The role of non-governmental organizations in advancing the global surgery and anesthesia goals

Non-governmental organizations (NGOs) are indispensable to social and economic development, particularly in states with limited resources or poor governance. With about five billion people globally lacking access to safe, timely and affordable surgical and anesthesia care, mostly in low-income and middle-income countries (LMICs), NGOs can play a critical role in meeting this significant surgical need and advancing the global surgery and anesthesia goals set by the Lancet Commission on Global Surgery in alignment with the Sustainable Development Goals (SDGs). Surgical-NGOs (s-NGOs) have historically and continue to play a vital role in reducing the surgical burden globally, providing at least 3 million surgical procedures annually in LMICs. They have done this primarily through service delivery by employing temporary platforms such as short-term surgical trips and self-contained surgical platforms or through the setting up of specialized hospitals. With the advent of the SDGs, s-NGOs are increasingly investing in strengthening local health systems by supporting various dimensions of the health systems building blocks. Health systems strengthening interventions by s-NGOs have primarily focused on the training of skilled local surgical workforce (pre-service and in-service) and investing in health infrastructure through equipment and supplies donations to capacitate local health facilities to provide high-quality sustainable surgical and anesthesia care. Despite these laudable efforts, s-NGOs have not been without challenges and criticism especially around the cost-effectiveness, sustainability, equity and quality of care provided. In this article, we review the current landscape of s-NGOs and the challenges they face. We also examine the roles of s-NGOs in advancing the global surgery and anesthesia goals and SDGs in light of the ongoing COVID-19 pandemic.

We Asked the Experts: Global Surgery—Seeing Beyond the Silo

The COVID-19 pandemic requires comprehensive health systems response, with 14% of infected people developing severe sickness leading to hospitalization and 5% admitted to an intensive care unit [1]. The need for oxygen and intensive care means that perhaps for the first time, surgery and anesthesia find themselves playing a central role in a global health emergency; but is global surgery integrated enough to the wider global health community to have an impact?

Simulation Based Training in Basic Life Support for Medical and Non-medical Personnel in Resource Limited Settings

Medical and non-medical personnel commonly encounter victims of life threatening injuries inflicted by various causes in diverse settings. More than 90% of global deaths and disability adjusted life-years (DALYs) lost because of injuries reportedly occur in low-income and middle-income countries (LMICs). The degree of readiness and competence to manage victims of accidents is likely to vary among individual care givers for knowledge, skill and confidence which would also depend on their training status. It would thus be justified that training in basic life support and other emergency clinical skills be administered to enhance competences in resuscitating the accident victims. Whatever the scale of a mass casualty incident, the first response will be carried out by members of the local community-not just health care staff and designated emergency workers,but also many ordinary citizens. Therefore, both medical and non-medical personnel should be targeted to receive training in basic life support (BLS). In medical training, the traditional (didactic) approach has been suggested to be an efficient and well-experienced training method while with the advances in technology the use of simulation-based medical training (SBMT) is increasing since SBMT provides a safe and supportive educational setting, so that students can improve their performance without causing adverse clinical outcomes. Similarly, the use of simulation based training in BLS would not only reduce the procedural associated risks but also benefit more participants from the public domain than would be the case if the training was conducted on human subjects. Compared with the developed world set-up simulation based training in resource constrained settings may not be that well established. This paper will therefore seek to examine the role of medical simulation as a necessary advancement and supplementary method of training in basic life support for medical and non-medical personnel in resource limited settings

Results from the first audit of an intensive care unit in Botswana

BACKGROUND: Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU
OBJECTIVES: To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes
METHODS: PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates
RESULTS: A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 – March 2018. Patient’s mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups
CONCLUSIONS: The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted

Foreign body ingestion in children presenting to a tertiary paediatric centre in South Africa: A retrospective analysis focusing on battery ingestion

Background. Ingestion of foreign bodies remains a frequent reason for presentation to paediatric emergency departments worldwide. Among the variety of objects ingested, button batteries are particularly harmful owing to their electrochemical properties, which can cause extensive injuries if not diagnosed and treated rapidly. International trends show an increasing incidence of button battery ingestion, leading to concern that this pattern may be occurring in South Africa. Limited local data on paediatric foreign body ingestion have been published.

Objectives. To assess battery ingestion rates in a tertiary paediatric hospital. We hypothesised that the incidence has increased, in keeping with international trends. Secondary objectives included describing admission rates, requirements for anaesthesia and surgery, and promoting awareness of the problems associated with battery ingestion.

Methods. We performed a retrospective, descriptive analysis of the Red Cross War Memorial Children’s Hospital trauma database, including all children under 13 years of age seen between 1 January 2010 and 31 December 2015 with suspected ingestion of a foreign body. The ward admissions database was then examined to find additional cases in which children were admitted directly. After exclusion of duplicate records, cases were classified by type of foreign body, management, requirement for admission, anaesthesia and surgery. Descriptive statistics were used to analyse the data in comparison with previous studies published from this database.

Results. Patient age and gender patterns matched the literature, with a peak incidence in children under 2 years of age. Over the 6-year period, 180 patients presented with food foreign bodies, whereas 497 objects were classified as non-food. After exclusion of misdiagnosed cases, the remaining 462 objects were dominated by coins (44.2%). Batteries were the causative agent in 4.8% (22/462). Although the subtypes of batteries were not reliably recorded, button batteries accounted for at least 64% (14/22). Most children who ingested batteries presented early, but more required admission, anaesthesia and surgery than children who ingested other forms of foreign body.

