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1.
Paediatr Anaesth ; 31(1): 13-15, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33378131
2.
Anesth Analg ; 2020 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-33264116

RESUMO

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

3.
Bull World Health Organ ; 98(10): 671-682, 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-33177757

RESUMO

Objective: To determine whether location-linked anaesthesiology calculator mobile application (app) data can serve as a qualitative proxy for global surgical case volumes and therefore monitor the impact of the coronavirus disease 2019 (COVID-19) pandemic. Methods: We collected data provided by users of the mobile app "Anesthesiologist" during 1 October 2018-30 June 2020. We analysed these using RStudio and generated 7-day moving-average app use plots. We calculated country-level reductions in app use as a percentage of baseline. We obtained data on COVID-19 case counts from the European Centre for Disease Prevention and Control. We plotted changing app use and COVID-19 case counts for several countries and regions. Findings: A total of 100 099 app users within 214 countries and territories provided data. We observed that app use was reduced during holidays, weekends and at night, correlating with expected fluctuations in surgical volume. We observed that the onset of the pandemic prompted substantial reductions in app use. We noted strong cross-correlation between COVID-19 case count and reductions in app use in low- and middle-income countries, but not in high-income countries. Of the 112 countries and territories with non-zero app use during baseline and during the pandemic, we calculated a median reduction in app use to 73.6% of baseline. Conclusion: App data provide a proxy for surgical case volumes, and can therefore be used as a real-time monitor of the impact of COVID-19 on surgical capacity. We have created a dashboard for ongoing visualization of these data, allowing policy-makers to direct resources to areas of greatest need.


Assuntos
Anestesiologia/estatística & dados numéricos , Infecções por Coronavirus/epidemiologia , Aplicativos Móveis/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Vigilância em Saúde Pública/métodos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Betacoronavirus , Humanos , Estudos Longitudinais , Pandemias
4.
Paediatr Anaesth ; 30(10): 1146-1148, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32741014

RESUMO

Anesthesia providers are familiar with the oculocardiac reflex, one type of trigeminocardiac reflex. While less common, arrhythmias associated with manipulation of other trigeminal nerve branches can occur. We report the presentation and management of bradycardia and asystole from stimulation of the mandibular branch of the trigeminal nerve during temporomandibular joint reconstruction.

5.
medRxiv ; 2020 May 08.
Artigo em Inglês | MEDLINE | ID: mdl-32511532

RESUMO

IMPORTANCE: The COVID-19 pandemic has disrupted global surgical capacity. The impact of the pandemic in low and middle income countries has the potential to worsen already strained access to surgical care. Timely assessment of surgical volumes in these countries remains challenging. OBJECTIVE: To determine whether usage data from a globally used anesthesiology calculator mobile application can serve as a proxy for global surgical case volume and contribute to monitoring of the impact of the COVID-19 pandemic, particularly in World Bank low income countries where official data collection is not currently practical. DESIGN: Subset of data from an ongoing observational cohort study of users of the application collected from October 1, 2018 to April 18, 2020. SETTING: The mobile application is available from public sources; users download and use the application per their own clinical needs on personal mobile devices. PARTICIPANTS: No user data was excluded from the study. Exposure(s): Events with impacts on surgical case volumes, including weekends, holidays, and the COVID-19 pandemic. Main Outcome(s) and Measure(s): It was previously noted that application usage was decreased on weekends and during winter holidays. We subsequently hypothesized that more detailed analysis would reveal impacts of country-specific or region-specific holidays on the volume of app use. RESULTS: 4,300,975 data points from 92,878 unique users were analyzed. Physicians and other anesthesia providers comprised 85.8% of the study population. Application use was reduced on holidays and weekends and correlated with fluctuations in surgical volume. The COVID-19 pandemic was associated with substantial reductions in app use globally and regionally. There was strong cross correlation between COVID-19 case count and reductions in app use. By country, there was a median global reduction in app use to 58% of baseline (interquartile range, 46%-75%). Application use in low-income continues to decline but in high-income countries has stabilized. CONCLUSIONS AND RELEVANCE: Application usage metadata provides a real-time indicator of surgical volume. This data may be used to identify impacted regions where disruptions to surgical care are disproportionate or prolonged. A dashboard for continuous visualization of these data has been deployed.

