Anesthesia in Resource-Poor Settings: The Médecins Sans Frontières Experience

Country

Project

Context

Program description

Afghanistan

Kabul

Conflict

Obstetrics, general surgery

Khost

Conflict

Obstetrics

Kunduz

Conflict

Obstetrics, general surgery

Burundi

Gitega

Post-conflict

Obstetrics (fistula repair)

Kabezi

Post-conflict

Obstetrics

DRC

Masisi

Conflict

Obstetrics, general surgery

Niangara

Conflict

Obstetrics, general surgery

Haiti

Tabarre

Stable

Orthopaedics, general surgery

India

Mon

Stable

Obstetrics, general surgery

Mali

Douentza

Conflict

Obstetrics, general surgery

Mauritania

Bassikounou

Conflict

Obstetrics, general surgery

Pakistan

Timurgara

Conflict

Obstetrics, general surgery

Philippines

Guiuan

Natural disaster

Obstetrics, general surgery

Sierra Leone

Post-conflict

Obstetrics

South Sudan

Gogrial

Conflict

Obstetrics, general surgery

Gumuruk

Conflict

General surgery

Somalia

Burao

Conflict

Obstetrics, general surgery

Syria

Jabal-Akkrad

Conflict

Obstetrics, general surgery

The core activity at these projects is the provision of lifesaving and essential surgery that requires only low technology and is based in district hospitals or in the subset of primary health centers with surgical capacity. Lifesaving surgery is defined as any procedure performed in response to an acute state in which the patient’s life, organ, or limb is at stake and surgery must be done as soon as possible, usually within hours. Essential surgery addresses conditions that may not immediately affect health or life but will considerably impair the quality of life or present a serious future health threat, and that are amenable to a proven surgical treatment.

Table 9.2 gives an overview of the main surgical activities in these and 10 other (no longer active) surgery projects during the years 2010–2013 [7]. Focusing on the 14,199 patients treated in 2013, the most common indication for surgery was obstetrical (44.6 % of all patients), 79 % of which were Caesarean sections (data not shown). Accidental trauma was second (26.8 %), followed by violent trauma (10.2 %). At the same time, certain projects involved more complex, specialized types of surgery, for example, high-standard orthopedic procedures such as osteosynthesis and obstetric fistula repair.

Table 9.2

Overview of surgical activities, 2010–2013

Indicator (#)	Total	2013	2012	2011	2010
Patients^a	59,824	14,199	14,583	19,296	11,746
Cases^b	77,048	19,395	19,145	22,964	15,544
Procedures^c	83,004	21,774	20,865	24,101	16,264
Main surgical indicators
Violent trauma^d	4,767 (xx %)	1,445 (10.2 %)	1,277 (8.8 %)	1,086 (5.6 %)	959 (8.2 %)
Accidental trauma	10,283 (xx %)	3,808 (26.8 %)	3,075 (21.1 %)	1,927 (12 %)	1,473 (12.5 %)
Obstetrical^e	25,719 (xx %)	6,337 (44.6 %)	6,785 (46.5 %)	7,644 (47.5 %)	4,953 (42.2 %)
Other pathologies	15,876 (xx %)	2,609 (18.4 %)	3,446 (23.6 %)	5,460 (34.0 %)	4,361 (37.1 %)
Total	56,605	14,199	14,583	16,077	11,746
Total	CK 56,646	14,199	14,583	16,077	11,746
No. of projects^f		18	22	21	19

^aNumber of new cases

^bNumber of Operating Room. visits

^cNumber of surgical procedures performed during an intervention. MSF data tools allow reporting up to three procedures. For data analysis, only the first entry is considered because not all projects reported multiple procedures in one surgical intervention

^dViolent trauma cases as cause for intervention (only new cases)

^ePercentage of Caesarean sections uses patient number (new cases) as the denominator

^fNumber of active projects during 2013

In terms of anesthesia practice, around 90 % of all surgeries in 2010–2013 used either general or spinal anesthesia, as shown in Table 9.3. General anesthesia in most MSF contexts uses the intravenous agents ketamine and thiopental as well as the inhalation agent halothane. We consider ketamine an excellent choice for field settings due to its ease of use and safety profile and its widespread uptake throughout middle- and low-income countries (Table 9.4). (However, projects that use ketamine must have resuscitation material available, due to the known risk of respiratory arrest.) Drugs used for muscular relaxation and intubation include depolarizing agents (suxamethonium) and non-depolarizing agents (vecuronium, atracurium).

Table 9.3

Types of anesthesia used at surgical projects, 2013

Type of anesthesia	2013		2012		2011		2010
Type of anesthesia	#	%	#	%	#	%	#	%
Spinal	7,208	37.2	7,294	38.1	7,797	39.7	5,224	33.6
General	7,945	41.0	7,971	41.6	7,961	40.5	7,033	45.2
Intubated	2,183	11.2	1,933	10.1	2,110	10.7	1,636	10.5
Local/regional	1,417	7.3	1,383	7.2	1,191	6.1	1,139	7.4
Combined/others	642	3.3	564	3.0	585	3.0	512	3.3
Total	19,395	100.0	19,145	100.0	19,644	100.0	15,544	100.0

Table 9.4

Ketamine doses and administration at MSF-Belgium surgical projects

Parameter	Anesthesia		Analgesia
Route	IM/rectal	IV	IM	IV
Dose (mg/kg)	8–10	1–2	2–4	0.3–0.8
Onset (min)	5	1–2	5	1–2
Duration (min)	20–30	10–15	–	–
Maintenance (mg/kg)	5	0.5–1	–	–
Frequency (min)	20–30	15–20	–	–

Spinal anesthesia (SA) is indicated for surgery below the umbilicus, i.e., lower limb surgery, surgery of the inguinal area and amputations; for Caesarean sections we use hyperbaric bupivacaine. Neither adrenaline nor opioids are added to our protocols, as we see no clear advantage.

Principles in MSF Field Anesthesia Practice

A key first principle in our surgical missions is that it is feasible, although challenging, to do safe anesthesia with basic tools and infrastructure: after all, millions of episodes of anesthetic administration are performed safely around the world every year in relatively low-technology settings. Clearly this requires anaesthetists with certain critical skills, but a trained anesthesiologist should know how to deal with the types of emergency situations (such as hemorrhagic shock or polytrauma), which happen everywhere. So in this sense there should be no essential difference between anesthetic practices in Western versus resource-poor settings; the difference is in practical implementation stemming from context-specific constraints.

Only gold members can continue reading. Log In or Register to continue