Conclusions. The study demonstrated that the local incidence of button battery ingestion may be increasing, although data are still limited.Admission, anaesthesia and surgery rates for batteries were higher in this cohort than for all other foreign bodies. As button batteries can mimic coins, with much more dire consequences on ingestion, our ability to expedite diagnosis and management hinges on a high index of suspicion. It is imperative to increase awareness among healthcare workers and parents.

Impact of capnography on patient safety in high- and low-income settings: a scoping review

Background: Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs.

Methods: We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included.

Results: The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes.

Conclusion: Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.

Using critical care physicians to deliver anesthesia and boost surgical caseload in austere environments: the Critical Care General Anesthesia Syllabus (CC GAS)

Background
Despite an often severe lack of surgeons and surgical equipment, the rate-limiting step in surgical care for the nearly five billion people living in resource-limited areas is frequently the absence of safe anesthesia. During disaster relief and surgical missions, critical care physicians (CCPs), who are already competent in complex airway and ventilator management, can help address the need for skilled anesthetists in these settings.

Methods
We provided a descriptive analysis that CCPs were trained to provide safe general anesthesia, monitored anesthesia care (MAC), and spinal anesthesia using a specifically designed and simple syllabus.

Results
Six CCPs provided anesthesia under the supervision of a board-certified anesthesiologist for 58 (32%) cases of a total of 183 surgical cases performed by a surgical mission team at St. Luc Hospital in Port-au-Prince, Haiti in 2013, 2017, and 2018. There were no reported complications.

Conclusions
Given CCPs’ competencies in complex airway and ventilator management, a CCP, with minimal training from a simple syllabus, may be able to act as an anesthesiologist-extender and safely administer anesthesia in the austere environment, increasing the number of surgical cases that can be performed. Further studies are necessary to confirm our observation.

Outcomes Associated With Anaesthetic Techniques for Caesarean Section in Low- And Middle-Income Countries: A Secondary Analysis of WHO Surveys

Associations between anaesthetic techniques and pregnancy outcomes were assessed among 129,742 pregnancies delivered by caesarean section (CS) in low- and middle-income countries (LMICs) using two WHO databases. Anaesthesia was categorized as general anaesthesia (GA) and neuraxial anaesthesia (NA). Outcomes included maternal death (MD), maternal near miss (MNM), severe maternal outcome (SMO), intensive care unit (ICU) admission, early neonatal death (END), neonatal near miss (NNM), severe neonatal outcome (SNO), Apgar score <7 at 5 minutes, and neonatal ICU (NICU) admission. A two-stage approach of individual participant data meta-analysis was used to combine the results. Adjusted odds ratio (OR) with 95% confidence intervals (CIs) were presented. Compared to GA, NA were associated with decreased odds of MD (pooled OR 0.28; 95% CI 0.10, 0.78), MNM (pooled OR 0.25; 95% CI 0.21, 0.31), SMO (pooled OR 0.24; 95% CI 0.20,0.28), ICU admission (pooled OR 0.17; 95% CI 0.13, 0.22), NNM (pooled OR 0.63; 95% CI 0.55, 0.73), SNO (pooled OR 0.55; 95% CI 0.48, 0.63), Apgar score <7 at 5 minutes (pooled OR 0.35; 95% CI 0.29, 0.43), and NICU admission (pooled OR 0.53; 95% CI 0.45, 0.62). NA therefore was associated with decreased odds of adverse pregnancy outcomes in LMICs.

Perianesthetic Concerns for the non-COVID-19 Patients Requiring Surgery During the COVID-19 Pandemic Outbreak: An Observational Study

The global health crisis caused by the COVID-19 virus, has being marked by a rapid spread, numerous severe respiratory cases and an elevated mortality rate [1]. It has forced World Health Organization to declare global emergency and governments to apply confinement measures and stop the scheduled medical activities [2]. Recommendations have been developed for the management of patients with COVID-19 requiring endotracheal intubation and critical cares [3]. In addition of surgical emergencies and cesarean sections, certain surgical or diagnostic procedures cannot be postponed due to the risk of unacceptable morbidity. Therefore, Health Ministries have authorized the performance of these procedures in accordance with specific rules. Data on this type of perioperative management for COVID-19 negative patients are rare.

Improving Quality of Surgical and Anaesthesia Care at Hospital Level in sub-Saharan Africa: A Systematic Review Protocol of Health System Strengthening Interventions

Introduction: Over 5 billion people in the world do not have access to safe, affordable surgical and anaesthesia care when needed. In order to improve health outcomes in patients with surgical conditions, both access to care and the quality of care need to be improved. A recent commission on high-quality health systems highlighted that poor-quality care is now a bigger barrier than non-utilisation of the health system for reducing mortality.

Aim: To carry out a systematic review to provide an evidence-based summary of hospital-based interventions associated with improved quality of surgical and anaesthesia care in sub-Saharan African countries (SSACs).

Methods and analysis: Three search strings (1) surgery and anaesthesia, (2) quality improvement hospital-based interventions and (3) SSACs will be combined. The following databases EMBASE, Global Health, MEDLINE, CINAHL, Web of Science and Scopus will be searched. Further relevant studies will be identified from national and international health organisations and publications and reference lists of all selected full-text articles. The review will include all type of original articles in English published between 2008 and 2019. Article screening, data extraction and assessment of methodological quality will be done by two reviewers independently and any disputes will be resolved by a third reviewer or team consensus. Three types of outcomes will be collected including clinical, process and implementation outcomes. The primary outcome will be mortality. Secondary outcomes will include other clinical outcomes (major and minor complications), as well as process and implementation outcomes. Descriptive statistics and outcomes will be summarised and discussed. For the primary outcome, the methodological rigour will be assessed.

Ethics and dissemination: The results will be published in a peer reviewed open access journal and presented at national and international conferences. As this is a review of secondary data no formal ethical approval is required.