7.
Paediatr Anaesth ; 30(3): 241-247, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31910309

RESUMO

The need for safe and quality pediatric anesthesia care in low- and middle-income countries (LMICs) is huge. An estimated 1.7 billion children do not have access to surgical care, and the majority are in LMICs. In addition, most LMICs do not have the requisite surgical workforce including anesthesia providers. Surgery is usually performed at three levels of facilities: district, provincial, and national referral hospitals. Unfortunately, the manpower, equipment, and other resources available to provide surgical care for children vary greatly at the different level facilities. The majority of district level hospitals are staffed solely by non-physician anesthesia providers with variable training and little support to manage complicated pediatric patients. Airway and respiratory complications are known to account for a large portion of pediatric perioperative complications. Management of the difficult pediatric airway pathology is a challenge for anesthesia providers regardless of setting. However, in the low-resource setting poor infrastructure, lack of transportation systems, and crippled referral systems lead to late presentation. There is often a lack of pediatric-sized anesthesia equipment and resources, making management of the local pathology even more challenging. Efforts are being made to offer these providers additional training in pediatric anesthesia skills that incorporate low-fidelity simulation. Out of necessity, anesthesia providers in this setting learn to be resourceful in order to manage complex pathologies with fewer, less ideal resources while still providing a safe anesthetic.

8.
Paediatr Anaesth ; 28(5): 392-410, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29870136

RESUMO

Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries are increasingly engaged in resource-limited areas, with short-term missions as the most common form of involvement. However, consensus recommendations currently do not exist for short-term missions in pediatric general surgery and associated perioperative care. The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for short-term missions based on extensive experience with short-term missions. Three distinct, but related areas were identified: (i) Broad goals of surgical partnerships between high-income countries and low- and middle-income countries. A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN) was endorsed by all groups; (ii) Guidelines for the conduct of short-term missions were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; and (iii) travel and safety considerations critical to short-term mission success were enumerated. A diverse group of stakeholders developed these guidelines for short-term missions in low- and middle-income countries. These guidelines may be a useful tool to ensure safe, responsible, and ethical short-term missions given increasing engagement of high-income country providers in this work.

9.
Anesth Analg ; 126(4): 1298-1304, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29547424

RESUMO

There are inadequate numbers of anesthesia providers in many parts of the world. Good quality educational programs are needed to increase provider numbers, train leaders and teachers, and increase knowledge and skills. In some countries, considerable external support may be required to develop self-sustaining programs. There are some key themes related to educational programs in low- and middle-income countries:(1) Programs must be appropriate for the local environment-there is no "one-size-fits-all" program. In some countries, nonuniversity programs may be appropriate for training providers.(2) It is essential to train local teachers-a number of short courses provide teacher training. Overseas attachments may also play an important role in developing leadership and teaching capacity.(3) Interactive teaching techniques, such as small-group discussions and simulation, have been incorporated into many educational programs. Computer learning and videoconferencing offer additional educational possibilities.(4) Subspecialty education in areas such as obstetric anesthesia, pediatric anesthesia, and pain management are needed to develop leadership and increase capacity in subspecialty areas of practice. Examples include short subspecialty courses and clinical fellowships.(5) Collaboration and coordination are vital. Anesthesiologists need to work with ministries of health and other organizations to develop plans that are matched to need. External organizations can play an important role.(6) Excellent education is required at all levels. Training guidelines could help to standardize and improve training. Resources should be available for research, as well as monitoring and evaluation of educational programs.


