Pediatric Anesthesia ISSN 1155-5645
REVIEW ARTICLE
Neonatal anesthesia with limited resources € senberg Adrian T. Bo Department Anesthesiology and Pain Management, Faculty Health Sciences, University Washington, Seattle, WA, USA
Keywords anesthesia; neonate; developing world; limited resources Correspondence €senberg, Seattle Children’s Adrian T. Bo Hospital, 4800 Sandpoint Way NE, Seattle WA 98105, USA Email: adrian.bosenberg @seattlechildrens.org Section Editor: Andy Wolf
Summary Neonates are the most vulnerable age group in terms of anesthetic risk and perioperative mortality, especially in the developing world. Prematurity, malnutrition, delays in presentation, and sepsis contribute to this risk. Lack of healthcare workers, poorly maintained equipment, limited drug supplies, absence of postoperative intensive care, unreliable water supplies, or electricity are further contributory factors. Trained anesthesiologists with the skills required for pediatric and neonatal anesthesia as well as basic monitoring equipment such as pulse oximetry will go a long way to improve the unacceptably high anesthetic mortality.
Accepted 23 September 2013 doi:10.1111/pan.12291
Introduction Neonates are the most vulnerable age group in terms of anesthetic risk and perioperative mortality, especially in the developing world (1). Even in the developed world where access to advanced medical care, sophisticated medical equipment, and healthcare providers are readily available, neonatal anesthesia is challenging. Excluding surgery, an estimated 10 million children die annually before their 5th birthday worldwide (2,3); that is, one of every six children born in Africa (2) or one of every 12 children born in South Asia (3). Approximately 50% of these deaths occur in neonatal period (1,3). Some of the major causes include birth asphyxia, prematurity, sepsis, HIV (4,5), and neonatal tetanus (6,7). In the low- and middle-income countries, neonates requiring surgery are especially vulnerable and their chances of survival considerably lower than their counterparts in the developed world. The developing world can be defined in many ways. Economists use national income, expressed as per capita gross national product where the lower the gross national product is, the poorer the health of the nation (3,4,8). Countries are also defined according to the Human Development Index (HDI), which ranks the average human development in each country on the basis of life expectancy, literacy, and gross 98
domestic product, that is, measures of health and quality of life (8). The developing world thus defined falls into the medium and low categories of human development. In terms of anesthesia practice, particularly neonatal anesthesia, one could argue that the divide is not as clear-cut. The reason being that even in some remote rural areas in some high HDI affluent countries, the provision of anesthesia for neonates may fall well below the level expected in some institutions of the developing world. International standards for safe practice of anesthesia, adopted by the World Federation of Societies of Anesthesiologists (WFSA) in 1992, are seldom met in developing countries (3,9– 11). It is not surprising therefore that perioperative mortality and morbidity are high by developed world standards; local expectations as a consequence are commensurate with the facilities and quality of the care available. This manuscript aims to outline the problems and some of the anesthetic challenges facing the anesthesia providers who provide anesthesia for elective or urgent neonatal surgery in the sometimes austere environments of the developing world. This information is based on personal experience and review of the literature, what little there is, pertaining to neonatal anesthesia in the developing world. © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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The problems Perinatal mortality in some parts of the developing world is ten times greater than those in developed countries (3,12,13). The common contributors to poor neonatal outcome include early childbearing, poor maternal health, fear, poor understanding, and lack of education but, above all, the lack of appropriate and quality medical services (9). In addition, well-meaning traditional healers have often contributed to a poor outcome by exposing the neonate to additional risk caused by potions that may be hepatic or renal toxic, or enemas that may perforate the bowel. One-third of women still have no access to medical services during pregnancy, and almost 50% do not have access to medical services for childbirth (14–17). The majority of parturients still prefer to deliver at home (18) or are delivered in rural health centers (16), where basic neonatal resuscitation equipment may be deficient or nonexistent (14,15). Delayed presentation occurs when the new parturient has to undertake long, sometimes arduous journeys to reach regional health centers (19). An initial misdiagnosis may lead to further delay in referral to a tertiary center (20), and referrals are usually only made when complications arise (9,14,21–27). For example, vomiting and diarrhea are common problems in populations who do not have access to fresh running water. As a consequence, intestinal atresia/obstruction would not initially be considered the likely cause of vomiting. In addition, inadequate radiological or laboratory facilities make accurate diagnosis difficult. These delays in presentation add to the anesthetic risk (11,20). The prospect of providing anesthesia for a toxic, acidotic, and dehydrated child with no access to laboratory investigations is daunting even in the best hands. Birth trauma from a precipitous delivery or complications of a prolonged labor add to the difficulty. An asphyxiated neonate may have significant cerebral edema or seizure disorder, hypoglycemia, hypocalcaemia, and coagulation defects. Failure to administer vitamin K at birth will further compound the coagulopathy. Electrolyte disturbances can be extreme resulting in a mixed metabolic picture in some situations. Resuscitation can be difficult and may be compounded by lack of appropriate resuscitation fluid. Some typical examples of the sort of issue providers face in the low- to middle-income countries include upper intestinal obstructions (28,29; duodenal atresia, pyloric stenosis, and ileal atresia) that are likely to present with significant metabolic disturbance that may need days to correct without access to parenteral nutrition. Anorectal malformations, one of the more common neonatal malformation in Africa (29–31), or colonic © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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atresia