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Nizeyimana F, Skelton T, Bould MD, Beach M, Twagirumugabe T. Perioperative Anesthesia-Related Complications and Risk Factors in Children: A Cross-Sectional Observation Study in Rwanda. Anesth Analg 2024; 138:1063-1069. [PMID: 37678238 DOI: 10.1213/ane.0000000000006641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Despite an increasing awareness of the unmet burden of surgical conditions, information on perioperative complications in children remains limited especially in low-income countries such as Rwanda. The objective of this study was to estimate the prevalence of perioperative anesthesia-related adverse events and to explore potential risk factors associated with them among pediatric surgical patients in public referral hospitals in Rwanda. METHODS Data were collected for all patients under 5 years of age undergoing surgery in 3 public referral hospitals in Rwanda from June to December 2015. Patient and family history, type of surgery, comorbidities, anesthesia technique, intraoperative adverse events and postoperative events in the postanesthesia care unit (PACU) were recorded. The incidence of perioperative adverse events was assessed and associated risk factors analyzed with univariate logistic regression. RESULTS Of 354 patients enrolled in this study 11 children had a cardiac arrest. Six (1.7%) suffered an intraoperative cardiac arrest, 2 of whom (0.6%) died intraoperatively. In the PACU, 6 (1.8%) suffered a postoperative cardiac arrest, 5 of whom (1.5%) died in the PACU. One child had both an intraoperative cardiac arrest and then a cardiac arrest in PACU but survived. Eighty-nine children (25.1%) had an intraoperative adverse event, whereas 67 (20.6%) had an adverse event in PACU. A review of the cases where cardiac arrest or death occurred indicated that there were significant lapses in the expected standard of care. Age <1 week was associated with cardiac arrest or death. CONCLUSIONS The rate of perioperative complications, including death, for children undergoing surgery in tertiary care hospitals in Rwanda was high. Quality improvement measures are needed to decrease this rate among surgical pediatric patients in this low resource setting.
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Affiliation(s)
- Francoise Nizeyimana
- From the Department of Anesthesia and Critical Care, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Teresa Skelton
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - M Dylan Bould
- Department of Anesthesiology, The Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Beach
- Department of Anesthesiology, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Theogene Twagirumugabe
- Department of Anaesthesiology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Anesthesiology and Pain Medicine, Critical Care and Emergency Medicine, University of Rwanda, Butare, Rwanda
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Nourian MM, Alshibli A, Kamau J, Nabulindo S, Amollo DA, Connell J, Eden SK, Seyoum R, Teklehaimanot MG, Tegu GA, Desta HB, Newton M, Sileshi B. Capnography access and use in Kenya and Ethiopia. Can J Anaesth 2024; 71:95-106. [PMID: 37914969 DOI: 10.1007/s12630-023-02607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 11/03/2023] Open
Abstract
PURPOSE Lack of access to safe and affordable anesthesia and monitoring equipment may contribute to higher rates of morbidity and mortality in low- and middle-income countries (LMICs). While capnography is standard in high-income countries, use in LMICs is not well studied. We evaluated the association of capnography use with patient and procedure-related characteristics, as well as the association of capnography use and mortality in a cohort of patients from Kenya and Ethiopia. METHODS For this retrospective observational study, we used historical cohort data from Kenya and Ethiopia from 2014 to 2020. Logistic regression was used to study the association of capnography use (primary outcome) with patient/procedure factors, and the adjusted association of intraoperative, 24-hr, and seven-day mortality (secondary outcomes) with capnography use. RESULTS A total of 61,792 anesthetic cases were included in this study. Tertiary or secondary hospital type (compared with primary) was strongly associated with use of capnography (odds ratio [OR], 6.27; 95% confidence interval [CI], 5.67 to 6.93 and OR, 6.88; 95% CI, 6.40 to 7.40, respectively), as was general (vs regional) anesthesia (OR, 4.83; 95% CI, 4.41 to 5.28). Capnography use was significantly associated with lower odds of intraoperative mortality in patients who underwent general anesthesia (OR, 0.31; 95% CI, 0.17 to 0.48). Nevertheless, fully-adjusted models for 24-hr and seven-day mortality showed no evidence of association with capnography. CONCLUSION Capnography use in LMICs is substantially lower compared with other standard anesthesia monitors. Capnography was used at higher rates in tertiary centres and with patients undergoing general anesthesia. While this study revealed decreased odds of intraoperative mortality with capnography use, further studies need to confirm these findings.
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Affiliation(s)
- Maziar M Nourian
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA.
