Awake prone positioning for COVID-19 patients at Eka Kotebe General Hospital, Addis Ababa, Ethiopia: A prospective cohort study

OBJECTIVES:
The objectives of the study were to evaluate the benefit of awake prone positioning in COVID-19 patients hospitalized at Eka Kotebe General Hospital, Addis Ababa, Ethiopia.

MATERIALS AND METHODS:
Consecutive patients with COVID-19 who require supplemental oxygen to maintain oxygen saturation of ≥90% during the month of October 2020 were enrolled. Structured questionnaires were employed to collect data. Admission oxygen saturation was recorded for each patient before and after their first proning session. Analysis of descriptive and comparison statistics was done using SPSS version 25.

RESULTS:
A total of 61 patients were included in the study. The mean age (+SD) for the cohort was 55.4 (+16.9) years. The average duration of proning was 5+2.5 h/session and 8+6 h/day. The average oxygen saturation before proning was 89% (SD 5.2) and 93% (SD 2.8) 1 h after proning (P < 0.001); supplemental oxygen requirements significantly decreased with prone ventilation, before proning: FiO2 0.33 (+0.14) versus 1 h after prone ventilation: FiO2 0.31 (+0.13) (P < 0.001). Oxygen improvement with prone ventilation was not associated with duration of illness or total prone position hours. When assessed at 28 days after admission, 55.7% (n = 34) had been discharged home, 1.6% (n = 1) had died, and 42.6 (n = 26) were still hospitalized. CONCLUSION: Awake prone positioning demonstrated improved oxygen saturation in our oxygen requiring COVID-19 patients. Even though further studies are needed to support causality and determine the effect of proning on disease severity and mortality, early institution of prone ventilation in appropriate oxygen requiring COVID-19 patients should be encouraged.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola

BACKGROUND:
The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014–2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country’s maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

METHODS:
Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible.

RESULTS:
Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1–3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided.

CONCLUSIONS:
Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

Assessment of feasibility and acceptability of family-centered care implemented at a neonatal intensive care unit in India

Background
A family-centered care (FCC) parent participation program that ensures an infant is not separated from parents against their will was developed for the caring of their small or sick newborn at a neonatal intensive care unit (NICU) in Delhi, India. Healthcare provider sensitization training directed at psychosocial and tangible support and an audio-visual training tool for parent-attendants were developed that included: 1) handwashing, infection prevention, protocol for entry; 2) developmentally supportive care, breastfeeding, expression of breastmilk and assisted feeding; 3) kangaroo mother care; and 4) preparation for discharge and care at home. The study aimed to examine the feasibility and acceptability of the FCC model in a NICU in India.

Methods
A prospective cohort design collected quantitative data on each parent-attendant/infant dyad at enrollment, during the NICU stay, and at discharge. Feasibility of the FCC program was measured by assessing the participation of parent-attendants and healthcare providers, and whether training components were implemented as intended. Acceptability was measured by the proportion of parent-attendants who participated in the trainings and their ability to accurately complete program activities.

Results
Of 395 NICU admissions during the study period, eligible participants included 333 parent-attendant/infant dyads, 24 doctors, and 21 nurses. Of the 1242 planned parent-attendant training sessions, 939 (75.6%) were held, indicating that program fidelity was high, and the majority of trainings were implemented as intended. While 50% of parent-attendants completed all 4 FCC training sessions, 95% completed sessions 1 and 2; 60% of the total participating parent-attendants completed session 3, and 75% completed session 4. Compliance rates were over 96% for 5 of 10 FCC parent-attendant activities, and 60 to 78% for the remaining 5 activities.

Conclusions
FCC was feasible to implement in this setting and was acceptable to participating parent-attendants and healthcare providers. Parents participated in trainings conducted by NICU providers and engaged in essential care to their infants in the NICU. A standard care approach and behavior norms for healthcare providers directed psychosocial and tangible support to parent-attendants so that a child is not separated from his or her parents against their will while receiving advanced care in the NICU.

