Last updated:10 January 2023
Open access articles
Malik M, Khan FA. Anesthetic drug shortages in Pakistan: a multicentre nationwide survey [epub ahead of print, 2022 Dec 28]. Can J Anaesth. 2022;1-8.
Keywords: anesthetic drugs; developing countries; patient safety.
Purpose: There is a paucity of literature on anesthetic drug shortages and their impact on patient safety in lower-middle-income countries. We sought to determine the magnitude of the problem, the effect on patient care and safety, and the adverse patient outcomes witnessed by anesthesiologists in Pakistan METHODS: We conducted a nationwide, multicentre, cross-sectional survey of a representative sample of anesthesiologists in Pakistan (January 2021 to June 2021). The survey questionnaire was adapted from the American Society of Anesthesiologists (ASA) survey on drug shortages and was modified based on the national essential medication list 2018 of Pakistan. It was distributed through Google Forms to anesthesiologists practicing in both the private and government sector. The names of hospitals or the identity of anesthesiologists was not required. The questionnaire consisted of 20 items and focused on the anesthesiologists' experience of drug shortages, the availability of drugs, and the impact of drug shortages on their individual practice.
Results: Two hundred and forty-six responses were received. Approximately 50% (122/246) of anesthesia practitioners in Pakistan reported anesthetic drug shortages. Fifty-seven percent of respondents mentioned using an inferior drug that may have significantly affected the delivery of anesthetic care. Four participants mentioned severe morbidity and another four mentioned observing a mortality associated with drug shortage.
Conclusion: Anesthetic drug shortages are common in anesthetic practice in Pakistan and they appear to affect patient care and outcomes.
Evans FM, Krotinger AA, Lilaonitkul M, et al. Evaluation of Open Access Websites for Anesthesia Education. Anesth Analg. 2022;135(6):1233-1244.
Background: While the prevalence of free, open access medical education resources for health professionals has expanded over the past 10 years, many educational resources for health care professionals are not publicly available or require fees for access. This lack of open access creates global inequities in the availability and sharing of information and may have the most significant impact on health care providers with the greatest need. The extent of open access online educational websites aimed for clinicians and trainees in anesthesiology worldwide is unknown. In this study, we aimed to identify and evaluate the quality of websites designed to provide open access educational resources for anesthesia trainees and clinicians.
Methods: A PubMed search of articles published between 2009 and 2020, and a Startpage search engine web search was conducted in May 2021 to identify websites using the following inclusion criteria: (1) contain educational content relevant for anesthesia providers or trainees, (2) offer content free of charge, and (3) are written in the English language. Websites were each scored by 2 independent reviewers using a website quality evaluation tool with previous validity evidence that was modified for anesthesia (the Anesthesia Medical Education Website Quality Evaluation Tool).
Results: Seventy-five articles and 175 websites were identified; 37 websites met inclusion criteria. The most common types of educational content contained in the websites included videos (66%, 25/37), text-based resources (51%, 19/37), podcasts (35%, 13/37), and interactive learning resources (32%, 12/37). Few websites described an editorial review process (24%, 9/37) or included opportunities for active engagement or interaction by learners (30%,11/37). Scores by tertile differed significantly across multiple domains, including disclosure of author/webmaster/website institution; description of an editorial review process; relevancy to residents, fellows, and faculty; comprehensiveness; accuracy; disclosure of content creation or revision; ease of access to information; interactivity; clear and professional presentation of information; and links to external information.
Conclusions: We found 37 open access websites for anesthesia education available on the Internet. Many of these websites may serve as a valuable resource for anesthesia clinicians looking for self-directed learning resources and for educators seeking to curate resources into thoughtfully integrated learning experiences. Ongoing efforts are needed to expand the number and improve the existing open access websites, especially with interactivity, to support the education and training of anesthesia providers in even the most resource-limited areas of the world. Our findings may provide recommendations for those educators and organizations seeking to fill this needed gap to create new high-quality educational websites.