| | - Amany Alshibli
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - John Kamau
- African Mission Healthcare, ImPACT Africa-Tanzania, Nairobi, Kenya
| | - Susan Nabulindo
- Department of Anesthesiology, University of Nairobi, Nairobi, Kenya
| | - Dennis A Amollo
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Svetlana K Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rahel Seyoum
- Department of Anesthesiology, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Gebrehiwot A Tegu
- Department of Anesthesiology, Bahir Dar University, Bahir Dar, Ethiopia
| | - Haftom B Desta
- Department of Anesthesiology, Mekelle University, Mekelle, Ethiopia
| | - Mark Newton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bantayehu Sileshi
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Endeshaw AS, Dejen ET, Zewdie BW, Addisu BT, Molla MT, Kumie FT. Perioperative mortality among trauma patients in Northwest Ethiopia: a prospective cohort study. Sci Rep 2023; 13:22859. [PMID: 38129464 PMCID: PMC10739862 DOI: 10.1038/s41598-023-50101-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Trauma is the leading cause of mortality in persons under 45 and a significant public health issue. Trauma is the most frequent cause of perioperative mortality among all surgical patients. Little is known about perioperative outcomes among trauma patients in low-income countries. This study aimed to assess the incidence and identify predictors of perioperative mortality among adult trauma victims at Tibebe Ghion Specialised Hospital. From June 1, 2019, to June 30, 2021, a prospective cohort study was conducted at Tibebe Ghion Specialized Hospital. Demographic, pre-hospital and perioperative clinical data were collected using an electronic data collection tool, Research Electronic Data Capture (REDCap). Cox proportional hazard model regression was used to assess the association between predictors and perioperative mortality among trauma victims. Crude and adjusted hazard ratio (HR) with a 95% confidence interval (CI) was computed; a p-value < 0.05 was a cutoff value to declare statistical significance. One thousand sixty-nine trauma patients were enrolled in this study. The overall incidence of perioperative mortality among trauma patients was 5.89%, with an incidence rate of 2.23 (95% CI 1.74 to 2.86) deaths per 1000 person-day observation. Age ≥ 65 years (AHR = 2.51, 95% CI: 1.04, 6.08), patients sustained blunt trauma (AHR = 3.28, 95% CI: 1.30, 8.29) and MVA (AHR = 2.96, 95% CI: 1.18, 7.43), trauma occurred at night time (AHR = 2.29, 95% CI: 1.15, 4.56), ASA physical status ≥ III (AHR = 3.84, 95% CI: 1.88, 7.82), and blood transfusion (AHR = 2.01, 95% CI: 1.08, 3.74) were identified as a significant predictor for perioperative mortality among trauma patients. In this trauma cohort, it was demonstrated that perioperative mortality is a healthcare burden. Risk factors for perioperative mortality among trauma patients were old age, patients sustaining blunt trauma and motor vehicle accidents, injuries at night, higher ASA physical status, and blood transfusion. Trauma care services need improvement in pre-hospital and perioperative care.
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Affiliation(s)
- Amanuel Sisay Endeshaw
- Department of Anesthesia, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Eshetu Tesfaye Dejen
- Department of Anesthesia, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Bekalu Wubshet Zewdie
- Department of Orthopedics and Traumatology, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Biniyam Teshome Addisu
- Department of Orthopedics and Traumatology, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Misganew Terefe Molla
- Department of Anesthesia, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Fantahun Tarekegn Kumie
- Department of Anesthesia, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
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Endeshaw AS, Molla MT, Kumie FT. Perioperative mortality among geriatric patients in Ethiopia: a prospective cohort study. Front Med (Lausanne) 2023; 10:1220024. [PMID: 38020168 PMCID: PMC10651902 DOI: 10.3389/fmed.2023.1220024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background With the dramatic growth in the aged population observed in developed and developing nations, the older population burdened by unmet demand for surgical treatment has become a significant yet unnoticed public health concern in resource-limited countries. Studies are limited regarding surgical mortality of geriatric patients in Africa. Therefore, this study aims to estimate the incidence and identify predictors of postoperative mortality using prospective data in a low-income country, Ethiopia. Methods and materials A prospective cohort study was conducted from June 01, 2019, to June 30, 2021, at a tertiary-level hospital in Ethiopia. Perioperative data were collected using an electronic data collection tool. Cox regression analysis was used to identify predictor variables. The association between predictors and postoperative mortality among geriatrics was computed using a hazard ratio (HR) with a 95% confidence interval (CI); p-value <0.05 was a cutoff value to declare statistical significance. Results Of eligible 618 patients, 601 were included in the final analysis. The overall incidence of postoperative mortality among geriatrics was 5.16%, with a rate of 1.91 (95% CI: 1.34, 2.72) deaths per 1,000 person-day observation. Age ≥ 80 years (Adjusted hazard ratio (AHR) = 2.59, 95% CI: 1.05, 6.36), ASA physical status III/IV (AHR = 2.40, 95%CI 1.06, 5.43), comorbidity (AHR = 2.53, 95% CI: 1.19, 7.01), and emergency surgery (AHR = 2.92, 95% CI: 1.17, 7.27) were the significant predictors of postoperative mortality among older patients. Conclusion Postoperative mortality among geriatrics was high. Identified predictors were age ≥ 80 years, ASA status III/IV, comorbidity, and emergency surgery. Target-specific interventions should be addressed to improve high surgical mortality in these patients.
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Affiliation(s)
- Amanuel Sisay Endeshaw
- Department of Anesthesia, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
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Kakembo N, Grabski DF, Situma M, Ajiko M, Kayima P, Nyeko D, Shikanda A, Okello I, Tumukunde J, Nabukenya M, Ogwang M, Kisa P, Muzira A, Ruzgar N, Fitzgerald TN, Sekabira J, Ozgediz D. Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis. J Surg Res 2023; 286:23-34. [PMID: 36738566 DOI: 10.1016/j.jss.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 12/05/2022] [Accepted: 12/24/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. MATERIALS AND METHODS Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. RESULTS A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. CONCLUSIONS This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.
