Global Anesthesiology and Intraoperative Neuromonitoring: Report from a Sustainable Collaboration

The stated mission of the ASA Committee on Global Health is to enhance, support, educate, represent and collaborate for safe anesthesia practice worldwide. As an ASA Committee on Global Health scholarship recipient, Dr. Simmons traveled to CURE Uganda in 2017 and fully felt the pull of that mission. It was during this trip, and subsequent visits thereafter, that the framework was set for the creation of an educational and clinical program that would significantly improve surgical and anesthesia care, support economic development with job creation, and improve career satisfaction of clinicians via the implementation of the first intraoperative neuromonitoring (IONM) program in Uganda. At the University of Colorado Hospital, where Drs. Simmons and Montejano practice, the Section of Neuroanesthesia supervises and directs the IONM program. Utilizing these unique skills and recognizing the need for this technology and its ability to enhance patient outcomes, work began toward training and educating both a supervising physician and IONM technologist. After nearly two years of preparation with meetings and strategy sessions, as well as education and training, the program was launched in March 2022. The overall success of the project demonstrates the great potential of collaboration between departments of anesthesiology, neurosurgery, and hospital leadership despite cultural differences and geographic locations.

A collaboration to improve perioperative acute pain care at the University Teaching Hospital of Butare, Rwanda

BACKGROUND: A perioperative acute pain care program integrating standardized assessment and treatment forms into pain care was developed and implemented at an urban hospital in Rwanda through a collaboration between Rwandan and Canadian experts. This study evaluated the perioperative acute pain care program using a quality improvement lens.

METHODS: Using the Model for Improvement: Plan, Do, Study, Act (PDSA) cycle, a mixed methods evaluation was performed. Over one year, 519 randomized patient chart audits were conducted and analyzed through control charts. Through purposeful sampling, focus groups comprised ofsurgeons and nurses (N=34) involved in pain care in surgery, obstetrics, and anesthesiology were performed and analyzed via thematic coding.

RESULTS: The average attempted form completion rate across all forms varied monthly between 56-93% (mean=79%; median=81%). Across all forms, both the mean and median total number of errors per form were 12.5. Enablers of form use included improved pain care for patients and feelings of professional satisfaction. Program implementation was challenged by resource constraints, form integration, and health care provider training.

CONCLUSION: Future quality improvement collaborations should identify and address improved pain care while working with local experts to ensure PDSA cycles are continuous, and evidence based.

Haemodynamic monitoring in patients undergoing high-risk surgery: a survey of current practice among anaesthesiologists at the University of the Witwatersrand

Background: Haemodynamic monitoring and optimisation in high-risk surgery patients improve postoperative outcomes. High-income countries (HICs) have reviewed their haemodynamic monitoring and management practices. There is, however, a paucity of literature in low- and middle-income countries (LMICs) in this regard. The aim of this study was to describe the current haemodynamic monitoring practice in high-risk surgery patients among anaesthesiologists at the University of the Witwatersrand.

Methods: A survey was conducted among anaesthesiologists at the University of the Witwatersrand using a convenience sampling method by means of an adapted questionnaire from previous research done on this topic.

Results: A total of 64 out of 76 questionnaires were analysed, attaining a response rate of 84%. Ninety-seven per cent of the respondents either provided or directly supervised anaesthesia for high-risk surgery patients. Ninety-seven per cent of them frequently monitored invasive arterial blood pressure (IABP), 68.8% monitored stroke volume variation (SVV) and 53% monitored cardiac output (CO). The most frequently optimised parameter was IABP (68.8%); while CO was optimised by only 39.1% of the respondents. The VigileoTM monitor was the most frequently used CO device (84.4%). The main reason for not monitoring CO was the use of dynamic parameters of fluid responsiveness as a surrogate for CO (57.8%). Seventy-five per cent of the respondents used SVV as a diagnostic indicator for volume expansion, but the haemodynamic effects of volume expansion were frequently assessed using change in heart rate (78.1%) and blood pressure (76.6%). Most of the respondents (98.4%) believed that their haemodynamic management practice could be improved.

