Rwanda
Burundi
Democratic Republic of Congo
Tanzania
Uganda
Africa
Global
Under 5 mortality rate (per 1,000 population)
55
104
146
54
69
95
48
Adult mortality (per 1,000 population)
317
345
384
342
385
383
176
Maternal mortality ratio (per 100,000 live births)
340
800
540
460
310
480
210
The capacity to perform safe surgery in Rwanda, while improving, is somewhat limited secondary to and inadequate infrastructure, surgical resources, and personnel. Up to 80 % of hospitals in the southern province reported absent or insufficient pulse oximetry, and 35 % reported no or inadequate oxygen supply [5]. Approximately 80 % of surgical procedures are performed at district level hospitals, which are typically less likely to have adequate capability for blood banking, amputations, closed or open fracture repairs, inhalational anesthetic administration, and chest tube insertion [5]. Many of the major surgical procedures are therefore performed at the referral hospitals. There are two public referral hospitals in Rwanda, the larger of which is Centre Hospitalier Universitaire, Kigali (CHUK). The other is Centre Hospitalier Universitaire, Butare (CHUB). These referral hospitals are equipped with eight and four general operating rooms, respectively. As shown in Table 18.2, in 2009 approximately 4,164 and 2,488 major surgeries were performed at CHUK and CHUB, respectively [5]. Although referral hospitals have better surgical capacity than their district-level counterparts, they still have some pragmatic limitations. On occasion, either of these large referral centers may have limited or absent surgical or anesthetic supplies, such as consistent capnography, local anesthetic agents, or banked blood products.
Hospital | Operating rooms | Major surgeries performed | Major and minor surgeries performed |
---|---|---|---|
University hospital—Kigali (CHUK) 2010 data | 14 | 4,164 | 7,682 |
University hospital—Butare (CHUB) 2009 data | 4 | 2,488 | 4,526 |
Limited personnel are also an issue. As of 2013, Rwanda has only 10 licensed anesthesiologists; the national anesthesia residency program currently has 16 trainees. In a continuing effort to build up Rwanda’s anesthesiology capability, organizations such as ASA/CASIEF and HRH provide a significant contribution to the anesthesia workforce. These visiting anesthesiologists not only participate in daily clinical care but also teach and mentor residents and Rwandan staff. A recent surgical capacity national collaboration meeting emphasized the important role of international efforts in enhancing the education of Rwandan health care providers and therefore increasing Rwandan health care in a sustainable manner [5].
Lack of medical supplies, electricity, or appropriately trained staff is of course a problem not exclusive to Rwanda. Infrastructure analyses across sub-Saharan Africa show common themes of inadequate supplies and equipment, limited monitoring, lack of appropriate training for anesthesia providers, and few qualified anesthetists [6, 7]. In one 2006 survey among 97 non-private hospital anesthesia providers in Uganda, only 23 % stated they had the minimum monitoring requirements to conduct a safe anesthetic in an adult patient. The most frequently unavailable items included pulse oximetry and oxygen source; running water and electricity were also described as not always available [7].
This shortage of physical and personnel resources directly impacts the type of anesthesia and analgesia available for orthopedic surgery. As orthopedic procedures account for approximately 40 % of the surgical caseload at CHUB, and orthopedic surgery is amenable to regional anesthetic techniques, this chapter focuses on regional anesthesia for orthopedic surgery. Despite the decrease in postoperative opioid consumption and improvement in patient satisfaction that is associated with peripheral nerve block techniques [8], few orthopedic surgery patients in Rwanda receive such blocks. Whereas 99 % of lower extremity surgery at both CHUB and CHUK is performed under spinal anesthesia, only 10–15 % of these patients receive supplemental peripheral nerve blockade for postoperative pain control. Although approximately 55 % of orthopedic cases at CHUB involve upper extremity fractures, very few patients are offered brachial plexus blockade either for surgical anesthesia or postoperative analgesia [9]. Frequently cited reasons by Rwandan anesthesiologists are lack of needles or local anesthetic solution and lack of skills regarding peripheral nerve block techniques [1]. The low prevalence of brachial plexus blockade is particularly unfortunate given its benefits when compared to general anesthesia, including decreased postoperative pain, improved readiness for discharge, and decreased nausea and vomiting [10]. In a setting such as Rwanda, where both material and personnel resources are significantly limited, the impact of a consistent regional anesthesia service may be substantial. Economical, clinical, and training spheres may all be positively affected.