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Affiliation(s)
- Nasser Kakembo
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Mbarara Hospital, Mbarara, Uganda
| | - Margaret Ajiko
- Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Peter Kayima
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - David Nyeko
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Anne Shikanda
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Innocent Okello
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Mary Nabukenya
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Martin Ogwang
- Department of Surgery, St. Mary's Lacor Regional Referral Hospital, Lacor, Uganda
| | - Phyllis Kisa
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Arlene Muzira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Nensi Ruzgar
- Yale University School of Medicine, New Haven, Connecticut
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John Sekabira
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, University of California, San Francisco, California
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Endeshaw AS, Kumie FT, Molla MT, Zeru GA, Abera KM, Zeleke ZB, Lakew TJ. Incidence and predictors of perioperative mortality in a low-resource country, Ethiopia: a prospective follow-up study. BMJ Open 2023; 13:e069768. [PMID: 37142313 PMCID: PMC10163475 DOI: 10.1136/bmjopen-2022-069768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVE This study aimed to assess the incidence and identify predictors of perioperative mortality among the adult age group at Tibebe Ghion Specialised Hospital. DESIGN A single-centre prospective follow-up study. SETTING A tertiary hospital in North West Ethiopia. PARTICIPANTS We enrolled 2530 participants who underwent surgery in the current study. All adults aged 18 and above were included except those with no telephone. PRIMARY OUTCOME MEASURES The primary outcome was time to death measured in days from immediate postoperative time up to the 28th day following surgery. RESULT A total of 2530 surgical cases were followed for 67 145 person-days. There were 92 deaths, with an incidence rate of 1.37 (95% CI 1.11 to 1.68) deaths per 1000 person-day observations. Regional anaesthesia was significantly associated with lower postoperative mortality (adjusted hazard ratio (AHR) 0.18, 95% CI 0.05 to 0.62). Patients aged ≥65 years (AHR 3.04, 95% CI 1.65 to 5.75), American Society of Anesthesiologist (ASA) physical status III (AHR 2.41, 95% CI 1.1.13 to 5.16) and IV (AHR 2.74, 95% CI 1.08 to 6.92), emergency surgery (AHR 1.85, 95% CI 1.02 to 3.36) and preoperative oxygen saturation <95% (AHR 3.14, 95% CI 1.85 to 5.33) were significantly associated with a higher risk of postoperative mortality. CONCLUSION The postoperative mortality rate at Tibebe Ghion Specialised Hospital was high. Age ≥65, ASA physical status III and IV, emergency surgery, and preoperative oxygen saturation <95% were significant predictors of postoperative mortality. Patients with the identified predictors should be offered targeted treatment.
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Affiliation(s)
- Amanuel Sisay Endeshaw
- Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Fantahun Tarekegn Kumie
- Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Misganew Terefe Molla
- Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Gashaw Abebe Zeru
- Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Kassaw Moges Abera
- Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Zebenay Bitew Zeleke
- Department of Surgery, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Tigist Jegnaw Lakew
- Department of Statistics, College of Natural and Computational Science, University of Gondar, Gondar, Ethiopia
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Ndaribitse C, Durieux ME, Adorno W, Brown DE, Tsang S, Naik BI. Digitization of Symbol-Denoted Blood Pressure Data From Intraoperative Paper Health Records in a Low-Middle-Income Country Using Deep Image Segmentation and Associated Postoperative Outcomes: A Feasibility Study. Anesth Analg 2023; 136:753-760. [PMID: 36017931 DOI: 10.1213/ane.0000000000006176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In low-middle-income countries (LMICs), perioperative clinical information is almost universally collected on paper health records (PHRs). The lack of accessible digital databases limits LMICs in leveraging data to predict and improve patient outcomes after surgery. In this feasibility study, our aims were to: (1) determine the detection performance and prediction error of the U-Net deep image segmentation approach for digitization of hand-drawn blood pressure symbols from an image of the intraoperative PHRs and (2) evaluate the association between deep image segmentation-derived blood pressure parameters and postoperative mortality and length of stay. METHODS A smartphone mHealth platform developed by our team was used to capture images of completed intraoperative PHRs. A 2-stage deep image segmentation modeling approach was used to create 2 separate segmentation masks for systolic blood pressure (SBP) and diastolic blood pressure (DBP). Iterative postprocessing was utilized to convert the segmentation mask results into numerical SBP and DBP values. Detection performance and prediction errors were evaluated for the U-Net models by comparison with ground-truth values. Using multivariate regression analysis, we investigated the association of deep image segmentation-derived blood pressure values, total time spent in predefined blood pressure ranges, and postoperative outcomes including in-hospital mortality and length of stay. RESULTS A total of 350 intraoperative PHRs were imaged following surgery. Overall accuracy was 0.839 and 0.911 for SBP and DBP symbol detections, respectively. The mean error rate and standard deviation for the difference between the actual and predicted blood pressure values were 2.1 ± 4.9 and -0.8 ± 3.9 mm Hg for SBP and DBP, respectively. Using the U-Net model-derived blood pressures, minutes of time where DBP <50 mm Hg (odds ratio [OR], 1.03; CI, 1.01-1.05; P = .003) was associated with an increased in-hospital mortality. In addition, increased cumulative minutes of time with SBP between 80 and 90 mm Hg was significantly associated with a longer length of stay (incidence rate ratio, 1.02 [1.0-1.03]; P < .05), while increased cumulative minutes of time where SBP between 140 and 160 mm Hg was associated with a shorter length of stay (incidence rate ratio, 0.9 [0.96-0.99]; P < .05). CONCLUSIONS In this study, we report our experience with a deep image segmentation model for digitization of symbol-denoted blood pressure from intraoperative anesthesia PHRs. Our data support further development of this novel approach to digitize PHRs from LMICs, to provide accessible, curated, and reproducible data for both quality improvement- and outcome-based research.
