1
|
Srinivasan I, Whyte S, Bailey K, Antrobus T, Hinkson-LaCorbinière K, Martin TW, Cravero JP, Mason LJ. Pediatric anesthesia in North America. Paediatr Anaesth 2024. [PMID: 38462910 DOI: 10.1111/pan.14872] [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: 11/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND AND OBJECTIVES This educational review outlines the current landscape of pediatric anesthesia training, care delivery, and challenges across Canada, Barbados, and the United States. DESCRIPTIONS AND CONCLUSIONS Approximately 5% of Canadian children undergo general anesthesia annually, administered by fellowship-trained pediatric anesthesiologists in children's hospitals, general anesthesiologists in community hospitals, or family practice anesthesiologists in underserved regions. In Canada, the focus is on national-level evaluation and accreditation of pediatric anesthesia fellowship training, addressing challenges arising from workforce shortages, particularly in remote areas. Barbados, a Caribbean nation, lacks dedicated pediatric hospitals but has provided pediatric anesthesia since 1972 through anesthetists with additional training. Challenges in its development, common to low-middle-income countries, include inadequate infrastructure and workforce shortages. Increased awareness of pediatric anesthesia as a sub-specialty could enhance perioperative care for Barbadian children. Pediatric anesthesia encompasses various specialties in the United States, with pediatric anesthesiologists playing a foundational role. Challenges faced include recruitment and retention difficulties, supply-chain shortages, and the proliferation of anesthesia sites, all impacting the delivery of modern, high-quality, and cost-effective patient care. Collaborative efforts at national and organizational levels strive to improve the quality and safety of pediatric anesthesia care in the United States.
Collapse
Affiliation(s)
- Ilavajady Srinivasan
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Simon Whyte
- Department of Anesthesiology, Pharmacology & Therapeutics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Katherine Bailey
- Department of Anesthesiology, Pharmacology & Therapeutics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | | | | | - Timothy W Martin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Joseph P Cravero
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda J Mason
- Department of Anesthesiology, Loma Linda University, Loma Linda, California, USA
| |
Collapse
|
2
|
Bhatia MB, Anderson CM, Hussein AN, Opondo B, Aruwa N, Okumu O, Fisher SG, Joplin TS, Hunter-Squires JL, Gray BW, Saula PW. Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients. J Surg Res 2024; 295:139-147. [PMID: 38007861 DOI: 10.1016/j.jss.2023.10.017] [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: 03/07/2023] [Revised: 09/15/2023] [Accepted: 10/28/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION Evidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States. METHODS We completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap. RESULTS We included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different. CONCLUSIONS Studying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.
Collapse
Affiliation(s)
- Manisha B Bhatia
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
| | | | | | - Brian Opondo
- Department of Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Nereah Aruwa
- Department of Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Otieno Okumu
- Department of Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Sarah G Fisher
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tasha Sparks Joplin
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - JoAnna L Hunter-Squires
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Department of Anaesthesia and Surgery, Moi University, Eldoret, Kenya
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Department of Pediatric Surgery, Riley Hospital for Children, Indianapolis, Indiana
| | - Peter W Saula
- Department of Anaesthesia and Surgery, Moi University, Eldoret, Kenya; Department of Paediatric Surgery, Shoe4Africa Children's Hospital, Eldoret, Kenya
| |
Collapse
|
3
|
Molla MT, Anley NS, Zewdie BW, Endeshaw AS, Kumie FT. 28-day perioperative pediatric mortality and its predictors in a tertiary teaching hospital in Ethiopia: a prospective cohort study. Eur J Med Res 2024; 29:24. [PMID: 38183106 PMCID: PMC10768305 DOI: 10.1186/s40001-023-01613-6] [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: 03/29/2023] [Accepted: 12/21/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Perioperative pediatric mortality is significantly higher in low-resource countries due to a scarcity of well-trained professionals and a lack of well-equipped pediatric perioperative services. There has been little research on pediatric mortality in low-income countries. Therefore, this study aimed to assess the incidence of perioperative pediatric mortality and its predictors in 28-day follow-up. METHODS The data were collected using REDCap, an electronic data collection tool, between June 01, 2019 and July 01, 2021. This study includes pediatric patients aged 0 to 17 years who underwent surgery in Tibebe Ghion Specialized Hospital over 28 days with a total of 1171 patients. STATA version 17 software was used for data analysis. Log-rank tests were fitted to explore survival differences. After bivariable and multivariable Cox regression analysis, an Adjusted Hazard Ratio (AHR) with a 95% Confidence Interval (CI) was reported to declare the strength of association and statistical significance. RESULTS There were 35 deaths in the cohort of 1171 pediatric patients. Twenty of the deaths were in neonates. The overall perioperative mortality among pediatric patients was 2.99%, with an incidence rate of 1.11 deaths per 1000 person day observation (95% CI 0.79, 1.54). The neonatal age group had an AHR = 9.59, 95% CI 3.77, 24.3), transfusion had an AHR = 2.6, 95% CI 1.11, 6.09), and the America Society of Anesthesiology physical status classification III and above had an AHR = 4.39, 95% CI 1.61, 11.9 were found the significant predictors of perioperative pediatric mortality. CONCLUSIONS In this study, the perioperative mortality of pediatric patients was high in the 28-day follow-up. Neonatal age, transfusion, and America Society of Anesthesiology physical status III and above were significant predictors of pediatric mortality. Therefore, perioperative surgical teams should give special attention to neonates, the America Society of Anesthesiology physical status III and above, and transfusion to reduce pediatric mortality.
Collapse
Affiliation(s)
- Misganew Terefe Molla
- Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Nebiyu Shitaye Anley
- Department of Surgery, Pediatric Surgery Unit, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Bekalu Wubshet Zewdie
- Department of Orthopedics and Traumatology, Pediatric Orthopedic Unit, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - 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
| |
Collapse
|
4
|
Gajewski J, Pittalis C, Borgstein E, Bijlmakers L, Mwapasa G, Cheelo M, Juma A, Sardana M, Brugha R. Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania. Front Pediatr 2023; 11:1189676. [PMID: 37325346 PMCID: PMC10265866 DOI: 10.3389/fped.2023.1189676] [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: 03/19/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ). Methods Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons. Results Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water. Conclusions With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.
Collapse
Affiliation(s)
- Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Global Surgery, University of Stellenbosch, Cape Town, South Africa
| | - Chiara Pittalis
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eric Borgstein
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Leon Bijlmakers
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Mweene Cheelo
- Surgical Society of Zambia, University Teaching Hospital Lusaka, Lusaka, Zambia
| | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Muskan Sardana
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|