Challenges of anesthetic monitoring in low and middle income countries
Faye Evans MD, Zippporah N. Gathuya MD, and Myron Yaster MD
Can you imagine providing anesthesia without monitoring heart rate, blood pressure, temperature, pulse oximetry capnography, end-tidal gas concentrations, airway pressure or inspired and expired oxygen levels? Probably not. Except for those who trained more than 35 years ago, very few of you have ever had to do this and the very thought would be inconceivable. And yet, in many low- and middle-income countries (LMICs), these monitors may or may not be available. Today’s PAAD by Atandi et al.1 is a snapshot of what is available in the major referral hospitals in Kenya. Monitors such as a pulse oximeter, non-invasive blood pressure monitoring, an electrocardiogram and capnography are considered standard anesthetic monitors by many national anesthesia societies and highly recommended (I.e., mandatory) or recommended by the WHO-WFSA Standards for a Safe Anesthetic.2 Regardless of location, these monitors have been shown to reduce perioperative mortality.
First and foremost, it’s not all doom and gloom and great strides have been made over the past decade. Before reading today’s PAAD or upon completing your read, please, please, please consider making a donation to LIFEBOX (www.lifebox.org) which is dedicated to making surgery and anesthesia safer through tools, training, and partnerships throughout the world. While you are probably familiar with their low cost, robust pulse oximeter, the Lifebox, you probably are not aware that this month you will see the launch of the Smile Train-Lifebox Capnograph. An affordable high-quality device that meets robust specifications for both the monitoring of pediatric patients and for use in variably- resourced settings. I would like to challenge ALL of you whether you are in a private practice, a community hospital, teaching hospital or wherever in the world you work, to make a contribution and to challenge your colleagues and partners and your employers to join in this effort.
And as way of full disclaimer: Faye is on the Lifebox Board and both Faye and Zippy have been very involved in the Smile Train – Lifebox Capnograph project. They are also involved in a panel discussion on the topic on Sunday at the ASA with Angela Enright. Myron Yaster MD
Original article
Atandi B, Chokwe T, Sulemanji D. Challenges of Anesthetic Monitoring in Low- and Middle-Income Countries: Availability of Equipment in Major Referral Hospitals in Kenya. Anesthesia & Analgesia. 2023; 137 (3): 648-655. PMID: 36730687
“The Association of Anaesthetists of Great Britain and Ireland (AAGBI)3 and the American Society of Anesthesiologists4, 5 have given recommendations on the minimum devices required for standard physiologic monitoring of patients undergoing procedural sedation or anesthesia. These include pulse oximetry, noninvasive blood pressure (NIBP) monitoring, electrocardiography (ECG), inspired and expired oxygen, carbon dioxide, nitrous oxide, and volatile anesthetic agents, and airway pressure. Peripheral nerve stimulators and temperature monitoring should be used as indicated.”1 We would add that having age-appropriate scales to obtain accurate weights should also be on this list.
“In LMICs, there is limited availability of equipment for basic anesthetic monitoring and the anesthetic monitoring is often incomplete.6-8 These data include some Sub-Saharan countries, and there are scarce data on Kenyan hospitals. We sought to determine the availability of basic anesthetic monitoring devices in major referral hospitals in Kenya.”1
What did they find? “Only 1 of 16 (6.25%) hospitals had all the monitoring devices recommended by the AAGBI. Automated noninvasive blood pressure (NIBP) monitoring and pulse oximetry were present in ALL operating theaters. However, for NIBP monitors the 4 standard adult sizes recommended the American Heart Association were only available in 15 of 103 (14.6%) operating theaters, neonate sized blood pressure cuffs in 39 of 103(37.9%) and pediatric blood pressure cuffs in 62 of 103 (60.2%).
