Anesthetic Care in Developing Countries: Equipment and Techniques. (Review Article).

ABSTRACT: Various organizations have been formed to provide short-term surgical services in developing countries. In these countries, the ability to provide effective anesthetic care requires the team to transport most of the equipment necessary to provide perioperative care for various surgical procedures. We review the basic supplies necessary to provide such care and discuss some of the issues related to the anesthesia machines, techniques, and monitoring in developing countries. Suggestions and options for preoperative assessment, intraoperative anesthetic care, and postoperative care, including pain management, are provided.

Various organizations have been formed to provide short-term surgical services in developing countries. In such areas, access to medical care is limited for several reasons, including a lack of appropriate supplies and equipment. The ability to provide anesthetic care in such environments frequently requires the anesthesia team to transport most of the equipment necessary to provide perioperative care for various surgical procedures. While some organizations provide high-technology services, such as cardiac surgery, (1) the majority of surgical services are less complex, necessitating limited postoperative monitoring. In fact, many of the surgical procedures offered are provided in an outpatient setting in the United States. Despite the relatively minor nature of some of the surgical procedures, the task of assembling all of the equipment and medications necessary to provide anesthetic care can be daunting. We will review the basic supplies needed to provide such care and discuss some of the issues related to the anesthesia machines, techniques, and monitoring in developing countries. Although the discussion is not meant to be authoritative, it represents our personal opinions and preferences after more than 20 such excursions.

ANESTHESIA MACHINES, VAPORIZERS, AND MONITORING

The issue that is foremost in most situations is the type of anesthesia machine available. Although portable machines are manufactured and may be available when trips are organized by large institutions, the anesthesia provider is frequently faced with using the basic machines that are available in developing countries. If possible, it is helpful to obtain information concerning the location and type of machine before arrival. It may be helpful to ask for a photograph of the anesthesia machine. Even in developing countries, a photograph usually can be made using a digital camera and the image sent via electronic mail, thereby avoiding the inherent problems of depending on local postal systems.

Individual vaporizers may be brought by the team, provided that the type of anesthesia machine is known ahead of time to ensure that the vaporizer and machine are compatible. Although much equipment--including anesthesia machines--may have been donated, such equipment often ends up collecting dust in closets because ongoing maintenance and repairs are not possible due to a lack of supplies and expertise. In most circumstances, the basic anesthesia machine includes an oxygen source and, at best, modern, variable bypass, flow-over vaporizers. However, in other circumstances, a pressurized oxygen source is not available, necessitating the use of draw-over vaporizers.

In the best of circumstances, one will be faced with an anesthesia machine of similar design to that used at home, including an oxygen source with a variable bypass, flow-over vaporizer. The oxygen source is unlikely to be from a wall outlet and more likely includes a cylinder (type E, G, or H). E cylinders (those commonly attached to the back of the anesthesia machine) contain 625 L of oxygen, corresponding to a pressure of 2,200 psi. The decrease in the pressure is proportional to the amount of oxygen left in the tank. G and H cylinders are much larger than E cylinders, containing 5,300 L and 6,900 L of oxygen, respectively, when full. Variations in the color of tanks may also be encountered. United States standards require oxygen tanks to be green, while the World Health Organization specifies that they are white.

When there is oxygen from a wall outlet, it is likely that this will be connected to large oxygen tanks outside the hospital and not liquid oxygen reservoirs as used in the United States. Although the latter allow the storage of large quantities of oxygen, they require the use of high pressures (5 to 10 atm) and low temperatures (-100[degrees] to -150[degrees]). Since this technology is frequently not available, the hospital oxygen supply often is from compressed oxygen tanks, and it is always possible that the oxygen supply may run low. Therefore, an emergency supply of oxygen (E or H cylinder) should be readily available in the operating room area. Additionally, a self-inflating resuscitation bag ensures that ventilation can accomplished with room air should the supply fail. The use of non-self-inflating resuscitation bags, though common practice in the anesthesia arena as a means of providing a fraction of inspired oxygen of 1.0, cannot provide effective ventilation without a compressed gas source and can not be used as a replacement for the self-inflating bag. Due to the cost and limited availability of the oxygen supply, whenever possible, the fresh gas flow should be minimal (1 to 2 L/min), and flows should be turned off when not in use. Other gases such as nitrous oxide and compressed air are not likely to be available. When such gases are available, safety devices such as working proportioning systems and the measurement of inspired oxygen concentration may not always be available.