Assuntos
Anestesiologia/educação , Anestesistas/educação , Países em Desenvolvimento , Educação Médica Continuada/métodos , Educação de Pós-Graduação em Medicina/métodos , Anestesiologia/economia , Anestesistas/economia , Anestesistas/provisão & distribução , Competência Clínica , Currículo , Países em Desenvolvimento/economia , Educação Médica Continuada/economia , Educação de Pós-Graduação em Medicina/economia , Custos de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Especialização
10.
Anesth Analg ; 126(4): 1305-1311, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29547425

RESUMO

There is an urgent need to train more anesthesia providers in low- and middle-income countries (LMICs). There is also a need to provide more educational opportunities in subspecialty areas of anesthetic practice such as trauma management, pain management, obstetric anesthesia, and pediatric anesthesia. Together, these subspecialty areas make up a large proportion of the clinical workload in LMICs. In these countries, the quality of education may be variable, there may be few teachers, and opportunities for continued learning and mentorship are rare. Short subspecialty courses such as Primary Trauma Care, Essential Pain Management, Safer Anaesthesia From Education-Obstetric Anaesthesia, and Safer Anaesthesia From Education-Paediatric Anaesthesia have been developed to help fill this need. They have the potential for immediate impact by providing an opportunity for continuing professional development and relevant subspecialty training. These courses are all short (1-3 days), are presented as an off-the-shelf package, and include a teach-the-teacher component. They use a variety of interactive teaching techniques and are designed to be adaptable and responsive to local needs. There is an emphasis on local ownership of the educational process that helps to promote sustainability. After an initial financial outlay to purchase equipment, the costs are relatively low. Short subspecialty courses appear to be part of the educational answer in LMICs, but there is a need for research to validate their role.


Assuntos
Anestesiologia/educação , Anestesistas/educação , Países em Desenvolvimento , Educação Médica Continuada/métodos , Educação de Pós-Graduação em Medicina/métodos , Especialização , Anestesiologia/economia , Anestesistas/economia , Anestesistas/provisão & distribução , Competência Clínica , Currículo , Países em Desenvolvimento/economia , Educação Médica Continuada/economia , Educação de Pós-Graduação em Medicina/economia , Custos de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Especialização/economia
11.
J Pediatr Surg ; 53(4): 828-836, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29223665

RESUMO

INTRODUCTION: Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries (HICs) are increasingly engaged in resource-limited areas, with short-term missions (STMs) as the most common form of involvement. However, consensus recommendations currently do not exist for STMs in pediatric general surgery and associated perioperative care. METHODS: The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for STMs based on extensive experience with STMs. RESULTS: Three distinct, but related areas were identified: 1) Broad goals of surgical partnerships between HICs- and low and middle-income countries (LMICs). A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN), was endorsed by all groups; 2) Guidelines for the conduct of STMs were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; 3) travel and safety considerations critical to STM success were enumerated. CONCLUSION: A diverse group of stakeholders developed these guidelines for STMs in LMICs. These guidelines may be a useful tool to ensure safe, responsible, and ethical STMs given increasing engagement of HIC providers in this work. LEVEL OF EVIDENCE: 5.


Assuntos
Lista de Checagem , Saúde Global/normas , Missões Médicas/normas , Pediatria/normas , Assistência Perioperatória/normas , Especialidades Cirúrgicas/normas , Procedimentos Cirúrgicos Operatórios/normas , Criança , Humanos , América do Norte
13.
Can J Anaesth ; 63(6): 674-81, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27117988

