Economic, health care, and anesthesia workforce status in Cambodia
The financial resources allocated to health care are meager in Cambodia (see in additional file 1) [14-16]. Per capita spending on healthcare is 18 times greater in the United Kingdom than in Cambodia. Although the medical education model in Cambodia is identical to the Western model, the number of physician anesthesia providers per 100,000 population is only one-sixth that in the United Kingdom. Additionally, the proportion of anesthesiologists with qualified training experience is even lower.
Epidemiology of anesthesia service
The records of 1953 patients were included in the study, with 1792 (91.8%) receiving general and regional anesthesia in the operating room and 161 (8.2%) receiving sedation for gastrointestinal endoscopy in the outpatient operating room. The male: female sex ratio was 1.53:1.00, and the mean age was 45.0 ± 16.6 years (range, 17–87 years).
All the patients undergoing surgery were preoperatively assessed by a physician anesthetist. Ninety percent of patients had an American Society of Anesthesiologists grade of 1 or 2. The baseline investigations included an electrocardiogram (ECG) and blood tests for a complete blood count, blood group, coagulation function, electrolyte levels, and liver and kidney function.
The types of surgery performed are presented in Table 1. The three most common procedures were appendectomy, fracture reduction and internal fixation, and cholecystectomy. Emergency surgery accounted for approximately 37.3% of the procedures, and most were performed in patients with trauma or general peritonitis.
Table 1. Patients’ baseline characteristics and surgical procedures
Observations (Total n = 1953)
|
n or n (%, CI)
|
Agea
|
43 (32-57)
|
Age<60
|
1545 (79.1%, 77.0-81.2)
|
Age≥60
|
408 (20.9%, 18.8-23.0)
|
Gender
|
|
Male
|
1180 (60.4%, 57.9-62.9)
|
Female
|
773 (39.6%, 37.1-42.1)
|
Emergencyb
|
728 (37.3%, 34.7-39.9)
|
ASA grade
|
|
Ⅰ
|
1061 (54.3%, 51.7-56.8)
|
Ⅱ
|
711 (36.4%, 33.9-38.9)
|
Ⅲ
|
150 (7.7%, 6.4-8.9)
|
Ⅳ
|
31 (1.6%, 1.4-1.9)
|
Types of surgery
|
|
Abdominal surgery
|
931 (52.0%; CI, 49.3-54.7)
|
Orthopedic surgery
|
495 (27.6%; CI, 25.2-29.9)
|
Urological surgery
|
263 (14.7%; CI, 12.8-16.6)
|
Brain surgery
|
48 (2.7%; CI, 1.8-3.5)
|
Other
|
56 (3.1%; CI, 2.2-4.0)
|
Five most common surgical interventions
|
1258 (70.2%; CI, 67.8-72.7)
|
Appendectomy
|
414
|
Open reduction and internal fixation surgery
|
406
|
Cholecystectomy
|
175
|
Urological endoscopic surgery
|
159
|
Exploratory laparotomy
|
104
|
Abbreviations: ASA, American Society of Anesthesiologists; CI, confidence interval.
aData are presented as median values and IQR.
bEmergency refer to the patients received emergency surgeries in the operating room.
Anesthetic techniques
After the patient entered the operating room, the anesthesiologist was responsible for the peripheral venous puncture. Pulse oximetry and noninvasive blood pressure measurement were performed for intraoperative monitoring in all patients. ECG monitoring was rarely used during surgery. Capnography, measurement of body temperature, and monitoring of neuromuscular function were not used in any patients because of a lack of equipment.
General anesthesia was performed in 54.3% of the patients. The combination of diazepam and propofol was used for anesthesia induction, isoflurane was used for maintenance, succinylcholine and vecuronium were used for muscle relaxation, and fentanyl was used for analgesia. Compressed air and oxygen were supplied by cylinders. For all patients undergoing general anesthesia, tracheal intubation and mechanical ventilation were applied with an Aestiva/57900 anesthesia machine (Datex-Ohmeda Inc., Madison, WI, USA). The regional anesthesia techniques performed were mainly spinal and brachial plexus blocks. Epidural anesthesia was rarely performed because of the lack of needles and supplies. At the end of surgery, all patients who underwent regional anesthesia were immediately transferred to the surgical wards, and patients who underwent general anesthesia were observed in a recovery ward. Table 2 lists the five most frequent complications as described by the anesthetists surveyed.
