Faye M. Evans

The impact of aprotinin on postoperative renal dysfunction in neonates undergoing cardiopulmonary bypass: a retrospective analysis.

BACKGROUND: Recent concern about the safety of aprotinin administration to adults has led to its suspension from worldwide markets. However, few studies have examined its safety in pediatric patients. Studies in children evaluating aprotinin’s safety have been hindered by the heterogeneity of pediatric patients and the inconsistency of clinical protocols. In this investigation, we retrospectively reviewed 200 neonatal cardiac surgical cases performed at our institution to examine the safety of aprotinin, focusing on postoperative renal dysfunction, using a consistent aprotinin dosing protocol. METHODS: Two-hundred consecutive neonates scheduled for palliative or corrective congenital cardiac surgery requiring cardiopulmonary bypass (CPB) from January 1, 2005 through February 28, 2007 were included in this retrospective investigation. Preoperative, intraoperative and postoperative data were collected and analyzed. Markers of safety included 72-h postoperative renal dysfunction, need for dialysis (peritoneal or hemodialysis), thrombosis and in-hospital mortality. RESULTS: Neonates were divided into those who received aprotinin (aprotinin group; n = 156) and those who did not (no aprotinin group; n = 44). Twenty-four and 72-h postoperative serum creatinine levels were significantly greater than baseline levels in both groups. The degree of change in creatinine levels was highly significant and similar between the two groups. A larger percentage of neonates in the aprotinin group developed renal dysfunction, although this difference was not statistically significant. Stepwise logistic regression, assessing the impact on renal dysfunction of all variables that indicated significance between neonates who did or did not receive aprotinin and between neonates who did or did not develop renal dysfunction, identified CPB time and age as significant predictors of postoperative renal dysfunction. All neonates who developed postoperative renal dysfunction had a CPB time of more than 100 min regardless of the use of aprotinin. Additionally, using this subset, similar percentages of renal dysfunction occurred in both groups. A second multivariable regression analysis to simultaneously account for the predictors of CPB time, age and aprotinin administration found CPB time to be the only significant predictor of renal dysfunction. Incidences of postoperative dialysis, postoperative thrombosis and in-hospital mortality were not statistically significantly different between the aprotinin and the no aprotinin groups. CONCLUSION: The occurrence of postoperative renal dysfunction in neonates was more significantly predicted by the duration of CPB than by the intraoperative administration of aprotinin. CPB times of more than 100 min appeared to be a critical marker for the development of postoperative renal dysfunction. Randomized prospective trials are needed to confirm the validity of our retrospective findings.

Developing a curriculum for anaesthesia training in low- and middle-income countries

The shortage of healthcare providers in low- and middle-income countries (LMICs) is well documented and is manifested by a profound lack of anaesthesia providers, especially throughout Sub-Saharan Africa. The need to develop and support training programs for physician and non-physician anesthetists in LMICs is therefore paramount to providing safe and cost effective anaesthesia care. Development of these training programs is multifaceted and must take into account the specific needs of the recipient country in order to be successful. Curriculum development should be directed towards sustainable change, ultimately reducing the need for outside support. To ensure viability as the new program develops, graduates need to be assimilated into the program as leaders. Emphasis needs to be placed on lessons learnt, professional conduct, and improving outcomes. Anaesthesia educational programs must emphasize quality, safety and professionalism in the providers and the care they deliver. Region-specific teaching methods should be developed using problem-based learning techniques and presenting data in a way that educates rather than castigates. There are good examples of programs that have been implemented to support education in LMICs. However, there are only a few that have successfully adopted a holistic approach to the entire curriculum. More often than not, programs have focused on specific areas of expertise of visiting teachers, rather than the needs of the recipient program. Because of the limited data available, it remains difficult to define any one clear path to achieving these goals. A combination of coordination and collaboration will increase the efficacy of implementing new or upgrading existing programs and will allow clearly defined paths to be defined in the future.

A New Approach to Teaching Obstetric Anaesthesia in Low-Resource Areas

Maternal mortality is high in many low- and middle-income countries. Unsafe anaesthesia contributes to this, especially for women requiring Caesarean section. Anaesthesia providers with limited skills and poor resources are often faced with complicated obstetric patients. A new course called SAFE-OB teaches a systematic approach to anticipating, preparing for, and dealing with obstetric anaesthetic emergencies. The course has now been taught in many African, Asian, and Latin countries. Initial follow-up suggests improvement in skills and knowledge, and effective translation of these to the workplace. Efforts are made to make the course locally owned and sustainable. We feel that SAFE-OB is an effective method of improving obstetric anaesthesia care.

A Geospatial Evaluation of Timely Access to Surgical Care in Seven Countries/Evaluation Geospatiale De L'acces En Temps Voulu Aux Soins Chirurgicaux Dans Sept pays/Una Evaluacion Geoespacial del Acceso Oportuno a la Atencion Quirurgica En Siete Paises

Abstract: Objective To assess the consistent availability of basic surgical resources at selected facilities in seven countries. Methods In 2010–2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao Peoples Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital’s catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available. Findings Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh. Conclusion Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group

INTRODUCTION Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries (HICs) are increasingly engaged in resource-limited areas, with short-term missions (STMs) as the most common form of involvement. However, consensus recommendations currently do not exist for STMs in pediatric general surgery and associated perioperative care. METHODS The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for STMs based on extensive experience with STMs. RESULTS Three distinct, but related areas were identified: 1) Broad goals of surgical partnerships between HICs- and low and middle-income countries (LMICs). A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN), was endorsed by all groups; 2) Guidelines for the conduct of STMs were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; 3) travel and safety considerations critical to STM success were enumerated. CONCLUSION A diverse group of stakeholders developed these guidelines for STMs in LMICs. These guidelines may be a useful tool to ensure safe, responsible, and ethical STMs given increasing engagement of HIC providers in this work. LEVEL OF EVIDENCE 5.