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Affiliation(s)
| | - Marcel E Durieux
- Departments of Anesthesiology and Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - William Adorno
- Department of Systems and Information Engineering, University of Virginia, Charlottesville, Virginia
| | - Donald E Brown
- Department of Systems and Information Engineering, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Nutrition and Exercise Physiology, Washington State University, Spokane, Washington
| | - Bhiken I Naik
- Departments of Anesthesiology and Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Misoi B, Mung'ayi V, Bal R, Mohammedali S. Sensitivity of a preanaesthesia screening and triage tool in identifying high-risk patients attending the preanaesthesia assessment clinic in a tertiary referral hospital in Sub-Saharan Africa: a diagnostic accuracy study. BMJ Open 2023; 13:e067603. [PMID: 36882252 PMCID: PMC10008346 DOI: 10.1136/bmjopen-2022-067603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
OBJECTIVES The use of preoperative triage questionnaires is an innovative way to mitigate the shortage of anaesthesiologists and to identify and refer high-risk patients early for evaluation. This study evaluates the diagnostic accuracy of one such questionnaire in identifying high-risk patients in a Sub-Saharan population. DESIGN Diagnostic accuracy study SETTING: The study was conducted in a preanaesthesia assessment clinic in a tertiary referral hospital in Sub-Saharan Africa. PARTICIPANTS The study had a sample size of 128, including all patients above the age of 18 scheduled for elective surgery under any modality of anaesthesia other than local anaesthesia presenting to the preanaesthesia clinic. Patients scheduled for cardiac and major non-cardiac surgery and those non-literate in English were excluded. OUTCOME MEASURES The sensitivity of the preanaesthesia risk assessment tool (PRAT) was the primary outcome measure. Other outcome measures were specificity, positive predictive value and negative predictive value. RESULTS Majority of patients were young and women with a mean age of 36 referred for obstetric and gynaecological procedures. The sensitivity of the PRAT in identifying high-risk patients was at 90.6% with 95% CI (76.9 to 98.2) in this current study while the specificity, negative predictive value (NPV) and positive predictive value (PPV) were 37.5% with 95% CI (24.0 to 43.7), 92.3% with 95% CI (77.7 to 97.0) and 32.6% with 95% CI (29.6 to 37.3) respectively. CONCLUSION The PRAT has a high sensitivity and may be used as a screening tool in identifying high risk patients to refer to the anaesthesiologist early before surgery. Adjusting the high risk criteria to fit the anaesthesiologists' assessments may improve the specificity of the tool.
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Affiliation(s)
- Brian Misoi
- General Surgery, Aga Khan University Hospital, Nairobi, Nairobi, Kenya
| | - Vitalis Mung'ayi
- Department of Anaesthesiology, The Aga Khan University Hospital Nairobi, Nairobi, Kenya
| | - Rajpreet Bal
- Department of Anaesthesiology, The Aga Khan University Hospital Nairobi, Nairobi, Kenya
| | - Shamshudin Mohammedali
- Department of Orthopaedic Surgery, The Aga Khan University Hospital Nairobi, Nairobi, Kenya
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Wild H, Stewart BT, LeBoa C, Jewell T, Mehta K, Wren SM. Perioperative Risk Assessment in Humanitarian Settings: A Scoping Review. World J Surg 2023; 47:1092-1113. [PMID: 36631590 DOI: 10.1007/s00268-023-06893-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND No validated perioperative risk assessment models currently exist for use in humanitarian settings. To inform the development of a perioperative mortality risk assessment model applicable to humanitarian settings, we conducted a scoping review of the literature to identify reports that described perioperative risk assessment in surgical care in humanitarian settings and LMICs. METHODS We conducted a scoping review of the literature to identify records that described perioperative risk assessment in low-resource or humanitarian settings. Searches were conducted in databases including: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, World Health Organization Catalog, and Google Scholar. RESULTS Our search identified 1582 records. After title/abstract and full text screening, 50 reports remained eligible for analysis in quantitative and qualitative synthesis. These reports presented data from over 37 countries from public, NGO, and military facilities. Data reporting was highly inconsistent: fewer than half of reports presented the indication for surgery; less than 25% of reports presented data on injury severity or prehospital data. Most elements of perioperative risk models designed for high-resource settings (e.g., vital signs, laboratory data, and medical comorbidities) were unavailable. CONCLUSION At present, no perioperative mortality risk assessment model exists for use in humanitarian settings. Limitations in consistency and quality of data reporting are a primary barrier, however, can be addressed through data-driven identification of several key variables encompassed by a minimum dataset. The development of such a score is a critical step toward improving the quality of care provided to populations affected by conflict and protracted humanitarian crises.
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Affiliation(s)
- Hannah Wild
- Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA
- Global Injury Control Section, Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Christopher LeBoa
- Department of Environmental Health Sciences, University of California Berkeley, Berkeley, CA, USA
| | - Teresa Jewell
- Health Science Library, University of Washington, Seattle, WA, USA
| | - Kajal Mehta
- Department of Surgery, University of Washington, 1959 NE Pacific St., Seattle, WA, 98195, USA
| | - Sherry M Wren
- Stanford University School of Medicine, Stanford, CA, USA
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Durieux ME, Naik BI. Scientia Potentia Est: Striving for Data Equity in Clinical Medicine for Low- and Middle-Income Countries. Anesth Analg 2022; 135:209-212. [PMID: 35709448 DOI: 10.1213/ane.0000000000005993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Marcel E Durieux
- From the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Shirley H, Wamai R. A Narrative Review of Kenya's Surgical Capacity Using the Lancet Commission on Global Surgery's Indicator Framework. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100500. [PMID: 35294388 PMCID: PMC8885340 DOI: 10.9745/ghsp-d-21-00500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/12/2022] [Indexed: 11/15/2022]
Abstract
Surgery, anesthesia, and obstetric (SAO) care is quickly being recognized for its critical role in cost-effectively improving global morbidity and mortality. Six core indicators for SAO capacity were established in 2015 by the Lancet Commission on Global Surgery (LCoGS) and include: SAO provider density, population proximity to surgery-ready facilities, annual national operative volume, a system to track perioperative mortality rate, and protection from impoverishing and catastrophic expenditures. The surgical capacity of Kenya, a lower-middle-income country, has not been evaluated using this framework. Our goal was to review published literature on surgery in Kenya to assess the country's surgical capacity and system strength. A narrative review of the relevant literature provided estimates for each LCoGS indicator. While progress has been made in expanding access to care across the country, key steps remain in the effort to provide equitable, affordable, and timely care to Kenya's population through universal health coverage. Additional investment into training SAO providers, operative infrastructure, and accessibility are recommended through a national surgery, obstetric, and anesthesia plan.