Table 2. Details of anesthesia practice
Qualification of individual performing anesthesia
|
n or n (%, CI)
|
Physician (specialist) anaesthetist
|
4
|
Non-specialist physician anaesthetist (general physician background)a
|
10
|
Nurse anaesthetist
|
1
|
Types of anesthesia
|
|
General anesthesia
|
1059 (54.3%; CI, 51.7-56.8)
|
Spinal anesthesia
|
550 (28.2%; CI, 25.9-30.5)
|
Brachial plexus block
|
183 (9.4%; CI, 7.9-10.9)
|
Sedation for gastrointestinal endoscopy
|
161 (8.2%; CI, 6.8-9.6)
|
Medications and fluids commonly used
|
|
Intravenous hypnotic agent
|
Diazepam,Propofol
|
Volatile anesthetic agent
|
Isoflurane
|
Analgesic agent
|
Fentanyl
|
Muscle relaxant agent
|
Succinylcholine Vecuronium bromide
|
Local anesthetic agent
|
Lidocaine,Bupivacaine
|
Intravenous fluids agent
|
Crystalloids
|
Five most frequent perioperative anesthesia complicationsb
|
|
Hypoxia
|
14
|
Hypotension and Hypertension
|
12
|
Arrhythmia
|
12
|
Shivering
|
10
|
Anaphylaxis
|
8
|
Abbreviations: CI, confidence interval;
aA graduate of a medical school who has not completed a specialist training program in anesthesia but has undergone some anesthesia training; bComplications suggested by the anesthesia providers form the questionnaire, data are presented as the number of staff suggested, and the total number of staff surveyed is 15.
Anesthesia-related death
One death was recorded during the study period. A 50-year-old man undergoing surgery for lumbar disc herniation developed sudden cardiac arrest during anesthesia induction. The patient had no preexisting comorbidities. Preoperative monitoring and blood analysis excluded heart disease, hypovolemia (normal heart rate, blood pressure, and pulse oximetry plethysmographic waveform), acute anemia, and electrolyte disturbance as possible causes of cardiac arrest. No ECG or end-tidal carbon dioxide monitoring were being performed when the cardiac arrest occurred. Decreased oxygen saturation and hypotension were first detected after propofol bolus injection. No signs of cutaneous rash or edema were present. Immediately after the cardiac arrest, ECG monitoring, chest compressions, tracheal intubation, and mechanical ventilation were performed. Ventilation difficulty was detected with a rise in the peak airway pressure after intubation. Adrenalin and sodium bicarbonate were then administered via a peripheral vein during cardiopulmonary resuscitation. Return of spontaneous circulation was achieved after 30 minutes of resuscitation, and the patient was transferred while still intubated and ventilated to the intensive care unit with the support of vasoactive drugs. However, after 3 days of coma (Glasgow coma scale score of 3 on day 3), the family discontinued treatment and the patient died of circulatory failure after 7 days.
Compliance with ISPPA
According to the ISSPA-recommend checklists, items that did not meet the standards are listed in Tables 4 to 8. The overall inter-rater Kappa coefficient was 0.75, indicating substantial agreement between the two raters.
Professional aspects
With respect to professional aspects, the main problem was the lack of available time, facilities, and financial support for professional training of all anesthesia providers. Additionally, no incident-reporting system with case analysis for anesthesia quality control had been established. Because of the nationwide shortage of anesthesiologists, physicians often need to provide anesthesia services in out-of-hospital clinics; thus, the physicians often practice with undue fatigue (Table 3).
Table 3. Compliance with ISSPA on professional aspects
Item
|
Standards
|
Compliance
|
Professional Status
|
Anesthesia be provided, led, or overseen by an anesthesiologist
|
AM
|
|
Local and national standards should be consistent with the ISSPA
|
PM
|
Professional Training
|
Formal training in a nationally accredited (postgraduate) education program and documentation of training
|
PM
|
Number of Anesthesia Providers
|
The number of anesthesiologists must be adequate to ensure effective leadership of anesthesia services and delivery of care.
|
AM
|
Professional Organizations
|
Anesthesia providers should form appropriate organizations at local, regional, and national levels for the setting of standards of practice, supervision of training, and continuing education with appropriate certification and accreditation
|
PM
|
Quality Assurance
|
An anonymous incident-reporting system with case analysis resulting in recommendations for alterations in practice
|
NM
|
Workload
|
A sufficient number of trained anesthesia providers should be available so that individuals may practice to a high standard without undue fatigue or physical demands
|
PM
|
|
Time should be allocated for education, professional development, administration, research, and teaching
|
NM
|
Abbreviations: AM, always met; PM, partially met; NM, never met.
Equipment, medications, and monitoring
With respect to equipment and medications, the questionnaire results reflected the lack of supplies and equipment for ECG monitoring, defibrillation, end-tidal carbon dioxide measurement, body temperature measurement, and neuromuscular monitoring (Table 4). This severely limits the monitoring items that can be carried out during and after surgery (Table 5). This was coupled with a lack of commonly used anti-arrhythmia and cardiovascular active drugs (Table 6), making it difficult to handle emergencies such as difficult airways, arrhythmia, and allergic reactions.