presents with massive distension that causes splinting of the diaphragm and significant respiratory compromise. Neonates with esophageal atresia almost inevitably present with right upper lobe pneumonia following aspiration. (32) Neonates with gastroschisis are at risk of overwhelming sepsis with every hour of bowel exposure. In addition, the exposed bowel becomes thickened and more distended. Unless primary exposure can be achieved, the chances of survival are small without access to ventilators or intravenous nutrition. Minimal intervention therapy without anesthesia has been suggested as a solution (33). Severe forms of congenital diaphragmatic hernia are unlikely to survive simply because initial resuscitation failed or the capability to maintain oxygenation is not available (34). Sophisticated ventilatory techniques are simply not available. Little or no attention is paid to the prevention, let alone the treatment for congenital anomalies of CNS (35,36). Very little elective neonatal surgery is carried out in low-income countries. Inguinal hernia repair is usually carried out soon after diagnosis in developed countries (35,37). With little chance of elective surgery in developing countries, many present with incarceration or intestinal obstruction adding to the anesthetic risk. Anesthetic challenges Neonatal anesthesia in the developing world is challenging (3,36,38–40), and it goes without saying that for the most part neonatal anesthetic practice has not kept pace with the advances made in developed countries (39). Even an experienced anesthesiologist, who has minimal access to laboratory or radiographic investigations and who is limited in the choice of drugs or resuscitation fluid, would be challenged to manage these newborns safely. Until relatively recently, in some countries, neonates were still not considered candidates for surgery because ‘they always die’ (40), whereas in others, they undergo surgery without anesthesia (41) because ‘it is safer’ and because some still believe that neonates do not feel pain. When surgery is performed, particularly in emergency situations, there are challenges that would not be contemplated in institutions with advanced medical facilities (16). Not only is there a lack of appropriately sized equipment (26), but it may be extremely difficult to provide the basic fundamentals of neonatal anesthesia without improvisation. For example, plastic sheeting and overhead lamps can go a long way in maintaining normothermia even in relatively cool climates without the need to resort to expensive warmers that require disposable equipment to function. But improvisation requires knowledge and understanding of those basic needs. 99
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In a recent survey, only 13% of anesthesiologists were able to provide safe anesthesia for children, let alone neonates (36). In this survey, the minimal requirements for anesthesia were the following: an oxygen supply; suction apparatus; a pulse oximeter; a tilting table; a pediatric breathing circuit; a laryngoscope, face masks, endotracheal tubes, oropharyngeal airways, and intravenous cannulae suitable for use in children (36). Implausible as these findings may seem to those who have not experienced the austere conditions in some parts of the developing world; many anecdotal reports, both recent and in the past, bear witness to this stark reality (Figure 1). Even neonates who have skillful anesthesia and surgery may die because of inadequate postoperative care (9,30). Development of highly specialized neonatal anesthetic and surgical services (33,41,42), essential for a good outcome after neonatal surgery (14,16,26,41), is a low priority in many low- to middle-income countries. Lack
of trained nursing staff and auxiliary personnel, lack of simple ventilators, and other essential equipment is prevalent. Overwhelming infection, sepsis, respiratory insufficiency, and surgical complications are the main causes of morbidity and mortality (14,16,41) (Figures 2 and 3). HIV-AIDS HIV remains an important healthcare problem, even for neonates, in sub-Saharan Africa, South-East Asia, and many parts of the developing world. Vertical transmission can occur either in utero, during labor and delivery,
(a)
Figure 2 Newborn with duodenal atresia presented with severe metabolic alkalosis and a respiratory rate of 20. Typical problems related to monitoring are shown – adult ECG electrodes, adult pulse oximeter probe, moist cotton–wool wraps in an attempt to keep the baby warm, and a NG tube draining into a disposable glove.
(b)
Figure 1 Newborn with an anorectal malformation. The diagnosis was initially missed at birth as a consequence massive distension caused severe respiratory distress (a), and Radiograph showing elevation of the diaphragm and massive ascites (b).
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Figure 3 Intensive care in the developing world. Overcrowded, minimal monitoring equipment except mothers at the bedside, patients lying two to a bed, few if any trained nursing staff available, oxygen supplementation provided by improvised continuous positive airway pressure (CPAP) from an oxygen concentrator and no ventilators. © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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or postnatally (6,42–46). Risk factors include maternal plasma viral load and breastfeeding. Current data indicate that mixed feeding (breastfeeding with other oral foods and liquids) is associated with the greatest risk of transmission (43). Perinatal transmission rates have been dramatically reduced by single-dose antiretroviral treatment, but this strategy protects only about 50% of infants. In developed areas of the world, triple antiretroviral therapy has reduced perinatal transmission by more than 90% (43). Differentiating those infants who are infected by vertical transmission from those who are not infected presents a difficult dilemma because one cannot easily differentiate between actively or passively acquired antibodies. All children born to HIV-positive mothers will have acquired HIV antibody for the first 6–18 months. Only 30–40% of those infants, who are actually infected, may go on to develop AIDS. The presence of HIV antibody is therefore not a reliable indicator of infection. More sophisticated expensive tests have been developed but are not yet widely available where it is needed most. All children born to HIV-positive mothers therefore should be considered potentially infected; if antibody persists beyond 15 months, infection can be assumed. Progression of the disease depends on the mode of