50 Pediatric Anesthesia in Developing Countries
THE POPULATION IN THE DEVELOPING WORLD CONTINUES TO GROW while world demographics trend toward an aging population in an urbanized, developed world. Children, many orphaned by the ravages of war, human immunodeficiency virus (HIV) infection,1 and famine, constitute more than one half of the population in many of these countries.2 Eighty-five percent of them will require surgery before their 15th birthday.3 The burden of surgical disease requires safe anesthesia,4,5 but provision of safe pediatric anesthesia6 and intensive care7–9 in the developing world presents serious challenges.10–12 Poverty, poor educational standards, and limited health resources characterize the developing world.5,6,13 Debt repayment, housing, education, social service, and health care provision are near-impossible tasks for most governments of these countries. Of the world’s poorest countries, 70% are in sub-Saharan Africa, and they are ravaged by HIV, malaria, and tuberculosis and are desperately short of health care providers.4,5
Pediatric anesthesia in these low-income countries has not kept pace with the advances made in the developed countries.4 International standards for the safe practice of anesthesia, adopted by the World Federation of Societies of Anaesthesiologists (WFSA) in 1992, are seldom met in developing countries.14–16 In one survey, only 13% of anesthesiologists were able to provide safe anesthesia for children.3 Consequently, perioperative mortality and morbidity rates in these countries are high by developed world standards5,17–21 although local expectations are commensurate with the facilities and quality of the available care.
This chapter outlines some of the many challenges that anesthesiologists face when providing anesthesia for children in a developing country. Different countries have different problems requiring different solutions. The problems faced in many tropical countries,8,13 for example, are completely different from those on a tropical island in the South Pacific22 or West Indies,23,24 at altitude in Nepal25 and Afghanistan,26 or in the humidity of sub-Saharan Africa.2,3,19,21,27–30 These diverse situations necessitate that generalizations be made. The main differences among the sites, however, are related to the personnel, the spectrum and nature of the pathology, the facilities and equipment available, and a tenuous supply of cheap, generic, and perhaps outmoded drugs.10,31
Children of the developing world are for the most part victims of circumstance; natural disasters, war, social unrest,32 and economic crises. For many, medical care or timely access to care is a remote or nonexistent possibility.10,25,30,33,34 Fear, poor understanding, 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-renal toxic or enemas that may perforate the bowel.35 Further delays occur when patients have to undertake long journeys to the hospital, and if the initial diagnosis is wrong, tertiary referral is made only when complications arise (Fig. 50-1).10,30,36,37
FIGURE 50-1 Peripheral gangrene of the hand. Severe dehydration in this infant was caused by severe gastroenteritis. Dehydration associated with delayed presentation, hypernatremia, herbal medications, and pneumonia are common contributors to this disastrous outcome.
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.37,38 Most patients present for surgery with generalized peritonitis, and perforation is common. In the developing world, the prospect of providing 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 laboratory2,13–15 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 quite likely that the stomach cannot be completely emptied of solids despite the tube.24
Perinatal mortality in some parts of the developing world is ten times greater than those in developed countries.5,39–41 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.30,34,41 Most parturients give birth at home or in rural health centers,34 where basic neonatal resuscitation equipment is deficient or nonexistent.30 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,”42 whereas in others, they undergo surgery without anesthesia23 because “it’s safer” and because some still believe that neonates do not feel pain. When surgery is performed on neonates, there are additional challenges, particularly in emergency situations.23 Appropriately sized equipment is lacking,36 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 anesthesia30,36,43 and in some centers may be the only choice for anesthesia.34,44 Apart from providing analgesia without respiratory depression, the need for postoperative ventilatory support for conditions such as esophageal atresia,45 congenital diaphragmatic hernia,46 and abdominal wall defects is reduced by continuous epidural analgesia (Fig. 50-2).