Conclusion: Anaesthesiologists at the University of the Witwatersrand frequently monitored and optimised IABP rather than CO in high-risk surgery patients. The respondents used dynamic parameters of fluid responsiveness as a surrogate for CO monitoring and as an indicator for volume expansion. Most of the respondents believed that their current haemodynamic management practice in this setting could be improved.

The state of surgery, obstetrics, trauma, and anaesthesia care in Ghana: a narrative review

Conditions amenable to surgical, obstetric, trauma, and anaesthesia (SOTA) care are a major contributor to death and disability in Ghana. SOTA care is an essential component of a well-functioning health system, and better understanding of the state of SOTA care in Ghana is necessary to design policies to address gaps in SOTA care delivery.

The aim of this study is to assess the current situation of SOTA care in Ghana.

A situation analysis was conducted as a narrative review of published scientific literature. Information was extracted from studies according to five health system domains related to SOTA care: service delivery, workforce, infrastructure, finance, and information management.

Ghanaians face numerous barriers to accessing quality SOTA care, primarily due to health system inadequacies. Over 77% of surgical operations performed in Ghana are essential procedures, most of which are performed at district-level hospitals that do not have consistent access to imaging and operative room fundamentals. Tertiary facilities have consistent access to these modalities but lack consistent access to oxygen and/or oxygen concentrators on-site as well as surgical supplies and anaesthetic medicines. Ghanaian patients cover up to 91% of direct SOTA costs out-of-pocket, while health insurance only covers up to 14% of the costs. The Ghanaian surgical system also faces severe workforce inadequacies especially in district-level facilities. Most specialty surgeons are concentrated in urban areas. Ghana’s health system lacks a solid information management foundation as it does not have centralized SOTA databases, leading to incomplete, poorly coded, and illegible patient information.

This review establishes that surgical services provided in Ghana are focused primarily on district-level facilities that lack adequate infrastructure and face workforce shortages, among other challenges. A comprehensive scale-up of Ghana’s surgical infrastructure, workforce, national insurance plan, and information systems is warranted to improve Ghana’s surgical system.

Troubleshooting obstetric spinal anaesthesia at district hospital level

Obstetric spinal anaesthesia is routinely used in South African district hospitals for caesarean sections, providing better maternal and neonatal outcomes than general anaesthesia in appropriate patients. However, practitioners providing anaesthesia in this context are usually generalists who practise anaesthesia infrequently and may be unfamiliar with dealing with complications of spinal anaesthesia or with conversion from spinal to general anaesthesia. This is compounded by challenges with infrastructure, shortages of equipment and sundries and a lack of context-sensitive guidelines and support from specialised anaesthetic services for district hospitals. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to obstetric spinal anaesthesia, and to address common concerns and queries. We stress that good clinical practice is essential to avoid predictable, common complications, and hence a thorough preoperative preparation is essential. We further discuss clinical indications for preoperative blood testing, spinal needle choice, the use of isobaric bupivacaine, spinal hypotension, failed or partial spinal block and pain during the caesarean section. Where possible, relevant local and international guidelines are referenced for further reading and guidance, and a link to a presentation of this topic is provided.

Nonphysician Sedation Providers in Africa: What Counts and What Is Being Counted?

“Not everything that can be counted counts, and not everything that counts can be counted.” – WB Cameron, Informal Sociology: A Casual Introduction to Sociological Thinking, 1963.

Does your anesthesia providers’ level of training impact your outcomes? This question has been widely evaluated and debated in the perioperative literature. With increasing demand for surgical and procedural services facilitated by anesthesia care globally, an answer will continue to be sought. Van der Merwe et al1 in their article “Postoperative outcomes associated with procedural sedation conducted by physician and non-physician anesthesia providers: findings from the prospective, observational African Surgical Outcomes Study (ASOS)” published in this month’s Anesthesia & Analgesia, have added to this discussion, with a secondary analysis of data from the African Surgical Outcomes Study (ASOS). Although their study provides some interesting insights into the outcomes of procedural sedation across the continent, our opinion is that the question remains largely unanswered.