Con: Pure service delivery is no longer needed in global surgical missions

Medical providers have a long history of volunteerism and service to those in need. For many of us, this concern for the health of others less fortunate represents why we were drawn to the medical profession in the first place. The Lancet Commission’s Report on Global Surgery highlights the vast health inequalities that exist between highand low-income countries. Five billion people do not have access to safe, affordable, surgical and anesthesia care when needed. Furthermore, 143 million additional surgical procedures are needed every year in lowand middle-income countries (LMICs) in order to save lives and prevent disability. Other important details are not as clearly defined. These relate to the most cost-effective, feasible, and replicable means to implement the systems needed to reduce these inequalities and promote health equity. A topic often debated in the anesthesia and surgical global health community is the role of the ‘‘global surgical mission’’ as part of the solution. There are extremes of opinions—from those who think there is no role for global surgical missions to others who think the missions should have an important role. For many, the role depends on the nature and organization of the mission. We contend that there is no role for pure service delivery in global surgical missions, except in cases where no other option exists. Surgical missions aim to address unmet healthcare needs in LMICs. While the surgical services and organizational structures they provide may differ, the real question is whether global surgical missions address unmet healthcare needs in an ethically responsible fashion. An additional question is whether there are evidence-based guidelines that can help to validate these practices. There is little homogeneity in defining the term ‘‘global surgical mission’’. When Sykes performed a systematic literature review for empirical evidence of medical mission activities and outcomes during 1993-2013, the author reported 45 different terms used to describe short-term medical service trips. For purposes of his review, Sykes specifically described medical service trips (MSTs) as ‘‘trips in which volunteer medical providers from highincome countries (HICs) travel to LMICs to provide health care over one to eight weeks.’’ Even within these parameters, these service-based care projects can be delivered via a variety of existing service platforms. The most common type of mission is the ‘‘short-term’’ servicebased surgical trip of one to three weeks’ duration. Typically organized around a specific surgical need (e.g., cleft lip/palate, pediatric cardiac surgery, or burn reconstruction), the primary goal of these efforts is to relieve the burden of disease at particular sites or in particular populations. These missions usually consist of self-contained teams comprising foreign surgeons, anesthesiologists, nurses, and support staff who travel together to pre-identified sites. These groups vary in their ability to adapt to host facilities and equipment. Some teams bring all of their equipment and supplies—the ‘‘surgical brigade model’’—while others rely on host supplies or some combination of the two. In contrast, there are longer-term platforms for global surgical missions that consist of self-contained surgical teams. These missions are led by non-governmental F. M. Evans, MD (&) Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Bader 3, Boston, MA, USA e-mail: Faye.Evans@childrens.harvard.edu

Health system assessment for safe surgical care in rural Nicaragua: a retrospective survey

Abstract Background To improve access to surgical care in rural Nicaragua, a collaboration was established between the Global Initiative for Childrens Surgery (GICS), Operation Smile Nicaragua, and the Nicaragua Ministry of Health. Prior to implementation of the surgical programme Surgery for the People Nicaragua, our aim was to perform a baseline assessment of the Nicaraguan health systems capacity to provide safe surgical care in its rural zones. Methods In June and July 2017, a retrospective baseline evaluation of safe surgical care provision was performed at two rural district hospitals in Las Minas using the GICS Optimal Resources tool, the WHO/Program in Global Surgery & Social Change (PGSSC) Surgical Assessment tool, the World Federation of Societies of Anesthesiologists Assessment tool, and the PGSSC Qualitative Assessment tool. Main outcome measures were: surgical workforce density, surgical volume, perioperative mortality rates, level of infrastructure, access to essential medicines, and health system financing. Findings The surgical workforce density was six per 100 000 population, including one paediatric surgeon (the WHO target surgical workforce density is 20 per 100 000 population). The surgical volume was 1050 procedures per 100 000 population per year; less than 10% of the surgical volume was paediatric. Perioperative mortality rates were low but not routinely collected: range 0·12%–0·50%. There were major needs in infrastructure including: additional operating theatres; running water at one site; post-anaesthetic recovery room areas; and paediatric-specific surgical wards. There was adequate access to essential medications including oxygen, anaesthetics, and antibiotics. Care at the two district hospitals was free, and there were no recorded out-of-pocket expenses for surgical patients. Interpretation A major success of the Nicaraguan health system is free surgical care, protecting patients from catastrophic expenditure. However, to improve access to surgical care in rural Nicaragua, there is a need for investments in human resources, particularly in anaesthesia and paediatric providers. Furthermore, there is a need for monitoring and evaluation of key indicators including perioperative mortality and complication rates. Funding UBS Optimus Foundation.