Pediatric anesthesia risk in Africa: Defining the problem, exploring solutions
Mark Gacii MD, Mattew J. Kynes MD, David E. Liston MD MPH
When I worked at Johns Hopkins I had many opportunities to teach pediatric anesthesia and pediatric advanced life support in many low, middle, and high income countries across the world. When I read today’s Pediatric Anesthesia Anesthesia Article of the day and its accompanying editorial, I reached out to Matt Kynes, the current chair of the Society for Pediatric Anesthesia’s Special Interest Group on Global Health. He recruited Mark Gacii and David Liston to assist him in writing today’s PAAD.
We are fortunate indeed to live in the richest country on earth. After reading today’s PAAD I’d like to challenge the PAAD readers to “vote with their feet (and pocket books)” by going to the Lifebox website and buy a pulse oximeter. LIfebox is a global non-profit that works to improve the safety of surgery and anesthesia in low- and middle-income countries. One of their goals is to ensure that all anesthetics are performed with pulse oximetry. Soooo, go to the website and buy a pulse oximeter (or 2). Challenge your colleagues to participate. Every contribution can be lifesaving.
https://donate.lifebox.org/campaign/lifebox-innovations/c215466
Myron Yaster MD
Original article
Larissa Cronjé, Alexandra M Torborg, Heidi M Meyer, Anisa Z Bhettay , Johan B J S Diedericks, Celeste Cilliers, et al. An Evaluation of Severe Anesthetic-Related Critical Incidents and Risks From the South African Paediatric Surgical Outcomes Study: A 14-Day Prospective, Observational Cohort Study of Pediatric Surgical Patients. Anesth Analg. 2022 Apr 1;134(4):728-739. PMID: 34928873
Editorial
Evans FM, Wake PB, Gathuya ZN, McDougall RJ. Access to Safe Pediatric Anesthesia in LMICs-The Problem Is Clear; It Is Time to Solve It! Anesth Analg. 2022 Apr 1;134(4):724-727. PMID: 35299212
How do we fix global inequities within the field of pediatric anesthesia?
As with any problem, we must first gain an understanding of the issues involved before determining how best to solve it.
It is from this perspective that we dive into a recent landmark article by Cronjé et al in the April issue of A&A. This study is the first to prospectively investigate severe anesthetic-related critical incidents (SARCIs) in children in Africa. The study is based in South Africa, a middle-income country (MIC), and uniquely sheds light on not only perioperative care but the mechanisms of an entire health care system. Key findings included a 3 times greater incidence of SARCIs and a 10 times greater incidence of perioperative cardiac arrest (POCA) compared to high-income countries (HIC). Furthermore, specific variables were identified as being associated with SARCIs: urgency and severity of surgery, younger age, respiratory infections, comorbidities, higher ASA status, and level of hospital care. Interestingly, the presence of specialist anesthesiologists managing the anaesthesia did not provide a benefit in terms of reduced incidence of SARCIs and peri-operative mortality, although they did tend to do the sicker and smaller children. Could this indicate a need for further pediatric anesthesia training even among anesthesiologists to address the challenges of this setting?
Based on their findings, the authors provided three broad recommendations: (1) increase investment in resources at first-level hospitals, (2) improve capacity at second-level hospitals for low-risk patients, and (3) refer high-risk patients to third-level hospitals where human and material resources for pediatric patients are better suited for managing these cases.
In their accompanying editorial, Faye Evans and colleagues (representing a wealth of experience in pediatric anesthesia practice and education from around the globe) drive home the realities of pediatric anesthesia care in low and middle-income countries (LMICs). And the reality is not good. In one stark example, mortality for the 7 most common gastrointestinal congenital conditions is a respectable 5.6% in HICs but a concerning 20% in MICs and a depressing 40% in low-income countries (LICs).(1) As physicians we know that diagnosis is critical but it’s not the goal—treatment is. By describing potential strategies to improve the capacity and outcome problems that lead to these poor outcomes, Evans and colleagues help move the conversation forward. Standards of care and training, adequate equipment, organizational systems, networking and ongoing education and support led by ministries of health, anesthesia societies, individual departments and collaborations are all necessary to bring care to an acceptable level regardless of a country’s income status. Importantly, these solutions need to be context specific – South Africa is not Mongolia which is not Papua New Guinea. LMICs are not homogenous as a group nor are they individually. The people best equipped to navigate dynamics within a specific context to identify appropriate solutions and apply them correctly are local leaders. Which brings us to someone making tremendous strides in equipping pediatric anesthesia leaders for the East, Central and Southern African contexts – Dr. Mark Gacii, Program Director at the University of Nairobi Paediatric Anaesthesia Fellowship.
In my [MG] home country of Kenya, which is an LMIC located in East Africa with a pediatric perioperative mortality rate of 1.7% (2), we have started addressing these deficiencies in several ways. There exists a robust support mechanism consisting of WhatsApp groups for anaesthesiologists that allows for immediate although virtual support. Professional bodies like the Kenya Society of Anaesthesiologists (K.S.A.), the Kenya Paediatric Society (K.P.A), and the nascent Society of Paediatric Anaesthesiologists of Kenya (S.P.A.K.) are leaders in policy formulation, training, and advocacy, especially for greater prioritization of specialist paediatric anaesthesiologists. We are also running one of the only pediatric anesthesiology fellowships on the continent, supplying pediatric anesthesiologists not only for Kenya but also for multiple countries in the region.
Unlike South Africa, the number of physician anesthesiologists in Kenya remains quite low even at referral hospitals. An immediate goal as suggested in the editorial may be the identification of one non-physician anaesthetist who would be trained to lead in managing the ill child before transfer and be a channel through which guidelines can be disseminated at the local level and feedback is given on their implementation and effect.
As the problem of outcome disparities for pediatric anesthesia come more into focus, we hope that the solutions to this crisis will, as well. This article brings us a step closer.
Mark Gacii MD, Mattew J. Kynes MD, David E. Liston MD MPH
References:
1. Wright NJ, Leather AJM, Ade-Ajayi N, et al. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study. Lancet. 2021;398:325–339.
2. Mark W. Newton, Savannah E. Hurt, Matthew D. McEvoy, Yaping Shi, Matthew S. Shotwell, John Kamau, Susane Nabulindo, Zipporah W. W. Ngumi, Warren S. Sandberg, Bantayehu Sileshi; Pediatric Perioperative Mortality in Kenya: A Prospective Cohort Study from 24 Hospitals. Anesthesiology 2020; 132:452–460