Several types of vaporizers are likely to be encountered. As mentioned earlier, in the best circumstances these will include standard, variable bypass, flow-over vaporizers. In all likelihood, no recent calibration will have been done on such equipment, so the actual delivered concentration may vary significantly from the set concentration. If the monitoring equipment that is brought with the team includes the availability of measurement of end-tidal anesthetic concentrations, potential problems are obviously minimized. If the anesthesia team has such equipment, it is helpful for future providers if a quick calibration of the vaporizer is done by attaching an anesthesia bag to the end of the circle system, setting the vaporizer at increasing concentrations, and recording the delivered concentration. This information can then be taped on the side of the vaporizer with the date of calibration for use by future teams.

In most circumstances, the availability of such monitoring equipment is limited, and its use in developing countries has not been our experience. Therefore, one is left to use a vaporizer with the potential for the delivery of erroneous concentrations of inhalational anesthetic agents. Our approach is to start the week of surgeries with older patients using intravenous (IV) induction. After endotra-cheal intubation, the vaporizer can be slowly increased, the cardiovascular response to the agent noted, and an estimate made of whether the vaporizer is appropriately calibrated. Although any of the commonly used inhalational agents can be used, it is our preference to use halothane because of its inexpensive price, as well as the ability to use the heart rate to judge the depth of anesthesia.

While one may be lucky to find conventional vaporizers, the supply of these devices is limited. We have found a combination of various vaporizers--isoflurane, halothane, enflurane, and even sevoflurane-but never a desflurane vaporizer. Residual anesthetic agent should be emptied and the vaporizer refilled with fresh agent, since the age of the residual anesthetic cannot be determined. Preservatives, such as thymol in halothane, can accumulate over time. Although thymol is not toxic, it can interfere with the functioning of the vaporizer.

Often, only one vaporizer is available. Since halothane or sevoflurane remain the most commonly used agents for inhalation induction, it is preferable to have them available for induction. However, in many circumstances the only vaporizer available is isoflurane. This problem may be compounded by the fact that one has only brought halothane. However, when the vapor pressures are known, it is possible to use halothane in an isoflurane vaporizer, or vice versa, provided that newer, indexed filling port vaporizers are not in use. The potential problems with such techniques are (1) the delivery of a mixture of inhalational agents if the vaporizer is not completely. emptied and (2) the potential for the delivery of a high concentration of halothane; the isoflurane vaporizer will deliver up to a concentration of 5%, and the enflurane vaporizer will deliver up to 7% enflurane, which is roughly 10% to 11% halothane when the difference in vapor pressures is considered. The problem of delivering a mixture of gases is avoided by completely draining the vaporizer and then filling it to the one fourth point and draining it again. By doing this, any residual anesthetic agent will be removed.

Although the potency of halothane is greater than that of isoflurane, halothane and isoflurane have roughly the same vapor pressure and therefore can be used interchangeably. On the other hand, the vapor pressure of enflurane is less than that of either halothane or isoflurane, and the administration of either isoflurane or halothane in an enflurane vaporizer will deliver 1.5 times the concentration that is set on the dial. If a sevoflurane vaporizer is not available, sevoflurane can be administered in a clinically relevant concentration using an enflurane vaporizer. (2) Although sevoflurane in a halothane or isoflurane vaporizer will only deliver an inspired concentration of 2.5% to 3.0%, thereby making inhalation induction a slow process, sevoflurane in an enflurane vaporizer will deliver an inspired concentration of 6% with the enflurane vaporizer set at 7% and fresh gas flows of 4 L/min. (2)

Alternatively, other types of vaporizers may also be found, including devices such as the Copper Kettle (Foregger Co, Puritan-Bennett, Mallinckrodt, St. Louis, Mo) or a Vernitrol (Ohio Medical Products, Madison, Wi) side arm. These devices require knowledge of gas flows and the vapor pressure of the specific anesthetic agent; their advantage lies in their being non-agent-specific and allowing the use of any inhalational anesthetic agent. These devices have a separate flow into the device that is mixed into the fresh gas flow. The gas flow into the vaporizer is then dispersed and bubbled through the inhalational agent and added to the fresh gas flow. The final concentration of the agent will depend on its vapor pressure, the gas flow through the device, and the total gas flow to the patient.