FIGURE 50-2 Gastroschisis is a major problem in the developing world. The outcome is poor because of a paucity of facilities for neonates. This defect was not diagnosed antenatally, and the patient presented late for closure, which proved difficult. Ventilatory support was not available, and a silo was fashioned. Unfortunately, the child died of overwhelming sepsis a week later.
Regrettably, even neonates who have skillful anesthesia and surgery may die because of inadequate postoperative care.44 Overwhelming infection, sepsis, respiratory insufficiency, and surgical complications are the main causes of morbidity and mortality.30,34 The development of highly specialized neonatal anesthesia and surgical services,7,40–42 essential for a good outcome after neonatal surgery,30,34,36 is a low priority.
Although the burden of disease is dominated by infections and malnutrition,4,5 pediatric trauma has a low level of advocacy and is given scant attention.30,36,47 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.36
Road traffic accidents are common. Even simple bone fractures have disastrous outcomes. Inappropriate management by traditional bonesetters frequently results in compartment syndromes or gangrene.47 Trauma prevention strategies are given low priority despite the acknowledged impact trauma has on the economy of any country. Many developing countries are at war, and this has led to massive trauma and injuries to children who are participants in the fighting or innocent bystanders.
Children may be victims of all aspects of violence. They face an intense struggle for survival as a consequence 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.48 Many sustain physical injuries and permanent disabilities, and a large number acquire sexually transmitted disease, including HIV infection and acquired immunodeficiency syndrome (AIDS). These HIV-positive child soldiers then become vectors in communities where they are deployed.49
For many of these children, acts of violence become their form of normality, and the former victims become the perpetrators.32 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.50
Children in war-torn areas sustain bullet, machete, or shrapnel wounds, and others are burned. They often sustain mutilating injuries (Figs. 50-3 and 50-4) that are not commonly seen in civilians.51 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.51 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.51 Although the war in Angola is essentially over, the cost of mine removal is beyond the means of local governments. Ironically, artificial limb manufacture has become a developing industry.51 Tragedies such as these are likely to be repeated in the ongoing conflicts in Afghanistan, Iraq, and Somalia.
FIGURE 50-3 Facial burn injuries are common in the developing world, and these children may require multiple episodes of anesthesia. A, Flame burns of the face are invariably associated with inhalation injuries that may necessitate ventilatory support in intensive care facilities, which are not readily available. B, Pain management and pain assessment are challenging. The pained expression on this child’s face is one of fear (and possible indignation about having the photograph taken) rather than actual pain.
FIGURE 50-4 Children fare poorly in war. This 8-year-boy bit a detonator he found while playing. Endotracheal intubation proved a major challenge without a fiberoptic laryngoscope, which is a luxury in the developing world.
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.
Pain management modalities for children in a First World environment are vastly different from those available to practitioners working with limited resources.52 Attempting to apply similar standards is fraught with difficulty. Illiteracy, malnutrition, poor cognitive development, different coping strategies, altitude (e.g., chronic hypoxia),53 and pharmacogenetic, cultural, and language differences all contribute to the complexity of the problem.54
Children of the developing world learn to cope with vastly different problems. They may be victims of poverty, malnutrition, violence (e.g., war, trauma, abuse), and their attitudes about pain and pain tolerance are diverse. Children from an impoverished background seem more stoic and indifferent to even severe pain. After cardiac surgery, for example, some appear to need very little pain relief and are easily soothed by lollipops (A. Davis, personal communication) or play therapy.33 Many walk from the intensive care unit to the general ward on the first postoperative day (A. Davis and R. Ing, personal communication).
Pain assessment of children from an impoverished background is difficult55 (see Fig. 50-3, B). Many children in acute pain do not show facial expressions. Is this stoicism or simply a reflection of malnutrition, lack of social stimulation, severity of illness, or even cultural attitude? Language difficulties, cultural barriers, willingness to share information, emotional expressiveness, and outdated attitudes of the caregiver may endorse this quandary. Some societies convey pain readily, but others teach that expression of pain is inappropriate. Although many pain assessment instruments are available, few have been validated in the developing world.55–57
There is an urgent need to develop pain treatment strategies that can be applied to the children of the developing world. Local conditions dictate their use and applicability. Simple pain management strategies may produce the most benefit with the least risk, whereas more complex techniques, which offer the most benefit, require a minimum standard of monitoring and regular reassessment to allow individualized titration of analgesia. These devices and personnel are seldom available to children of the developing world. The final choice of analgesia is therefore dictated by economic pressures or by the facilities available rather than what would be considered best for the child.
