Case Note: Monday Sept 20, 2010 (2067/6/4) 54 yrs male of 60kg, suffering from pain in left loin with urinary problem, elective caseSurgical plan: ‘pyelolithotomy’ of left side Surgical time 76 minutes, Maintenance uneventful andRecovery smooth.
15th wca 2012 ppt
Dr RB Rana and Team Nepal
Dr Rana RB, Dr Manandhar ML, Mr Shrestha Naba RajNational Academy of Medical Sciences, Kathmandu, Bagmati Zone: Nepal (ASIA)
Nepal is a land-locked Asian country which borders India to its east, south and west and China to its north. It covers an area of 147,181 km2 and varies between an altitude of 60 m and 8,848 m (Mt Everest). Current population 27.5 million (2010 projected) with an annual growth rate of 1.94 per cent (CBS 2009)1.
MMR (2010 survey) as 229/100,000 live births. (by training to community worker & doctors) MDG5 target for 2015 is to reduce 213. Among these deaths, some 41% occur in a health facility (FHD 2009). Workup: ◦ Producing doctors capable of providing obstetric care including c-section and ◦ Producing anesthesia assistant to provide anesthesia under supervision in health facility of remote areas.
Anesthesia assistants (AA) are paramedical staffs working under the government with three years medical science background and at least 6 months anesthesia assistant training. Now AA training is of one year duration with the same background since 2011. These attempts will help expand and strengthen Comprehensive Emergency Obstetric Care sites in different areas of need. Nepal is also attempting to improve access to surgical services to the remote areas by availing an anesthesia machine which is affordable, simple to use, and requiring easy maintenance. We evaluated the appropriateness and user friendliness of the Universal Anesthesia Machine (UAM) in our context.
UAM2 is a simple anesthetic British Standards3 work station that looks familiar with clear layout. The key differences from a standard Boyles machine are the oxygen concentrator, drawover vaporizer, breathing bellows and balloon valve. The system provides continuous anesthesia flow, reverting to drawover mode if air is entrained or if electricity fails (O2 concentration stops), with the vaporizer and bellows continuing to function as normal. In both modes, oxygen can alternately be supplied via cylinder, central line or the side emergency inlet. Almost all parts are designed to require minimum or no services for maintenance4.
• To assess the functions of the UAM in terms of reliable oxygen supply, anesthetic agent flow, breathing system and scavenging system and• To assess the user friendliness,
Four UAM machines provided by the NICK SIMONS’ Foundation, New York were distributed to four different hospitals (two central and two peripheral hospitals) of Nepal. Three to five days orientation to at least one qualified anesthesiologist and anesthesia assistants of each of individual sites were oriented with didactic and live demonstration. All the users were also oriented with an evaluation system by recording in the pre-set form. The readymade forms contained the patients demographic information, surgical details, oxygen monitor findings, airway management, breathing circuit types and maintenance and recovery details as shown in the table below.
A team of anesthetist, biomedical technician and administrator carried out follow-up visited to each site every two months. Continuous communication was maintained between follow-up visits through email and phone calls to help for any problem and their management. Adequate forms to record various parameters of patient and the machine were also made available. At the end of the study period, three user anesthesiologists and 8 user AAs were asked to rate the user perspective of layout and setting up of machine and also the UAM response to patients variables as shown in figure 6. Collected records were finally analyzed.
Age (yrs) / Sex Distribution 294300250200 128150100 36 38 30 50 6 10 11 21 20 21 19 2 0 0 <1 1-5 6-10 10-15 16-50 51-60 >60 Male Female
Total case 641 in 6 months and one week. Figure 1 shows: ◦ smallest patient was of 22 days and ◦ oldest is 85 years old. Elective 69% and 31% found as emergency. Figure 2 shows ◦ Gen Surg 35% ◦ Obstetric 17% were obstetric Figure 3: ◦ The original bellow was used in majority of the cases ◦ Ayre’s T-piece and Bain’s circuit Maintenance aurnd recovery of patients are shown in figure 4 & 5. Oxygen saturation in elective and emergency patients are shown in figure 6. The user evaluation of the machine and the patient parameter are shown in figure 7 and 8.
It may be too early to conclude the evaluation of UAM and its usefulness. However, the result clearly favors the acceptability of the UAM due to its simplicity, safety, reliability and functionality. It can be easily oriented within a week and can be used confidently. Most of the user commented about the handheld bellow which sticks the user with the machine and patient (favoring ASA standard I monitoring).This initial impression to the UAM is very positive in Nepal’s context. It is reliable in terms of oxygen supply system, vaporizer and use of a variety of breathing circuits. Its simplicity, versatility and negligible maintenance cost having continuous flow and combined drawover system in different geographic locations (remote area) are attractive features to any resource limited areas to serve quality anesthesia in comfortable way.
1. Nepal Millennium development goals report, Progress report 2011.2. Fenton PM. Maternal deaths and anaesthesia technology in the 21st century. Anaesthesia News 2010; 273: 5-83. AAGBI (2009) Section 4: Standards. In: Safe Management of Anaesthetic Related Equipment. AAGBI, London: 8-94. OES Medical (2010) Universal Anaesthetic Machine User Manual CE 0120 Doc 1973- 510