Another potential problem, which we have not faced, is the provision of anesthesia without the availability of compressed gases or oxygen. Solutions to this problem include the use of draw-over vaporizers in which the patient's own inspiratory effort is used to entrain room air and draw it through the vaporizer. The use of such devices and their role in anesthetic care in developing countries is outlined in articles by Ezi-Ashi et al. (3,4) Alternatively, a continuous flow of gas can be provide by an air compressor with or without the addition of supplemental oxygen. When providing anesthesia at higher altitudes (greater than 4,000 feet), an additional problem with any device such as a draw-over vaporizer that uses ambient air is the limited [PO.sub.2] of ambient air, necessitating the use of some form of supplemental oxygen. When oxygen tanks are not available, supplemental oxygen may be provided by oxygen concentrators. These devices pass ambient air over a molecular sieve (zeolite granules), which removes water vapor and nitrogen by surface absorption, leaving 85% to 90% oxygen. (5)

Because of these issues, the first step in planning the anesthetic, as it is back home, is to evaluate and check the equipment. Determine the amount of oxygen available and its source, and make plans for a back-up if the hospital supply fails (by having a spare E cylinder available). Plan ahead, since obtaining additional oxygen tanks may take days. Check the integrity of the anesthesia machine. Drain and then refill the vaporizers. If the equipment is available, do a calibration check on the vaporizers and record the information and date on a piece of tape placed on the side of the vaporizer. Check the soda lime in the machine. More importantly, watch it during the first case to be sure that it does not need to be changed. Totally exhausted soda lime will not change color. We find it reassuring to watch the soda lime change color so that we know it is working. Most of the machines will not have prepackaged containers of soda lime but will have loose granules. If no soda lime is available, non-rebreathing ci rcuits can be used (Mapleson, Bain), but they will require a greater fresh gas flow and the use of more oxygen. Most of the anesthesia machines will not have functioning scavenging devices. Extra corrugated tubing can be connected to the exhaust port on the anesthesia machine and run out a nearby window or at least into a hallway, so that one is not left rebreathing halothane in a hot operating room.

Identify the source of suction and check its function. Many suction devices are old and the bottles cracked, requiring repair before use. For both the machine and the monitoring devices transported from the home country, the electrical source becomes a significant issue. If possible, this should be checked before leaving home so that appropriate converters and grounding devices are available.

Because of obvious difficulties that can be encountered with use of the in-country anesthesia machine and/or vaporizers, intraoperative monitoring of the patient becomes significantly important. The monitoring should be similar to that used at home, including a precordial stethoscope, noninvasive blood pressure monitoring, continuous electrocardiography, pulse oximetry, and temperature monitoring. Although end-tidal [CO.sub.2] monitoring is recommended, its availability tends to be limited on most transport-type monitors that are small enough to allow for easy transport to and from the destination. Alternatively, disposable devices which show the presence of [CO.sub.2] in exhaled gases based on color changes on the indicator paper can be used (Easy Cap II [CO.sub.2] Detector; Nellcor-Puritan-Bennett, Mallinckrodt, St. Louis, Mo). Although these devices do not provide an actual end-tidal [CO.sub.2] measurement, they do show the presence or absence of [CO.sub.2] in exhaled gases, thereby helping to assess endo tracheal tube position. While several different types and manufacturers of monitors are available, only a limited number are willing to loan monitors for this purpose. We have found that the only company that makes an effort to help with such undertakings is Protocol Systems Inc (Beaverton, Ore), the manufacturer of the Propaq system. Fortunately, the Propaq system is also the most compact and lightweight of any of the monitoring systems, thereby facilitating transport. The monitor can be placed in a backpack or carry-on luggage to avoid damage that may occur with shipping or checked baggage. Additionally, the system does have an attachment for in-line infrared [CO.sub.2] monitoring. However, we have found that this device is slightly fragile and may work only intermittently after transport.

