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Poletto S, Trevisanuto D, Ramaswamy VV, Seni AHA, Ouedraogo P, Dellacà RL, Zannin E. Bubble CPAP respiratory support devices for infants in low-resource settings. Pediatr Pulmonol 2023; 58:643-652. [PMID: 36484311 DOI: 10.1002/ppul.26258] [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] [Received: 07/13/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
Approximately 46% of the 5.2 million annual under-5 deaths derive from neonatal conditions commonly associated with hypoxemia or acute respiratory distress. It has been estimated that 98% of these deaths occur in low- and middle-income countries (LMICs). Effective implementation of noninvasive respiratory support at all levels of healthcare could significantly reduce neonatal mortality. Several factors limit the widespread and effective implementation of noninvasive respiratory support in LMICs, including inadequate infrastructure, lack of proper instrumentation, shortage of skilled staff, costly disposables, and difficulties in the supply of consumables and spare parts. The aim of this state-of-the-art paper is to provide a detailed evaluation of the commercially available devices providing noninvasive respiratory support in LMICs, focusing on bubblecontinuous positive airway pressure (bCPAP). bCPAP might be administrated using a variety of different commercial devices, including devices specifically designed for LMICs, as well as using self-made systems. We described all the equipment required for safe and effective implementation of bCPAP, including air and oxygen sourced, pressure-reducing valves and flowmeters, air-oxygen blending systems, humidifiers, respiratory support devices, patient circuits, and airway interfaces. Specifically, we critically evaluated the advantages and disadvantages of various existing solutions within the context of low-resource settings.
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Affiliation(s)
- Sofia Poletto
- Technologies for Respiration Laboratory, Electronics, Information and Bioengineering Department (DEIB), Politecnico di Milano, Milan, Italy
| | | | | | | | | | - Raffaele L Dellacà
- Technologies for Respiration Laboratory, Electronics, Information and Bioengineering Department (DEIB), Politecnico di Milano, Milan, Italy
| | - Emanuela Zannin
- Neonatal Intesive Care Unit at Fondazione Monza e Brianza per il Bambino e la sua Mamma (MBBM), Monza, Italy
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Mokuolu OA, Adesiyun OO, Ibrahim OR, Suberu HD, Ibrahim S, Bello SO, Mokikan M, Obasa TO, Abdulkadir MB. Appraising Neonatal Morbidity and Mortality in a Developing Country Categorized by Gestational Age Grouping and Implications for Targeted Interventions. Front Pediatr 2022; 10:899645. [PMID: 35712627 PMCID: PMC9196884 DOI: 10.3389/fped.2022.899645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/29/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Despite the relatively higher neonatal morbidity and mortality in developing countries, there are limited data on the detailed analysis of the burden in Nigeria. With a database of over 14,000 admissions, this study presents a compelling picture of the current trends disaggregated by their gestational age groups. It provides unique opportunities for better-targeted interventions for further reducing newborn mortality in line with SDG 3, Target 3.2. Methods This prospective observational study involved newborn babies admitted to the Neonatal Intensive Care Unit of the University of Ilorin Teaching Hospital, Kwara State, Nigeria, between January 2007 and December 2018. The outcome was the neonatal mortality rates. The exposure variables included birth weight, gestational age (preterm versus term), and clinical diagnosis. Frequencies were generated on tables and charts, and the trends or associations were determined. Results Of the 14,760 neonates admitted, 9,030 (61.2%) were term babies, 4,847 (32.8%) were preterm babies, and in 792 (5%) of the admissions, the gestational ages could not be determined. Males constituted a higher proportion with 55.9%, and the total number of deaths in the study period was 14.7%. The mortality ratio was highest among babies with a birth weight of less than 1,000 g (38.0%) and gestational age of less than 28 weeks (65.5%). The trend analysis showed that the mortality rate decreased from 17.8 to 13% over the 12 years, p-value < 0.0001. For term babies, mortality decreased by 45%, from 15.7% in 2007 to 8.7% in 2018, while the decline in mortality for preterm babies was 28.4%, from 25.7% in 2007 to 18.4% in 2018. For both categories, p-values were < 0.001. Regarding morbidity in term babies, asphyxia occurred in (1:3), jaundice (1:5), sepsis (1:6), and respiratory disorders (1:6) of admissions. For mortality, asphyxia occurred in (1:2), sepsis (1:5), jaundice (1:8), and respiratory disorders (1:10) of deaths. The leading causes of morbidity among preterm babies were asphyxia (1:4), sepsis (1:5), respiratory disorders (1:9), and jaundice (1.10). For mortality, their contributions were asphyxia (≈1:2); sepsis (1:5); respiratory disorders (1:9), and jaundice (1:10). Conclusion There was a marked improvement in neonatal mortality trends. However, severe perinatal asphyxia, sepsis, hyperbilirubinemia, and respiratory disorders were the leading conditions contributing to 75% of the morbidities and mortalities. Measures to further accelerate the reduction in neonatal morbidity and mortality are discussed.