transmission; vertically acquired infection is more aggressive. Twenty to thirty percent of HIV-infected children will develop profound immune deficiency and AIDS-defining illnesses within a year, whereas twothirds will have a slowly progressive disease. The course of the disease depends on a variety of factors and includes timing of infection in utero, the viral load, and the mother’s stage of the disease. Universal precautions should be strictly applied for all anesthetic procedures. Extra care should be taken when anesthetizing an infected newborn. Precautions to prevent contamination of the anesthetic circuits should also be taken. Disposable equipment, bacterial filters, and disposable circuits are recommended, but the prohibitive cost for most institutions in developing countries limits the use of disposables. Reusable equipment should be cleaned, sterilized, and decontaminated according to the manufacturer’s instructions but this all costs money. Fortunately, the HIV virus is sensitive to a range of disinfectants (45). Pain Pain management in neonates is another factor that perhaps divides the developed world from the developing world (47). Providing safe pain relief in the face of limited resources, a limited spectrum of analgesics, if any, and inadequately trained staff is a challenge (36,47,48). © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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Attempting to apply similar standards to those used in sophisticated units is fraught with difficulty. Illiteracy, malnutrition, poor cognitive development, differing copying strategies, pharmacogenetic, cultural and language differences all add to the complexity of the problem (49,50). Children of the developing world learn to cope with vastly different problems. Their attitude toward pain, and tolerance thereof, is different. Children from an impoverished background seem more stoical and indifferent to even severe pain. This attitude seems to be instilled at an early age, perhaps even as babies, by parents are incredibly stoical. Drugs and equipment Drugs and equipment essential to provide safe anesthesia for children and particularly neonates are often lacking (14,23,26,36,48). The supply of anesthetic gases and drugs is erratic and unreliable (3,36). Furthermore, the cost of many drugs, particularly the modern agents, has risen above and beyond the reach of most health budgets. Anesthesiologists in developing countries therefore have to resign themselves to using cheaper agents or generics. Ether or halothane to this day remains the mainstay of anesthesia in many countries (36,39,48,51,52). Ether is cheaper and probably safer than halothane, although its use is limited by its flammability. This extreme flammability limits its transportability and therefore its availability in remote areas. Ketamine is probably the most commonly used anesthetic agent in rural settings (36) because it is simple to use, provides anesthesia, analgesia, cardiovascular stability with some preservation of the airway reflexes (36,53–55). In many countries, anesthesia for neonates remains largely ketamine based (3,14,36,41,56) even when halothane or ether is available. This is dictated not only by its ease of use, but also lack of airway equipment such as tracheal tubes, facemasks, or breathing circuits and the perception that intravenous access is not necessary or that intravenous cannulae of appropriate size are simply not available (3,54). Other drugs considered basic to modern anesthesia are seldom available for a variety of reasons (3,36,48,52). These include induction agents (propofol), neuromuscular blocking agents, analgesics (morphine, pethidine), reversal agents (neostigmine, naloxone), and long-acting local anesthetics (bupivacaine, ropivacaine). Morphine or other opioids may not be permitted in some cultures. The ability to deal with complications, such as malignant hyperthermia, is virtually impossible because dantrolene is prohibitively expensive. 101
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Regional anesthesia has many potential benefits in terms of safety, cost savings, and avoiding the need for postoperative ventilation and for immediate postoperative analgesia (14,26,33,36,56–60). Generally, children in developing countries are very accepting of this form of analgesia. However, there seems to be a general reluctance to perform regional anesthesia in children (26,37,48), let alone neonates, even in some institutions in the developed world. Possible reasons for this include lack of training or expertise, fear of failure, and the unavailability of drugs, disposables, and other ancillary equipment. Electrical supplies are unreliable in many hospitals in the developing world. In some, particularly in rural areas, neither mains electricity nor a functional generator can be relied upon (3,36). General facilities for infection control, such as running water, disinfectants, or gloves, are inconsistent even though the reuse of disposable equipment such as endotracheal tubes is considered normal practice (3,36). Monitoring is very basic – a precordial stethoscope and a finger on the pulse (36). EKG monitoring is used when available but its use is dependent on a constant electricity supply and proper maintenance. Appropriately sized blood pressure cuffs are scarce. Pulse oximetry has been shown to be the most useful monitor and should be available in all centers where pediatric surgery is performed (14,53). Unfortunately, this ideal is far from reality despite the efforts of the WFSA’s Lifeboxâ project (39). Simplicity and safety has long been the key to anesthetic equipment in developing countries. (53,61) Ideally, a suitable anesthetic machine should be inexpensive, versatile, robust and able to withstand extreme climatic conditions, able to function even if the supply of cylinders or electricity is interrupted, easy to understand and operate by those with limited training, economical to use, and easily maintained by locally available skills. (62,63) Generally, anesthetic machines fall into two categories: modern sophisticated machines or simple low-maintenance equipment (64). Modern electronic machines, provided by wellmeaning donors, have a poor track record in austere environments (65). Sophisticated equipment needs to be understood and require maintenance but individuals trained to repair this equipment are seldom available, nor are service contracts considered viable. Unfortunately, these machines are invariably discarded when the first fault occurs because guarantees are unlikely to be honored and faults are considered too expensive to repair. Poorly maintained equipment becomes hazardous and even life threatening in untrained hands (64). 102
