From the Department of Anesthesia, Mercy Ships, Port of Toamasina, Toamasina, Madagascar.
Department of Anesthesia, Great Ormond Street Hospital for Children, London, United Kingdom.
Anesth Analg. 2018 Aug;127(2):506-512. doi: 10.1213/ANE.0000000000003512.
Two-thirds of the world's population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined. Little is known concerning the incidence of anesthesia complications. Mercy Ships uses fully trained staff, and infrastructure and equipment resources similar to that of high-income countries, allowing the influence of these factors to be disentangled from patient factors when evaluating anesthesia and surgical outcomes after NGO sponsored surgery. We aimed to estimate the incidence of anesthesia-related and postoperative complications during a 2-year surgical mission in Madagascar.
As part of quality assurance and participation in a new American Society of Anesthesiologists Anesthesia Quality Institute sponsored NGO Outcomes registry, Mercy Ships prospectively recorded anesthesia-related adverse events. Adverse events were grouped into 6 categories: airway, cardiac, medication, regional, neurological, and equipment. Postoperative complications were predefined as 16 adverse events and graded for patient impact using the Dindo-Clavien classification.
Data were evaluated for 2037 episodes of surgical care. The overall anesthesia adverse event rate was 2.0% (confidence interval [CI], 1.4-2.6). The majority (85% CI, 74-96) of adverse events occurred intraoperatively with 15% (CI, 3-26) occurring in postanesthesia care unit. The most common intraoperative adverse event, occurring 7 times, was failed regional (spinal) anesthesia that was due to unexpectedly long surgery in 6 cases; bronchospasm and arrhythmias were the second most common, occurring 5 times each. There were 217 postoperative complications in 191 patients giving an overall complication rate of 10.7% (CI, 9.3-12.0) per surgery and 9.4% (CI, 8.1-10.7) per patient. The most common postoperative complication was unexpected return to the operating room and the second most common was surgical site infection (39.2%; CI, 37.0-41.3 and 33.2%; CI, 31.1-35.3 of all complications, respectively). The most common (42.9%; CI, 40.7-45.1) grade of complication was grade II. There was 1 death.
This study adds to the scarce literature on anesthesia outcomes after mission surgery in low- and middle-income countries. We join others in calling for an international NGO anesthesia and surgical outcome registry and for all surgical NGOs to adopt international standards for the safe practice of anesthesia.
世界上有三分之二的人口无法获得安全的麻醉和外科护理。非政府组织（NGO）在弥合这一差距方面发挥着重要作用，但外科手术结果存在差异。在复杂手术后，报告的术后并发症发生率高达 20 倍，不良结果的原因尚不清楚。关于麻醉并发症的发生率知之甚少。“仁慈”号船使用的是经过全面培训的工作人员，基础设施和设备资源与高收入国家相似，这使得在评估 NGO 赞助手术后的麻醉和外科手术结果时，可以将这些因素与患者因素区分开来。我们旨在估计马达加斯加为期两年的外科手术任务中与麻醉相关的并发症发生率。
作为质量保证的一部分，并参与美国麻醉医师协会麻醉质量协会赞助的 NGO 结果登记处的新研究，“仁慈”号船前瞻性地记录了与麻醉相关的不良事件。不良事件分为 6 类：气道、心脏、药物、区域、神经和设备。术后并发症被预先定义为 16 种不良事件，并使用 Dindo-Clavien 分类法对患者的影响进行分级。
对 2037 例外科护理的情节进行了评估。总体麻醉不良事件发生率为 2.0%（置信区间[CI]，1.4-2.6）。大多数（85%CI，74-96）不良事件发生在手术期间，15%（CI，3-26）发生在麻醉后护理病房。最常见的术中不良事件是 7 次失败的区域（脊髓）麻醉，其中 6 例是由于手术时间过长；支气管痉挛和心律失常是第二常见的不良事件，各发生 5 次。191 名患者中有 217 名发生术后并发症，手术总体并发症发生率为 10.7%（CI，9.3-12.0），患者总体并发症发生率为 9.4%（CI，8.1-10.7）。最常见的术后并发症是意外返回手术室，第二常见的是手术部位感染（39.2%；CI，37.0-41.3 和 33.2%；CI，31.1-35.3 分别占所有并发症的比例）。最常见（42.9%；CI，40.7-45.1）的并发症等级为 2 级。有 1 例死亡。
本研究增加了关于在中低收入国家进行使命手术后麻醉结果的稀缺文献。我们与其他人一起呼吁建立一个国际 NGO 麻醉和外科手术结果登记处，并呼吁所有外科 NGO 采用国际安全麻醉实践标准。