RESUMO

PURPOSE: There is growing evidence to suggest that the current generation of medical students and young physicians is interested in global health. However, there are few data on the interest in global health by students pursuing a career in anesthesiology. The objective of this survey was to evaluate the importance of global health opportunities in regard to applicants' choice of anesthesiology residency programs. METHODS: Anesthesiology residency program directors in the United States were invited to distribute an online survey to recently matched residents. To reduce study bias, the survey included a wide selection of reasons for program choices in addition to global health. Participants were asked to rate independently, on a scale of 1 to 10 (1 = least important, 10 = most important), the importance that each factor had on their selection of an anesthesiology residency program. RESULTS: Of the 117 U.S. anesthesiology programs contacted, 87 (74%) distributed the survey. Completed surveys were obtained from 582 of 1,092 (53%) polled participants. All factors assessed were rated between 5 and 9 and the global health median [interquartile range] rating was 6 [3-7]. Nearly half of the survey respondents were interested in incorporating global health into future careers. More than three-quarters reported being interested in participating in, or reading about, global health activities during their residency. Responders with previous global health experience, or who were interested in an "in-country" experience, were more likely to choose programs that had global health opportunities available during residency. CONCLUSIONS: Anesthesia residency program applicants are interested in global health. Having a global health opportunity was an important reason for choosing a residency program, comparable to some more traditional factors. Regardless of previous global health experience, the majority of future anesthesia residents are either planning or considering participation in global health activities during or after training.


Assuntos
Anestesiologia/educação , Atitude do Pessoal de Saúde , Escolha da Profissão , Saúde Global , Internato e Residência/estatística & dados numéricos , Adulto , Anestesiologia/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Internato e Residência/métodos , Masculino , Estudantes de Medicina/estatística & dados numéricos , Estados Unidos
14.
Best Pract Res Clin Anaesthesiol ; 26(1): 17-21, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22559953

RESUMO

The shortage of healthcare providers in low- and middle-income countries (LMICs) is well documented and is manifested by a profound lack of anaesthesia providers, especially throughout Sub-Saharan Africa. The need to develop and support training programs for physician and non-physician anesthetists in LMICs is therefore paramount to providing safe and cost effective anaesthesia care. Development of these training programs is multifaceted and must take into account the specific needs of the recipient country in order to be successful. Curriculum development should be directed towards sustainable change, ultimately reducing the need for outside support. To ensure viability as the new program develops, graduates need to be assimilated into the program as leaders. Emphasis needs to be placed on lessons learnt, professional conduct, and improving outcomes. Anaesthesia educational programs must emphasize quality, safety and professionalism in the providers and the care they deliver. Region-specific teaching methods should be developed using problem-based learning techniques and presenting data in a way that educates rather than castigates. There are good examples of programs that have been implemented to support education in LMICs. However, there are only a few that have successfully adopted a holistic approach to the entire curriculum. More often than not, programs have focused on specific areas of expertise of visiting teachers, rather than the needs of the recipient program. Because of the limited data available, it remains difficult to define any one clear path to achieving these goals. A combination of coordination and collaboration will increase the efficacy of implementing new or upgrading existing programs and will allow clearly defined paths to be defined in the future.


Assuntos
Anestesiologia/educação , Currículo , Educação Médica/métodos , África ao Sul do Saara , Comportamento Cooperativo , Países em Desenvolvimento , Humanos , Enfermeiras Anestesistas/educação , Desenvolvimento de Programas , Recursos Humanos
15.
World J Surg ; 35(8): 1770-80, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21562869

RESUMO

BACKGROUND: In low-income countries, unmet surgical needs lead to a high incidence of death. Information on the incidence and safety of current surgical care in low-income countries is limited by the paucity of data in the literature. The aim of this survey was to assess the surgical and anesthesia infrastructure in Rwanda as part of a larger study examining surgical and anesthesia capacity in low-income African countries. METHODS: A comprehensive survey tool was developed to assess the physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, and equipment and medications at district-level hospitals in sub-Saharan Africa. The survey was administered at 21 district hospitals in Rwanda using convenience sampling. RESULTS: There are only nine Rwandan anesthesiologists and 17 Rwandan surgeons providing surgical care for a population of more than 10 million. The specialty-trained Rwandan surgeons and anesthesiologists are practicing almost exclusively at referral hospitals, leaving surgical care at district hospitals to the general practice physicians and nurses. All of the district hospitals reported some lack of surgical infrastructure including limited access to oxygen, anesthesia equipment and medications, monitoring equipment, and trained personnel. CONCLUSIONS: This survey provides strong evidence of the need for continued development of emergency and essential surgical services at district hospitals in Rwanda to improve health care and to comply with World Health Organization recommendations. It has identified serious deficiencies in both financial and human resources-areas where the international community can play a role.