Did COVID-19 Pandemic change Anaesthesia Practices in India: A Multi-centre Cross-sectional Study

Introduction
The anaesthetic management for surgeries during the COVID-19 pandemic has posed unique challenges. Safety of all healthcare workers is an additional concern along with heightened risk to patients during General Anesthesia (GA). COVID-19 pneumonia and aerosol generation may be exacerbated during airway intervention and GA. We aimed to assess the change in the mode of anaesthesia due to the pandemic.

Methods
A research consortium led by WHO Collaboration Centre for Research in Surgical Care Delivery in Low and Middle Income countries, India, conducted this retrospective cross-sectional study in 12 hospitals across the country. We compared the anaesthesia preferences during pandemic (April 2020) to a corresponding pre pandemic period (April 2019)

Results
A total of 636 out of 2,162 (29.4%) and 156 out of 927 (16.8%) surgeries were performed under GA in April 2019 and April 2020 respectively, leading to a fall of 13% in usage of GA. A 5% reduction in GA and a 12% increase in the usage of regional anaesthesia was observed for cesarean sections. There was no significant change in anesthesia for laparotomies and fracture surgeries. However, 14% increase in GA usage was observed in surgeries for local soft tissue infections and necrotic tissues.

Conclusion
Though overall usage of GA reduced marginally, the change was mainly contributed by anesthesia for caesarean births. The insignificant change in anaesthesia for other surgeries may be attributed to the lack of facilities for spinal anaesthesia and may reflect the risk taking behaviour of healthcare professionals in COVID-19 pandemic.

The Preparing Residents for International Medical Experiences (PRIME) Simulation Workshop: Equipping Surgery and Anesthesia Trainees for International Rotations

Abstract
Introduction: Although global health training expands clinical and sociocultural expertise for graduate medical trainees and is increasingly in demand, evidence-based courses are limited. To improve self-assessed competence for clinical scenarios encountered during international rotations, we developed and assessed a simulation-based workshop called Preparing Residents for International Medical Experiences. Methods: High-fidelity simulation activities for anesthesiology, surgery, and OB/GYN trainees involved three scenarios. The first was a mass casualty in a low-resource setting requiring distribution of human and material resources. In the second, learners managed a septic operative patient and coordinated postoperative care without an ICU bed available. The final scenario had learners evaluate a non-English-speaking patient with pre-eclampsia. We paired simulation with small-group discussion to address socio-behavioural factors, stress, and teaching skills. Participants evaluated the quality of the teaching provided. In addition, we measured anesthesiology trainees’ self-assessed competence before and after the workshop. Results: The workshop included 23 learners over two iterations. Fifteen trainees (65%) completed the course evaluation, 93% of whom strongly agreed that the training met the stated objectives. Thirteen out of 15 (87%) anesthesiology trainees completed the competence survey. After the training, more trainees indicated confidence in providing clinical care with indirect supervision or independently. Mean self-assessed competency scores on a scale of 1–5 increased for all areas, with a mean competency increase of 0.3 (95% CI, 0.2–0.5). Discussion: Including simulation in a pretravel workshop can improve trainees’ self-assessed competence for a variety of scenarios involving clinical care in limited-resource settings

Cardiac anesthesiologist and the global capacity building to tackle rheumatic valvular heart disease

Rheumatic heart disease (RHD) is considered the neglected disease of the tropics and is endemic in several low- and middle-income countries (LMIC). 1 It still is an important cause of preventable morbidity and mortality associated with cardiovascular disease among children and young adults. The disease has seen a sharp decrease in most high-income countries (HIC) and primarily, the LMICs of Asia and Africa face the brunt of RHD, which also imposes huge economic burden. 2 In addition, RHD is also a significant cause of maternal mortality. 3 For precise understanding of the burden of RHD, it needs to be appreciated that LMICs are more populous (more than 5 times that of HICs) and that RHD remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery. 4 Furthermore, LMICs provide very different levels of cardiac surgical services for their population. There has been an impressive significant growth in the cardiac surgical capacity in middle-income countries, even so, there is a wide gap between patients in need of intervention / surgery and those who actually receive it. In addition, the diversity of health care facilities in these countries has led to availability of state-of-the art facilities to a select few (affluent) with majority (poor and under-privileged) having to rely on the overwhelmed public hospitals. The situation in the low-income countries is even worse.

Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade

Abstract
Objective
We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women’s opinions on their overall experience of PPH care.

Methods
This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction. Key outcomes were reported pain (on a scale 0–10) in the immediate postpartum period and receipt of antibiotics within four weeks postpartum (a proxy for postpartum infection). Outcomes related to satisfaction with care and aspects women liked most and least about PPH care were also reported.

Results
Among women diagnosed with PPH, 58 were in the UBT group and 2188 in the no-UBT group. Self-reported, post-discharge antibiotic use within four weeks postpartum was similar in the UBT (3/58, 5.6%) and no-UBT groups (100/2188, 4.6%, risk ratio = 1.22, 95% confidence interval [CI]: 0.45–3.35). A high postpartum pain score of 8–10 was more common among women in the UBT group (17/46, 37.0%) than in the no-UBT group (360/1805, 19.9%, relative risk ratio = 3.64, 95% CI:1.30–10.16). Most women were satisfied with their care (1935/2325, 83.2%). When asked what they liked least about care, the most common responses were that medications (580/1511, 38.4%) and medical supplies (503/1511, 33.3%) were unavailable.

Conclusion
UBT did not increase the risk of postpartum infection among this population. Women who receive UBT may experience higher degrees of pain compared to women who do not receive UBT. Women’s satisfaction with their care and stockouts of medications and other supplies deserve greater attention when introducing new technologies like UBT.

Surgical residents’ opinions on international surgical residency in Flanders, Belgium

Background
International electives benefit training of medical residents due to exposure to an increased scope of pathologies, improved physical examination skills, communication across cultural boundaries and more efficient resource utilization. Currently there is no mechanism for Belgian surgical residents to participate in international training opportunities and little research has addressed the international mobility of Belgian residents. The goal of this study was to examine the attitudes of Belgian residents towards international training among surgical residents.

Methods
An anonymous, structured electronic questionnaire was sent to a cohort of Belgian residents, including surgical residents, by e-mail and social media.

Results
In total, 342 respondents filled out the questionnaire out of a total of 5906 Belgian residents. The results showed that 334 of the residents came from Flanders (10.8%) and 8 came from French-speaking Brussels and Wallonia (0.28%). Surgical specialties represented 46% of respondents and included surgical, obstetric and anaesthesiology residents. The majority (98%) were interested in an international rotation, both in low- and middle-income countries (LMICs) and in high-income countries. A total of 84% were willing to conduct an international rotation during holidays and 91% would participate even when their international stay would not be recognised as part of their residency training. A minority (38%) had undertaken an international rotation in the past and, of those, 5% went to an LMIC.

Conclusion
The majority of surgical residents consider an international rotation as educationally beneficial, even though they are rarely undertaken. Our survey shows that in order to facilitate foreign rotations, Flemish universities and governmental institutions will have to alleviate the regulatory, logistical and financial constraints.

Regional anesthesia educational material utilization varies by World Bank income category: A mobile health application data study

Introduction
Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level.

Methods
We retrospectively analyzed data collected from the free Android app “Anesthesiologist” from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block).

Results
Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic.

Conclusion
The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.

Distance-Learning Initiatives Targeting Non-physician Anesthesia Providers in Low-Resource Environments

Abstract
Purpose of Review
“Distance-learning” encompasses a variety of didactics, from self-directed online learning to focused courses and programs. Despite increasing internet availability, focused distance-learning courses are rarely practiced in low- or middle-income countries, particularly among non-physician anesthetists. This review aims to discuss the availability, significance, and challenges of distance-learning programs for non-physician anesthesia providers in low-resource settings.

Recent Findings
Task shifting and sharing in anesthesia remains essential in low-resource settings to meet the demand of surgical need. Distance-learning may be the ideal option in these settings, as it can be used to train the individual at their workplace even in remote areas. Different models and techniques are described. Success depends on the course design, communication strategies, handling of technical issues, and support mechanisms.

Summary
Distance-learning should be an essential part of training and in-service support for non-physician anesthetists. Global advocates of safe, effective anesthesia services need to support the development and delivery of distance-learning courses.