Neonatal or pediatric ventilators are virtually nonexistent outside the main centers (14). Small intravenous cannulae are a precious commodity. Laryngoscopes, both metal and plastic, are usually available but generally not well maintained. Laryngeal mask airways in pediatric sizes are less freely available. Intravenous fluids, if not manufactured locally, are expensive. Many developing countries do not have any local production facilities (53). Syringe pumps and other control devices are impractical where electricity supply is erratic. Closed or semiclosed anesthetic systems are considered dangerous in an environment where the oxygen supply is erratic (66) and agent monitors are not available (23). The erratic supply of soda lime and compressed gas cylinders further limits it use. Consequently, the potential benefits and cost savings of low-flow anesthesia are lost, (67) and scavenging is a low priority. Human resources Anesthesia does not enjoy a high profile and lacks the voice to demand access to resources in developing countries. The critical shortage of workforce is a barrier to progress (14,36,48,66,68–74). Anesthesia is frequently delivered by non-physicians (3,14,26,36), a reality that has remained constant over many decades. Some countries, such as Nigeria, Kenya and India, have trained significant numbers of physician anesthetists who tend to practice in large hospitals in urban areas and not in rural districts (36,53). The majority of anesthetics in rural communities are still provided by nurses or unqualified personnel, with little medical background, who are ‘trained on the job’ (3,14,26,53). In many African (75) and Asian countries, (76) the doctor/patient ratio is so low that the ideal of employing a physician specifically to provide anesthesia is often out of the question (36,70). 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 an improved lifestyle exacerbates these human resource difficulties (36,66,69,70). Anesthesia is still not perceived as an attractive career for many undergraduates, (69,70) who receive little, if any, exposure to the specialty (72,74). Indeed, very few developing countries can afford specialist anesthesiologists, except possibly in the principal hospitals. Supervision of ‘non-physician anesthetists’ is invariably inadequate and access to textbooks, journals, or other medical literature is limited (3,36). Internet access, considered the norm in the developed world, is limited given that electrical supplies and telecommunication networks © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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are unreliable, although this situation is changing rapidly. Despite erratic electrical supplies, inconsistent oxygen delivery, paucity of up-to-date drugs, and equipment (3,36), many provide lifesaving anesthesia. Few have received formal training in pediatric or neonatal anesthesia because, even when physician anesthetists are trained, the training is very adult orientated and few ever feel confident anesthetizing children let alone neonates. This is understandable in view of the lack of supervision, the severity of the patient’s condition, and equipment that is more suited for adults. Conclusion Guidelines for pediatric and neonatal anesthesia, evolved over time in the UK, USA, and Australia (77,78), may be untenable in many parts of the developing world. Despite the difficulties, every attempt should be made to exercise the same standard of care. Faced with these obstacles, different standards may emerge in different parts of the world. Such standards need not necessarily be considered inferior but may well open the way for the integration of new ideas (77). A safe anesthetic is not necessary the most expensive one. After all, it is generally not the agents that we use but the skill with which we use them that determines outcome. It should never be necessary to depart from the dictum ‘primum non nocere’. What can be performed to improve the lot of neonates who undergo anesthesia in the developing world? Send
money is one suggestion! (79) Unfortunately, with all the goodwill in the world, there is no guarantee that the money ever reaches the right people or is put to the best use. Purchasing equipment without subsequent maintenance is wasteful. Disposables are short-lived even if they are recycled. Human resources are needed! The WHO has recently recognized that surgery is a public health issue and has launched the ‘Safe Surgery Saves Lives’ program. The WHO has also emphasized that safe surgery does not exist without safe anesthesia (36). Training anesthesiologists in the skills required for pediatric and neonatal anesthesia is a slow process, but it is hoped that this training will soon snowball. The best manner in which to do this is open to debate (74,79–90). Through a WFSA-driven sponsorship program, a cohort of pediatric anesthesiologists is being trained in Chile (84), Rwanda, Tunisia, India, Kenya (88), and South Africa (85). The advantage of this training is that the trainees are exposed to similar problems to those they would encounter in their own country. On completion of their training they must return to their country of origin and champion the development of pediatric anesthesia as a speciality. (36,85) Acknowledgments/Disclosures No disclosures or conflict of interests. Funding This research was carried out without funding.
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66 Sanou I, Vilasco B, Obey A et al. Evolution of the demography of anesthesia practitioners in French speaking Sub-Saharan Africa. Ann Fr Anesth Reanim 1999; 18: 642–646. 67 Ezi Ashi TI, Papworth DP, Nunn JF. Inhalational anaesthesia in developing countries. Anaesthesia 1983; 38: 729–735. 68 Ouro-Bang’na Maman AF, Zoumenou E, Zeminkande J et al. Anaesthesia training: when and how it is conducted in Frenchspeaking Sub-Saharan Africa. Update Anaesth 2008; 1: 42–44. 69 Dambisya YM. The fate and career destinations of doctors who qualified at Uganda’s Makerere Medical School in 1984: retrospective cohort study. BMJ 2004; 329: 600–601. 70 Eastwood JB, Conroy RE, Naicker S et al. Loss of health professionals from sub-Saharan Africa: the pivotal role of the UK. Lancet 2005; 365: 1893–1900. 71 Akinyemi OO, Soyannwo AO. The choice of anaesthesia as a career by undergraduates in a developing country. Anaesthesia 1980; 35: 712–715. 72 Soyannwo OA, Elegbe EO. Anaesthetic manpower development in West Africa. Afr J Med Sci 1999; 28: 163–165. 73 Adnet P, Diallo A, Sanou J et al. Anesthesia practice by nurse anesthetists in French speaking Sub-Saharan Africa. Ann Fr Anesth Reanim 1999; 18: 636–641.