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Affiliation(s)
- Olugbenga Ayodeji Mokuolu
- Neonatal Intensive Care Unit, Department of Pediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
- Department of Pediatrics and Child Health, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
| | - Omotayo Oluwakemi Adesiyun
- Neonatal Intensive Care Unit, Department of Pediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
- Department of Pediatrics and Child Health, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
| | - Olayinka Rasheed Ibrahim
- Neonatal Intensive Care Unit, Department of Pediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Habibat Dirisu Suberu
- Neonatal Intensive Care Unit, Department of Pediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Selimat Ibrahim
- Centre for Malaria and Other Tropical Diseases Care, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Surajudeen Oyeleke Bello
- Neonatal Intensive Care Unit, Department of Pediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Moboni Mokikan
- Department of Biostatistics and Epidemiology, East Tennessee State University, Johnson City, TN, United States
| | - Temitope Olorunshola Obasa
- Neonatal Intensive Care Unit, Department of Pediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
- Department of Pediatrics and Child Health, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
| | - Mohammed Baba Abdulkadir
- Neonatal Intensive Care Unit, Department of Pediatrics, University of Ilorin Teaching Hospital, Ilorin, Nigeria
- Department of Pediatrics and Child Health, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
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Nowadly CD, Portillo DJ, Davis ML, Hood RL, De Lorenzo RA. The Use of Portable Oxygen Concentrators in Low-Resource Settings: A Systematic Review. Prehosp Disaster Med 2022; 37:1-8. [PMID: 35232523 DOI: 10.1017/s1049023x22000310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Portable oxygen concentrators (POCs) are medical devices that use physical means to separate oxygen from the atmosphere to produce concentrated, medical-grade gas. Providing oxygen to low-resources environments, such as austere locations, military combat zones, rural Emergency Medical Services (EMS), and during disasters, becomes expensive and logistically intensive. Recent advances in separation technology have promoted the development of POC systems ruggedized for austere use. This review provides a comprehensive summary of the available data regarding POCs in these challenge environments. METHODS PubMed, Google Scholar, and the Defense Technical Information Center were searched from inception to November 2021. Articles addressing the use of POCs in low-resource settings were selected. Three authors were independently involved in the search, review, and synthesis of the articles. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. RESULTS The initial search identified 349 articles, of which 40 articles were included in the review. A total of 724 study subjects were associated with the included articles. There were no Level I systematic reviews or randomized controlled trials. DISCUSSION Generally, POCs are a low-cost, light-weight tool that may fill gaps in austere, military, veterinary, EMS, and disaster medicine. They are cost-effective in low-resource areas, such as rural and high-altitude hospitals in developing nations, despite relatively high capital costs associated with initial equipment purchase. Implementation of POC in low-resource locations is limited primarily on access to electricity but can otherwise operate for thousands of hours without maintenance. They provide a unique advantage in combat operations as there is no risk of explosive if oxygen tanks are struck by high-velocity projectiles. Despite their deployment throughout the battlespace, there were no manuscripts identified during the review involving the efficacy of POCs for combat casualties or clinical outcomes in combat. Veterinary medicine and animal studies have provided the most robust data on the physiological effectiveness of POCs. The success of POCs during the coronavirus disease 2019 (COVID-19) pandemic highlights the potential for POCs during future mass-casualty events. There is emerging technology available that combines a larger oxygen concentrator with a compressor system capable of refilling small oxygen cylinders, which could transform the delivery of oxygen in austere environments if ruggedized and miniaturized. Future clinical research is needed to quantify the clinical efficacy of POCs in low-resource settings.
