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O RIGINAL ARTICLE

Anesthesia for Children With Craniofacial Abnormalities in the Developing Countries: Challenges and Future Directions

Ann M. Melookaran, MD, Sirisha A. Rao, MD, Sible B. Antony, MD, and Adriana Herrera, MD

Abstract: Interest in global health to provide safer pediatric surgical care in developing countries has increased during the last decade. A collaborative effort between surgeons and anesthesiologists has pro- vided the opportunity to deliver specialized care to children, particu- larly in the areas of cleft lip and palate repair. However, medical resources, facilities, and adequately trained personnel, especially in pediatric anesthesia, are often limited in these countries. Challenges, educational efforts, and future directions for the globalization of anesthesia are discussed. Involvement of international entities may help raise awareness, channel efforts, expand programs and encourage volunteerism to ultimately provide safer care to pediatric patients, have better outcomes and reduced anesthesia-related morbidity and mortality.

Key Words: Anesthesia in developing countries, anesthesia training, craniofacial abnormalities, global health, medical missions, pediatric anesthesia

( J Craniofac Surg 2015;26: 1069–1072)

C raniofacial abnormalities are a diverse group of complex congenital defects that affect the face and head. Approxi-

mately, 1 case of orofacial cleft occurs in every 500–550 births, with variations in prevalence among different ethnic groups, geo- graphic distribution and socioeconomic classes. According to the Centers for Disease Control and Prevention, there are about 2651 babies born with cleft palate and about 4437 babies born with cleft lip with or without cleft palate annually in the United States. 1 Providing pediatric anesthesia in the United States for these patients with greater complexity is done regularly. There are even centers that specialize in these patients around the country. This is not the case in the developing world. Several international organizations that have traveled to developing countries for surgical missions have provided insight into the unique challenges they met in providing and optimizing anesthetic care for these patients. Countries may be classified according to their Gross National Income (GNI) per capita per year. Countries with a GNI of US$ 11 905 and less are classified to be developing countries. 2 They are

distributed around the globe. In addition to lower income, these

From the Yale-New Haven Hospital, New Haven, CT. Received December 3, 2014. Accepted for publication December 9, 2014. Address correspondence and reprint requests to Ann Marie Melookaran, Yale Department of Anesthesia, 333 Cedar Street, TMP 3, P.O. Box 208051, New Haven, CT 06520-8051. E-mail: ann.melookaran@yale.edu There are no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001674

countries also have lower standard of living, lower life expectancy, and poorer education. Interest in global health awareness has increased in the last decade and has generated reflection into ways

to improve surgical care in the developing countries. Anesthesiol-

ogy involvement in this change is critical. Many efforts have been made by multiple groups around the world to try to find the best way to deliver specialized surgical care such as plastic surgery for patients with craniofacial and cleft lip/cleft palate abnormalities. The majority of cases are children and a priority to provide safe care to this population is crucial. The lack of trained personnel compromises the ability to provide appropriate medical care, which affects safety and outcomes. There is a need for anesthesiologists in the developing world. Promoting both anesthesiology and surgery is

essential as part of global health initiatives. The problem remains as

to how do we facilitate education, quality improvement, and assure

the effort is sustainable by the community. Volunteer medical trips to developing countries include a team of surgeons, anesthesiologists, and perioperative care providers who work together to deliver safe medical care. 3,4 It is well known

that access to specialized health care in developing nations is often limited or nonexistent. The challenges include the shortage of physician providers, the lack of adequately trained anesthesia providers with expertise in pediatric patients, and also the lack of adequate equipment and facility capabilities. 57 The training of the anesthesia providers in developing countries varies and the skills and abilities learned are not always standardized. Many of the anesthesia providers have not attended medical school or anesthesia residency, much less a pediatric anesthesiology fellowship. Instead, they have completed either a few months course, a shadowing experience, or are working under the supervision of a surgeon. 7 The problem is even more serious with neonatal anesthesia care. For craniofacial procedures such as cleft lip and cleft palate repairs,

a pediatric-trained anesthesiologist is preferred but not always

available; anesthesiologists experienced in the care of children may also help fill this need. 8,9 When complex craniofacial pro- cedures are to be performed a higher level of expertise from the anesthesia care team is recommended. Challenges regarding the facility capabilities and access are of constant concern when providing anesthesia in developing countries. 6 One of the major concerns in practicing in the devel- oping world is the reliability of electricity in hospitals. 10,11 This is especially critical when oxygen supplies are provided by an oxygen concentrator. Teams must ensure there is a backup plan in place if electricity is cut off. 11 This is not an uncommon scenario around the developing world. Many surgical protocols have been described based on age, weight, and the extent of the craniofacial surgical procedure. The anesthetic technique varies based on the age, expertise, equipment, medication availability, and the facility capacity. 35,12,13 Monitor- ing equipment is often limited in host countries. Medications are scarce and medical supplies such as endotracheal tubes, facemasks, oral airways, nasal airways are frequently disinfected and reused because of limited resources. 4,5,10,11,14 Anesthesia machines are

