who are defined as assistants to the anaesthesiologist, having a supportive and collaborative role, monitoring vital signs, administering (like in France) general anaesthesia or regional anaesthesia through devices placed by the anaesthesiologist.

The question which this situation arises is the following one: could the current system in Europe be identified as ‘anaesthesia teamwork?’ And a second one: could this system solve, soon, the problem of manpower shortage?

This term, introduced by the North American literature, considers that the “anaesthesia care team” appears to be the safest method of delivering anaesthesia care” and that “evidence is very supportive that the anaesthesiologist-led anaesthesia care team is the most cost-effective method of delivering anaesthesia” (14).

This system has been investigated in Europe, too, (15), comparing the results of the activity of an anaesthesiologist alone (2832 patients) with an anaesthesia care team (anaesthesiologist and a nurse anaesthesiologist- 2842 patients). The authors found that the anaesthesia teamwork was associated with decreased 30-day postoperative mortality and shorter length of stay when compared with the solo anaesthesiologist. This result could be explained by “two heads being better than one”.

But the system discussed and studied in that article refers to the team which works 1:1, meaning one physician and one nurse, and this could not solve, at all, the shortage of manpower in anaesthesia.

The American system of teamwork provides the possibility that the “physician anaesthesiologist determines which procedural tasks, if any, may be delegated” to the other member of the team (16), including the so-called anaesthesia assistant (AA). In this case, the anaesthesiologist could supervise two operating rooms at the same time, after he/she delegates specific tasks to each of the two non-medical professionals, one in each room.

As one could understand from this short presentation, the solution is neither simple nor uniform for all countries and hospitals.

Data about the excellent outcome of the anaesthesia care teamwork is encouraging. Still, nobody is entitled to forget that together with the need for more manpower, and the economic aspects of the anaesthesiologist daily activity, our status and image in the eyes of the medical community and public opinion should be preserved and even improved.

In any system to be selected, the role and position of the anaesthesiologist are to stay unique: he/she is the person in charge of patient safety, he/she is the professional who decides upon the anaesthesia technique, and he/she is the only one who delegates, if necessary, various parts of the anaesthesia activity to other members of the team.

As a paraphrase to the famous Ambroise Parre’s sentence, yes, the anaesthesiologist is the only master on the board of anaesthesia, and it has to remain as it is!



1.Vreede E at al. Anesth Analg 2019;129:1199

2.Law TL et al. Anesth Analg 2019;129:839

3.Lemos P et al. Acta Medica Portuguesa 2018;31:254

4.Kempthorne P et al. Anesth Analg 2017;125:981

5.Eggers BC, Macario A. Curr Opin Anesthesiol 2006;19:207

6.Del Grosso B, Boyd S. AANA Journal 2019;87:205

7.Gunn IP et al. AANA Journal 1987;55:97

8.Beutler JM. HealthAffairs.org January 16, 2020

9.Bortmann  J et al. AANA 2019;87:269

10.Ostrowski AM et  al. AANA 2019;87:11

11.Meursen V et al. Eur J Anaesth 2010;27:773

12.Clergue F. Eur J Anaesth 2010;27:761

13.Tenedios C et al. Eur J Anaesth 2018;35:108

14.Abenstein JP, Warner MA. Anesth Analg 1996;82:1273

15.Dony P et al. Eur J Anaesth 2019;36:64

16.American Society of Anesthesiologists. Statement on the Anesthesia Care Team (last amended on October 23, 2019)


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