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Affiliation(s)
- Craig D Nowadly
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TexasUSA
| | - Daniel J Portillo
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TexasUSA
| | - Maxwell L Davis
- Department of Respiratory Therapy, Keesler Air Force Base, Biloxi, Mississippi, USA
| | - R Lyle Hood
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TexasUSA
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TexasUSA
| | - Robert A De Lorenzo
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TexasUSA
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Adeoti A, Desalu O, Elebiyo T, Aremu O. Misconception on oxygen administration among patients and their caregivers in Ado Ekiti, Nigeria. Ann Afr Med 2022; 21:269-273. [PMID: 36204914 PMCID: PMC9671189 DOI: 10.4103/aam.aam_63_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Appropriate oxygen administration is a life-saving therapy; however, patients and their caregivers could decline such therapy for several reasons. Poor perceptions may delay consent to oxygen therapy. There is a lack of data on the perception of oxygen use among patients and caregivers in our setting. Hence, this study was aimed at evaluating the perception of patients and their caregivers toward emergency oxygen use in a tertiary hospital in Nigeria. Materials and Methods: This survey was a descriptive cross-sectional study conducted between December 2017 and May 2018 at a tertiary hospital in southwestern Nigeria. We administered a structured questionnaire to 334 eligible patients and their 539 caregivers while on admission. Results: A significant proportion of the patients compared to their caregivers have had oxygen therapy in the past 40.6% versus. 6.9% P < 0.0001. The majority of the participants (patients vs. caregivers 84.7% vs. 81.1% P = 0.511) believed oxygen therapy to be beneficial and safe for use (patients vs. caregivers 79.4% vs. 78.6%; P = 0.8949). However, 21.1% of patients and 19.5% of caregivers believed it is solely for terminally ill patients. More than 50% of patients and caregivers thought oxygen can cause adverse effects and fire outbreaks. Most of the respondents considered oxygen therapy as expensive (patients vs. caregivers; 78.2% vs. 87.2%; P = 0.0176) which was regarded as a possible barrier to treatment (patients vs. caregivers 81.9% vs. 85.0% P = 0.3893). <1% of both patients and their caregivers have had any form of training in basic life support. Conclusion: The misconceptions about oxygen use require urgent attention by raising community awareness and knowledge toward improving the acceptability of this life-saving intervention.
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Mir F, Ali Nathwani A, Chanar S, Hussain A, Rizvi A, Ahmed I, Memon ZA, Habib A, Soofi S, Bhutta ZA. Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial. BMJ Open 2021; 11:e046158. [PMID: 34535473 PMCID: PMC8451312 DOI: 10.1136/bmjopen-2020-046158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh. METHODS AND ANALYSIS A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study. ETHICS AND DISSEMINATION Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT03588377.
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Affiliation(s)
- Fatima Mir
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Apsara Ali Nathwani
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Suhail Chanar
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Amjad Hussain
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Imran Ahmed
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Zahid Ali Memon
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Atif Habib
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Sajid Soofi
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
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Won A, Suarez-Rebling D, Baker AL, Burke TF, Nelson BD. Bubble CPAP devices for infants and children in resource-limited settings: review of the literature. Paediatr Int Child Health 2019; 39:168-176. [PMID: 30375281 DOI: 10.1080/20469047.2018.1534389] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Early management of respiratory distress is critical to reducing mortality in infants and children in resource-limited settings. Bubble continuous positive airway pressure (bCPAP) can offer effective and affordable non-invasive respiratory support. Objective: To determine the best physical components of bubble CPAP circuits for respiratory support of children in low-resource settings. Methods: Using PubMed, CINAHL and LILACS, studies of any design in any language published before June 2017 which examined the physical components of bCPAP circuits were identified and reviewed. Results: After screening, the review included 45 articles: 17 clinical trials, 11 literature reviews, 10 technical assessments of bCPAP components, three reports of real-world implementation in low-resource settings, three cost analyses and one case report. There is no ideal bCPAP circuit for all settings and patients, but some choices are generally better than others in designing a circuit for low-resource settings. Oxygen concentrators are usually the best source of oxygen. As yet, there is no affordable and accurate oxygen blender. Nasal prongs are the simplest patient interface to use with the fewest complications but are not the cheapest option. Expiratory limbs should be at least 1 cm in diameter. Home-made pressure generators are effective, safe and affordable. Conclusion: This narrative review found many studies which evaluated the real clinical outcomes with bCPAP in the target population as well as technical comparison of bCPAP components. However, many studies were not blinded or randomised and there was significant heterogeneity in design and outcome measures. Abbreviations: bCPAP, bubble continuous positive airway pressure; CPAP, continuous positive airway pressure; FiO2, fractional oxygen concentration; HFNC, high-flow nasal cannula; HIC, high-income countries; LMIC, low- and middle-income countries; NP, nasopharyngeal; O2, oxygen; PEEP, positive end-expiratory pressure; PICO, Population, Intervention, Comparison and Outcome.