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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Melookaran et al

The Journal of Craniofacial Surgery Volume 26, Number 4, June 2015

usually in short supply or unreliable and other techniques such as total intravenous anesthesia or regional anesthesia may be preferred. Challenges are also encountered in postoperative care. Limited staff, lack of training in complication management and postopera- tive pain control, constrained resources, and lack of monitoring and resuscitation equipment are to be considered. 4,11,12,14 The neonatal group brings additional challenges. Limitations include lack of not only personnel with adequate training but also specialty equipment. Safety is the primary concern and appropriate knowledge about medications and resuscitation in this age group is critical. Other considerations include the long-term effects of surgery on a neo- nate, the occasional need for a neonatal ICU, or trained personnel in the recovery room, as well as long-term follow-up and management of these children. 14

ANESTHESIOLOGY AND GLOBAL HEALTH

There is a recognized need and desire to assist in the delivery of surgical care, especially to children, in countries where there are scarce clinical resources and a deficiency of trained subspecialty surgeons. 15,16 Providing safe anesthesia in developing countries although difficult will contribute to reduced morbidity and mortality in these countries. During the years, many models of assistance and surgical or anesthesia partnerships have been described in the literature, describing services and education con- cepts that may be afforded by low-income nations. 16 The goal of many of them has been to create opportunities for service, edu- cation, and self-sustainability. Most of the models have been successful, demonstrating there is probably not a unique solution. As global health practitioners, it is important to recognize and accept that our interactions will be influenced by local cultural, historical, socioeconomic, and educational issues. This can con- tribute to the success or failure of these initiatives. Being sensitive to these differences will allow for a better understanding between local communities and visitors and generate less conflict. There will be a bidirectional learning experience 17 and a close collaboration that will affect positively any effort.

Medical Supplies and Equipment

The availability of anesthesia machines in developing countries may be limited, broken, poorly maintained, or even obsolete. The development of anesthesia machines that can be safely used in remote locations, or places with scarce resources where there is no reliable oxygen supply or electricity, is indispensable. Development of the Glostavent anesthesia machine (Diamedica (UK) Ltd., Devon, United Kingdom) for developing countries 18,19 is to be applauded. It allows providing inhalational anesthesia without a compressed gas supply. This machine will continue to function during an interruption of electricity or oxygen supply. It has been modified during the years with the input of anesthesia providers that have used it in hostile conditions. A portable version is available and is now widely accepted for use in both adult and pediatric patients in the operating room and as a ventilator in recovery room areas and ICUs. Equipment development like this will help anesthe- sia providers to administer safer care. The lack of appropriate monitoring equipment in developing countries is enormous. The American Society of Anesthesiologists (ASA) also took an initiative to improve anesthesia safety world- wide in 2009 by forming the Global Humanitarian Outreach (GHO) Committee. One of the GHO programs through the ASA is the Lifebox program. 20 This program was started in 2010 after a collaboration of the WHO, World Federation of Societies of Anaesthesiologists (WFSA), the Harvard School of Public Health, and the Association of Anaesthetists of Great Britain and Ireland. 6 In the United States, it is led by a team of ASA volunteers that

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provide pulse oximeters as well as training for their use in patient monitoring in low- and middle-income countries. Each Lifebox costs $250, which includes training materials for classrooms and self-learning. Between 2013 and 2014, the GHO sent volunteers to Guatemala, Nicaragua, Bolivia, and Guyana to help fill the pulse oximeter gap. Many anesthesia societies around the world have joined and supported this effort. Another extremely important challenge is related to lack of supplies. Initiatives such as REMEDY (Recovered Medical Equip- ment for the Developing World) started in 1991 by Dr. William Rosenblatt, an anesthesiologist at Yale University, is a non-profit organization that works to promote nationwide recovery of opened but unused surplus surgical supplies. Its goal is to help reduce waste and distribute these supplies with teaching packets about the recovery process to areas of need. 21 They have also helped imple- ment this program in many hospitals around the country. Protocols for recovery and which supplies can and should be recovered can all be found on the REMEDY website as well as teaching packets and recommendations.

