COVID-19 pandemic in west Africa Martinez-Alvarez, Melisa; Jarde, Alexander; Usuf, Effua ...
The Lancet global health,
05/2020, Letnik:
8, Številka:
5
Journal Article
WHO defines universal health coverage (UHC) as “access to needed essential health services, without financial hardship”.1 UHC requires about US$100 per head for an essential package of 218 ...interventions, and approximately $50 per head for a basic package of 108 of the highest priority interventions.2 Yet, estimates in 2016 suggested that only nine of the 49 low-income and middle-income countries (LMICs) could afford the essential package, and that 16 countries could afford the 108 highest priority interventions of the basic package.2 At an average government spend on health in low-income countries of only $9 per head in 2018 (1·2% of Gross National Product), literally every cent counts.3 Surgical care is an indivisible component of UHC,4 yet the outcomes in low-income countries are poor.5,6 Provision of quality surgical care in these countries is difficult because resources and finances are limited. Surgical site infections (SSI) predominate perioperative complications,6 with a higher burden and more antibiotic resistance in low-income countries.9 The need for appropriate global guidelines for prevention of SSI is therefore important.10 However, some recommendations are based on little evidence, with a negative financial effect in low-income countries. Similar to FALCON, evidence is needed to challenge other controversial practice guidelines in low-income countries, such as the WHO recommendation for the use of liberal inspired oxygen concentrations of 80% during surgery to prevent SSI.11,12 The retraction of several trials has raised further concerns regarding the evidence base.13 The COVID-19 pandemic has highlighted the importance of oxygen as a scarce health-care resource, emphasising the need to establish the evidence for the recommendation for liberal inspired oxygen to prevent SSI.
The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric ...hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown.
This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used.
Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio aOR, 1.093; 95% confidence interval CI, 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 1.2% vs 3/2968 0.1%, P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 9.8% vs 73/2669 2.7%, P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality.
Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.
There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing ...anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death.
A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included.
Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval CI) of 8.3 (2.7-25.6).
The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.
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