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Affiliation(s)
- Alice Won
- a Division of Global Health and Human Rights, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Daniela Suarez-Rebling
- a Division of Global Health and Human Rights, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Arianne L Baker
- b Department of Pediatrics , Harvard Medical School , Boston , USA.,c Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
| | - Thomas F Burke
- a Division of Global Health and Human Rights, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA.,b Department of Pediatrics , Harvard Medical School , Boston , USA
| | - Brett D Nelson
- b Department of Pediatrics , Harvard Medical School , Boston , USA.,d Division of Global Health, Department of Pediatrics , Massachusetts General Hospital , Boston , USA
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7
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Calderon R, Morgan MC, Kuiper M, Nambuya H, Wangwe N, Somoskovi A, Lieberman D. Assessment of a storage system to deliver uninterrupted therapeutic oxygen during power outages in resource-limited settings. PLoS One 2019; 14:e0211027. [PMID: 30726247 PMCID: PMC6364892 DOI: 10.1371/journal.pone.0211027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 01/07/2019] [Indexed: 11/19/2022] Open
Abstract
Access to therapeutic oxygen remains a challenge in the effort to reduce pneumonia mortality among children in low- and middle-income countries. The use of oxygen concentrators is common, but their effectiveness in delivering uninterrupted oxygen is gated by reliability of the power grid. Often cylinders are employed to provide continuous coverage, but these can present other logistical challenges. In this study, we examined the use of a novel, low-pressure oxygen storage system to capture excess oxygen from a concentrator to be delivered to patients during an outage. A prototype was built and tested in a non-clinical trial in Jinja, Uganda. The trial was carried out at Jinja Regional Referral Hospital over a 75-day period. The flow rate of the unit was adjusted once per week between 0.5 and 5 liters per minute. Over the trial period, 1284 power failure episodes with a mean duration of 3.1 minutes (range 0.08 to 1720 minutes) were recorded. The low-pressure system was able to deliver oxygen over 56% of the 4,295 power outage minutes and cover over 99% of power outage events over the course of the study. These results demonstrate the technical feasibility of a method to extend oxygen availability and provide a basis for clinical trials.
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Affiliation(s)
- Ryan Calderon
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Melissa C. Morgan
- Department of Pediatrics, University of California San Francisco, San Francisco, California, United States of America
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- Maternal, Adolescent, Reproductive, and Child Health Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mark Kuiper
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
| | - Harriet Nambuya
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Nicholas Wangwe
- Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Akos Somoskovi
- Intellectual Ventures Global Good Fund, Bellevue, Washington, United States of America
| | - Daniel Lieberman
- Intellectual Ventures Laboratory, Bellevue, Washington, United States of America
- * E-mail:
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8
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Bradley BD, Light JD, Ebonyi AO, N'Jai PC, Ideh RC, Ebruke BE, Nyassi E, Peel D, Howie SRC. Implementation and 8-year follow-up of an uninterrupted oxygen supply system in a hospital in The Gambia. Int J Tuberc Lung Dis 2018; 20:1130-4. [PMID: 27393551 PMCID: PMC4937752 DOI: 10.5588/ijtld.15.0889] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
SETTING: A 42-bed hospital operated by the Medical Research Council (MRC) Unit in The Gambia. OBJECTIVE: To devise, test and evaluate a cost-efficient uninterrupted oxygen system in the MRC Hospital. DESIGN: Oxygen cylinders were replaced with oxygen concentrators as the primary source of oxygen. An uninterruptable power supply (UPS) ensured continuity of power. Hospital staff were trained on the use of the new system. Eight years post-installation, an analysis of concentrator maintenance needs and costs was conducted and user feedback obtained to assess the success of the system. RESULTS: The new system saved at least 51% of oxygen supply costs compared to cylinders, with savings likely to have been far greater due to cylinder leakages. Users indicated that the system is easier to use and more reliable, although technical support and staff training are still needed. CONCLUSION: Oxygen concentrators offer long-term cost savings and an improved user experience compared to cylinders; however, some technical support and maintenance are needed to upkeep the system. A UPS dedicated to oxygen concentrators is an appropriate solution for settings where power interruptions are frequent but short in duration. This approach can be a model for health systems in settings with similar infrastructure.