Table 4. Availability of equipment according to ISSPA
Location
|
Always available
|
Sometimes available
|
Never available
|
Preoperative area
|
Dedicated space for preoperative assessment
|
|
|
Operating room
|
Adequate lighting
Tilting operating table
Supply of oxygen ( oxygen cylinders)
Oropharyngeal airways
Facemasks
Appropriate sized laryngoscope and laryngoscope blades for adult patients
Appropriate sized endotracheal tubes for adult patients
Suction device and catheters
Adult self-inflating bags
Equipment for IV infusions and injection of medications for adult patients
Equipment for spinal anesthesia or regional blocks
Sterile gloves
Stethoscope
Pulse oximeter
Electrocardiogram
Noninvasive blood pressure monitor with appropriate sized cuffs for adult patients
Work surface and storage for equipment and medications
System for delivering inhalational anesthesia (plenum)
Examination (nonsterile) gloves
|
Intubation aids (eg, Magill forceps, bougie, stylet)
Automated ventilator with disconnect alarm
Adult supraglottic airways
Infusion pumps
Intra-arterial blood pressure monitor
Temperature monitor (intermittent)
Warming blanket
|
Access to a defibrillator
Carbon dioxide detector
IV pressure infusor bag
Device for warming IV fluids, blood
Continuous waveform capnography
Peripheral neuromuscular transmission monitor (nerve stimulator)
Inhalational anesthetic concentration monitor
Temperature monitor (continuous electronic)
Intensive care ventilator
|
Postanesthesia recovery area
|
Adequate lighting
Supply of oxygen (cylinders)
Suction device and suction catheters
Facemasks
Electrocardiography
Pulse oximeter
Noninvasive blood pressure monitor with
appropriate sized cuffs for adult patients
Dedicated space for recovering patients
Examination gloves (nonsterile)
|
Adult self-inflating bags
Temperature monitor (intermittent)
|
Access to a defibrillator
|
Table 5. Compliance with ISSPA on intraoperative and postoperative monitoring
Items
|
Always Met
|
Sometimes Met
|
Never Met
|
Intraoperative Monitoring
|
Audible signals and alarms at all times
Continuous use of pulse oximetry
Intermittent noninvasive blood pressure monitoring
Continuous use of an electrocardiogram
Continuous measurement of inspired and expired gas volumes
Urine output monitoring (in appropriate cases)
|
Clinical observation by an appropriately trained anesthesia provider
Inspired oxygen concentration monitor
Disconnect alarm (when mechanical ventilator used)
Continuous measurement and display of arterial blood pressure (in appropriate cases)
|
Carbon dioxide detector for patients undergoing intubation
Device to prevent delivery of a hypoxic gas mixture
Intermittent temperature monitoring
Peripheral neuromuscular transmission monitor (when muscle relaxants used)
Continuous waveform capnographya for patients undergoing general anesthesia and deep sedation
Continuous measurement of inspired and expired inhalational anesthetic concentrations
Continuous electronic temperature monitoring (in appropriate cases)
Processed EEG in appropriate cases
|
Postoperative Monitoring
|
Continuous use of pulse oximetry
Intermittent noninvasive blood pressure monitoring
Urine output monitoring (in appropriate cases)
|
Clinical observation:
Tissue oxygenation and perfusion
Respiratory rate and quality
Pulse rate and quality
|
Assessment of pain score using age appropriate scale
Intermittent temperature monitoring
|
Table 6. Availability of medications according to ISSPA
Items
|
Always available
|
Sometimes available
|
Never available
|
Intraoperative medications
|
Ketamine
Diazepam
Fentanyl
Local anesthetic (Lidocaine, Bupivacaine)
Propofol
Thiopental
Isoflurane
Succinylcholine
Vecuronium
Neostigmine
|
Morphine
Sevoflurane
Rocuronium
Midazolam
|
Cisatracurium
Pancuronium
Atracurium
|
IV fluids
|
Saline
|
Mannitol
Ringer’s lactate
|
Plasmalyte
|
Resuscitative medications
|
Oxygen
Epinephrine
Atropine
Ephedrine
|
Hydrocortisone
Norepinephrine
Dopamine
Amiodarone
|
Dextrose
Metaraminol
Phenylephrine
|
Postoperative medications
|
Acetaminophen (paracetamol)
Tramadol
|
Morphine
Appropriate nonsteroidal anti-inflammatory medicine (eg, ibuprofen)
|
Gabapentin
Oxycodone
|
Other medications
|
Furosemide
Nitroglycerine
Hydralazine
|
Magnesium
Calcium chloride
Heparin
|
Salbutamol
Hydralazine
|
Conduct of anesthesia
With respect to the conduct of anesthesia, no safety checklist such as the World Health Organization safe surgery checklist was utilized during the whole process of care. When responsibility for care is transferred from one anesthesia provider to another, the process of handing over patient information is arbitrary. Still, postoperative administration of opioids and other analgesics depends mainly on the doctor’s habits rather than on assessment and certain analgesic modalities (Table 7).
