Bridging the Gap: Emergency. Anesthesia Through Ketamine

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1 Bridging the Gap: Emergency Anesthesia Through Ketamine By Zaid Altawil, MD Post- doctoral Research Fellow Department of Emergency Medicine Division of Global Health & Human Rights Massachusetts General Hospital Despite advances in health technologies and emergency services delivery worldwide, vast disparities persist. Close to five billion people do not have access to safe and affordable surgical care when they need it the most.(1) Shortages of emergency procedures such as laparotomies, open fracture repair and caesarean section are especially prevalent in low- to middle-income countries (LMIC) where nine out of ten people cannot access basic surgical care. It is estimated that of the 313 million procedures undertaken worldwide, only 6% occur in the poorest countries of the world.(1) To overcome this deficit, 143 million additional life-saving and life-improving surgical procedures are necessary.(2) Unmet needs are largely concentrated in Africa, particularly in its eastern, western and central sub-saharan regions. Within these regions, obstacles are compounded by deficiencies in anesthetic services required to support surgery. Surgical and anesthesia capabilities go hand in hand with deficits in one area directly affecting the progress of the other. The poorest regions in the world have the lowest density of anesthesiologists and anesthetists.(3, 4) In Uganda, there are 0.05 anesthetists for every people.(5) In Rwanda, the

2 corresponding number is 0.09,(6) and in Ethiopia it is as low as 0.02/100,000.(7) Factors responsible for this paucity of anesthesia providers include political instability, corruption, emigration of trained providers, and devastation of the labor force by HIV/AIDS, tuberculosis, and malaria.(8) Among providers, studies have shown that less than 10% are able to provided anesthesia at any time, mostly because of a lack of medications and supplies.(5, 9) The field of anesthesia in LMIC countries also experiences a high proportion of brain drain, mostly due to poor remuneration, difficult working conditions and few training positions. A study of seventy-eight government hospitals in seven LIMC countries revealed that there were no physician anesthesiologists in surveyed hospitals in four of the countries (Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia).(10) In recent years, provision of services has shifted away from anesthesiologists. Currently, most anesthesia in cesarean deliveries is administered by individuals who are not physicians themselves but have a few years of anesthetist training.(11) The education of non-physician anesthetists varies considerably, from no formal qualification to training for 1 3 years.(12) Post-qualification training in limited resources is seriously hampered as well; anesthesia providers in LMIC countries who complete training either as a physician or mid-level providers, such as nurses and midwives, have almost no access to mentorship, continuing education, and professional development.(13) In April of 2015 the Lancet Global Surgery Commission published their core indicators for monitoring universal access to surgical and anesthesia case. Under the title Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development, these indicators serve as targets for public health efforts and

3 health systems strengthening initiatives worldwide. Among the Global Surgery Commission s goals for 2030 is achieving a minimum of 80% coverage of essential surgical and anesthesia per country, as well as maintaining at least 20 surgical, anesthetic and obstetric physicians per 100,000 population by 2030.(1) These targets are proving difficult to achieve. As previously mentioned, efforts to decrease the gap in anesthesia services through traditional methods are time-consuming, expensive and unlikely to achieve the required targets. This calls for new and innovative measures that can circumvent these challenges. One such innovation has been devised by Dr. Thomas Burke and his team of Global health practitioners at Massachusetts General Hospital s Division of Global Health and Human Rights (GHHR), a sub-division of the department of Emergency Medicine. Their solution involves using Ketamine, an ultra-low-cost anesthetic agent that has been used safely worldwide for over 40 years, as a safe back-up anesthesia for emergency lifesaving and life-improving procedures. Ketamine use has been widely reported in the literature, with more than 22,000 cases documenting its use. It has been used for many operative procedures, often with minimal equipment and training, yet with an extremely attractive safety record. While virtually all other sedative agents compromise airway and hemodynamic reflexes by their very nature, ketamine enhances minute ventilation and other respiratory and hemodynamic properties. It is worth noting that while Ketamine has been routinely used in the Emergency Department for sedation, few clinically standardized pathways for its use as an anesthetic exist, and its implementation has often been unregulated and disorganized.(14, 15) It is precisely this obstacle that has provided the impetus for the development of GHHRs innovation.