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Affiliation(s)
- B D Bradley
- Centre for Global Engineering and Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada
| | - J D Light
- Engineering Science, University of Toronto, Toronto, Ontario, Canada
| | - A O Ebonyi
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - P C N'Jai
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - R C Ideh
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - B E Ebruke
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - E Nyassi
- Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - D Peel
- Ashdown Consultants, Hartfield, UK
| | - S R C Howie
- Centre for Global Engineering and Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada; Medical Research Council Unit The Gambia, Fajara, The Gambia, Department of Paediatrics, University of Auckland, Auckland, Centre for International Health, University of Otago, Dunedin, New Zealand
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Graham HR, Ayede AI, Bakare AA, Oyewole OB, Peel D, Gray A, McPake B, Neal E, Qazi S, Izadnegahdar R, Falade AG, Duke T. Improving oxygen therapy for children and neonates in secondary hospitals in Nigeria: study protocol for a stepped-wedge cluster randomised trial. Trials 2017; 18:502. [PMID: 29078810 PMCID: PMC5659007 DOI: 10.1186/s13063-017-2241-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 10/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxygen is a life-saving, essential medicine that is important for the treatment of many common childhood conditions. Improved oxygen systems can reduce childhood pneumonia mortality substantially. However, providing oxygen to children is challenging, especially in small hospitals with weak infrastructure and low human resource capacity. METHODS/DESIGN This trial will evaluate the implementation of improved oxygen systems at secondary-level hospitals in southwest Nigeria. The improved oxygen system includes: a standardised equipment package; training of clinical and technical staff; infrastructure support (including improved power supply); and quality improvement activities such as supportive supervision. Phase 1 will involve the introduction of pulse oximetry alone; phase 2 will involve the introduction of the full, improved oxygen system package. We have based the intervention design on a theory-based analysis of previous oxygen projects, and used quality improvement principles, evidence-based teaching methods, and behaviour-change strategies. We are using a stepped-wedge cluster randomised design with participating hospitals randomised to receive an improved oxygen system at 4-month steps (three hospitals per step). Our mixed-methods evaluation will evaluate effectiveness, impact, sustainability, process and fidelity. Our primary outcome measures are childhood pneumonia case fatality rate and inpatient neonatal mortality rate. Secondary outcome measures include a range of clinical, quality of care, technical, and health systems outcomes. The planned study duration is from 2015 to 2018. DISCUSSION Our study will provide quality evidence on the effectiveness of improved oxygen systems, and how to better implement and scale-up oxygen systems in resource-limited settings. Our results should have important implications for policy-makers, hospital administrators, and child health organisations in Africa and globally. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12617000341325 . Retrospectively registered on 6 March 2017.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Department of Paediatrics, University College Hospital, Ibadan, Nigeria.
