Isabeau Walker

Anaesthesia services in developing countries: defining the problems

We describe the use of a questionnaire to define the difficulties in providing anaesthesia in Uganda. The results show that 23% of anaesthetists have the facilities to deliver safe anaesthesia to an adult, 13% to deliver safe anaesthesia to a child and 6% to deliver safe anaesthesia for a Caesarean section. The questionnaire identified shortages of personnel, drugs, equipment and training that have not been quantified or accurately described before. The method used provides an easy and effective way to gain essential data for any country or national anaesthesia society wishing to investigate anaesthesia services in its hospitals. Solutions require improvements in local management, finance and logistics, and action to ensure that the importance of anaesthesia within acute sector healthcare is fully recognised. Major investment in terms of personnel and equipment is required to modernise and improve the safety of anaesthesia for patients in Uganda.

Paediatric surgery and anaesthesia in south-western Uganda: a cross-sectional survey

OBJECTIVE to study paediatric surgery rates in south-western Uganda, compare them to rates in England, and determine if existing surgical facilities and workforce meet World Health Organization (WHO) standards. METHODS to obtain information on surgical facilities and workforce, we conducted a cross-sectional survey of all hospitals performing major surgery in 14 districts of south-western Uganda in 2007-2008. Using theatre logbook data, we determined the surgical rates, types of surgery performed and in-theatre surgical outcomes. FINDINGS of 72 hospitals surveyed, 29 were performing major surgery. None met WHO standards for essential surgery. There were 0.7 accredited surgeons per 100.000 population and no paediatric surgeons. Most anaesthetists were not physicians (accredited anaesthetist per 100.000 population: 1.1). The annual surgical rate for children aged ≤ 14 years was 180 operations per 100.000 population; most were emergency procedures. The annual surgical rate for patients of all ages was 652 operations per 100.000 population, with a median of 422 per operating theatre (range: 60-3497) and of 226 per surgeon (range: 60-1748). Mission or nongovernmental organization (NGO) hospitals, which had 44% of the hospital beds in the region, performed 3039 (55%) of the paediatric operations. Externally funded surgeons performed 80% of the 140 cleft lip and palate operations. Four in-theatre deaths occurred in children ≤ 14 years old (in-theatre mortality: 7.7 deaths per 10.000 operations). CONCLUSION access to all surgery, including paediatric surgery, is poor in south-western Uganda and investment in basic health-care facilities and surgical workforce and training is urgently needed. Mission and NGO hospitals make a valuable contribution to elective surgery, and externally funded surgeons make an important contribution to specialist surgery. In-theatre mortality was lower than reported for similar settings.

Anaesthetic management of the child with sickle cell disease

Summary Sickle cell disease (SCD) is a relatively common inherited disorder of haemoglobin with significant morbidity and mortality. This review describes the epidemiology and pathophysiology of the disease, and discusses the clinical manifestations found in children with SCD. A discussion of the evidence concerning the perioperative management of such children is presented.

Global oximetry: an international anaesthesia quality improvement project

Pulse oximetry is mandatory during anaesthesia in many countries, a standard endorsed by the World Health Organization ‘Safe Surgery Saves Lives’ initiative. The Association of Anaesthetists of Great Britain and Ireland, the World Federation of Societies of Anaesthesiologists and GE Healthcare collaborated in a quality improvement project over a 15‐month period to investigate pulse oximetry in four pilot sites in Uganda, Vietnam, India and the Philippines, using 84 donated pulse oximeters. A substantial gap in oximeter provision was demonstrated at the start of the project. Formal training was essential for oximeter‐naïve practitioners. After introduction of oximeters, logbook data were collected from over 8000 anaesthetics, and responses to desaturation were judged appropriate. Anaesthesia providers believed pulse oximeters were essential for patient safety and defined characteristics of the ideal oximeter for their setting. Robust systems for supply and maintenance of low‐cost oximeters are required for sustained uptake of pulse oximetry in low‐ and middle‐income countries.

Specialist surgery in the developing world: luxury or necessity?

