Pediatric Anesthesia in Developing Countries

The Child

Children of the developing world are, for the most part, victims of circumstance: natural disasters, war, refugees, social unrest, and economic crises. For many, medical care or timely access to care can be a remote or nonexistent possibility. Fear, poor understanding of medical problems, and poor education often result in delayed presentation. Frequently, prior visits to well-meaning traditional healers expose the child to additional risks caused by potions that may be hepatic or nephrotoxic or enemas that can lead to bowel perforation. Further delays occur when children need to undertake long journeys to the hospital and if the initial diagnosis is incorrect, tertiary referral is often made only when complications occur ( Fig. 51.1 ).

A typical example is acute appendicitis, a relatively uncommon condition in the developing world, where many other causes for a change in bowel habit are initially suspected. Most children present for surgery with generalized peritonitis, and perforation is common. In the developing world, the prospect of providing emergent anesthesia for a toxic, acidotic, and dehydrated child is daunting.

Another example is infantile hypertrophic pyloric stenosis, also uncommon in developing countries, where symptoms other than the classic triad of bile-free vomiting, visible peristalsis, and a palpable tumor are more likely. The unsuspecting anesthesiologist, who may have no access to a laboratory and is limited in the choice of fluid for resuscitation, would be challenged to manage the extreme metabolic derangements in these infants.

Superstition plays a role in compounding the anesthesia risk. For example, rural Vietnamese believe that it is not good to die with an empty stomach. Parents consider surgery to be an enormous risk so they feed their children beforehand. In these circumstances, passage of a nasogastric tube before induction is routine, although it is very unlikely that the stomach can be completely emptied of solids.

Perinatal mortality in some parts of the developing world is 10 times greater than those in developed countries. The common denominators are early childbearing, poor maternal health, and lack of appropriate and quality medical services. Although lifesaving practices for most infants have been known for decades, one-third of pregnant women still have no access to medical services during pregnancy, and almost 50% do not have access to medical services for childbirth. Most parturients give birth at home or in rural health centers, where basic neonatal resuscitation equipment is deficient or nonexistent. Those who require surgery may need to be transferred, but specialized transport teams rarely exist.

In some hospitals, neonates are not candidates for surgery because “they always die,” whereas in others, they undergo surgery without anesthesia because “it's safer” and because some still believe that neonates do not feel pain. When neonates undergo surgery, there are additional challenges, particularly in emergency situations. Appropriately sized equipment is lacking, and it may be extremely difficult to maintain normothermia even in relatively warm climates without improvisation. Regional anesthesia can play a significant role in neonatal anesthesia and in some centers may be the only choice for anesthesia. Apart from providing analgesia without respiratory depression, the need for postoperative ventilatory support for conditions such as esophageal atresia, congenital diaphragmatic hernia, and abdominal wall defects can be reduced by continuous epidural analgesia ( Fig. 51.2 ).

Regrettably, even neonates who receive skilled anesthesia and surgery may die because of inadequate postoperative care. Overwhelming infection, sepsis, respiratory insufficiency, and surgical complications are the main causes of morbidity and mortality. The development of highly specialized neonatal anesthesia and surgical services, essential for a good outcome after neonatal surgery, is a low priority.

Although the burden of disease is dominated by infections and malnutrition, pediatric trauma has a low level of advocacy and is given scant attention. Socioeconomic advances in some countries have introduced a new danger in the form of faster, more powerful vehicles without the necessary maintenance culture or road discipline. Road traffic accidents are inevitable, and effective systems to handle the polytrauma victims that result are hard to find.

Even simple bone fractures may have disastrous outcomes. Inappropriate management by traditional bonesetters frequently results in compartment syndromes or gangrene. Trauma prevention strategies are given low priority despite the acknowledged impact of trauma on the economy of any country. Many developing countries are at war, and this has led to massive trauma and injuries to children who may be either participants in the fighting or innocent bystanders.