| | - Adejumoke I Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Oladapo B Oyewole
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Eleanor Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Shamim Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Level 2 East, 50 Flemington Road, Parkville, VIC, 3052, Australia
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10
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Graham H, Tosif S, Gray A, Qazi S, Campbell H, Peel D, McPake B, Duke T. Providing oxygen to children in hospitals: a realist review. Bull World Health Organ 2017; 95:288-302. [PMID: 28479624 PMCID: PMC5407252 DOI: 10.2471/blt.16.186676] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To identify and describe interventions to improve oxygen therapy in hospitals in low-resource settings, and to determine the factors that contribute to success and failure in different contexts. METHODS Using realist review methods, we scanned the literature and contacted experts in the field to identify possible mechanistic theories of how interventions to improve oxygen therapy systems might work. Then we systematically searched online databases for evaluations of improved oxygen systems in hospitals in low- or middle-income countries. We extracted data on the effectiveness, processes and underlying theory of selected projects, and used these data to test the candidate theories and identify the features of successful projects. FINDINGS We included 20 improved oxygen therapy projects (45 papers) from 15 countries. These used various approaches to improving oxygen therapy, and reported clinical, quality of care and technical outcomes. Four effectiveness studies demonstrated positive clinical outcomes for childhood pneumonia, with large variation between programmes and hospitals. We identified factors that help or hinder success, and proposed a practical framework depicting the key requirements for hospitals to effectively provide oxygen therapy to children. To improve clinical outcomes, oxygen improvement programmes must achieve good access to oxygen and good use of oxygen, which should be facilitated by a broad quality improvement capacity, by a strong managerial and policy support and multidisciplinary teamwork. CONCLUSION Our findings can inform practitioners and policy-makers about how to improve oxygen therapy in low-resource settings, and may be relevant for other interventions involving the introduction of health technologies.
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Affiliation(s)
- Hamish Graham
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Shidan Tosif
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Amy Gray
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
| | - Shamim Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Harry Campbell
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland
| | | | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Trevor Duke
- Centre for International Child Health, University Department of Paediatrics, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia
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Bradley BD, Chow S, Nyassi E, Cheng YL, Peel D, Howie SRC. A retrospective analysis of oxygen concentrator maintenance needs and costs in a low-resource setting: experience from The Gambia. HEALTH AND TECHNOLOGY 2015. [DOI: 10.1007/s12553-015-0094-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Moll JR, Vieira JE, Gozzani JL, Mathias LAST. Oxygen concentrators performance with nitrous oxide at 50:50 volume. Braz J Anesthesiol 2014; 64:164-8. [PMID: 24907874 DOI: 10.1016/j.bjane.2013.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Few investigations have addressed the safety of oxygen from concentrators for use in anesthesia in association with nitrous oxide. This study evaluated the percent of oxygen from a concentrator in association with nitrous oxide in a semi-closed rebreathing circuit. METHODS Adult patients undergoing low risk surgery were randomly allocated into two groups, receiving a fresh gas flow of oxygen from concentrators (O293) or of oxygen from concentrators and nitrous oxide (O293N2O). The fraction of inspired oxygen and the percentage of oxygen from fresh gas flow were measured every 10 min. The ratio of FiO2/oxygen concentration delivered was compared at various time intervals and between the groups. RESULTS Thirty patients were studied in each group. There was no difference in oxygen from concentrators over time for both groups, but there was a significant improvement in the FiO2 (p<0.001) for O293 group while a significant decline (p<0.001) for O293N2O. The FiO2/oxygen ratio varied in both groups, reaching a plateau in the O293 group. Pulse oximetry did not fall below 98.5% in either group. CONCLUSION The FiO2 in the mixture of O293 and nitrous oxide fell during the observation period although oxygen saturation was higher than 98.5% throughout the study. Concentrators can be considered a stable source of oxygen for use during short anesthetic procedures, either pure or in association with nitrous oxide at 50:50 volume.