Assuntos
Anestesiologia/educação , Anestesiologia/organização & administração , Países em Desenvolvimento , Cirurgia Geral/educação , Cirurgia Geral/organização & administração , Hospitais de Distrito , Coleta de Dados , Previsões , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/tendências , Necessidades e Demandas de Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Área Carente de Assistência Médica , Equipe de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/tendências , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/tendências , Encaminhamento e Consulta/organização & administração , Ruanda , Recursos Humanos , Organização Mundial da Saúde
16.
Anesth Analg ; 108(2): 448-55, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19151271

RESUMO

BACKGROUND: Recent concern about the safety of aprotinin administration to adults has led to its suspension from worldwide markets. However, few studies have examined its safety in pediatric patients. Studies in children evaluating aprotinin's safety have been hindered by the heterogeneity of pediatric patients and the inconsistency of clinical protocols. In this investigation, we retrospectively reviewed 200 neonatal cardiac surgical cases performed at our institution to examine the safety of aprotinin, focusing on postoperative renal dysfunction, using a consistent aprotinin dosing protocol. METHODS: Two-hundred consecutive neonates scheduled for palliative or corrective congenital cardiac surgery requiring cardiopulmonary bypass (CPB) from January 1, 2005 through February 28, 2007 were included in this retrospective investigation. Preoperative, intraoperative and postoperative data were collected and analyzed. Markers of safety included 72-h postoperative renal dysfunction, need for dialysis (peritoneal or hemodialysis), thrombosis and in-hospital mortality. RESULTS: Neonates were divided into those who received aprotinin (aprotinin group; n = 156) and those who did not (no aprotinin group; n = 44). Twenty-four and 72-h postoperative serum creatinine levels were significantly greater than baseline levels in both groups. The degree of change in creatinine levels was highly significant and similar between the two groups. A larger percentage of neonates in the aprotinin group developed renal dysfunction, although this difference was not statistically significant. Stepwise logistic regression, assessing the impact on renal dysfunction of all variables that indicated significance between neonates who did or did not receive aprotinin and between neonates who did or did not develop renal dysfunction, identified CPB time and age as significant predictors of postoperative renal dysfunction. All neonates who developed postoperative renal dysfunction had a CPB time of more than 100 min regardless of the use of aprotinin. Additionally, using this subset, similar percentages of renal dysfunction occurred in both groups. A second multivariable regression analysis to simultaneously account for the predictors of CPB time, age and aprotinin administration found CPB time to be the only significant predictor of renal dysfunction. Incidences of postoperative dialysis, postoperative thrombosis and in-hospital mortality were not statistically significantly different between the aprotinin and the no aprotinin groups. CONCLUSION: The occurrence of postoperative renal dysfunction in neonates was more significantly predicted by the duration of CPB than by the intraoperative administration of aprotinin. CPB times of more than 100 min appeared to be a critical marker for the development of postoperative renal dysfunction. Randomized prospective trials are needed to confirm the validity of our retrospective findings.


Assuntos
Aprotinina/uso terapêutico , Ponte Cardiopulmonar , Hemostáticos/uso terapêutico , Nefropatias/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Aprotinina/efeitos adversos , Procedimentos Cirúrgicos Cardíacos , Feminino , Cardiopatias Congênitas/cirurgia , Hemostáticos/efeitos adversos , Mortalidade Hospitalar , Humanos , Recém-Nascido , Complicações Intraoperatórias/fisiopatologia , Nefropatias/etiologia , Nefropatias/fisiopatologia , Testes de Função Renal , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Análise de Regressão , Diálise Renal , Estudos Retrospectivos , Trombose/epidemiologia , Resultado do Tratamento
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