Anesthesia does not enjoy a high profile and lacks the voice to demand access to resources in developing countries. The critical shortage of manpower is a barrier to progress.5,8 Anesthesia is frequently delivered by nonphysicians,3,6,58 a reality that has remained constant over many decades. Most anesthetics are administered by nurses or unqualified personnel who have little medical background and are “trained on the job.”3,36 In many African5,59 and Asian countries,5,60 the ratio of doctors to patients often is so small that the ideal of employing a physician specifically to provide routine anesthesia is out of the question.5,61,62 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 difficulties.3,5,10,58,61–64
Anesthesia is not perceived as an attractive career for many undergraduates,63 who receive little or no exposure to the specialty.64 In some countries, surgery is performed without the “luxury” of anesthesia.65 Few developing countries can afford specialist anesthesiologists, except possibly in the principal hospitals. Supervision of “nonphysician anesthesiologists” is invariably inadequate,66 and access to textbooks, journals, or other medical literature is limited. Internet access depends on a reliable electrical supply, telecommunications network, and a computer, luxuries that are considered the norm in the developed world.67,68
Despite these problems, many individuals provide high-quality anesthesia for a limited range of surgical procedures, but 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 and fear. This is understandable in view of the lack of supervision, the severity of the child’s condition, and the equipment that is more suited for adults. Invariably, the “pediatric anesthesiologist” is someone who may have a special interest in or affinity for children or who has been allocated to pediatric anesthesia for the day because there is no one else. A genuine pediatric anesthesiologist is a luxury.
On a more positive note, the World Health Organization (WHO) has recognized that surgery is a public health issue and has launched the Safe Surgery Saves Lives program.5,16,17,62,69 The WHO has emphasized that safe surgery does not exist without safe anesthesia.10,11,16,17 Training anesthesiologists in the skills required for pediatric anesthesia is a slow process. It is hoped that the WFSA program69–78 will snowball so that children undergoing surgery in developing countries will reap the benefit.
Many pathologic conditions that are seldom seen in industrialized countries are more prevalent in developing countries because of poor health education, malnutrition, proximity of livestock to humans, earth-floored homes, poor sanitation, and contaminated water supplies (Fig. 50-5). Some conditions that are prevalent worldwide and relevant to the anesthesiologist are considered in the following sections.
FIGURE 50-5 A, Global distribution of human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS). Developing countries, particularly sub-Saharan Africa, carry the greatest health burden with the poor resources. B, The global distribution of malaria is remarkably similar to that of HIV/AIDS. Blood products in these regions carry an enormous risk, even if family members act as donors. C, Global distribution of tuberculosis (TB) in 2005.
(A, From AIDS Epidemic Update, p. 66. Available at data.unaids.org/pub/EpiReport/2006/2006_EpiUpdate_en.pdf, page 66 [accessed July 2012]; B, from World Malaria Report. Available at www.rbm.who.int/wmr2005/html/map3.htm [accessed July 2012]; C, from World Health Report, 2006. Available at www.who.int/whr/2006/en/ [accessed July 2012].)