To date, most of the literature evaluating the association between anesthesia care provider type and outcomes has focused on anesthesia care in highly developed health care systems. Questions have focused on task-shifting, where the responsibility for tasks is shifted from a more highly trained health care provider to health workers with shorter training and fewer qualifications, and task-sharing, where both levels of providers perform the task and may even work closely together. Examples include family doctors in Canada providing unsupervised anesthesia care in community hospitals after adding an additional year of training in anesthesia to their family medicine residency program; certified registered nurse anesthetists (CRNAs), practicing independently in many US states; and French anesthesiologists supervising nurse anesthetists with a 1:2 ratio. Ultimately, the hope is that by shifting/sharing tasks, access to care will improve with less-resource input and with similar (or in the case of task-sharing) even safer outcomes.2

Countries with a gross national income per capita of <$12,696 US dollars (USDs) are often (problematically) lumped together as low- and middle-income countries (LMICs)3 regardless of the profound diversity in this categorization, which contains around 85% of the world’s population.4 There is a critical shortage in human resources for health (HRH) globally, particularly in anesthesia. However, HRH are one of the most complex parts of health systems, with huge international variation in terms of numbers of health care workers, their training, their point of entry into training, their scope of practice, interprofessionalism, resilience, burnout, and retention of health care workers within the system.5–7 Developing a deep understanding of how to most effectively and efficiently provide safe anesthesia care is an urgent priority in improving global surgical outcomes; however, nuances in context make generalizations problematic.

Ven der Merwe et al1 aimed to evaluate this question by comparing patient outcomes when procedural sedation was delivered by nonphysician versus physician anesthesia providers. The primary data source, the ASOS, is a landmark study, where investigators collected a large amount of data (11,422 patients) over a relatively short amount of time, with good coverage of a broad geographic area.8 Its largely descriptive statistical analysis has been highly informative of perioperative outcomes in Africa, which appear to be much worse than previously published global data. In contrast, the Van der Merwe et al1 study is a small subset of the primary data (336 patients, ~3% of the full cohort), with a more complex comparative statistical analysis, with the authors concluding that receipt of sedation from a nonphysician provider was significantly associated with increased odds of severe complications. While these results must be interpreted with great caution (as we will outline below), the findings raise important questions about perioperative health care systems in Africa.

The other opioid crisis: the situation in low-resource countries

Numerous articles in this Special Issue describe an opioid crisis where there is too much opioid, especially in Canada, the USA, and some other high-income countries. Nevertheless, for the majority of the world’s population—people living in low-resource countries—the problem is not enough opioid. In most of the world’s countries, patients are living and dying in severe pain because of limited or no availability of opioid medications.

The scale of the crisis
The World Health Organization (WHO) estimates that 80% of the world’s population (5.5 billion out of 7 billion people) have insufficient access to controlled medications to treat moderate-to-severe pain.1 This is despite morphine, fentanyl, and methadone being included in the WHO’s Model List of Essential Medicines.2 All countries are required to submit yearly opioid usage data to the International Narcotics Control Board, and recently collated data show that low- and middle-income countries (LMICs) used only 10% of the world’s ids. In comparison, a handful of high-income countries (Canada, the USA, Australia, New Zealand, and some European countries) consumed over 90%.3 This means that patients in most of the world are unable to access appropriate, effective treatment for the management of acute pain or pain at the end of life, leading to extreme levels of avoidable suffering.