Patients suffering from conditions requiring specialist intervention cannot obtain treatment when facilities do not exist locally. Specialist visiting teams in a number of surgical disciplines have attempted to address these issues in collaboration with local clinicians. These interventions require careful planning and communication to achieve optimum results. Several teams have been successful in building long‐term relationships that have lead to important clinical developments in the local country.

Anaesthesia in Developing Countries

Anaesthesia is in crisis in many parts of the world. This supplement, Anaesthesia in Developing Countries, has been produced by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) as a contribution to the Council of Science Editors’ initiative to draw attention to the global issue of poverty and human development. In a year when the AAGBI celebrates its 75th anniversary, ‘75 years of improving patient safety’, we should recognise that millions of people have little in the way of anaesthesia provision. Many of the articles and accounts in the supplement are from Africa, reflecting the fact that most of the poorest nations in the world are situated in sub-Saharan Africa, and for them the situation is the most desperate. Anaesthesia is an essential component of secondary healthcare and when anaesthesia services are inadequate, difficulties are experienced in a number of specialties, particularly obstetrics. Caesarean section rates of between 5% and 10% have been suggested for optimal maternal and neonatal outcomes [1]. In many poorer nations, obstetric and anaesthesia services are severely limited: Caesarean section rates are often less than 1%. Commonly, mothers in such countries are condemned to a 1 : 16 lifetime risk of death in childbirth and an even higher chance of neonatal death or birth injury. Maternal mortality rates of 1% exist in some areas [2]. Little is published about anaesthesia in developing countries, particularly in rural areas. Anaesthesia is a technology-based specialty and is especially vulnerable when resources are limited – without the required facilities, anaesthetists are unable to care for their patients. A recent study in Anaesthesia [3] demonstrated the difficulties faced by colleagues in Uganda where adequate supplies of drugs and equipment to safely anaesthetise a patient requiring Caesarean section were available in only 6% of cases, for an adult requiring for laparotomy in 23% of cases, and for a child in only 13% of cases. Even in India, a country with many physician anaesthetists and some first-rate services, lack of anaesthesia provision in rural areas is a major contributing factor to high maternal mortality rates [4]. The profession of anaesthesia has a low status in many developing countries. Emigration of medical staff is partly to blame [5], leaving few role models to encourage the development of the specialty and subsequently very low numbers of medical graduates entering anaesthesia training. The consequence in many countries is a technician-based specialty with poor image, low wages, inadequate equipment and conditions that limit professional development. In the UK we are fortunate to have a physician anaesthetist for every patient undergoing surgery – a ratio of around 12 000 anaesthetists for a population of 64 million. In many countries the ratio is one medical anaesthetist to several million. The danger of pursuing a uniquely medical model in countries where it is unattainable is a gross underprovision of anaesthesia services for the population [4]. As the medical model of service has proved impossible for many countries, non-medical anaesthetists are commonly employed. Anaesthesia training for such nurses or clinical officers requires well resourced, effective training programmes, with expert teaching and practical instruction and should be at least 2–3 years in length. In reality, many are trained for considerably less time, often supervised by poorly trained practitioners passing on bad practice, thus exacerbating the difficulties. The avoidable anaesthetic mortality in some services has recently been reported to be as high as 1 : 150 anaesthetics, with 50% of deaths being obstetric [6]. This supplement examines the difficulties in providing essential anaesthesia services. It gives an overview of global health and global health politics and details aspects of anaesthesia provision including intensive care, obstetrics, paediatrics, and pain relief. The authors have experience in different parts of the world, but inserted throughout the supplement are case histories from anaesthesia students and anaesthetic clinical officers working in sub-Saharan Africa in 2007. These accounts describe their day-to-day reality. They describe practice that needs support and a political will to change. The different employing agencies, equipment and drugs that might be encountered are discussed, also the issue of donation of equipment to the developing world. We have considered how sustainable links can be developed between NHS Trusts and hospitals in the developing world. Anaesthetists live in the global village. The knowledge that our colleagues struggle in such basic situations should encourage us to support the development of our specialty worldwide. This is the reason that this supplement has been written. We hope that it will act to inform and encourage those who feel that gross deprivations in healthcare should not simply be accepted. Action is needed, not just at a personal level, but at institutional, national and international levels. Overseas development agencies need to recognise the place of anaesthesia services in patient care. We hope all who read this supplement will reflect on the difficulties described. The first article, Lamula’s story, gives us reason to celebrate the value of our National Health Service and the good fortune of our patients and UK anaesthesia.