The Propaq monitor also allows for temperature monitoring with a reusable, malleable probe. Although hypothermia is uncommon, hyperthermia may occur in operating rooms without air-conditioning. Our practice is to keep 3 to 4 L saline in the refrigerator in the event that significant hyperthermia needs to be treated. On the rare occasions when air-conditioning is available, covering the patient with plastic sheets (which are frequently used to wrap the sterile supplies) is an effective means of maintaining body temperature. The Propaq temperature monitor requires special attachments to be used with the probes on standard esophageal stethoscopes. Our preference is to use the disposable temperature probes that are self-adhesive on one side and can be placed on the patient's forehead (Crystalline II; Sham, Tampa, Fla). Although meant for one-time use, the adhesive allows for repeated use. The Propaq monitor also has the capability of providing invasive hemodynamic monitoring, provided one has the appropriate cab le and transducer. Although the need for such devices is limited in the majority of procedures, invasive arterial blood pressure monitoring may be desirable if controlled hypotension is used during orthopedic or maxillofacial surgery. Additionally, unexpected intraoperative problems (latex or drug sensitivities) may result in cardiovascular compromise, during which invasive hemodynamic monitoring may be helpful.

MEDICATIONS AND SUPPLIES

A listing of suggested medications is provided in Table 1, and suggested equipment and supplies are listed in Table 2. These are not meant to be all-inclusive lists nor do we suggest that all of these medications and supplies must be brought. Each person's list will be tailored according to personal preference and the types of procedures to be done. When transporting medications, one should remember that those shipped or packed in checked baggage may be subjected to extremes of temperature. Also, although many medications may be effective long past their expiration dates, there are no studies to determine the longevity of medications. In some countries, the local health care providers may view the use of outdated medications as providing less than the quality of care that we provide in our own country, and therefore we cannot suggest that this is an appropriate practice. Additionally, the custom officials of many countries will check baggage for outdated medications and confiscate them. Once one vial of outd ated medicine is found, it is almost certain that the entire contents of the bags will be checked.

ANESTHETIC TECHNIQUES

Preoperative Evaluation

Perioperative care begins with the preoperative screening of patients during the preanesthesia evaluation. Many patients will have never had medical care previously, and therefore a thorough history and physical examination are needed to rule out associated medical conditions that may affect anesthetic care. It is not uncommon for patients with undiagnosed congenital heart disease to show up for what might otherwise be a routine outpatient surgical procedure. While it is always heartbreaking to have to refuse surgical care to any patient, there are limited facilities to deal with these problems and what might occur after anesthesia. Most of the hospitals in which we have worked do not have facilities for postoperative monitoring or mechanical ventilation. The limited capabilities for postoperative monitoring may limit the ability to provide anesthetic care for full-term infants younger than 44 weeks old and preterm infants younger than 50 to 60 weeks old due to the risks of postoperative apnea. Preoperative l aboratory evaluation is based on the child's current health evaluation and the anticipated surgical procedure.

Depending on the hospital, access to preoperative laboratory and radiographic evaluations may be limited. Anemia may be more common than in this country due to the presence of parasitic infections and nutritional issues; however, this rarely has an impact on the preoperative evaluation. Due to the lack of availability of routine blood tests, it may be beneficial to bring the equipment required to measure hematocrits, especially if procedures involving blood loss are anticipated.

Premedication and Anesthetic Induction

In the hectic environment of these operating rooms, premedication may be quickly overlooked. However, its importance is magnified in situations where language barriers may limit the anesthesiologists' ability to converse with the patients. Once IV access is established, midazolam can be administered to allow for easy parental separation. Alternatively, oral pre-medication with midazolam or ketamine can be used in the same manner as it is in the United States. Midazolam or ketamine can be mixed with ibuprofen elixir, acetaminophen elixir, or grape or orange soda obtained from a local store. Alternatively, ketamine (4 to 5 mg/kg) mixed with midazolam (0.1 mg/kg) and glycopyrrolate (0.01 mg/kg) can be administered intramuscularly (IM) as the premedicant. This combination also provides analgesia for IV catheter placement, facilitating IV induction, and alternatively can be used to provide sedation and analgesia during regional techniques, such as spinal anesthesia. The duration of the IM mixture is such that it frequently provides adequate sedation during administration of the spinal anesthetic as well as the 60- to 70-minute surgical procedure.

After premedication, inhalation induction can be accomplished and IV access secured. Because there are often no ventilators available on the anesthesia machines, our preference is to use short-acting neuromuscular blocking agents (mivacurium) to facilitate endotracheal intubation, followed by spontaneous resolution of the neuromuscular blockade and use of spontaneous ventilation with intermittent assistance. Alternatively, endotracheal intubation can be performed under deep inhalational anesthesia, which can be supplemented with lidocaine or propofol. If an IV induction is planned, the combination of propofol and lidocaine provides a deep enough plane of anesthesia and muscle relaxation to allow for intubation without use of a neuromuscular blocking agent.