Epiu I, Tindimwebwa JV, Mijumbi C, et al. Challenges of Anesthesia in Low- and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa. Anesth Analg. 2017;124(1):290-299.
Background: The United Nations 2015 Millennium Development Goals targeted a 75% reduction in maternal mortality. However, in spite of this goal, the number of maternal deaths per 100,000 live births remains unacceptably high across Sub-Saharan Africa. Because many of these deaths could likely be averted with access to safe surgery, including cesarean delivery, we set out to assess the capacity to provide safe anesthetic care for mothers in the main referral hospitals in East Africa.
Methods: A cross-sectional survey was conducted at 5 main referral hospitals in East Africa: Uganda, Kenya, Tanzania, Rwanda, and Burundi. Using a questionnaire based on the World Federation of the Societies of Anesthesiologists (WFSA) international guidelines for safe anesthesia, we interviewed anesthetists in these hospitals, key informants from the Ministry of Health and National Anesthesia Society of each country (Supplemental Digital Content, http://links.lww.com/AA/B561).
Results: Using the WFSA checklist as a guide, none of respondents had all the necessary requirements available to provide safe obstetric anesthesia, and only 7% reported adequate anesthesia staffing. Availability of monitors was limited, and those that were available were often nonfunctional. The paucity of local protocols, and lack of intensive care unit services, also contributed significantly to poor maternal outcomes. For a population of 142.9 million in the East African community, there were only 237 anesthesiologists, with a workforce density of 0.08 in Uganda, 0.39 in Kenya, 0.05 in Tanzania, 0.13 in Rwanda, and 0.02 anesthesiologists in Burundi per 100,000 population in each country.
Conclusions: We identified significant shortages of both the personnel and equipment needed to provide safe anesthetic care for obstetric surgical cases across East Africa. There is a need to increase the number of physician anesthetists, to improve the training of nonphysician anesthesia providers, and to develop management protocols for obstetric patients requiring anesthesia. This will strengthen health systems and improve surgical outcomes in developing countries. More funding is required for training physician anesthetists if developing countries are to reach the targeted specialist workforce density of the Lancet Commission on Global Surgery of 20 surgical, anesthetic, and obstetric physicians per 100,000 population by 2030.
Bartovic J,Datta SS, Severonic S, D'Annaa V.Ensuring equitable access to vaccines for refugees and migrants during the COVID-19 pandemic. Bulletin of the World Health Organisation. 2021; 99:3-3a. doi:10.2471/BLT.20.267690
Pouramin P, Li CS, Busse JW, et al. Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study.Lancet Global Health. 2020;8(5):e711-e720. doi:10.1016/S2214-109X(20)30067-X
Kayambankadzanja RK, Likaka A, Mndolo SK, Chatsika GM, Umar E, Baker T. Emergency and critical care services in Malawi: findings from a nationwide survey of health facilities. Malawi Medical Journal. 2020;32(1):19-23. doi:10.4314/mmj.v32i1.5
Dobson GP. Trauma of major surgery: a global problem that is not going away. International Journal of Surgery. 2020;81:47-54. doi:10.1016/j.ijsu.2020.07.017
Marun GN, Morriss WW, Lim JS, Morriss JL, Goucke CR.Addressing the challenge of pain education in low-resource countries: essential pain management in Papua New Guinea. Anesthesia and Analgesia. 2020;2020 Mar 12.
Pakenham-Walsh N, Godlee F. Healthcare information for all [published correction appears in BMJ. 2020 Feb 28;368:m818]. BMJ. 2020;368:m759. Published 2020 Feb 28. doi:10.1136/bmj.m759
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Holmaas G, Abate A, Woldetsadik A, Hevrøy O. Establishing a sustainable training programme in anaesthesia in Ethiopia [epub ahead of print, 2022 Jun 24]. Acta Anaesthesiol Scand. 2022;10.1111/aas.14106.
Keywords: Ethiopia; Low-income countries; Postgraduate anaesthesia education; sustainability.