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Affiliation(s)
| | - Richard Wamai
- Department of Cultures, Societies and Global Studies, Northeastern University, College of Social Sciences and Humanities, Integrated Initiative for Global Health, Boston, MA, USA
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Changes in Surgical Volume and Outcomes During the Coronavirus Disease 2019 Pandemic at Two Tertiary Hospitals in Ethiopia: A Retrospective Cohort Study. Anesth Analg 2022; 134:1297-1307. [PMID: 35171877 DOI: 10.1213/ane.0000000000005946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Limited data exist concerning how the coronavirus disease 2019 (COVID-19) pandemic has affected surgical care in low-resource settings. We sought to describe associations between the COVID-19 pandemic and surgical care and outcomes at 2 tertiary hospitals in Ethiopia. METHODS We conducted a retrospective observational cohort study analyzing perioperative data collected electronically from Ayder Comprehensive Specialized Hospital (ACSH) in Mekelle, Ethiopia, and Tibebe Ghion Specialized Hospital (TGSH) in Bahir Dar, Ethiopia. We categorized COVID-19 exposure as time periods: "phase 0" before the pandemic (November 1-December 31, 2019, at ACSH and August 1-September 30, 2019, at TGSH), "phase 1" starting when elective surgeries were canceled (April 1-August 3, 2020, at ACSH and March 28-April 12, 2020, at TGSH), and "phase 2" starting when elective surgeries resumed (August 4-August 31, 2020, at ACSH and April 13-August 31, 2020, at TGSH). Outcomes included 28-day perioperative mortality, case volume, and patient district of origin. Incidence rates of case volume and patient district of origin (outside district yes or no) were modeled with segmented Poisson regression and logistic regression, respectively. Association of the exposure with 28-day mortality was assessed using logistic regression models, adjusting for confounders. RESULTS Data from 3231 surgeries were captured. There was a decrease in case volume compared to phase 0, with adjusted incidence rate ratio (IRR) of 0.73 (95% confidence interval [CI], 0.66-0.81) in phase 1 and 0.90 (95% CI, 0.83-0.97) in phase 2. Compared to phase 0, there were more patients from an outside district during phase 1 lockdown at ACSH (adjusted odds ratio [aOR], 1.63 [95% CI, 1.24-2.15]) and fewer patients from outside districts at TGSH (aOR, 0.44 [95% CI, 0.21-0.87]). The observed 28-day mortality rates for phases 0, 1, and 2 were 1.8% (95% CI, 1.1-2.8), 3.7% (95% CI, 2.3-5.8), and 2.9% (95% CI, 2.1-3.9), respectively. A confounder-adjusted logistic regression model did not show a significant increase in 28-day perioperative mortality during phases 1 and 2 compared to phase 0, with aOR 1.36 (95% CI, 0.62-2.98) and 1.54 (95% CI, 0.80-2.95), respectively. CONCLUSIONS Analysis at 2 low-resource referral hospitals in Ethiopia during the COVID-19 pandemic showed a reduction in surgical case volume during and after lockdown. At ACSH, more patients were from outside districts during lockdown where the opposite was true at TGSH. These findings suggest that during the pandemic patients may experience delays in seeking or obtaining surgical care. However, for patients who underwent surgery, prepandemic and postpandemic perioperative mortalities did not show significant difference. These results may inform surgical plans during future public health crises.
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Harris PA, Delacqua G, Taylor R, Pearson S, Fernandez M, Duda SN. The REDCap Mobile Application: a data collection platform for research in regions or situations with internet scarcity. JAMIA Open 2021; 4:ooab078. [PMID: 34527889 PMCID: PMC8435658 DOI: 10.1093/jamiaopen/ooab078] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/21/2021] [Accepted: 09/01/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives To share our approach for designing, developing, and deploying the Research Electronic Data Capture (REDCap) Mobile Application, details about its dissemination and support through the REDCap Consortium, and a set of lessons learned and guidance recommendations for others developing mobile platforms to support research in regions or situations with internet scarcity. Materials and Methods We defined minimum viable product requirements centered around Android and iOS platform availability, data capture specifications and project initiation workflow, study data synchronization, and data security. After launch, we added features based on feedback from end-users and REDCap administrators. We prioritized new features based on expected impact, difficulty, and anticipated long-term cost for sustainability. Results We chose Apache Cordova, a combined iOS and Android development framework, based on targeted end-user technology expectations, available programmer resources, and the need to provide solutions for resource-limited settings. The REDCap Mobile Application was launched in 2015, has been enabled at over 800 REDCap Consortium partner organizations, and has supported diverse scientific studies around the world. Discussion Apache Cordova enabled early software releases for both iOS and Android, but required ongoing optimization efforts to improve software responsiveness. Developing a robust and efficient mobile device synchronization architecture was difficult without direct access to global network infrastructures for testing. Research teams in sub-Saharan Africa helped our development team understand and simulate real-world scenarios of intermittent internet connectivity. Conclusion Guidance recommendations based on designing, developing, deploying, and disseminating the REDCap Mobile Application may help other teams looking to develop clinical research informatics applications.
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Affiliation(s)
- Paul A Harris
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Giovanni Delacqua
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert Taylor
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott Pearson
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michelle Fernandez
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals. Surgery 2021; 170:1397-1404. [PMID: 34130809 DOI: 10.1016/j.surg.2021.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 04/27/2021] [Accepted: 05/04/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. METHODS Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. RESULTS From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. CONCLUSION This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.