4 The package, named Every Second Matters- Ketamine (ESM-Ketamine), trains health providers in basic pharmacology, appropriate monitoring, basic respiratory management of adults and newborns (including the American Academy of Pediatrics --Helping Babies Breathe program) and case-based learning through didactics and operating theater time. Training materials also include checklists and wall-charts to encourage information retention and quality assurance. What is really striking about this initiative, however, is that it is a five-day training program, in other words a fraction of the time required to train anesthetists traditionally. Even more impressive is the fact that the ESM-Ketamine per-patient cost is just under $2, potentially saving thousands of patients from the crippling debt brought on by exorbitant healthcare bills. When an emergent case that requires anesthesia services presents at a participating facility, an immediate attempt is made to secure a trained anesthetist. If no anesthesia provider is available and the only other option is a delay that would potentially lead to suffering, death, or loss of opportunity to improve life, the ESM-Ketamine protocol is activated. The MGH team has successfully completed initial work related to ESM-Ketamine in the country of Kenya. To date, health care providers from five rural hospitals in Kenya have been trained on the ESM-Ketamine package and have been able to support over 300 emergency surgical procedures via the ESM-Ketamine pathway when no anesthetist was available. The procedures range from simple wound debridement to major emergency surgeries such as caesarean sections, laparotomies for bowel obstruction and open fracture repair. ESM-Ketamine has recently been awarded a $250,000 Saving Lives at Birth seed

5 grant to roll out its training package across the 5 facilities in Western Kenya. The GHHR team also plans to expand ESM-Ketamine to another six additional health facilities and train a total of 24 ESM-Ketamine providers. This evidence-based innovation will directly save many lives in Western Kenya and has the potential to inform a new opportunity for saving and improving tens of thousands, if not millions, of lives. Through innovative solutions such as ESM-Ketamine, targets such as those outlined in Global Surgery 2030 may soon be an achievable reality. 1. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2. Rose J, Weiser TG, Hider P, Wilson L, Gruen RL, Bickler SW. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. The Lancet Global Health. 2015;3:S13- S Dubowitz G, Detlefs S, McQueen KK. Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices. World journal of surgery. 2010;34(3): McQueen KK. Anesthesia and the global burden of surgical disease. International anesthesiology clinics. 2010;48(2): Hodges S, Mijumbi C, Okello M, McCormick B, Walker I, Wilson I. Anaesthesia services in developing countries: defining the problems. Anaesthesia. 2007;62(1): Notrica MR, Evans FM, Knowlton LM, McQueen KK. Rwandan surgical and anesthesia infrastructure: a survey of district hospitals. World journal of surgery. 2011;35(8): Chao TE, Burdic M, Ganjawalla K, Derbew M, Keshian C, Meara J, et al. Survey of surgery and anesthesia infrastructure in Ethiopia. World journal of surgery. 2012;36(11): Tawfik L, Kinoti SN. The impact of HIV/AIDS on the health workforce in developing countries. document de base préparé pour Le Rapport sur la santé dans le monde. 2006:8. 9. Linden AF, Sekidde FS, Galukande M, Knowlton LM, Chackungal S, McQueen KK. Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda s public hospitals. World journal of surgery. 2012;36(5): LeBrun DG, Chackungal S, Chao TE, Knowlton LM, Linden AF, Notrica MR, et al. Prioritizing essential surgery and safe anesthesia for the Post Development

6 Agenda: operative capacities of 78 district hospitals in 7 low- and middle- income countries. Surgery. 2014;155(3): Anderson RE, Ahn R, Nelson BD, Chavez J, de Redon E, Burke T. Defining the anesthesia gap for reproductive health procedures in resource- limited settings. International Journal of Gynecology & Obstetrics. 2014;127(3): Dyer RA, Reed AR, James MF. Obstetric anaesthesia in low- resource settings. Best Practice & Research Clinical Obstetrics & Gynaecology. 2010;24(3): Schnittger T. Regional anaesthesia in developing countries. Anaesthesia. 2007;62(s1): Bisanzo M, Nichols K, Hammerstedt H, Dreifuss B, Nelson SW, Chamberlain S, et al. Nurse- administered ketamine sedation in an emergency department in rural Uganda. Annals of emergency medicine. 2012;59(4): Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Annals of emergency medicine. 2011;57(5):

An innovative safe anesthesia and analgesia package for emergency pediatric procedures and surgeries when no anesthetist is available

Schwartz et al. International Journal of Emergency Medicine (2016) 9:16 DOI 10.1186/s12245-016-0113-8 International Journal of Emergency Medicine ORIGINAL RESEARCH Open Access An innovative safe anesthesia