Continuous electrocardiography (ECG) was available in 102 of 103 (99%) operating theaters, skin temperature monitoring probes in 73 of 103 (70.9%), and capnography in only 49 (47.6%). A nerve stimulator was accessible in 5 of 16 (31.25%) hospitals. One of the regional referral hospitals did not have a PACU and 9 of 96 (9.4%) of PACU beds were without any monitoring devices at all. Pulse oximetry was the most common device (84.4%) of the PACU beds equipped with monitoring. In 5 of 16 (31.25%) procedural sedation areas, pulse oximetry was the only monitoring device, whereas there were No devices present in 2 of 16 (12.5%) sedation areas. Portable multiparameter devices used for patient transport were present in 5 of 16 (31.25%) hospitals.”1
Thus, the good news: in the operating theatres, ECG, pulse oximetry and NIBP were almost always available, albeit appropriate size BP cuffs for smaller and younger patients were clearly not. On the other hand, the recovery areas and non-OR procedural areas were poorly equipped. Capnography and end-tidal gas analysis remains a real issue with more than half of the ORs lacking this equipment. Less than a third of the facilities studied had access to monitoring neuromuscular blockade. Thus, a lot of progress has been made at the national referral and teaching hospitals, but much work and equipment are still needed. One would expect that the findings at the district hospital and in the rural areas are much worse.
Finally, as I said in my opening remarks, I (MY) would like to take the review of this article as a challenge to all of our readers to individually donate to LIFEBOX (www.donate.lifebox.org) AND to inspire your colleagues, partners, employers and students/trainees to donate individually or as a group. Several years ago, the Society for Pediatric Anesthesia and the Pediatric Anesthesia Program Directors Association laid down a similar gauntlet and we raised thousands of dollars in this effort. Let’s do it again! A pulse oximeter (plus training) costs $250. The Smile Train-Lifebox capnograph (a dual parameter pulse oximeter capnography) costs (plus training) $1,000. I will start the ball rolling and donate $250 today.
Send us your thoughts and Myron will post in the Friday Reader response.
References
1. Atandi BO, Chokwe TM, Sulemanji DS. Challenges of Anesthetic Monitoring in Low- and Middle-Income Countries: Availability of Equipment in Major Referral Hospitals in Kenya. Anesthesia and analgesia. Sep 1 2023;137(3):648-655. doi:10.1213/ane.0000000000006287
2. Gelb AW, Morriss WW, Johnson W, et al. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesthesia and analgesia. Jun 2018;126(6):2047-2055. doi:10.1213/ane.0000000000002927
3. Checketts MR, Alladi R, Ferguson K, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. Jan 2016;71(1):85-93. doi:10.1111/anae.13316
4. Epstein BS. ASA adopts standards for the practice of anesthesiology. Archives of surgery (Chicago, Ill : 1960). Oct 1987;122(10):1215-6. doi:10.1001/archsurg.1987.01400220125027
5. Pandya AN, Majid SZ, Desai MS. The Origins, Evolution, and Spread of Anesthesia Monitoring Standards: From Boston to Across the World. Anesthesia and analgesia. Mar 1 2021;132(3):890-898. doi:10.1213/ane.0000000000005021
6. Thoms GM, McHugh GA, O'Sullivan E. The Global Oximetry initiative. Anaesthesia. Dec 2007;62 Suppl 1:75-7. doi:10.1111/j.1365-2044.2007.05305.x
7. Jooste R, Roberts F, Mndolo S, Mabedi D, Chikumbanje S, Whitaker DK, O'Sullivan EP. Global Capnography Project (GCAP): implementation of capnography in Malawi - an international anaesthesia quality improvement project. Anaesthesia. Feb 2019;74(2):158-166. doi:10.1111/anae.14426
8. Albert V, Mndolo S, Harrison EM, O'Sullivan E, Wilson IH, Walker IA. Lifebox pulse oximeter implementation in Malawi: evaluation of educational outcomes and impact on oxygen desaturation episodes during anaesthesia. Anaesthesia. Jun 2017;72(6):686-693. doi:10.1111/anae.13838