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Watters DA, Wilson L. The Comparability and Utility of Perioperative Mortality Rates in Global Health. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-020-00432-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Blaise Pascal FN, Malisawa A, Barratt-Due A, Namboya F, Pollach G. General anaesthesia related mortality in a limited resource settings region: a retrospective study in two teaching hospitals of Butembo. BMC Anesthesiol 2021; 21:60. [PMID: 33622245 PMCID: PMC7901086 DOI: 10.1186/s12871-021-01280-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/15/2021] [Indexed: 12/05/2022] Open
Abstract
Background General anaesthesia (GA) in developing countries is still a high-risk practice, especially in Africa, accompanied with high morbidity and mortality. No study has yet been conducted in Butembo in the Democratic Republic of the Congo to determine the mortality related to GA practice. The main objective of this study was to assess mortality related to GA in Butembo. Methods This was a retrospective descriptive and analytic study of patients who underwent surgery under GA in the 2 main teaching hospitals of Butembo from January 2011 to December 2015. Data were collected from patients files, anaesthesia registries and were analysed with SPSS 26. Results From a total of 921 patients, 539 (58.5%) were male and 382 (41.5%) female patients. A total of 83 (9.0%) patients died representing an overall perioperative mortality rate of 90 per 1000. Out of the 83 deaths, 38 occurred within 24 h representing GA related mortality of 41 per 1000. There was a global drop in mortality from 2011 to 2015. The risk factors of death were: being a neonate or a senior adult, emergency operation, ASA physical status > 2 and a single deranged vital sign preoperatively, presenting any complication during GA, anaesthesia duration > 120 minutes as well as visceral surgeries/laparotomies. Ketamine was the most employed anaesthetic. Conclusion GA related mortality is very high in Butembo. Improved GA services and outcomes can be obtained by training more anaesthesia providers, proper patients monitoring, improved infrastructure, better equipment and drugs procurement and considering regional anaesthesia whenever possible.
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Affiliation(s)
- Furaha Nzanzu Blaise Pascal
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi. .,Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo.
| | - Agnes Malisawa
- Matanda Hospital of Butembo, Butembo, Democratic Republic of the Congo
| | - Andreas Barratt-Due
- Division of Emergencies and Critical Care, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Felix Namboya
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gregor Pollach
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi
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Li HW, Saruni SI, Carpenter K, Chepkemoi E, Ochieng NA, Obanda LN, Haskett L, Cornetta K, Brown C, Korir M, Keung CH, Kussin PS. Use of a Novel Trigger Tool to Identify Palliative Care Needs in Surgical Patients at a National Referral Hospital in Kenya: A Pilot Study. J Palliat Med 2021; 24:1455-1460. [PMID: 33625266 DOI: 10.1089/jpm.2020.0669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Addressing unmet palliative care needs in high-risk surgical patients in low- and middle-income countries must include innovative approaches to limitations in personnel and culturally acceptable assessment modalities. Objectives: We assessed the utility of a novel seven-item "Step-1" trigger tool in identifying surgical patients who may benefit from palliative care. Design: All adult patients (≥18 years) on general surgery, neurosurgery, and orthopedic surgery wards were enrolled over a four-month period. Setting/Subjects: This study took place at Moi Teaching and Referral Hospital (MTRH), one of two Kenyan national referral hospitals. Measurements: The "Step-1" trigger tool was administered, capturing provider estimates of prognosis, cancer history, social barriers, admission frequency, hospice history, symptom burden, and functional decline/wasting. A cut-point of ≥3 positive factors was selected, indicating a patient may benefit from palliative care. Results: A total of 411 patients were included for analysis. Twenty-five percent (n = 102) of patients had scores ≥3. The cut-point of ≥3 was significantly associated with identifying high-risk patients (HRP; χ2 = 32.3, p < 0.01), defined as those who died or were palliatively discharged, with a sensitivity and specificity of 63.9% and 78.9%, respectively. Survey questions with the highest overall impact included: "Would you be not surprised if the patient died within 12 months?," "Are there uncontrolled symptoms?," and "Is there functional decline/wasting?" Conclusions: This pilot study demonstrates that the "Step-One" trigger tool is a simple and effective method to identify HRP in resource-limited settings. Although this study identified three highly effective questions, the seven-question assessment is flexible and can be adapted to different settings.
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Affiliation(s)
- Helen W Li
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Kyle Carpenter
- Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Eunice Chepkemoi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Nancy Adhiambo Ochieng
- Department of Pulmonology, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Lindsay Haskett
- Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Kenneth Cornetta
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Colleen Brown
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,St. Vincent Indianapolis Hospital, Indianapolis, Indiana, USA
| | | | - Connie H Keung
- Department of Surgery, Indiana University, Indianapolis, Indiana, USA.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Peter S Kussin
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Pulmonology, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Abstract
Abstract
Background
The global surgery access imbalance will have a dramatic impact on the growing population of the world’s children. In regions of the world with pediatric surgery and anesthesia manpower deficits and pediatric surgery–specific infrastructure and supply chain gaps, this expanding population will present new challenges. Perioperative mortality rate is an established indicator of the quality and safety of surgical care. To establish a baseline pediatric perioperative mortality rate and factors associated with mortality in Kenya, the authors designed a prospective cohort study and measured 24-h, 48-h, and 7-day perioperative mortality.
Methods
The authors trained anesthesia providers to electronically collect 132 data elements for pediatric surgical cases in 24 government and nongovernment facilities at primary, secondary, and tertiary hospitals from January 2014 to December 2016. Data assistants tracked all patients to 7 days postoperative, even if they had been discharged. Adjusted analyses were performed to compare mortality among different hospital levels after adjusting for prespecified risk factors.
Results
Of 6,005 cases analyzed, there were 46 (0.8%) 24-h, 62 (1.1%) 48-h, and 77 (1.7%) 7-day cumulative mortalities reported. In the adjusted analysis, factors associated with a statistically significant increase in 7-day mortality were American Society of Anesthesiologists Physical Status of III or more, night or weekend surgery, and not having the Safe Surgery Checklist performed. The 7-day perioperative mortality rate is less in the secondary (1.4%) and tertiary (2.4%) hospitals when compared with the primary (3.7%) hospitals.