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Affiliation(s)
- Jorge Ronaldo Moll
- Hospital Geral de Bonsucesso do Ministério da Saúde, Rio de Janeiro, RJ, Brazil
| | - Joaquim Edson Vieira
- Departament of Surgery, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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13
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Moll JR, Vieira JE, Gozzani JL, Mathias LAST. Desempenho de concentradores de oxigênio com óxido nitroso em volume de 50:50. Braz J Anesthesiol 2014; 64:164-8. [DOI: 10.1016/j.bjan.2013.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 06/10/2013] [Indexed: 10/25/2022] Open
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Duke T, Peel D, Graham S, Howie S, Enarson PM, Jacobson R. Oxygen concentrators: a practical guide for clinicians and technicians in developing countries. ACTA ACUST UNITED AC 2013; 30:87-101. [DOI: 10.1179/146532810x12637745452356] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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15
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Coghill M, Ambalavanan N, Chatburn RL, Hibberd PL, Wright LL, Carlo WA. Accuracy of a novel system for oxygen delivery to small children. Pediatrics 2011; 128:e382-7. [PMID: 21727103 PMCID: PMC3387857 DOI: 10.1542/peds.2010-3745] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Oxygen therapy for infants and small children in developing countries is often not available. Entrainment devices may provide an accurate and precise concentration of oxygen when used at the flow rates appropriate for infants and small children. METHODS A continuously adjustable entrainment device was tested to determine the concentrations and flows of oxygen delivered by using low inlet flow rates suitable for therapy for infants and small children and 3 distinct oxygen delivery systems that varied in their resistive load. RESULTS The use of long and large bore, low resistance tubing (similar to a mask) resulted in the delivery of oxygen concentrations that tracked closely (accurate and precise) to values indicated by the entrainment device. The directly connected system with lower resistance (similar to a hood) produced a similar profile of concentrations and flow rates to the large bore tubing but with even greater accuracy. The use of a long and narrow tubing with higher resistance (similar to a cannula) did not deliver accurate oxygen concentrations. In fact, this high-resistance system failed to work as intended, and instead of entraining air, a large proportion (sometimes >50%) of the oxygen delivered to the entrainment device was ejected through its vents. CONCLUSIONS Entrainment devices can deliver accurate oxygen concentrations at low flow rates if used with low resistance delivery systems; however, entrainment devices are not suitable for use with high resistance delivery systems such as a standard nasal cannula.
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Affiliation(s)
- Matthew Coghill
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | - Linda L. Wright
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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16
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Kamath BD, MacGuire ER, McClure EM, Goldenberg RL, Jobe AH. Neonatal mortality from respiratory distress syndrome: lessons for low-resource countries. Pediatrics 2011; 127:1139-46. [PMID: 21536613 PMCID: PMC9923778 DOI: 10.1542/peds.2010-3212] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Respiratory distress syndrome (RDS) is a major contributor to neonatal mortality worldwide. However, little information is available regarding rates of RDS-specific mortality in low-income countries, and technologies for RDS treatment are used inconsistently in different health care settings. Our objective was to better understand the interventions that have decreased the rates of RDS-specific mortality in high-income countries over the past 60 years. We then estimated the effects on RDS-specific mortality in low-resource settings. Of the sequential introduction of technologies and therapies for RDS, widespread use of oxygen and continuous positive airway pressure were associated with the time periods that demonstrated the greatest decline in RDS-specific mortality. We argue that these 2 interventions applied widely in low-resource settings, with appropriate supportive infrastructure and general newborn care, will have the greatest impact on decreasing neonatal mortality. This historical perspective can inform policy-makers for the prioritization of scarce resources to improve survival rates for newborns worldwide.
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Affiliation(s)
- Beena D. Kamath
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; ,Address correspondence to Beena D. Kamath, MD, MPH, Cincinnati Children's Hospital Medical Center, MLC 7009, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail:
| | - Emily R. MacGuire
- Department of Statistics and Epidemiology, Research Triangle Institute, Durham, North Carolina; and
| | - Elizabeth M. McClure
- Department of Statistics and Epidemiology, Research Triangle Institute, Durham, North Carolina; and
| | - Robert L. Goldenberg
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Alan H. Jobe
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Howie SRC, Hill S, Ebonyi A, Krishnan G, Njie O, Sanneh M, Jallow M, Stevens W, Taylor K, Weber MW, Njai PC, Tapgun M, Corrah T, Mulholland K, Peel D, Njie M, Hill PC, Adegbola RA. Meeting oxygen needs in Africa: an options analysis from the Gambia. Bull World Health Organ 2011; 87:763-71. [PMID: 19876543 DOI: 10.2471/blt.08.058370] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Accepted: 04/06/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare oxygen supply options for health facilities in the Gambia and develop a decision-making algorithm for choosing oxygen delivery systems in Africa and the rest of the developing world. METHODS Oxygen cylinders and concentrators were compared in terms of functionality and cost. Interviews with key informants using locally developed and adapted WHO instruments, operational assessments, cost-modelling and cost measurements were undertaken to determine whether oxygen cylinders or concentrators were the better choice. An algorithm and a software tool to guide the choice of oxygen delivery system were constructed. FINDINGS In the Gambia, oxygen concentrators have significant advantages compared to cylinders where power is reliable; in other settings, cylinders are preferable as long as transporting them is feasible. Cylinder costs are greatly influenced by leakage, which is common, whereas concentrator costs are affected by the cost of power far more than by capital costs. Only two of 12 facilities in the Gambia were found suitable for concentrators; at the remaining 10 facilities, cylinders were the better option. CONCLUSION Neither concentrators nor cylinders are well suited to every situation, but a simple options assessment can determine which is better in each setting. Nationally this would result in improved supply and lower costs by comparison with conventional cylinders alone, although ensuring a reliable supply would remain a challenge. The decision algorithm and software tool designed for the Gambia could be applied in other developing countries.