Maintenance Anesthesia and Postoperative Care

Maintenance anesthesia generally consists of spontaneous ventilation with an inhalational anesthetic agent. When available, an opioid such as fentanyl can be titrated to provide supplemental analgesia. The use of spontaneous ventilation allows for an additional measure of the depth of anesthesia and an effective means of titrating IV opioids.

Depending on the surgical procedure, postoperative analgesia can be provided with rectal acetaminophen (30 to 40 mg/kg), infiltration of local anesthesia into the surgical wound, or one of several types of peripheral or central regional blocks. (7,8) Techniques of bilateral infraorbital nerve blockade have been used to provide analgesia after cleft lip repair. (9) Methods of prolonging the duration of local anesthetic blockade for central and peripheral block include the addition of clonidine or opioids such as morphine. (10-12) Although we frequently use clonidine (1 [mu]g/kg) added to the local anesthetic solution for central or peripheral blockade, the use of neuraxial opioids is not recommended unless there is postoperative monitoring of cardiorespiratory function and the availability of someone to intervene should respiratory depression develop. With advanced planning and ongoing education of the local nursing staff and physicians, neuraxial opioids can be used in these settings and often provide more e ffective analgesia than intermittent, on-demand dosing of opioids. (10)

As an alternative to general anesthesia, regional anesthesia, such as spinal anesthesia or peripheral nerve blockade, can be used for many of these surgical procedures. (7 8 13 14) Sedation and analgesia for these procedures can be provided with IM and/or IV ketamine and midazolam. The techniques and drug choices for spinal anesthesia have been reviewed. (14) Although our preference is to use tetracaine crystals mixed in 10% dextrose to provide for a hyperbaric solution, isobaric solutions (0.5% to 0.75%) of either bupivacaine or 1evobupivacaine can also be used. The addition of a small dose of fentanyl (0.5 [micro]g/kg) to the local anesthetic solution may improve the quality of the surgical block, decrease the severity of tourniquet pain, and provide some measure of postoperative analgesia. Aside from being what we consider an equal alternative to general analgesia for many surgical procedures, the use of spinal anesthesia in developing countries is cost-effective (requiring only the cost of the drug used) , allows for rapid room turnover, and limits the reliance on the anesthesia machine in the host country. Many of the commercially available spinal needles are metal and allow for resterilization and reuse. Even with repeated use, these needles are sharp enough to permit use without difficulty.

The major postoperative issue of concern to the anesthesia care provider is the ongoing monitoring of respiratory function. The postanesthesia care unit (PACU) should be equipped with an oxygen source, suction, a set of emergency medications, and some means of monitoring respiratory function, such as pulse oximetry. If additional monitors are not available, a brief period of time in the operating room can ensure adequate recovery from the effects of the general anesthetic before sending the patient to the PACU or inpatient floor. Since nursing help may be limited on the inpatient wards, we suggest making sure that the patients are relatively awake before discharge from the PACU. In specific situations, the ongoing administration of IV fluids may not be possible. In these circumstances, we would suggest that children be well-hydrated before discharge to the inpatient ward.

Other postoperative issues include treatment of nausea and vomiting and pain control. With the limited use of nitrous oxide, lack of a need to reverse neuromuscular blockade, and limited use of parenteral opioids, we have seen a limited number of patients with postoperative nausea and vomiting. However, when it does occur, it can be treated with ondansetron or droperidol.

Postoperative pain management can be difficult due to the lack of availability of IV access, limited access to medications, and a high patient-to-nurse ratio. Regional anesthetic techniques including a combination of local anesthetics with clonidine can provide 12 to 14 hours of postoperative analgesia. For major surgical procedures, epidural catheters that are covered with a sterile, bio-occlusive dressing and are clearly labeled can be left in place for 48 to 72 hours and intermittently dosed with a local anesthetic solution (0.125% to 0.2% bupivacaine or ropivacaine).

Although nursing personnel may be limited, parental presence is not. It is helpful to include the parents in the postoperative analgesia plan by having them administer ibuprofen or acetaminophen at a fixed interval (every 4 to 6 hours), supplemented as needed with a weak opioid by mouth (codeine, oxycodone, hydrocodone, or tramadol). (15) The latter medications can be dispensed by the parents after careful instruction, thereby alleviating some of the extra workload that is placed on the nursing staff of the hospital during such trips. Using medications with alternative routes of delivery, such as intranasal butorphanol, has also proven efficacious in such situations. (16) Although not the preferred choice, in specific circumstances, IM opioids may need to be used.