Conclusions
The authors have established a baseline pediatric perioperative mortality rate that is greater than 100 times higher than in high-income countries. The authors have identified factors associated with an increased mortality, such as not using the Safe Surgery Checklist. This analysis may be helpful in establishing pediatric surgical care systems in low–middle income countries and develop research pathways addressing interventions that will assist in decreasing mortality rate.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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19
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Burden of emergency pediatric surgical procedures on surgical capacity in Uganda: a new metric for health system performance. Surgery 2020; 167:668-674. [DOI: 10.1016/j.surg.2019.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/17/2019] [Accepted: 12/04/2019] [Indexed: 11/24/2022]
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Perioperative mortality at Tibebe Ghion Specialized Teaching Hospital, Ethiopia: A longitudinal study design. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kisa P, Grabski DF, Ozgediz D, Ajiko M, Aspide R, Baird R, Barker G, Birabwa-Male D, Blair G, Cameron B, Cheung M, Cigliano B, Cunningham D, D'Agostino S, Duffy D, Evans F, Fitzgerald TN, Galiwango G, Gerolmini D, Gerolmini M, Kakembo N, Kambugu JB, Lakhoo K, Langer M, Muhumuza MF, Muzira A, Nabukenya MT, Naik-Mathuria B, Nakku D, Nankunda J, Ogwang M, Okello I, Penny N, Reimer E, Sabatini C, Sekabira J, Situma M, Ssenyonga P, Tumukunde J, Villalona G. Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda. World J Surg 2019; 43:1435-1449. [PMID: 30617561 DOI: 10.1007/s00268-018-04905-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is a significant unmet need for children's surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration. METHODS The stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area. RESULTS The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals. CONCLUSION Collaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders.
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Affiliation(s)
- Phyllis Kisa
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, USA
| | - Doruk Ozgediz
- Department of Surgery, Yale University School of Medicine, New Haven, USA.
| | | | | | - Robert Baird
- Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Gillian Barker
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Doreen Birabwa-Male
- Mulago National Referral Hospital, Uganda Ministry of Health, Kampala, Uganda
| | - Geoffrey Blair
- Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Brian Cameron
- Department of Surgery, McMaster University Faculty of Health Sciences, Hamilton, Canada
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, USA
| | | | | | | | - Damian Duffy
- Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Faye Evans
- Department of Anesthesiology, Harvard Medical School, Boston, USA
| | | | | | | | | | - Nasser Kakembo
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | | | - Kokila Lakhoo
- Department of Paediatric Surgery, Oxford University, Oxford, UK
| | - Monica Langer
- Department of Surgery, Northwestern University School of Medicine, Chicago, USA
| | | | - Arlene Muzira
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - Mary T Nabukenya
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | | | - Doreen Nakku
- Department of Surgery, Mbarara University of Science and Technology Faculty of Medicine, Mbarara, Uganda
| | - Jolly Nankunda
- Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda
| | | | - Innocent Okello
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - Norgrove Penny
- Department of Orthopedics, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Eleanor Reimer
- Department of Anesthesiology, University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Coleen Sabatini
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, USA
| | - John Sekabira
- Department of Surgery, Makerere University School of Medicine, Kampala, Uganda
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology Faculty of Medicine, Mbarara, Uganda
| | | | - Janat Tumukunde
- Department of Anesthesiology, Makerere University School of Medicine, Kampala, Uganda
| | - Gustavo Villalona
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, USA
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Osinaike B, Ayandipo O, Onyeka T, Alagbe-Briggs O, Mohammed A, Oyedepo O, Nuhu A, Asudo F, Akanmu O, Nwokorie C, Mohammed A, Edubio M, Izuora K, Mohammed R, Nweze O, Efu M, Eguma S, Jasper A, Ewah R, Akhideno I, Nnaji C, Ado S, Ogboli-Nwasor E, Atiku M, Salisu I, Adinoyi Y, Agu E, Desalu I, Samuel L, Olorode Y, Fatungase O, Akinwonmi O, Faponle F, Idowu O, Isamade E, Aliyu A, Buba S, Hamza G, Onajin-Obembe B, Amanor-Boadu S. Nigerian surgical outcomes – Report of a 7-day prospective cohort study and external validation of the African surgical outcomes study surgical risk calculator. Int J Surg 2019; 68:148-156. [DOI: 10.1016/j.ijsu.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/24/2019] [Accepted: 06/04/2019] [Indexed: 12/14/2022]
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Abstract
BACKGROUND Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality. METHODS This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality. RESULTS There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001). CONCLUSIONS Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.
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Affiliation(s)
- Meghan Prin
- From the Department of Anesthesiology and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York
| | - Stephanie Pan
- Department of Biostatistics, Icahn School of Medicine at Mt Sinai, New York, New York
| | - Janey Phelps
- Department of Anesthesiology and Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Godfrey Phiri
- Department of Anesthesiology, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Abstract
PURPOSE OF REVIEW Two-thirds of the world's population lacks access to surgical care, many of them being children. This review provides an update on recent advances in global children's surgery. RECENT FINDINGS Surgery is being increasingly recognized as an essential component of global and child health. There is a greater focus on sustainable collaborations between high-income countries (HICs) and low-and-middle-income countries (HICs and LMICs). Recent work provides greater insight into the global disease burden, perioperative outcomes and effective context-specific solutions. Surgery has continued to be identified as a cost-effective intervention in LMICs. There have also been substantial advances in research and advocacy for a number of childhood surgical conditions. SUMMARY Substantial global disparities persist in the care of childhood surgical conditions. Recent work has provided greater visibility to the challenges and solutions for children's surgery in LMICs. Capacity-building and scale up of children's surgical care, more robust implementation research and ongoing advocacy are needed to increase access to children's surgical care worldwide.