Table 7. Compliance with ISSPA on conduct of anesthesia
Item
|
Standards
|
Compliance
|
Personnel
|
One anesthesia provider should be dedicated to each patient and be present in the anesthetizing location throughout each anesthetic.
|
AM
|
|
A trained assistant (operating room nurse or technician) should be available to assist the anesthesia provider
|
AM
|
|
The anesthesia provider is responsible for the transport of the patient to a suitable postanesthesia recovery area and the detailed transfer of care to an appropriately trained healthcare worker
|
PM
|
Preanesthetic Assessment and Consent
|
The patient must be assessed by the anesthesia provider prior to administration of anesthesia, preferably prior to entry into the operating room, and an appropriate anesthetic plan formulated and documented in the patient’s medical record
|
AM
|
|
Consent consistent with hospital policy, preferably written, should be obtained
|
AM
|
Preanesthetic Checks
|
The anesthesia provider must ensure that the facilities and personnel are adequate for the delivery of safe anesthesia and all medications and equipment (including the anesthesia machine delivery system) have been checked prior to commencing the anesthetic
|
AM
|
WHO Safe Surgery Checklist
|
The use of the checklist, appropriately modified for local conditions and priorities
|
NM
|
Record Keeping
|
A record of the details of each anesthetic should be made and preserved with the patient’s medical record
|
AM
|
Postanesthesia Care
|
All patients who have had an anesthetic (general anesthesia, moderate or deep sedation, regional anesthesia) should remain where anesthetized until recovered or be transported safely to a specifically designated recovery area for postanesthesia recovery
|
AM
|
|
The postanesthesia recovery area must be adequately staffed by healthcare workers trained to manage patients recovering from anesthesia and surgery
|
AM
|
|
Oxygen, suction, a means of ventilation (eg, self-inflating bag-mask system), and emergency resuscitation medications must be immediately available
|
PM
|
Transfer of Care and Delegation of Care
|
When responsibility for care is transferred from one anesthesia provider to another, or to a nurse or other healthcare worker, all relevant information about the patient’s history, medical condition, anesthetic status, and plan should be communicated to that person
|
NM
|
Pain Management
|
All patients are entitled to appropriate efforts to prevent and alleviate postoperative pain using appropriate medications and modalities
|
PM
|
Abbreviations: AM, always met; PM, partially met; NM, never met.
Anesthesia provider’s suggestions for safe anesthesia
Anesthesia providers were asked to make free-text comments about ways in which anesthesia safety could be improved in their hospital (Table 8). The main categories were improvements in equipment, availability of anesthetic drugs, access to reliable monitoring, and more training opportunities. These comments indicate that the anesthesia services had long been limited by the economic conditions of the region and that providers had difficulties in maintaining the safety of anesthesia with limited medical expense.
Table 8. Anesthetists’ suggestions and comments for making anesthesia safera
Suggestions
|
n
|
Better availability of anesthetic equipment eg. anesthesia machine
|
15
|
Better availability of monitors, eg. carbon dioxide detector
|
15
|
Better salary
|
14
|
Better availability of resuscitative drugs and equipments
|
12
|
Timely repair of the equipment
|
10
|
Better availability of medical supplies eg. electrode patch for ECG
|
10
|
Theoretical and practical training
|
8
|
Comments
|
|
‘The two anesthesia machines in the operating room are used for a longtime, lack of maintenance and have serious air leak problem.’
|
|
‘We added isoflurane in the only sevoflurane vaporizer, which makes it hard to control the depth of anesthesia.’
|
|
‘With the help of the Internet, we are keen to learn the latest advances in anesthesiology, but because of the lack of equipment and training, our ability to progress was limited.’
|
|
‘One of the serious problems I have encountered is intraoperative awareness. This is a problem that may cause great trauma to patients. It is also a legal issue, but we have ignored it.’
|
|
‘In order to control medical expenses, we used the least amount of drugs and materials, which damages the safety of anesthesia.’
|
|
‘The process we use to dispense large bottles of medication to each patient can lead to contamination.’
|
|
aSuggested by the anesthesia providers from the questionnaire.
Data are presented as the number of staff members who made suggestions; the total number of staff surveyed was 15.