CLEANING SUPPLIES

In developing countries, conservation of supplies remains a primary concern throughout the course of the trip. Many of the supplies that we consider disposable (anesthesia masks, endotracheal tubes, suction catheters) can be cleaned and reused. When these items are discarded, they may be retrieved from the garbage by the local hospital staff to be cleaned and reused at a later date. Any metal equipment (spinal or epidural needles) can be autoclaved, packaged in sterile containers, and reused. They should not be sterilized with detergents or cleaners, since residual chemicals on these needles may cause a chemical meningitis or arachnoiditis. As in the United States, strict sterile technique must be maintained to prevent cross-contamination between patients. Equipment such as needles and syringes, though they can be resterilized, should be changed in between cases. Regardless of the country in which one is working, the risk of transmission of blood-borne viral infections is always present.

Before cleaning or sterilization, tubes, masks, and other supplies should be cleaned of particulate organic material. A supply of standard test tube brushes may be helpful in cleaning the inside of endotracheal tubes and suction catheters. Repeated steam sterilization of plastic material will cause discoloration of the plastic and, more importantly, weakening of the plastic with the potential for kinking of endotracheal tubes. We prefer soaking plastic materials in a cleaning solution, such as a diluted chlorine solution (household bleach 30 mL per liter of water). After rinsing with distilled or chlorinated water, the equipment can then be immersed in 70% isopropyl alcohol for 10 minutes and allowed to air dry. If other chemical cleaners are used, such as glutaraldehyde (Cidex), thorough rinsing is suggested because residual amounts may cause mucosal damage. (17)

CONCLUSION

There can be significant challenges in providing anesthetic care in an unfamiliar environment. In developing countries, these challenges can be magnified by the need to use unfamiliar equipment, working in crowded, un-air-conditioned operating rooms, and working long hours with few breaks. For one's first experience, it is usually best to join a team with anesthesia providers who have previously worked in such situations. The rewards of such efforts cannot be expressed in words. Relatively simple surgical procedures that we take for granted in the United States, such as repair of a club foot or a cleft lip and palate, may not otherwise be available in developing countries. The long-term impact that such surgery can have on a child's life can only be appreciated by seeing the joy in parents' eyes when the procedure is completed.

From the Departments of Child Health and Anesthesiology, the University of Missouri, Columbia, and the Department of Anesthesiology, Columbia University, New York, NY.

Dr. Tobias is on the speaker's bureau for Astra-Zeneca Pharmaceuticals, Glaxo-Wellcome, Abbott Pharmaceuticals, and Organon and is a consultant for Astra-Zeneca, Organon, and Abbott. Neither Mr. Kim nor Ms. Davis have any commercial or proprietary interest in any drug, devide, or equipment mentioned in this article.

Reprint requests to Joseph D. Tobias, MD, University of Missouri, Department of Child Health, 3W40H Health Sciences Center, One Hospital Dr, Columbia, MO 63212.

References

(1.) Schechter WS, Navado A, Jordan D, et al: Paediatric cardiac anaesthesia in a developing country. paediatr Anaesth 1998; 8:283-292

(2.) Tobias JD: Administration of sevoflurane using other agent-specific vaporizers. Am J Therapeutics 1998; 5:383-385

(3.) Ezi-Ashi TI, Papworth DP, Nunn JF: Inhalational anaesthesia in developing countries. Part 1: The problems and a proposed solution. Anaesthesia 1983; 38:729-735

(4.) Ezi-Ashi TI, Papworth DP, Nunn JF: Inhalational anaesthesia in developing countries. Part 2: Review of existing apparatus. anaesthesia 1983; 38:736-747

(5.) Jarvis DA, Brock-Utne JG: Use of an oxygen concentrator linked to a draw-over vaporizer (anesthesia delivery system for underdeveloped nations). Anesth Analg 1991; 72:805-810

(6.) Waisman Y, Klein BL, Boenning DA, et al: Prospective, randomized study comparing L-epinephrine and racemic epinephrine in the treatment of laryngotracheitis. Pediatrics 1992; 89:302-306

(7.) Tobias JD, Mencio GA: Popliteal fossa block for postoperative analgesia after foot surgery in infants and children. J Pediatr Orthop 1999; 19:511-514

