From the Department of Anesthesia and Intensive Care, St Olav's Hospital, Trondheim, Norway.
Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
Anesth Analg. 2018 Jun;126(6):2056-2064. doi: 10.1213/ANE.0000000000002733.
Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe.
In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization.
The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were <5%. The estimated institutional maternal mortality ratio was 573 (provincial), 251 (district), and 211 (mission hospitals) per 100,000 live births. Basic monitoring equipment (oximeters, electrocardiograms, sphygmomanometers) was reported available in theatres. Several unsafe practices continue: general anesthesia without a secure airway, shortage of essential drugs for spinal anesthesia, inconsistent use of recovery area or use of table tilt or wedge, and insufficient blood supplies. Postoperative analgesia management was reported inadequate.
This study identified areas where anesthetic provision and care could be improved. Provincial hospitals, where district/mission hospitals refer difficult cases, did not have the higher level anesthesia expertise required to manage these cases. More intensive mentorship and supervision from senior clinicians is essential to address the shortcomings identified in this survey, such as the implementation of evidence-based safe practices, supply chain failures, high maternal morbidity, and mortality. Training of medical officers and NAs should be strengthened in leadership, team work, and management of complications.
剖宫产术是中低收入国家最常见的手术，因此可以根据该手术评估麻醉服务的提供情况。本研究旨在评估在津巴布韦的省级、地区级和教会医院进行剖宫产时使用的麻醉类型、麻醉提供者的培训水平，并记录基本麻醉药物和设备的供应情况。
在这项针对 8 所省级、21 所地区级和 13 所教会医院的横断面调查中，使用世界麻醉医师学会和世界卫生组织制定的标准工具改编的结构化问卷，对现场麻醉提供者进行了访谈。
参与本调查的医院麻醉人员构成中，22%为医师，77%为护士麻醉师（NAs）；55%的 NAs 被认为是独立的麻醉提供者，26%是麻醉提供者的助手，19%没有接受过麻醉方面的正规培训。唯一的专科麻醉医师在一家省级医院兼职。在接受访谈前的 3 个月内，81%的剖宫产手术采用了椎管内麻醉，19%采用全身麻醉，其中 4%为无气管插管的氯胺酮。机构剖宫产率的平均值为活产儿的 13.6%，但有 5 家地区医院低于 5%。据估计，机构孕产妇死亡率为每 10 万活产儿 573（省级）、251（地区级）和 211（教会医院）。手术室报告配备了基本监测设备（血氧计、心电图仪、血压计）。一些不安全的做法仍在继续：全身麻醉无安全气道，椎管内麻醉基本药物短缺，复苏区使用不一致或使用倾斜或楔形物，血液供应不足。术后镇痛管理报告不足。
本研究确定了可以改进麻醉服务和护理的领域。省级医院接收地区/教会医院的疑难病例，但缺乏管理这些病例所需的较高水平的麻醉专业知识。必须通过资深临床医生进行更密集的指导和监督，以解决本调查中发现的问题，例如实施基于证据的安全做法、供应链故障、高孕产妇发病率和死亡率。应加强对医师和 NAs 的培训，以提高领导力、团队合作能力和并发症管理能力。