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74 Jacob R. Pro: Anesthesia for children in the developing world should be delivered by medical anesthetists. Pediatr Anesth 2009; 19: 35–38. 75 Harrison GG. Anaesthesia in Africa: difficulties and directions. World Anaesth 1997; 1: 2. 76 Lertakyamanee J, Tritrakern T. Anaesthesia manpower in Asia. World Anaesth 1999; 3: 13–15. 77 Unger F, Ghosh P. International cardiac surgery. Semin Thorac Cardiovasc Surg 2002; 14: 321–323. 78 Anonymous . International standards for a safe practice of anaesthesia. Eur J Anaesthesiol 1993; 10: 12–15. 79 Bogod DG. One day for Africa: anaesthesia in Uganda and beyond. Anaesthesia 2007; 82: 1–3. 80 World Health Organization. Safe Surgery Saves Lives. The Second Global Patient Safety Challenge. Geneva: World Health Organization, 2008. Available at: http:// www.who.int/patientsafety/safesurgery/en/. Accessed 12 November, 2013. 81 Walker IA, Wilson IH. Anaesthesia in developing countries – a risk for patients. Lancet 2008; 371: 968–969. 82 Khambatta HJ, Westheimer DN, Power RW et al. Safe, low-technology anesthesia system for medical missions to remote locations. Anesthesiology 2006; 104: 1354–1356.
83 Cote CJ. The WFSA pediatric anesthesia fellowships: origins and perspectives. Pediatr Anesth 2009; 19: 28–29. 84 Cavallieri S, Canepa P, Campos M. Evolution of the WFSA education program in Chile. Pediatr Anesth 2009; 19: 38–41. 85 Gathuya Z. Pro: Pediatric anesthesia in developing countries is best achieved by selective out of country scholarships. Pediatr Anesth 2009; 19: 42–44. 86 Walker IA. Con: Pediatric anesthesia training in the developing countries is best achieved by out of country scholarships. Pediatr Anesth 2009; 19: 45–49. 87 Wilson IH. Con: Anesthesia for children should be provided by medical anesthetists. Pediatr Anesth 2009; 19: 39–41. 88 Newton M, Bird P. Impact of parallel anesthesia and surgical provider training in sub-Saharan Africa: a model for a resourcepoor setting. World J Surg 2010; 34: 445–452. 89 Ozgediz D, Poenaru D. The burden of pediatric surgical conditions in low and middle income countries: a call to action. J Pediatr Surg 2012; 47: 2305–2311. 90 Faponle AF, Sowande OA, Adejuyigbe O. Anaesthesia for neonatal surgical emergencies in a semi-urban hospital, Nigeria. East Afr Med J 2004; 81: 568–573.
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REVIEW ARTICLE
Neonatal anesthesia with limited resources € senberg Adrian T. Bo Department Anesthesiology and Pain Management, Faculty Health Sciences, University Washington, Seattle, WA, USA
Keywords anesthesia; neonate; developing world; limited resources Correspondence €senberg, Seattle Children’s Adrian T. Bo Hospital, 4800 Sandpoint Way NE, Seattle WA 98105, USA Email: adrian.bosenberg @seattlechildrens.org Section Editor: Andy Wolf
Summary Neonates are the most vulnerable age group in terms of anesthetic risk and perioperative mortality, especially in the developing world. Prematurity, malnutrition, delays in presentation, and sepsis contribute to this risk. Lack of healthcare workers, poorly maintained equipment, limited drug supplies, absence of postoperative intensive care, unreliable water supplies, or electricity are further contributory factors. Trained anesthesiologists with the skills required for pediatric and neonatal anesthesia as well as basic monitoring equipment such as pulse oximetry will go a long way to improve the unacceptably high anesthetic mortality.
Accepted 23 September 2013 doi:10.1111/pan.12291
Introduction Neonates are the most vulnerable age group in terms of anesthetic risk and perioperative mortality, especially in the developing world (1). Even in the developed world where access to advanced medical care, sophisticated medical equipment, and healthcare providers are readily available, neonatal anesthesia is challenging. Excluding surgery, an estimated 10 million children die annually before their 5th birthday worldwide (2,3); that is, one of every six children born in Africa (2) or one of every 12 children born in South Asia (3). Approximately 50% of these deaths occur in neonatal period (1,3). Some of the major causes include birth asphyxia, prematurity, sepsis, HIV (4,5), and neonatal tetanus (6,7). In the low- and middle-income countries, neonates requiring surgery are especially vulnerable and their chances of survival considerably lower than their counterparts in the developed world. The developing world can be defined in many ways. Economists use national income, expressed as per capita gross national product where the lower the gross national product is, the poorer the health of the nation (3,4,8). Countries are also defined according to the Human Development Index (HDI), which ranks the average human development in each country on the basis of life expectancy, literacy, and gross 98
domestic product, that is, measures of health and quality of life (8). The developing world thus defined falls into the medium and low categories of human development. In terms of anesthesia practice, particularly neonatal anesthesia, one could argue that the divide is not as clear-cut. The reason being that even in some remote rural areas in some high HDI affluent countries, the provision of anesthesia for neonates may fall well below the level expected in some institutions of the developing world. International standards for safe practice of anesthesia, adopted by the World Federation of Societies of Anesthesiologists (WFSA) in 1992, are seldom met in developing countries (3,9– 11). It is not surprising therefore that perioperative mortality and morbidity are high by developed world standards; local expectations as a consequence are commensurate with the facilities and quality of the care available. This manuscript aims to outline the problems and some of the anesthetic challenges facing the anesthesia providers who provide anesthesia for elective or urgent neonatal surgery in the sometimes austere environments of the developing world. This information is based on personal experience and review of the literature, what little there is, pertaining to neonatal anesthesia in the developing world. © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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The problems Perinatal mortality in some parts of the developing world is ten times greater than those in developed countries (3,12,13). The common contributors to poor neonatal outcome include early childbearing, poor maternal health, fear, poor understanding, and lack of education but, above all, the lack of appropriate and quality medical services (9). In addition, well-meaning traditional healers have often contributed to a poor outcome by exposing the neonate to additional risk caused by potions that may be hepatic or renal toxic, or enemas that may perforate the