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.
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.
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.
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).
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.
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).
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.