Anaesthesia in resource-poor areas

Background

The variation in resources available to healthcare systems in regional populations of the world is widely acknowledged. The terms developed and developing world mislead, suggesting binary options and inevitable progress to a complete state. The reality is a skewed spectrum of resource and development dictated by the combined influences of geography, climate, economics, politics, culture and conflict. Development at the weakest end of the spectrum often loses momentum and is easily driven backwards. The poor of the world are exposed to greater personal and environmental health risks; they are less well nourished, have fewer health choices and have less access to health information and high-quality healthcare. The consequence is a burden of illness and disability with devastating consequences for individuals and struggling healthcare systems.

Challenges to the provision of anaesthesia

This chapter focuses on the provision of anaesthesia and critical care in the poorest-resourced communities of the world. The ceiling of what can be achieved may be curbed by an inadequate supply of clean running water, electricity, medicines, equipment, skilled staff, education and transport. Patients may present with low expectations, advanced pathological conditions and complications from the ministrations of traditional healers. While international agencies set goals and contend with the complexity of world health inequity, individuals focus on alleviating pain and suffering at a local level. For the anaesthesia provider, this means attempting to provide safe anaesthesia, analgesia, critical care and peer education in an unpredictable environment over which they have limited control. A solid foundation of theoretical knowledge and strong practical skills are required. Access to a wider medical community brings valuable support. Consensus standards may encourage significant development even when achieving specific goals proves impossible. An awareness of recent advances and the potential offered by new technologies must be contextualised shrewdly. Cultural awareness and linguistic skills provide valuable insights and facilitate the management of complex medical situations. Highly developed non-technical skills, teamwork, pragmatism and tireless optimism are essential tools against falling standards and professional burnout.

Attention to personal health and safety is particularly important. Workplace dangers include poorly maintained electrical equipment, explosive anaesthetic vapours, contaminated sharps, exposure to lethal pandemics and the risk of violence. Neglect of one's own physical and mental health is hazardous. If the lone anaesthesia provider in a large isolated community is unable to work, the impact for patients can be devastating. Healthcare facilities rarely have enough staff to meet the needs of the community they serve. Staff are obliged to be generalists, and the 24-h emergency management of the most urgent cases dominates the workload.

Population and procedures

The bulk of the surgical work comprises obstetric emergencies and the management of abscesses, wounds and fractures ( Box 45.1 ). The anaesthesia required may be considered basic, but the patient is often in poor condition and requires significant preoperative resuscitation. Preoperative assessment follows universal principles with the emphasis on clinical signs rather than investigations. Special consideration needs to be given to the common conditions affecting the local community. These might include the effects of parasitic disease and severe anaemia (e.g. malaria and schistosomiasis), malnutrition, HIV/AIDS, tuberculosis, massive goitre, pregnancy-induced hypertensive disease, advanced molar pregnancy and the effects of traditional medicines. Populations are usually relatively young, and a large proportion of the patients treated will be infants and children. In some settings, most elective surgical work is performed by visiting specialists. This can be a challenge for the lone anaesthesia provider obliged to meet the requirements of more complex procedures with an unfamiliar team. If a visiting team includes a specialist anaesthesia provider, the resident anaesthetist may be offered a rare opportunity for education and case-based discussion. Visiting teams may depart having overburdened their hosts with challenging patients and their complex postoperative care needs.

Anaesthesia without electricity or pressurised gas supplies

Recommended international standards for the safe provision of anaesthesia were updated and ratified by the World Federation of Societies of Anaesthesiologists (WFSA) in 2010. The WFSA defined three levels of healthcare setting in which general anaesthesia may be delivered ( Table 45.1 ).

The infrastructure standards recommended for even the most basic settings require electricity or pressurised gas supplies to provide oxygen. In reality, many institutions in remote and resource-poor environments are obliged to operate without oxygen for all or some of the time. Anaesthesia providers in these circumstances need to employ simple and safe techniques that offer patients rapid recovery requiring minimal postoperative care. Institutional self-reliance supports a resilient service. Equipment must be affordable, durable and easy to maintain locally ( Table 45.2 ).

The cost and infrastructure required to deliver liquid oxygen from a vacuum-insulated evaporator (see Chapter 16 ) makes this an unachievable option for most hospitals in resource-poor environments. Reliance on a cylinder supply alone reduces dependence on electricity but is relatively costly and can be unreliable when delivery depends upon poorly maintained roads and vehicles. Many anaesthetists prefer the low running costs of an oxygen concentrator and reserve a backup oxygen cylinder for emergency use during electricity blackouts. A well-maintained portable oxygen concentrator can provide up to 8 L min ^–1 of 90%–95% oxygen ( Fig. 45.1 ). It draws atmospheric air through a series of dust filters and compresses it before passing it through a zeolite filter column. Nitrogen is reversibly adsorbed onto zeolite, and the residual oxygen-rich gas is passed to a reservoir before delivery to a breathing system. Several zeolite filters operate alternately to avoid filter exhaustion. Modern machines can also provide up to 10 L min ^–1 air, which when mixed with the oxygen output allows titration of inspired oxygen concentration and enough volume to drive basic pneumatic ventilators. Some machines can compress small volumes of oxygen within a reservoir. When combined with an uninterruptible power supply unit (UPS) usefully this prolongs oxygen delivery for up to 20 min after an electricity supply fails.

Conduct of anaesthesia

The mainstays of general anaesthesia in these circumstances are intravenous anaesthesia with ketamine, draw-over inhalational anaesthesia or a combination of both. Spontaneously breathing anaesthesia can be provided with a surprisingly small selection of relatively inexpensive and stable pharmacological agents ( Table 45.3 ). Atropine and lidocaine may be administered routinely before ether or halothane anaesthesia to counter hypersalivation and malignant arrhythmias. Spontaneous breathing techniques that require minimal skilled airway intervention are favoured. Regional anaesthesia offers many advantages but is not appropriate for all procedures. Supplies of essential drugs should be maintained, but this often proves impossible.