Children and War

Children may be victims of all aspects of violence. They face an intense struggle for survival because of displacement, separation from or loss of parents, poverty, hunger, and disease. They are vulnerable to the abuse of abandonment, abduction, rape, and forced soldiering. An estimated 300,000 children are used as child soldiers in more than 30 countries. Many sustain physical injuries and permanent disabilities, and a large number acquire sexually transmitted disease, including HIV and AIDS. These HIV-positive child soldiers then become vectors in communities where they are deployed.

For many of these children, acts of violence become their form of normality, and former victims become the perpetrators. Survivors are subjected to the total collapse of economic, health, social, and educational infrastructures. Lost and abandoned children sleep on the streets and are forced to beg for food while trying to find their families. Many become child laborers or turn to crime or prostitution for survival.

Children in war-torn areas sustain bullet, machete, or shrapnel injuries, and others are burned. They often sustain mutilating injuries ( Figs. 51.3 and 51.4 ) that are not commonly seen in civilians. Land mines are responsible for killing or maiming an estimated 12,000 civilians per annum. In Angola, a country with the highest rate of amputees in the world, there were an estimated 5.5 land mines for every child. Continuing land mine explosions remain a legacy of this conflict. These blast injuries leave children without feet or lower limbs and with genital injuries, blindness, and deafness—a pattern of injury that has become a post–civil war syndrome encountered by surgeons worldwide. Although the war in Angola is over, the cost of mine removal is beyond the means of local governments. Ironically, artificial limb manufacture has become a developing industry. Tragedies such as these are likely to be repeated in the ongoing conflicts in Afghanistan, Syria, South Sudan, and Somalia.

The terrible psychological effects of war persist even though the armed conflict may be over. Mental and psychiatric disorders with all the ramifications of posttraumatic stress disorder are common among child survivors.

Human Resources

Anesthesia does not enjoy a high profile and lacks the voice to demand access to basic resources in developing countries. The critical shortage of manpower is a barrier to progress. Anesthesia is frequently delivered by nonphysicians, a reality that has remained constant over many decades. Most anesthetics are still administered by nurses or unqualified personnel who have little medical background and are “trained on the job.” In many African and Asian countries, the ratio of doctors to patients is often so small that the ideal of employing a physician specifically to provide routine anesthesia is out of the question. Salaries are insufficient to attract suitably trained and qualified practitioners for more than short periods. Emigration of scarce trained personnel to developed countries in search of better salaries and improved lifestyles exacerbates these human resource shortfalls.

Anesthesia is not perceived as an attractive career for many undergraduates, who receive little or no exposure to the specialty. In some countries, surgery is performed without the “luxury” of anesthesia. Few developing countries can afford specialist anesthesiologists, possibly excepting the principal hospitals. Supervision of “nonphysician anesthesiologists” is invariably inadequate, and access to textbooks, journals, or other medical literature is limited. Internet access is invaluable but depends on a reliable electrical supply, telecommunications network, and a computer.

Despite these problems, many individuals provide high-quality anesthesia for a limited range of surgical procedures. Few receive formal training in pediatric or neonatal anesthesia. Inadequately trained anesthesiologists tend to shy away from children, particularly neonates and infants, because of the perceived difficulty or fear. This is understandable in view of the lack of supervision, the severity of the child's condition, and equipment that is more suited for adults. Invariably, the “pediatric anesthesiologist” is someone who may simply have a special interest in or affinity for children, or is allocated to pediatric anesthesia for the day because there is no one else. A genuine pediatric trained anesthesiologist is a luxury.

On a more positive note, the WHO has recognized that surgery is a public health issue and has launched the Safe Surgery Saves Lives campaign. The WHO has emphasized that safe surgery does not exist without safe anesthesia. Training anesthesiologists in the skills required for pediatric anesthesia is a slow process. Hopefully the WFSA fellowship programs will snowball so that children undergoing surgery in developing countries will reap the benefit.

Pathology

Many pathologic conditions seldom seen in industrialized countries are more prevalent in developing countries because of poor health education, malnutrition, the proximity of livestock to humans, earth-floored homes, poor sanitation, and contaminated water supplies ( Fig. 51.5 ). Some conditions prevalent worldwide and relevant to the anesthesiologist are considered in the following sections.