bowel. One-third of women still have no access to medical services during pregnancy, and almost 50% do not have access to medical services for childbirth (14–17). The majority of parturients still prefer to deliver at home (18) or are delivered in rural health centers (16), where basic neonatal resuscitation equipment may be deficient or nonexistent (14,15). Delayed presentation occurs when the new parturient has to undertake long, sometimes arduous journeys to reach regional health centers (19). An initial misdiagnosis may lead to further delay in referral to a tertiary center (20), and referrals are usually only made when complications arise (9,14,21–27). For example, vomiting and diarrhea are common problems in populations who do not have access to fresh running water. As a consequence, intestinal atresia/obstruction would not initially be considered the likely cause of vomiting. In addition, inadequate radiological or laboratory facilities make accurate diagnosis difficult. These delays in presentation add to the anesthetic risk (11,20). The prospect of providing anesthesia for a toxic, acidotic, and dehydrated child with no access to laboratory investigations is daunting even in the best hands. Birth trauma from a precipitous delivery or complications of a prolonged labor add to the difficulty. An asphyxiated neonate may have significant cerebral edema or seizure disorder, hypoglycemia, hypocalcaemia, and coagulation defects. Failure to administer vitamin K at birth will further compound the coagulopathy. Electrolyte disturbances can be extreme resulting in a mixed metabolic picture in some situations. Resuscitation can be difficult and may be compounded by lack of appropriate resuscitation fluid. Some typical examples of the sort of issue providers face in the low- to middle-income countries include upper intestinal obstructions (28,29; duodenal atresia, pyloric stenosis, and ileal atresia) that are likely to present with significant metabolic disturbance that may need days to correct without access to parenteral nutrition. Anorectal malformations, one of the more common neonatal malformation in Africa (29–31), or colonic © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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atresia presents with massive distension that causes splinting of the diaphragm and significant respiratory compromise. Neonates with esophageal atresia almost inevitably present with right upper lobe pneumonia following aspiration. (32) Neonates with gastroschisis are at risk of overwhelming sepsis with every hour of bowel exposure. In addition, the exposed bowel becomes thickened and more distended. Unless primary exposure can be achieved, the chances of survival are small without access to ventilators or intravenous nutrition. Minimal intervention therapy without anesthesia has been suggested as a solution (33). Severe forms of congenital diaphragmatic hernia are unlikely to survive simply because initial resuscitation failed or the capability to maintain oxygenation is not available (34). Sophisticated ventilatory techniques are simply not available. Little or no attention is paid to the prevention, let alone the treatment for congenital anomalies of CNS (35,36). Very little elective neonatal surgery is carried out in low-income countries. Inguinal hernia repair is usually carried out soon after diagnosis in developed countries (35,37). With little chance of elective surgery in developing countries, many present with incarceration or intestinal obstruction adding to the anesthetic risk. Anesthetic challenges Neonatal anesthesia in the developing world is challenging (3,36,38–40), and it goes without saying that for the most part neonatal anesthetic practice has not kept pace with the advances made in developed countries (39). Even an experienced anesthesiologist, who has minimal access to laboratory or radiographic investigations and who is limited in the choice of drugs or resuscitation fluid, would be challenged to manage these newborns safely. Until relatively recently, in some countries, neonates were still not considered candidates for surgery because ‘they always die’ (40), whereas in others, they undergo surgery without anesthesia (41) because ‘it is safer’ and because some still believe that neonates do not feel pain. When surgery is performed, particularly in emergency situations, there are challenges that would not be contemplated in institutions with advanced medical facilities (16). Not only is there a lack of appropriately sized equipment (26), but it may be extremely difficult to provide the basic fundamentals of neonatal anesthesia without improvisation. For example, plastic sheeting and overhead lamps can go a long way in maintaining normothermia even in relatively cool climates without the need to resort to expensive warmers that require disposable equipment to function. But improvisation requires knowledge and understanding of those basic needs. 99
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In a recent survey, only 13% of anesthesiologists were able to provide safe anesthesia for children, let alone neonates (36). In this survey, the minimal requirements for anesthesia were the following: an oxygen supply; suction apparatus; a pulse oximeter; a tilting table; a pediatric breathing circuit; a laryngoscope, face masks, endotracheal tubes, oropharyngeal airways, and intravenous cannulae suitable for use in children (36). Implausible as these findings may seem to those who have not experienced the austere conditions in some parts of the developing world; many anecdotal reports, both recent and in the past, bear witness to this stark reality (Figure 1). Even neonates who have skillful anesthesia and surgery may die because of inadequate postoperative care (9,30). Development of highly specialized neonatal anesthetic and surgical services (33,41,42), essential for a good outcome after neonatal surgery (14,16,26,41), is a low priority in many low- to middle-income countries. Lack
of trained nursing staff and auxiliary personnel, lack of simple ventilators, and other essential equipment is prevalent. Overwhelming infection, sepsis, respiratory insufficiency, and surgical complications are the main causes of morbidity and mortality (14,16,41) (Figures 2 and 3). HIV-AIDS HIV remains an important healthcare problem, even for neonates, in sub-Saharan Africa, South-East Asia, and many parts of the developing world. Vertical transmission can occur either in utero, during labor and delivery,
(a)
Figure 2 Newborn with duodenal atresia presented with severe metabolic alkalosis and a respiratory rate of 20. Typical problems related to monitoring are shown – adult ECG electrodes, adult pulse oximeter probe, moist cotton–wool wraps in an attempt to keep the baby warm, and a NG tube draining into a disposable glove.