(8.) Kinder-Ross A, Eck JB, Tobias JD: Pediatric regional anesthesia: beyond the caudal. Anesth Analg 2000; 91:16-26

(9.) Nicodemus HF, Ferrer MJR, Critobal VC, et al: Bilateral infraorbital block with 0.5% bupivacaine as postoperative analgesia following cheiloplasty in children. Scand J Plast Reconstr Hand Surg 1991; 25:253-257

(10.) Tobias JD, Mateo C, Ferrer MJR, et al: Intrathecal morphine for postoperative analgesia following repair of frontal encephaloceles in children: comparison with intermittent, on-demand dosing of nalbuphine. J Clin Anesth 1997; 9:280-284

(11.) Casati A, Magistris L, Fanelli G, et al: Small-dose clonidine prolongs postoperative analgesia after sciatic-femoral nerve block with 0.75% ropivacaine for foot surgery. Anesth Analg 2000; 91:388-392

(12.) Luz G, Innerhofter P, Oswald E, et al: Comparison of clonidine 1 microgram/kg with morphine 30 micrograms/kg for postoperative caudal analgesia in children. Eur J Anaesth 1999; 16:42-46

(13.) Tobias JD, Mencio GA: Regional anesthesia for clubfoot surgery in children. Am J Therapeutics 1998; 5:273-277

(14.) Tobias JD: Spinal anaesthesia in infants and children. Paediatr Anaesth 2000; 10:5-16

(15.) Tobias JD: Tramadol for postoperative analgesia in adolescents following orthopedic surgery in a third world country. Am J Pain Manage 1996; 6:51-53

(16.) Tobias JD, Rasmussen GE: Transnasal butorphanol for postoperative analgesia following paediatric surgery in a third world country. Paediatr Anaesth 1995; 5:63-66

(17.) Smoot CE III, Johnson M, Graham DR, et al: Operating safely in an underdeveloped country. Cleft Palate Craniofac J 1992; 29:444-450

TABLE 1

Suggested Medications

Medications                Comments

Resuscitation medications
Atropine (1.0 mg/mL or
 0.4 mg/mL)
 Lidocaine (2%)            Ventricular arrhythmias may be
                           seen during the use of
                           spontaneous ventilation
                           (hypercarbia), halothane, and
                           increased temperature due to
                           the temperature of the
                           operating room. Can also be
                           used for topical anesthesia of
                           the airway or local
                           infiltration before IV or
                           regional blockade.

Calcium chloride or
 gluconate (10%)
Epinephrine                Although 1 mL vials are
                           available, our preference is
                           to take one 30 mL vial (1 mg/
                           mL. This can be obtained from
                           adult resusciation boxes.
                           Epinephrine can be used as the
                           1:1,000 (1 mg/mL) solution for
                           subcutaneous administration to
                           treat anaphylaxis or
                           bronchospasm, as a 1:10,000
                           solution for resusciation, or
                           as a 1:10,000 solution to
                           treat hypotension. The 1:1,000
                           solution can also be used as
                           an aerosol to treat
                           postintubation croup. Although
                           the time-honored thrapy has
                           been racemic epinephrine
                           (2.25%), recent studies have
                           shown no difference in the
                           efficacy and cardiovascular
                           effects of racemic and
                           L-epinephrine. (6)

Emergency medications
  Aminophylline
  Cimetidine and/or
  ranitidine
  Dantrolene               May not be available in
                           developing countries. Its cost
                           may limit availability for
                           transport to these locations.
                           Recently outdated vials are
                           better than none.

  Sodium bicitra
  Dexamethasone
  Diphenhydramine
  Ephedrine
  Glucose ([D.sub.50])     Can be added to IV fluids to
                           provide [D.sub.5] or
                           [D.sub.2,5] for younger
                           patients or used to provide a
                           [D.sub.10] base for hyperbaric
                           spinal anesthesia.