An estimated 33.4 million people are living with HIV. Most cases occur in the developing world (90%), with sub-Saharan Africa (22.4 million) and Southeast Asia (3.8 million) making up two thirds of the global total; approximately 6% are children (see Fig. 50-5, A).79 More than 25 million have died of HIV-related diseases since 1981, and as a consequence, there are an estimated 14 million orphans in sub-Saharan Africa alone.79 Worldwide, more than 1000 children are newly infected with HIV each day; most of these children are in sub-Saharan Africa.80 The prevalence of HIV seropositivity varies from one country to another. In this environment, it is prudent for the anesthesiologist and surgeon81 to assume a positive status for every patient until proved otherwise.36
Although some success has been achieved in slowing the transmission of HIV in developed countries,81–87 there are numerous barriers to the treatment of HIV-infected children in the developing world. Only 4 million people in low- to middle-income countries have access to treatment.79 Treatment of children has lagged behind that of adults, in part because of the expense and the lack of pediatric antiretroviral drug formulations84 but mainly due to poor human resources and infrastructure for administration of treatment.88 Only an estimated 38% children infected with HIV receive treatment.79
Children can be infected by vertical transmission from the mother (>90%) or when sexually abused (≈2%) by an infected adult.89 Transmission through blood products remains a risk, but with the global trend toward volunteer donors and more sophisticated testing of blood, this risk is expected to diminish. Vertical transmission can occur in utero, during labor and delivery, or postnatally. Risk factors include maternal plasma viral load and breastfeeding.80,86 Data indicate that mixed feeding (i.e., breastfeeding with other oral foods and liquids) is associated with the greatest risk of transmission.90 Perinatal transmission rates have been dramatically reduced by universal HIV testing of pregnant women, provision of antiretroviral therapy (when needed for maternal health) or prophylaxis, elective cesarean delivery, and avoidance of breastfeeding.80,86 Highly active antiretroviral therapy (HAART), the triple antiretroviral therapy, has changed HIV from a fatal illness to a chronic disease with decreased mortality rates and improved quality of life86; however, these strategies require resources.
In practical terms, it is difficult to differentiate infants who are infected by vertical transmission from those who are not infected because differentiating between actively or passively acquired antibodies is virtually impossible in low-income countries. All children born to HIV-positive mothers have acquired HIV antibodies for the first 6 to 18 months. Only 30% to 40% of the infants who are infected may go on to develop AIDS. The presence of HIV antibody is therefore not a reliable indicator of infection. More sophisticated and expensive tests have been developed but are not widely available. All children born to HIV-positive mothers should be considered infected; if antibody persists beyond 15 months, infection should be assumed.
Progression of the disease depends on the mode of transmission; vertically acquired infection is more aggressive than other forms. Between 20% and 30% of untreated HIV-infected children will develop profound immunodeficiency and AIDS-defining illnesses within a year, whereas two thirds will have a slowly progressive disease. The course of the disease depends on a variety of factors, including timing of infection in utero, the viral load, the mother’s stage of the disease, and whether the mother is receiving antiretroviral therapy. Treatment of children depends on clinical category, CD4 T-cell cell count, viral load, and age at the time of diagnosis. According to the current state of knowledge, after HAART is started, it must be carried on lifelong. This implies great challenges in adherence to avoid development of resistance and to evade long-term adverse effects of HIV therapy. Emerging drug resistance in children in low- and middle-income countries has necessitated new treatment strategies.84,87
The clinical manifestation of HIV in infants and children depends on whether they have been managed with antiretrovirals.81,84,87 Most have asymptomatic infections, and the presentation may be subtle, such as failure to thrive, lymphadenopathy, hepatosplenomegaly, interstitial pneumonia, chronic diarrhea, or persistent oral thrush. Some present for the first time with life-threatening disease. Chronic diarrhea, wasting, and severe malnutrition predominate in Africa, whereas systemic and pulmonary pathologies are more common in the United States and Europe. Recurrent bacterial infections, chronic parotid swelling, lymphocytic interstitial pneumonitis (LIP), and early onset of progressive neurologic deterioration are characteristic of children with AIDS.