Outcomes and Quality Improvement

Standards for volunteer missions are essential for successful and safe trips. 4,5,8,9 Volunteer missions are rewarding experiences for many surgeons and anesthesiologists but such efforts require appro- priate planning to guarantee providing the best surgical and anes- thetic care. Politis et al 8 in conjunction with the Society of Pediatric Anesthesia (SPA) published the anesthesiology guidelines for care of children in developing countries. These were reviewed and endorsed by the boards of the American Society of Plastic Surgeons, the Plastic Surgery Educational Foundation, the SPA, the American Cleft Palate Craniofacial Association, the American Society of Maxillofacial Surgeons, European Society of Plastic, Reconstruc- tive and Aesthetic Surgery, and the American Association for Hand Surgery, Interplast, Operation Smile International and Smile Train. Those guidelines can be found in ‘‘Guidelines for the Care of Children in the Less Developed World.’’ 8 In addition, Schneider et al. published the plastic surgery guidelines for providing care to children in developing countries. These were reviewed and approved by the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation, and the SPA. There are presently many professional organizations that help organize and support such volunteer efforts and these documents are a source when planning an international mission trip. Even though many of the short-term trips are not the ideal way to approach globalization, there is still value to surgical missions that focus on specific surgeries such as cleft lip/cleft palate, especially in communities with extreme poverty that cannot have access to any specialized care. 15 In the long term, as new efforts for access to specialized surgical and anesthetic care are being addressed by the WHO and the WFSA, finding ways to integrate short-term trips into a bigger model would be optimal. Over time, many types of partnerships between developing countries and the developed world have been established, all in an effort to globalize health and find ways to empower communities to sustain education and offer better and safer care to their own people. One of the present obstacles when trying to improve the standards and quality of care in developing countries is the need for more robust data collection to identify deficient areas and outcomes. Fisher et al 5 was one of the first large scale cohort analysis that looked at anesthesia outcomes and established areas of quality improvement in such medical missions, specifically Oper- ation Smile. Some of the barriers identified included a lack of accountability with variability in charting and reporting, poor

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# 2015 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Anesthesia and Craniofacial Abnormalities

volunteer screening in terms of level of expertise and adaptability, and the lack of standards for monitoring, charting, and reporting

adverse events. In 2005, Operation Smile took an initiative to better account for critical events by establishing an electronic medical record with the ability to retrospectively evaluate cases from

previous missions.

In 2012, Bainbridge et al 23 presented an

assessment of perioperative and anesthetic-related mortality in developed and developing countries. They showed a decline in perioperative mortality, although the decline was much more significant in developed countries. This confirms that there is a big discrepancy between the developed and developing countries and there is a need for global health improvement to help reduce this gap. It was recommended that every organization should have a way to collect data regarding critical events, anesthesia quality markers,

and surgical complications. 9 This data can be later used for devel- oping plans to improve quality of care, safety, and outcomes.

4,5,22

Education

Many developing countries have less than 1 anesthesiologist per 100 000 people. 17 Children that undergo anesthesia should be managed by anesthesiologists whose competence in pediatric anesthesia is adequate. When thinking about quality improvement and outcomes, education becomes a crucial piece. The degree of expertise in anesthesia has affect on quality of care and safety. Complications such as intraoperative cardiac arrest are significantly lower in pediatric patients anesthetized by a pediatric anesthesiol- ogist; however, the educational level is low for both physicians and nonphysicians in many countries. There is evidence that life-saving interventions can be delegated to midlevel health care workers, but only if they are appropriately educated and trained. 24 Projects to expand education and anesthesia training have been started around the world. We describe some of the efforts below. The Overseas Teaching Program (OTP) was established in 1990 by The ASA to address the need to train anesthesia providers in Africa at a time when there was 1 anesthesiologist for several million people. Since its establishment, the OTP has supported educational programs in Ghana, Rwanda, Tanzania, and Zambia. These programs evolved to become a collaboration with the WFSA. Today, the Rwanda program remains supported by the ASA; however, this commitment is expected to end in 2015 as the ASA tries to expand the program to other countries. 17 The WFSA has developed a pediatric fellowship in which groups of anesthe- siologists are being trained in Chile, Rwanda, Tunisia, India, Kenya, and South Africa. 7,14 The goal of the WFSA fellowship is to expose these clinicians to pediatric scenarios they will eventually encounter in the own country with limited resources. At the end of their training, the physicians return to their home country with the ability to train more anesthesiologists in craniofacial abnormalities. The GHO has also collaborated with a number of medical schools to facilitate their mission. The Medical University of South Carolina and University of Virginia send residents and faculty throughout the year to Weill-Bugando Center in Mwanza, Tanza- nia, for a continuing anesthesia education program. Residents are supervised by senior faculty but take on the responsibility for providing anesthesia education both in the operating room as well as the medical school. The hope is to eventually develop and sustain an anesthesiology residency program. Many residency programs around the country including Yale, our residency program, have a long history of mission trips with opportunities for residents supervised by faculty to join voluntary missions. Their experience may vary from group to group but residents still have the oppor- tunity to share teaching experiences inside and outside the operating room in the visiting countries.