Background: Lack of qualified staff is a major hindrance for quality and safety improvements in anaesthesia and critical care in many low-income-countries. Support in specialist training may enhance perioperative treatment and have a positive downstream impact on other hospital services, which may improve the overall standard of care.
Methods: Between 2011 and 2019, consultant anaesthetists from Haukeland University Hospital in Norway supported a postgraduate anaesthesia-training programme at Addis Ababa University / Tikur Anbessa Specialized Hospital in Ethiopia. The aim of the programme was to build a self-sustainable work force of anaesthetists across the country who could perform high quality anaesthesia within the confinement of limited local resources. Over the course of 10 years, an almost continuous rotation of experienced anaesthetists and intensivists assisted training of Ethiopian residents in anaesthesia and critical care. Local specialists organised the programme; however, external support was necessary during this period to establish a sustainable training programme.
Results: Since the programme's commencement at Addis Ababa University in 2011, 159 residents have entered the programme and 71 have graduated. As the number of qualified anaesthetists increased, Ethiopian specialists gradually obtained responsibility for the programme. Candidates are recruited from various regions and from neighbouring countries. Five other Ethiopian training sites have been established. To date (May 2022), 112 residents have completed their training in Ethiopia, and 195 residents expect to graduate within three years.
Conclusion: Nearly 11 years after establishment of the programme, locally trained highly qualified anaesthetists work in Ethiopia's major hospitals throughout the country.
Hirsch LA. Is it possible to decolonise global health institutions? Lancet. 2021;397(10270):189-190.
Keywords: Global health; Anti-racism
In the past year, decolonising global health has gained prominence. Much of this movement has come from students of global health in high-income countries and preceded the recurrence of Black Lives Matter movements after the violent murder of George Floyd. Black Lives Matter and Decolonising Global Health movements have managed to shake schools of global health if not to their core then at least awake. As a reaction schools of global health have made statements about racial equality and have avowed to address racism, increase staff and student diversity, and to train their staff in the art of decolonisation. I have been involved in these processes of decolonisation at my own institution. Yet I also view such efforts critically.
Khan FA, Merry AF. Improving Anesthesia Safety in Low-Resource Settings. Anesth Analg. 2018;126(4):1312-1320.
The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the "Bellwether Procedures" (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.
Lal A, Erondu NA, Heymann DL, Gitahi G, Yates R. Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage. Lancet. 2021 Jan 2;397(10268):61-67. doi: 10.1016/S0140-6736(20)32228-5.
Prasad A. Loyce Pace: equity, solidarity, and humility in global health. Lancet. 2021 Jan 2;397(10268):16. doi: 10.1016/S0140-6736(20)32670-2.
Loh PS, Chaw SH, Shariffuddin II, Ng CC, Yim CC, Hashim NHM. A developing nation's experience in using simulation-based training as a preparation tool for the Coronavirus disease 2019 outbreak. Anesthesia and Analgesia. 2021 Jan;132(1):15-24. doi: 10.1213/ANE.0000000000005264. Lonergan D. I am a Mzungu. Anesthesiology. 2020 Sep 1;133(3):667-669. doi: 10.1097/ALN.0000000000003264.
Henry JA, Volk AS, Kariuki SK, et al. Ending neglected surgical diseases (NSDs): definitions, strategies, and goals for the next decade [published online ahead of print, 2020 Aug 11]. International Journal of Health Policy and Management. 2020;10.34172/ijhpm.2020.140. doi:10.34172/ijhpm.2020.140
Ma X, Marinos J, De Jesus J, Lin N, Sung CY, Vervoort D. Human rights-based approach to global surgery: a scoping review [published online ahead of print, 2020 Aug 21]. International Journal of Surgery. 2020;82:16-23. doi:10.1016/j.ijsu.2020.08.004
Goucke, RC, Chaudakshetrin, P. Pain: a neglected problem in the low-resource setting. Anesth Analg. 2018;126(4):1283–1286.