The Lancet Commission on Palliative Care and Pain Relief (LCPCPR) published a report in 2017 detailing the global problem of low access to opioids and describing an “access abyss” for those living in low-resource areas.4 The authors estimated that in 2015 over 60 million people were suffering from symptoms that needed palliative care and pain relief. In low-resource countries, the situation is made worse because of the combination of low availability of medications and increased burden of pain due to undertreatment and late presentation of many conditions such as cancer and HIV/AIDS. This is illustrated by the Figure, showing a world map where the areas of countries are distorted in proportion to their opioid use divided by their burden of painful disease.4 Canada and the USA are vastly enlarged while other parts of the world (such as Africa and parts of Asia) are barely visible.

A retrospective analysis of peri-operative medication errors from a low-middle income country

Identifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and the steps followed prior to drug administration. Our objective was to identify, extract and analyze the medication errors (MEs) reported in our critical incident reporting system (CIRS) database over the last 15 years (2004–2018) and to review measures taken for improvement based on the reported errors. CIRS reported from 2004 to 2018 were identified, extracted, and analyzed using descriptive statistics and presented as frequencies and percentages. MEs were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, American Society of Anesthesiologist (ASA) status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement. Total MEs reported were 311, medication errors were reported, 163 (52%) errors occurred in ASA II and 90 (29%) ASA III patient, and 133 (43%) during induction. During administration phase 60% MEs occurred and 65% were due to human error. ADEs were found in 86 (28%) reports, 58 of which were significant, 23 serious and five life-threatening errors. The majority of errors involved neuromuscular blockers (32%) and opioids (13%). Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents. Medication errors were more frequent during administration. ADEs were occurred in 28% MEs.

Anaesthetists’ knowledge and frequency of use of neuromuscular monitoring at the University of the Witwatersrand

Background: The use of neuromuscular blocking agents (NMBA) during general anaesthesia (GA) can result in postoperative residual neuromuscular blockade (PRNMB). Studies have shown that PRNMB can be reduced with the use of neuromuscular monitors (NMM). Data from South Africa about the knowledge and use of NMM is scarce. Therefore, this study aimed to determine the knowledge and the frequency of use of NMM in the Department of Anaesthesia at the University of the Witwatersrand (Wits).

Methods: A prospective, contextual study design was employed using a self-administered online questionnaire developed by the researcher with the assistance of senior anaesthetists. The study population consisted of all anaesthetists working in the Department of Anaesthesia at Wits. A convenience sampling method was used and a completed returned online questionnaire implied consent. Adequate knowledge was defined as a score of 65.5%, as determined by the Angoff method.

Results: From a total of 208 anaesthetists, 126 completed the questionnaire. There was an inadequate level of knowledge of NMM among anaesthetists in the department. Sixty-four per cent (64%) of the participants achieved less than the score of 65.5% as set by the Angoff method. The participants’ mean score for the questionnaire was 57%. The level of knowledge differs significantly among participants, depending on professional designation, with a p-value < 0.009. Medical officers and second-year registrars scored significantly below the Angoff score with p-values of 0.0005 and 0.02, respectively. First-year registrars recorded the highest score, followed by fourth-year registrars. The frequency of use of NMM in the department was low at 13%. Conclusion: The level of knowledge among anaesthetists regarding NMM was inadequate. There is a need for the improvement of knowledge regarding NMM use, by ongoing education in the department. The use of NMM in the department was also low. The most common reason for not using NMM was the unavailability of these monitors.

Perioperative outcomes – more than sevoflurane and scalpels

It is well understood that access to safe surgery is a major challenge in low- and middle-income countries (LMICs), where over five billion people do not have reliable access to surgical care, resulting in an estimated 17 million avoidable deaths per annum.1 Bickler et al. have predicted that up to 90% of children in LMICs will manifest a surgically treatable condition before the age of 15.2 If these conditions are not managed effectively, they result in severe morbidity or mortality. Butler et al. have echoed this sentiment, noting that up to 20% of children in Rwanda, Sierra Leone, Nepal, and Uganda needed surgery but that 62% of that cohort had an unmet surgical need.3 Despite paediatric surgical services in South Africa being positioned to offer a wide range of safe paediatric surgical interventions,4 the paucity of surgeons results in limited access to centralised centres and much of the population remains unserved.5