Another interesting program for trainees is the traveling fellow- ship for senior anesthesiology residents offered by The Society for Education in Anesthesia (SEA) and Health Volunteers Overseas (HVO). 2527 Residents spend 3–4 weeks in a developing country providing anesthesia education, including helping providers in the host country develop quality assurance tools, track progress, and collect outcomes data. The SEA-HVO presently has active projects in Blantyre, Malawi, and Ho Chi Minh City, Vietnam. HVO also has a number of programs to expand nurse anesthetists within Belize, Bhutan, and Cambodia. Access to general medicine books, anesthesia-specific books and journals may be difficult and limited. The use of multimedia tech- nologies allows information and education to be available to more people and countries; however, not every place has access to this technology. In other areas, the lack of reliable electricity makes this effort even more difficult. Educational videos for skills and pro- cedures, lectures, resuscitation modules, group discussions, and interactive learning are tools that can be used. This can also be a way to provide continued medical education and start considering accreditation. Only after providing better training tools and improv- ing medical knowledge, can expectations for changes in the standards for providing safer care be addressed. Many institutions already have these types of programs that are shared with developing countries. An initiative by the WFSA is to create a ListServ account with the University of Ottawa. It will allow them to have hundreds of participants worldwide. 24 Their plan is to use an e-mail based system that guarantees timely replies and consultation about upcoming complex cases and debriefing of cases. Other uses would include discussions about issues relevant to pediatric anesthesia globally. 24 Without doubt, exchanges like these would facilitate collaboration and multidisciplinary team work. Once this type of collaboration is widespread, we may see safer care with a reduction in anesthesia- related mortality. Earlier, it was stated that pediatric and neonatal population requires practitioners with a level of expertise and adequate resus- citation skills to deliver safer care. The training that many prac- titioners have in developing countries is mainly for the adult population. In many places, younger children do not receive any surgical care because of this lack of pediatric anesthesia expertise. To lead our specialty in globalization of anesthesia, WFSA has supported some programs in education. One of the programs WFSA supports is ‘‘SAFE Paediatrics’’, a 3-day course for anesthetists (physicians and nonphysicians) working in developing countries to enhance their skills in providing quality pediatric anesthesia care. Opportunities for research are many. Health providers trained in developed countries can contribute to research in areas of patient advocacy, medical education, health systems, policy making and changes, equipment design, funding initiatives, and many others. In many countries, health care, and especially anesthesia delivery in pediatric population, is not a priority. There is a need to raise awareness of this problem and promote community involvement. Once this process is started, opportunities for research may increase as there will be a better support system, ability to create databases, follow patients, and even funding sources that will facilitate this effort. Steps to create sustainable globalization changes will need to be more profound. Some of those steps have been taken in many developed countries. Awareness needs to be raised in all of the younger generations of physicians in training that will help in this health globalization process. Medical schools around the country are more frequently offering international experiences in develop- ing countries. As an example, Yale University and their Yale Global Health Initiative has involved the medical school as well as many of their other schools in the university. This is a great way to generate enthusiasm and interest for more physicians and nonphysicians to join this project and take leadership roles in time.

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CONCLUSION

Globalization of safe health care around the world is a priority; however, this will be a slow and long process. We should not feel discouraged but indeed we should be motivated. To succeed and sustain, many people and parties must be committed. Charity and funding must continue to be encouraged. Volunteers need to be continually recruited. All of these efforts will facilitate campaigns and raise awareness of the need for anesthesiologists, especially pediatric anesthesiologists in developing countries. International entities can also support educational initiatives, help with funding and improving the opportunities for globalization. Entities such as WHO and WFSA can help organize and channel efforts. Education and recruitment of younger generations of physicians and nonphy- sicians will contribute in the process. They will be the ones leading our specialty and who will continue any endeavors that have already started and the new ones to come. As health care providers, educators, and volunteers, we are constantly challenged, working toward improvements in how we provide safer and higher quality care with better outcomes. Our surgical colleagues are looking into ways to provide better and safer surgical care; providing safer and expert anesthesia care needs to be part of that. Globalization of anesthesia is a huge task. Anesthesiologists should be active participants in this process and not just spectators.

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# 2015 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.