The WHO Surgical Safety Checklist: the evidence.

Of the more than 230 million patients who undergo surgery each year, 7 million suffer a disabling complication, and one million die (Weiser 2008). These numbers are substantial, and through the WHO Surgical Safety Checklist, the issues surrounding safe surgery are at last receiving attention on the international stage.

Paediatric anaesthesia in developing countries

Each year millions of children undergo surgery in the developing world with inadequate facilities, equipment and drugs. In many hospitals, anaesthesia is largely dependent on the availability of ketamine. Application of well‐established clinical techniques, particularly for postoperative pain control, would relieve unnecessary suffering in children. Improvements in peri‐operative care are required by investment in health systems and training.

Impact of the european working time directive on the training of paediatric anaesthetists

The European Working Time Directive and the New Deal have decreased the number of hours worked by anaesthetic trainees. We implemented the Working Time Directive in May 2004 and evaluated the effect of its implementation on training. During two 6‐month periods, one before and one after the change, we determined the number of operating lists undertaken by each Specialist Registrar in Anaesthesia. After implementation of the Working Time Directive, the mean number of lists performed by Specialist Registrars decreased from 24 to 21 lists per registrar per month, a 13% decrease. Exposure to subspecialty lists was the same in both periods, but this was at the expense of general lists and those in remote locations. We conclude that the Working Time Directive has had a measurable impact on the training of paediatric anaesthetists, but that the significance of this change for clinical practice has not yet been measured.

Fast-track paediatric cardiac surgery: the feasibility and benefits of a protocol for uncomplicated cases

OBJECTIVE Fast-track patient pathways for cardiac surgery are used in adult practice and by necessity is a mainstay in the developing world. We aimed to introduce a fast-track protocol for uncomplicated paediatric open-heart surgery cases and to subsequently review the results of this change in practice. METHODS A fast-track protocol co-ordinated by the Advanced Nurse Practitioners was introduced in January 2006 for children aged over 6 months undergoing uncomplicated open-heart procedures. We conducted a review of prospectively collected data on all included patients. The setting was a tertiary paediatric cardiac surgical centre in the UK. The outcome measures for audit were: patient fitness to leave the intensive care unit (ICU) on the day of surgery and hospital length of stay. RESULTS Included children had a mean age 6 (standard deviation (SD) 4.9) years and mean weight 22.7 (SD 17.6) kg. Of the 194 patients included, 153 (79%) were fit to leave the ICU on the day of surgery. Patients undergoing surgery for ventricular septal defect: odds ratio (OR) 2.8 (95% CI: 1.2-5.6) P=0.01 and left ventricular outflow tract obstruction: OR 5.5 (95% CI: 1.4-21.2) P=0.01, were more likely to be unfit than atrial septal defect and right ventricular outflow tract obstruction. Patients undergoing surgery in the afternoon were more likely to be unfit than those undergoing surgery in the morning: OR 2.3 (95% CI: 1.2-4.8) P=0.03. No relationship was found between age or weight and fitness to fast track. Median length of hospital stay for the whole cohort was 3 (range: 2-11) days. After adjustment for case mix, there was significant evidence that length of hospital stay reduced as experience with the protocol increased over the series of patients RC -0.02 (95% CI: -0.01 to -0.03) P<0.01. CONCLUSION A fast-track programme can be implemented safely and effectively if the appropriate support including a step-down ward area is put in place. Greater experience with this type of protocol leads to reductions in the length of hospital stay for children aged over 6 months undergoing uncomplicated open-heart surgery. Fast-track cases should be performed in the morning.