Access to Safe Pediatric Anesthesia in LMICs-The Problem Is Clear; It Is Time to Solve It!

Pediatric Perioperative Mortality in Southeastern (SE) Nigeria-A Multicenter, Prospective Study

BACKGROUND

The perioperative mortality rate is a key indicator of the quality of surgical services in low and middle-income countries (LMIC). Objective: To determine the perioperative mortality rate of pediatric surgical conditions and the predictive factors in Southeastern Nigeria. Methodology: A prospective, multicenter study of peri-operative mortalities occurring in children under 18 years in five tertiary hospitals in Southeastern Nigeria over nine months was conducted. All-cause and case-specific in-hospital peri-operative mortality rates, as well as predictive factors, were identified. The mortality rate was expressed as percentages with a 95% confidence interval. The data were analyzed using SPSS 26.

RESULTS

A total of 775 patients underwent anesthesia or surgery, with 28 deaths. The 30-day perioperative mortality rate was 3.61% (95% CI = 2.41- 5.18); 1.94% (95% CI = 1.09-3.17 within 24 hours, and 1.17% (95% CI = 0.91-2.91) from 24 hours to 30 days after the procedure. The mortality rate was 100% for gastroschisis and ruptured omphalocele, with overwhelming sepsis being the major cause of death (53.6%). Significant determinants of mortality were a higher ASA status (AOR)=13.944, 95% CI=1.509-128.851, p=0.020, sedation without ventilatory support (AOR)=15.295, 95% CI=3.304-70.800, p=0.001, and associated comorbidities (AOR)=65.448, 95% CI=11.244-380.962, p=0.001.

CONCLUSION

The pediatric peri-operative mortality rate in Southeastern Nigeria is high for gastroschisis. Associated comorbidities, higher ASA status, and sedation without ventilatory support were significant predictors ofmortality.

Incidence of complications after nonoperating room anesthesia in children in a low- and middle-income country: A prospective and observational study

INTRODUCTION

Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low- and middle-income countries.

AIMS

The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors.

METHODS

In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low- and middle-income country. Patients were divided into two groups: complications or no-complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications.

RESULTS

We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia-related morbidity were: critically-ill children (aOR = 2.490; 95% CI: 1.55-11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017-31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55-613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080-0.867).

CONCLUSIONS

The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high-risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies.

Children's Anaesthesia and perioperative care challenges, and innovations

The 2015 Sustainable Development Goals emphasise good health to all with reduced inequalities, and surgical and anaesthesia care is essential to achieve these. https://sdgs.un.org/goals. However, it has been estimated that 1.7 billion children do not have access to safe anaesthesia and surgery when needed and this disproportionately affects children in low- and middle-income countries (1). It is alarming that 1 in 10 individuals in LMICs do not have access to safe surgical care. Both safe surgery and anaesthesia are essential for ensuring that individuals receive proper medical attention. Economically viable public health initiatives that can avert many disability-adjusted years are needed. (2-4) Morbidity and mortality from surgical disease and anaesthesia care remain high in low-income countries, unlike in high-income countries. The incidence of severe anaesthesia-related critical events and perioperative cardiac arrest is between three and ten times more in LMICs than in HICs (5-7) A baseline POMR that is 100 times higher in LMICs compared to HICs is reported. (8) This perioperative morbidity and mortality gap is more evident in neonates and younger age groups, especially in children with congenital abnormalities. The challenges facing providers of anaesthesia and perioperative care are multifactorial and include but are not limited to the inadequate workforce, inadequate and inappropriate infrastructure, lack of adequate and appropriately sized equipment, including monitors, and safe monitoring capacity, supply chain challenges for medicines and reusable consumables, unreliable supply of oxygen and blood products, lack of data and research for policy formulation, inadequate resource allocation from governments and lack of safety culture among other things. In paediatrics, this is further multiplied by the variability in the sizes of the patients, from neonates to older children (9).