Economic Impact
Regional anesthesia has the potential to be cost-effective. For example, spinal anesthesia, which is already used in Rwanda for virtually all lower extremity and many intra-abdominal and pelvic procedures, can provide significant cost savings when compared to general anesthesia. Spinal anesthesia has been shown to improve cost-effectiveness in orthopedic as well as gynecologic surgery [11, 12]. A study conducted in Sweden from 2007 to 2009 compared the potential perioperative and recovery costs involved with each type of anesthetic. As shown in Table 18.3, a significant cost-savings per patient can occur with an estimated savings of approximately US$800 per patient when combined with a multimodal pain control regimen and minimization of opioids.
Table 18.3
Economic impact of spinal versus general anesthesia in hysterectomy patients in Sweden (in US$) [12]
Costs | General anesthesia | Spinal-morphine anesthesia | Difference in costs |
---|---|---|---|
Time in operating theater | 1,362 | 1,305 | 57 |
Anesthetic drugs | 42 | 22 | 20 |
Time in post-anesthesia care unit | 263 | 218 | 45 |
Sick leave | 3,856 | 3,172 | 684 |
Total cost | 5,523 | 4,717 | 806 |
The use of peripheral nerve blockade, though, has been associated with considerable start-up costs. Some of these costs can be prohibitive in a limited-resource setting. While one study has shown that an ultrasound-guided brachial plexus block can be a cost effective anesthetic for arthroscopic shoulder surgery, resulting in a savings of approximately $220 USD per case [11], the use of ultrasound-guided blocks in a developing country hospital has its own challenges. Ultrasound machines are very expensive, usually costing more than $10,000 USD. While the initial cost of the machine may be recuperated over several years in a high volume practice, such an economic plan might not be feasible in a Rwandan hospital that, on average, provides 70 anesthetics a week, of which less than half would be considered potential candidates for peripheral nerve blockade. In addition, ultrasound machines require specialized maintenance and repair, which often is not readily available in a developing country.
Most studies regarding the cost-effectiveness of peripheral nerve blockade seem to indicate, however, that time involved with the block, as well as overall anesthesia-care time is the largest determinant of cost-effectiveness [13–15]. One retrospective study examining orthopedic and trauma patients found that brachial plexus blockade was less cost-effective than either general anesthesia or spinal anesthesia, particularly during short surgery [13]. A small prospective study suggested that use of brachial plexus block for outpatient hand surgery is associated with greater cost when compared to general anesthesia [14]. In these studies, increased cost is secondary to: (a) the more extensive time required to perform the block, and (b) the nursing time needed for patient monitoring after the block is completed and prior to entry into the operating room. Another prospective analysis from workers at Duke University, however, indicates that a regional anesthesia nursing team (block nurses) in fact increases operating room efficiency [15].
Translating this data to the situation in Rwanda requires special consideration of the work flow and day-to-day resources available. In both referral hospitals in Rwanda, there is no designated preoperative regional anesthesia “block” area, nor is there sufficient nursing staff to monitor a patient in such an area. However, average operating room turnover time at the Rwandan referral hospitals is 1–1.5 h, which is significantly greater than turnover times at the Canadian, German, and US hospitals where these studies were conducted. The patient could, therefore, be brought into the operating room while the surgical team is preparing instruments for the case. The regional anesthesia resident or faculty would be responsible for performing the nerve block and thereafter the patient could be monitored by the anesthesia provider assigned to the case. This method could minimize any potential delay in surgical start time. Additionally, the more frequent use of peripheral nerve blockade could have an effect on post-anesthesia care. Recovery room space is restricted to eight PACU beds in Butare. Unfortunately, these beds are also used for emergency room and ICU overflow, thus actual recovery space can be even more limited. Staffing for PACU consists only of one nurse and an anesthesia technician (who also provides sedation for minor procedures and responds to cardiopulmonary arrest events throughout the hospital), and supervised by the ICU anesthesiology attending physician. A patient who received a peripheral nerve block as the surgical anesthetic would have an abbreviated PACU stay and lessen the burden on recovery room staff.
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