Trauma

In low- and middle-income countries, trauma, often from road traffic collisions, is one of the leading causes of morbidity and mortality. The approach to treating trauma in resource limited settings can be quite different to that in high-resource settings, requiring a lot of improvisation. The concepts of damage control surgery and resuscitation are covered, as are considerations for difficult patient groups such as head injuries, burns, and spinal injuries. The injury patterns seen as a result of armed conflicts (gun shots, blast injuries) will be unfamiliar to most anaesthetists and are also addressed in the chapter.

Context

The chapter provides the reader with information on the non-clinical background to working as an anaesthetist in a low-resource setting. It concentrates on important concepts that should inform the way you practise and teach, rather than technical aspects of anaesthesia. Although technical aspects of delivering anaesthesia are usually uppermost in the minds of anaesthetists new to working in low-resource settings, it is often the case that adapting successfully to the local context proves the more challenging aspect. Topics covered include humanitarian and developmental principles, teaching anaesthesia, looking after your own health, being a good visitor, and how to adapt your practice.

Drugs and transfusion

The chapter covers drugs in common use in resource-poor settings that may be unfamiliar to anaesthetists practising in high-resource settings, primarily ketamine and the volatile anaesthetic agents halothane and ether. Ketamine is one of the core drugs in use in resource-poor environments and as such a significant proportion of the chapter is given over to it: how it works, side effects and how to attenuate them and useful ketamine ‘recipes’. It also contains advice on ‘workarounds’ when other familiar drugs are unavailable, e.g. vasopressors, muscle relaxants. Lastly, blood transfusion is a major difficulty in most parts of the world and this chapter gives practical advice on dealing with this reality.

Tropical Medicine for Anaesthetists

Many tropical diseases will be unfamiliar to anaesthetists from high-resource settings but are common in low- and middle-income countries. They lead to a significant burden of morbidity and mortality, and some knowledge of the commonly presenting ones and how they might impact on conduct of anaesthesia is essential to anaesthetists practising in these settings. The chapter covers the essentials of several tropical diseases including malaria, tuberculosis, cholera, and typhoid. The chapter outlines for each disease the aetiology, pathophysiology, clinical features, diagnosis, management, and anaesthetic implications. Diseases that are also found in high-resource settings, such as diarrhoea and HIV, are also covered on the basis that they are much more likely to be encountered in a low-resource setting.

Critical Care

The concept of critical care in low-resource settings covers a very broad range of circumstances and settings from the ability to offer ventilation and inotropes through to an area with simply enhanced observations and/or nursing ratios. Low staffing and training levels on the general wards may necessitate admission of patients who simply require frequent observations and rapid recognition of deterioration; admission criteria may therefore be different to those in highly resourced settings. The chapter starts by describing the limits and challenges of providing critical care in low-resource settings and goes on to describe approaches to organ support. It then goes on to describe a pragmatic approach to caring for specific conditions in a low-resource critical care.

Regional Anaesthesia

In low-resource settings regional anaesthesia forms an essential part of anaesthetic practice, especially in the context of poor access to postoperative analgesia and recovery facilities, or where general anaesthesia is not available or may be high risk. Safe practice for performance of regional anaesthesia is outlined as well as the emergency management of local anaesthetic toxicity. The chapter covers a range of upper limb, lower limb, and trunk blocks. It describes, where possible, ultrasound, nerve stimulator, and landmark techniques for each block since available equipment may vary. Neuraxial techniques for neonates, infants, and children are described along with local anaesthetic dosages.

General and Urological Surgery

The chapter covers some of the general and urological conditions likely to be encountered by anaesthetists working in low-resource settings. Some such conditions are familiar to all anaesthetists, but the resources to manage them may be different: this chapter therefore particularly includes a description of laparotomy under spinal anaesthesia and a consideration of the risks and benefits of this technique. In addition some surgeries more commonly performed in low- and middle-income countries, e.g. bladder stone excision, non-traumatic splenectomy, and hydatid cyst excision are outlined, together with appropriate approaches and techniques for the non-specialist anaesthetist. Both elective and emergency conditions are included.

Anaesthesia Equipment and Utilities

The chapter covers anaesthetic equipment that may not be familiar to anaesthetists practising in high-resource settings. Primarily this means draw-over anaesthesia equipment—recognition, set-up, usage in adults and children, and practical tips. How to maintain your equipment yourself so that it continues to function safely is covered. The chapter also considers the two basic utilities of anaesthetic practice that are often taken for granted in high-resource settings—oxygen and electricity—and how to cope with an unpredictable supply of both. Hygiene and sterilization, a responsibility that often falls to the medical team in resource-poor settings, is also covered with practical advice on how to do it yourself.

Obstetrics and Gynaecology

In low-resource settings, obstetrics and gynaecology frequently forms a large part of the anaesthetist’s workload. The chapter serves both as an aide-memoire for those who are not regular practitioners in obstetric anaesthesia and as a guide to adapting your practice in low-resource settings. It contains practical advice on analgesia in labour and anaesthesia for Caesarean section, including spinal, general anaesthesia, and local anaesthesia techniques. It contains advice on drug alternatives in the absence of commonly used obstetric drugs, e.g. spinal bupivacaine. There are also sections on management of pre-eclampsia and obstetric haemorrhage, both of which are commonly encountered in low-resource settings. Neonatal resuscitation and non-obstetric surgery in the pregnant patient are also covered.

Paediatric Anaesthesia

In high-resource settings most paediatric anaesthesia is undertaken by specialist or subspecialist practitioners. In remote and resource-poor settings it is usual for anaesthetists to care for all ages of patient, and paediatrics can therefore form a large part of the non-specialist’s workload. The chapter contains essential knowledge for the non-specialist paediatric anaesthetist, including equipment sizing, drug doses, and fluid therapy, mostly in handy ‘quick-look’ tables. The presentation and management of common perioperative comorbidities such as malnutrition and sickle cell anaemia are also discussed. The bulk of the chapter covers practical advice on anaesthesia for a range of common paediatric and neonatal surgeries.