Pulmonary disease remains the leading cause of morbidity and mortality.91–93 Bacterial pneumonia, viral pneumonia, and pulmonary tuberculosis are common in children throughout the developing world. The course of these infections is more fulminant when associated with HIV infection.94 Acute opportunistic infections occur when the CD4 T-cell count falls; they include Pneumocystis (carinii) jiroveci pneumonia (PCP or PJP), cytomegalovirus infection, and the more typical Haemophilus influenzae, Streptococcus pneumoniae, and respiratory syncytial virus infections.91,92,94 The classic presentation of PCP is fever, tachypnea, dyspnea, and marked hypoxemia, but in some children, the presentation is more indolent, with hypoxemia preceding clinical or radiologic changes.95
LIP is a slowly progressive, chronic form of lung disease seen in older children. It can lead to an insidious onset of dyspnea, cough, and chronic hypoxia with normal auscultatory findings and can cause pulmonary lymphoid hyperplasia in AIDS patients. In contrast to adults, LIP in children may cause acute respiratory failure, which is treated with steroids and bronchodilators. The clinical manifestations affecting otolaryngologists96 and dental surgeons97 have been outlined. Management of the upper airway may be difficult in the presence of stomatitis and gingival disease. Intubation may be difficult in the presence of acute (i.e., candidal infection) or chronic epiglottitis (i.e., lymphoid hyperplasia), necrotizing laryngotracheitis, Kaposi sarcoma (Fig. 50-6), or laryngeal papillomas (Fig. 50-7). These comorbid respiratory disorders can challenge even the most experienced pediatric anesthesiologist (Fig. 50-8).
FIGURE 50-6 Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) are an increasing problem is developing countries, particularly in sub-Saharan Africa. The skin manifestations in this 8-year-old boy indicate Kaposi sarcoma, an AIDS-defining tumor.
FIGURE 50-7 Laryngeal papilloma. Papillomas, caused by the human papillomavirus, are prevalent in low socioeconomic groups and have the highest incidence in the 2- to 5-year-old age-group. This age distribution is changing in the human immunodeficiency virus–exposed population. Even in well-equipped institutions, anesthesia for these patients can be challenging.
FIGURE 50-8 Kaposi sarcoma is a marker for acquired immunodeficiency syndrome (AIDS). A, AIDS was previously considered to be rare in children, but it may affect the airway at different levels, as shown in this 12-year-old girl. She is clearly fatigued from the respiratory distress caused by Kaposi sarcoma at three levels: base of the tongue, tonsil, and trachea. She also has an underlying pneumonia. Significant supraclavicular recession suggests upper airway obstruction. B, The Kaposi sarcoma of the base of the tongue, tonsil, and trachea is shown on a poor-quality, lateral neck radiograph, which illustrates one of the many difficulties faced in remote areas, high quality imaging. C, Laryngoscopic view of the Kaposi sarcoma at the base of the tongue and the tonsil. D, Computed tomography shows a large retropharyngeal Kaposi sarcoma (arrows) obstructing the upper airway. The poor quality of the scan reflects inexperienced radiographers using the poor-quality equipment commonly found in developing countries.
Cardiac disease is being recognized with increasing frequency in HIV-infected children. The pathogenesis of cardiomyopathy is multifactorial and includes pulmonary insufficiency, anemia, nutritional deficiencies, specific viral infections, and drug therapy. Left and right ventricular dysfunction, arrhythmias, and pericardial effusions occur, but pulmonary hypertension is rare.98 HIV may directly infect the myocardium, leading to early electrocardiographic (ECG) changes and abnormal echocardiograms showing hyperdynamic left ventricular dysfunction or evidence of diminished contractility (e.g., dilated cardiomyopathy, myocarditis).
The gastrointestinal tract is commonly involved,99 particularly in those living in tropical countries, and affected children show evidence of malabsorption (i.e., slim), chronic recurrent diarrhea, dysphagia, failure to thrive, or enteric infection. They may require endoscopy for diagnostic studies. From the point of view of the anesthesiologist, there is an increased risk of reflux due to esophagitis, which may be caused by infection (e.g., Candida, cytomegalovirus) or drugs (e.g., zidovudine). Pseudobulbar palsy, a manifestation of central neurologic involvement, or esophageal strictures may occur.