(b)
Figure 1 Newborn with an anorectal malformation. The diagnosis was initially missed at birth as a consequence massive distension caused severe respiratory distress (a), and Radiograph showing elevation of the diaphragm and massive ascites (b).
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Figure 3 Intensive care in the developing world. Overcrowded, minimal monitoring equipment except mothers at the bedside, patients lying two to a bed, few if any trained nursing staff available, oxygen supplementation provided by improvised continuous positive airway pressure (CPAP) from an oxygen concentrator and no ventilators. © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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or postnatally (6,42–46). Risk factors include maternal plasma viral load and breastfeeding. Current data indicate that mixed feeding (breastfeeding with other oral foods and liquids) is associated with the greatest risk of transmission (43). Perinatal transmission rates have been dramatically reduced by single-dose antiretroviral treatment, but this strategy protects only about 50% of infants. In developed areas of the world, triple antiretroviral therapy has reduced perinatal transmission by more than 90% (43). Differentiating those infants who are infected by vertical transmission from those who are not infected presents a difficult dilemma because one cannot easily differentiate between actively or passively acquired antibodies. All children born to HIV-positive mothers will have acquired HIV antibody for the first 6–18 months. Only 30–40% of those infants, who are actually infected, may go on to develop AIDS. The presence of HIV antibody is therefore not a reliable indicator of infection. More sophisticated expensive tests have been developed but are not yet widely available where it is needed most. All children born to HIV-positive mothers therefore should be considered potentially infected; if antibody persists beyond 15 months, infection can be assumed. Progression of the disease depends on the mode of transmission; vertically acquired infection is more aggressive. Twenty to thirty percent of HIV-infected children will develop profound immune deficiency and AIDS-defining illnesses within a year, whereas twothirds will have a slowly progressive disease. The course of the disease depends on a variety of factors and includes timing of infection in utero, the viral load, and the mother’s stage of the disease. Universal precautions should be strictly applied for all anesthetic procedures. Extra care should be taken when anesthetizing an infected newborn. Precautions to prevent contamination of the anesthetic circuits should also be taken. Disposable equipment, bacterial filters, and disposable circuits are recommended, but the prohibitive cost for most institutions in developing countries limits the use of disposables. Reusable equipment should be cleaned, sterilized, and decontaminated according to the manufacturer’s instructions but this all costs money. Fortunately, the HIV virus is sensitive to a range of disinfectants (45). Pain Pain management in neonates is another factor that perhaps divides the developed world from the developing world (47). Providing safe pain relief in the face of limited resources, a limited spectrum of analgesics, if any, and inadequately trained staff is a challenge (36,47,48). © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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Attempting to apply similar standards to those used in sophisticated units is fraught with difficulty. Illiteracy, malnutrition, poor cognitive development, differing copying strategies, pharmacogenetic, cultural and language differences all add to the complexity of the problem (49,50). Children of the developing world learn to cope with vastly different problems. Their attitude toward pain, and tolerance thereof, is different. Children from an impoverished background seem more stoical and indifferent to even severe pain. This attitude seems to be instilled at an early age, perhaps even as babies, by parents are incredibly stoical. Drugs and equipment Drugs and equipment essential to provide safe anesthesia for children and particularly neonates are often lacking (14,23,26,36,48). The supply of anesthetic gases and drugs is erratic and unreliable (3,36). Furthermore, the cost of many drugs, particularly the modern agents, has risen above and beyond the reach of most health budgets. Anesthesiologists in developing countries therefore have to resign themselves to using cheaper agents or generics. Ether or halothane to this day remains the mainstay of anesthesia in many countries (36,39,48,51,52). Ether is cheaper and probably safer than halothane, although its use is limited by its flammability. This extreme flammability limits its transportability and therefore its availability in remote areas. Ketamine is probably the most commonly used anesthetic agent in rural settings (36) because it is simple to use, provides anesthesia, analgesia, cardiovascular stability with some preservation of the airway reflexes (36,53–55). In many countries, anesthesia for neonates remains largely ketamine based (3,14,36,41,56) even when halothane or ether is available. This is dictated not only by its ease of use, but also lack of airway equipment such as tracheal tubes, facemasks, or breathing circuits and the perception that intravenous access is not necessary or that intravenous cannulae of appropriate size are simply not available (3,54). Other drugs considered basic to modern anesthesia are seldom available for a variety of reasons (3,36,48,52). These include induction agents (propofol), neuromuscular blocking agents, analgesics (morphine, pethidine), reversal agents (neostigmine, naloxone), and long-acting local anesthetics (bupivacaine, ropivacaine). Morphine or other opioids may not be permitted in some cultures. The ability to deal with complications, such as malignant hyperthermia, is virtually impossible because dantrolene is prohibitively expensive. 101
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Regional anesthesia has many potential benefits in terms of safety, cost savings, and avoiding the need for postoperative ventilation and for immediate postoperative analgesia (14,26,33,36,56–60). Generally, children in developing countries are very accepting of this form of analgesia. However, there seems to be a general reluctance to perform regional anesthesia in children (26,37,48), let alone neonates, even in some institutions in the developed world. Possible reasons for this include lack of training or expertise, fear of failure, and the unavailability of drugs, disposables, and other ancillary equipment. Electrical supplies are unreliable in many hospitals in the developing world. In some, particularly in rural areas, neither mains electricity nor a functional generator can be relied upon (3,36). General facilities for infection control, such as running water, disinfectants, or gloves, are inconsistent even though the reuse of disposable equipment such as endotracheal tubes is considered normal practice (3,36). Monitoring is very basic – a precordial stethoscope and a finger on the pulse (36). EKG monitoring is used when available but its use is dependent on a constant electricity supply and proper maintenance. Appropriately sized blood pressure cuffs are scarce. Pulse oximetry has been shown to be the most useful monitor and should be available in all centers where pediatric surgery is performed (14,53). Unfortunately, this ideal is far from reality despite the efforts of the WFSA’s Lifeboxâ project (39). Simplicity and safety has long been the key to anesthetic equipment in developing countries. (53,61) Ideally, a suitable anesthetic machine should be inexpensive, versatile, robust and able to withstand extreme climatic conditions, able to function even if the supply of cylinders or electricity is interrupted, easy to understand and operate by those with limited training, economical to use, and easily maintained by locally available skills. (62,63) Generally, anesthetic machines fall into two categories: modern sophisticated machines or simple low-maintenance equipment (64). Modern electronic machines, provided by wellmeaning donors, have a poor track record in austere environments (65). Sophisticated equipment needs to be understood and require maintenance but individuals trained to repair this equipment are seldom available, nor are service contracts considered viable. Unfortunately, these machines are invariably discarded when the first fault occurs because guarantees are unlikely to be honored and faults are considered too expensive to repair. Poorly maintained equipment becomes hazardous and even life threatening in untrained hands (64). 102
Neonatal or pediatric ventilators are virtually nonexistent outside the main centers (14). Small intravenous cannulae are a precious commodity. Laryngoscopes, both metal and plastic, are usually available but generally not well maintained. Laryngeal mask airways in pediatric sizes are less freely available. Intravenous fluids, if not manufactured locally, are expensive. Many developing countries do not have any local production facilities (53). Syringe pumps and other control devices are impractical where electricity supply is erratic. Closed or semiclosed anesthetic systems are considered dangerous in an environment where the oxygen supply is erratic (66) and agent monitors are not available (23). The erratic supply of soda lime and compressed gas cylinders further limits it use. Consequently, the potential benefits and cost savings of low-flow anesthesia are lost, (67) and scavenging is a low priority. Human resources Anesthesia does not enjoy a high profile and lacks the voice to demand access to resources in developing countries. The critical shortage of workforce is a barrier to progress (14,36,48,66,68–74). Anesthesia is frequently delivered by non-physicians (3,14,26,36), a reality that has remained constant over many decades. Some countries, such as Nigeria, Kenya and India, have trained significant numbers of physician anesthetists who tend to practice in large hospitals in urban areas and not in rural districts (36,53). The majority of anesthetics in rural communities are still provided by nurses or unqualified personnel, with little medical background, who are ‘trained on the job’ (3,14,26,53). In many African (75) and Asian countries, (76) the doctor/patient ratio is so low that the ideal of employing a physician specifically to provide anesthesia is often out of the question (36,70). 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 an improved lifestyle exacerbates these human resource difficulties (36,66,69,70). Anesthesia is still not perceived as an attractive career for many undergraduates, (69,70) who receive little, if any, exposure to the specialty (72,74). Indeed, very few developing countries can afford specialist anesthesiologists, except possibly in the principal hospitals. Supervision of ‘non-physician anesthetists’ is invariably inadequate and access to textbooks, journals, or other medical literature is limited (3,36). Internet access, considered the norm in the developed world, is limited given that electrical supplies and telecommunication networks © 2013 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 98–105
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are unreliable, although this situation is changing rapidly. Despite erratic electrical supplies, inconsistent oxygen delivery, paucity of up-to-date drugs, and equipment (3,36), many provide lifesaving anesthesia. Few have received formal training in pediatric or neonatal anesthesia because, even when physician anesthetists are trained, the training is very adult orientated and few ever feel confident anesthetizing children let alone neonates. This is understandable in view of the lack of supervision, the severity of the patient’s condition, and equipment that is more suited for adults. Conclusion Guidelines for pediatric and neonatal anesthesia, evolved over time in the UK, USA, and Australia (77,78), may be untenable in many parts of the developing world. Despite the difficulties, every attempt should be made to exercise the same standard of care. Faced with these obstacles, different standards may emerge in different parts of the world. Such standards need not necessarily be considered inferior but may well open the way for the integration of new ideas (77). A safe anesthetic is not necessary the most expensive one. After all, it is generally not the agents that we use but the skill with which we use them that determines outcome. It should never be necessary to depart from the dictum ‘primum non nocere’. What can be performed to improve the lot of neonates who undergo anesthesia in the developing world? Send
money is one suggestion! (79) Unfortunately, with all the goodwill in the world, there is no guarantee that the money ever reaches the right people or is put to the best use. Purchasing equipment without subsequent maintenance is wasteful. Disposables are short-lived even if they are recycled. Human resources are needed! The WHO has recently recognized that surgery is a public health issue and has launched the ‘Safe Surgery Saves Lives’ program. The WHO has also emphasized that safe surgery does not exist without safe anesthesia (36). Training anesthesiologists in the skills required for pediatric and neonatal anesthesia is a slow process, but it is hoped that this training will soon snowball. The best manner in which to do this is open to debate (74,79–90). Through a WFSA-driven sponsorship program, a cohort of pediatric anesthesiologists is being trained in Chile (84), Rwanda, Tunisia, India, Kenya (88), and South Africa (85). The advantage of this training is that the trainees are exposed to similar problems to those they would encounter in their own country. On completion of their training they must return to their country of origin and champion the development of pediatric anesthesia as a speciality. (36,85) Acknowledgments/Disclosures No disclosures or conflict of interests. Funding This research was carried out without funding.
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