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Are Postoperative Clinical Outcomes Influenced by Length of Stay in the Postanesthesia Care Unit? J Perianesth Nurs 2018; 34:386-393. [PMID: 30337197 DOI: 10.1016/j.jopan.2018.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE To compare clinical outcomes of patients who required a prolonged length of stay in the postanesthesia care unit (PACU) with a control group. DESIGN A single-center purposive-sampled retrospective medical record and database audit. METHODS Patients with prolonged PACU stays were compared to a group of patients whose stay was less than median for outcome measures: rapid response team (RRT) activation, cardiac arrest, unanticipated intensive care unit admissions, and survival to discharge. FINDINGS A total of 1,867 patients were included in the analysis (n = 931 prolonged stay and n = 933 control group). Prolonged stay in PACU was higher among patients who were older, had higher American Society of Anesthesiologist score, and were discharged to wards during the afternoon or late nursing shift. RRT activation after discharge from PACU occurred in more patients in the study group compared with the control group (7% vs 1%, respectively). There were no cardiac arrests recorded in either group within the 24 hours after PACU discharge period. CONCLUSIONS Prolonged stay in the PACU for 2 or more hours because of clinical reasons appears to be associated with a higher incidence of clinical deterioration in the ward setting requiring RRT intervention within 24 hours after discharge from PACU.
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Hewitt-Smith A, Bulamba F, Olupot C, Musana F, Ochieng JP, Lipnick MS, Pearse RM. Surgical outcomes in eastern Uganda: a one-year cohort study. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1517476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- A Hewitt-Smith
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - F Bulamba
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - C Olupot
- Mbale Regional Referral Hospital, Mbale, Uganda
| | - F Musana
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - JP Ochieng
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - MS Lipnick
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - RM Pearse
- Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Biccard BM, Madiba TE, Kluyts HL, Munlemvo DM, Madzimbamuto FD, Basenero A, Gordon CS, Youssouf C, Rakotoarison SR, Gobin V, Samateh AL, Sani CM, Omigbodun AO, Amanor-Boadu SD, Tumukunde JT, Esterhuizen TM, Manach YL, Forget P, Elkhogia AM, Mehyaoui RM, Zoumeno E, Ndayisaba G, Ndasi H, Ndonga AKN, Ngumi ZWW, Patel UP, Ashebir DZ, Antwi-Kusi AAK, Mbwele B, Sama HD, Elfiky M, Fawzy MA, Pearse RM. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet 2018; 391:1589-1598. [PMID: 29306587 DOI: 10.1016/s0140-6736(18)30001-1] [Citation(s) in RCA: 332] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 09/18/2017] [Accepted: 09/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. METHODS We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899). FINDINGS We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died. INTERPRETATION Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective. FUNDING Medical Research Council of South Africa.
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Affiliation(s)
- Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, South Africa.
| | | | - Hyla-Louise Kluyts
- Department of Anaesthesiology, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Dolly M Munlemvo
- Anaesthesiology, University Hospital of Kinshasha, Democratic Republic of the Congo
| | - Farai D Madzimbamuto
- Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Apollo Basenero
- Ministry of Health and Social Services Namibia, Windhoek, Namibia
| | | | | | | | - Veekash Gobin
- Ministry of Health and Quality of Life, Jawaharlal Nehru Hospital, Rose Belle, Mauritius
| | - Ahmadou L Samateh
- Department of Surgery, Edward Francis Small Teaching Hospital, Banjul, The Gambia
| | - Chaibou M Sani
- Department of Anesthesiology, Intensive Care and Emergency, National Hospital of Niamey, Niamey, Republic of Niger
| | - Akinyinka O Omigbodun
- Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | | | - Tonya M Esterhuizen
- Centre for Evidence Based Health Care, Stellenbosch University, Stellenbosch, South Africa
| | - Yannick Le Manach
- Departments of Anesthesia & Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University and Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, ON, Canada
| | - Patrice Forget
- Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Anesthesiology and Perioperative Medicine, Brussels, Belgium
| | | | - Ryad M Mehyaoui
- Hospital of Cardiovasculaire Pathology, Universitar Hospital, Algeria
| | - Eugene Zoumeno
- Faculté des Sciences de la Santé de Cotonou, Hôpital de la mère et de l'enfant, Lagune de Cotonou, Benin
| | - Gabriel Ndayisaba
- Kamenge Teaching Hospital, Department of Surgery, Bujumbura, Burundi
| | - Henry Ndasi
- Department of Orthopaedics and General Surgery, Baptist Hospital, Mutengene, Cameroon
| | | | - Zipporah W W Ngumi
- Department of Anaesthesia, University of Nairobi School of Medicine, Nairobi, Kenya
| | - Ushmah P Patel
- Anaesthesiology, University Teaching Hospital, Lusaka, Zambia
| | | | - Akwasi A K Antwi-Kusi
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Bernard Mbwele
- HIV/AIDS Care and Treatment & PMTCT, Christian Social Service Commission, Mwanza, Tanzania
| | - Hamza Doles Sama
- Anaesthesia Intensive Care Medicine Pain Management, Sylvanus Olympio University Teaching Hospital, Lomé TOGO, Togo
| | | | - Maher A Fawzy
- Anesthesia, ICU & Pain Management Departments, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rupert M Pearse
- Intensive Care Medicine, Queen Mary University of London, London, UK
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Kassebaum NJ, McQueen K. The Role of Cost-Effectiveness Analysis in Global Anesthesia. Anesth Analg 2018; 126:1397-1399. [PMID: 29309321 DOI: 10.1213/ane.0000000000002738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas J Kassebaum
- From the Division of Pediatric Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington.,Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | - Kelly McQueen
- Departments of Anesthesiology.,Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.,Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
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