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Affiliation(s)
- Stephen R C Howie
- Bacterial Diseases Programme, Medical Research Council Laboratories, Banjul, Gambia.
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Abstract
This article identifies the key challenges facing critical care practitioners in Africa. As a continent with a large proportion of the poorest countries and a plethora of unique diseases that place large demands for critical resources, the provision of care is largely in the context of severely constrained human and material resources. Diverse cultures and social norms predicate sensitivity to community values in the provision of care. Such realities demand novel approaches to the provision of critical care.
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Affiliation(s)
- Sats Bhagwanjee
- Department of Anesthesiology, Johannesburg Hospital and University of the Witwatersrand, Area 361, Johannesburg, South Africa.
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Dünser MW, Baelani I, Ganbold L. A review and analysis of intensive care medicine in the least developed countries. Crit Care Med 2006; 34:1234-42. [PMID: 16484925 DOI: 10.1097/01.ccm.0000208360.70835.87] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To give critical care clinicians in Western nations a general overview of intensive care medicine in less developed countries and to stimulate institutional or personal initiatives to improve critical care services in the least developed countries. DATA SOURCE In-depth PubMed search and personal experience of the authors. DATA SYNTHESIS In view of the eminent burden of disease, prevalence of critically ill patients in the least developed countries is disproportionately high. Despite fundamental logistic (water, electricity, oxygen supply, medical technical equipment, drugs) and financial limitations, intensive care medicine has become a discipline of its own in most nations. Today, many district and regional hospitals have units where severely ill patients are separately cared for, although major intensive care units are only found in large hospitals of urban or metropolitan areas. High workload, low wages, and a high risk of occupational infections with either the human immunodeficiency virus or a hepatitis virus explain burnout syndromes and low motivation in some health care workers. The four most common admission criteria to intensive care units in least developed countries are postsurgical treatment, infectious diseases, trauma, and peripartum maternal or neonatal complications. Logistic and financial limitations, as well as insufficiencies of supporting disciplines (e.g., laboratories, radiology, surgery), poor general health status of patients, and in many cases delayed presentation of severely sick patients to the intensive care unit, contribute to comparably high mortality rates. CONCLUSION More studies on the current state of intensive care medicine in least developed countries are needed to provide reasonable aid to improve care of the most severely ill patients in the poorest countries of the world.
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Affiliation(s)
- Martin W Dünser
- Division of General and Surgical Intensive Care Medicine, Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Austria
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Dünser M, Baelani I, Ganbold L. [The specialty of anesthesia outside Western medicine with special consideration of personal experience in the Democratic Republic of the Congo and Mongolia]. Anaesthesist 2006; 55:118-32. [PMID: 16425039 PMCID: PMC7096088 DOI: 10.1007/s00101-006-0979-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During the last decades anesthesia has developed into a wide ranging specialty in western countries, whereas in most developing and newly industrializing nations it still focuses on its core discipline, the perioperative care of the surgical patient. Poor socioeconomic status and inadequate financing of health systems result in a high burden of disease, a high rate of self-financing of healthcare costs by the patients, as well as insufficient personnel, infra-structural and material equipment of most healthcare facilities. Important limiting factors for anesthesia are low educational standards and a widespread lack of oxygen and medical gas supplies, as well as locally serviceable medical equipment. Studies evaluating the status of anesthesia in developing and newly industrializing nations in detail are urgently needed in order to provide aid on national and international as well as institutional and private levels for the development of anesthesia in poor countries.
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Affiliation(s)
- M Dünser
- Klinik für Anästhesie, Medizinische Universität, Innsbruck, Osterreich.
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