  Flumazenil
  Furosemide
  Labetalol
  Mannitol
  Metered dose inhalers/
  liquid formulation
  (albuterol,
  ipratropium).
  Naloxone
  Nicardipine
  Phenylephrine
  Propranolol and/or
  esmolol
  Sodium bicarbonate

Anesthesia and
 perioperative
 medications
  Inhalational anesthetic
   agents
  Bupivacaine,             Concentrations of 0.75% or 1%
  levobupivacaine,         can be diluted to 0.2 to 0.25%
  ropivacaine              with physiologic normal saline
                           (IV solution) for use in
                           central or peripheral blocks.
                           This allows for the transport
                           of a minimum number of vials.
                           A 30 mL, 1% vial of
                           ropivacaine can be diluted to
                           150 mL of 0.2%, enough for 15
                           caudals in 10 kg patients.
                           Solutions of 0.75% bupivacaine
                           or levobupivacaine can be used
                           for isobaric spinal
                           anesthesia. Alternatively,
                           hyperbaric tetracaine or
                           bupivacaine can be carried
                           seperately.

  Neuromuscular blocking   Succinylcholine for emergency
  agents                   IM administration; short-
                           acting agents (mivacurium) to
                           facilitate endotracheal
                           intubation. Longer acting
                           agents may be needed based on
                           the intended surgical
                           procedures.

  Glycopyrrolate
  IV Induction agents      Propofol, penothal, ketamine,
                           etomidate.
  Midazolam                In addition to IV
                           administration, can also be
                           used for oral or intranasal
                           premedication.
  Neostigmine
  Opioids                  Check with country of
                           destination, regarding
                           restrictions on transport of
                           contolled agents such as
                           morphine or fentanyl.
                           Alternatively, these or other
                           analgesic agents may be
                           available in the country of
                           destination. Many developing
                           countries have IV preparations
                           of tramadol and nonsteroidal
                           anti-inflammatory agents that
                           are not available in the
                           United States. Alternatively,
                           there seem to be fewer
                           restrictions on obtaining and
                           transporting the agonist/
                           antagonists such as
                           butorphanol, dezocine, or
                           nalbuphine.

  Analgesic agents         Acetaminophen (tablets,
                           elixir, suppositories),
                           ibuprofen, oral week
                           opioids (acetaminophen with
                           codeine, hydrocodone, or
                           oxycodone).

  Antibiotics              IV (cefazolin) and oral
                           (amoxicillin-clavulanate
                           potassium [Augmentin],
                           cephalexin, [Keflex]).
  Antiemetics              Droperidol, ondansetron

IV = Intravenous; IM = intramuscular.
TABLE 2

Anesthesia Equipment and Supplies

Equipment and Supplies                    Comments

Laryngoscopes
Laryngeal mask airways (LMAs)   Means to deal with the anticipated
                                or unanticipated difficult airway
                                may be limited.
                                The availability of the LMA may
                                be helpful, and a disposable
                                type is now available, which may
                                limit cost.
Anesthesia masks
Anesthesia circuits
Endotracheal tubes
Intubating stylets
Oral and nasal airways
Spacing device or attachment
  for metered dose inhalers
Oxygen-powered nebulizer        For delivery of epinephrine, albuterol.
Magill's forceps
Flashlights                     Power failures may occur.
Inflatable pressure bags        For rapid fluid administration or
                                invasive pressure monitoring.
Soda lime
Self-inflating resuscitation
bags
IV Access supplies
  Tourniquets
  Catheters
  Alcohol swabs                 These can be made by cutting up
                                gauze sponges and soaking them
                                in alcohol rather than bringing
                                a box of standard alcohol swabs.
  IV Tubing and extension sets
  IV Fluids                     Usually best obtained or bought
                                in the country of destination.
                                Each I L bag will weigh 1 Kg;
                                shipping costs may be prohibitive.
                                Arrangements to buy these should
                                be made in advance, since it may
                                take a few days to arrange for
                                delivery. They may be in plastic
                                or glass bottles, necessitating
                                some form of vent to allow free
                                flow of the fluid. This can be
                                accomplished by inserting a
                                needle in the rubber stopper
                                of the bottle. Outside the
                                United States, lactated Ringer's
                                solution is referred to as Hartmann's
                                solution.
  T-pieces                      Can also be used to attach the
                                syringe to the needle for a
                                regional block. This allow
                                easy exchange of the syringe
                                without inadvertent movement
                                of the needle.
  Bio-occlusive dressings
Tape
Syringes
Benzoin
Nonsterile and sterile gloves
Protective eye goggles
Artificial tears
Yankauer and lOF and 14F
  suction catheters
Temperature strips              Crystalline II; Sham, Tampa, Fla.
Esophageal stethoscope
Replacement batteries for
  laryngoscope and nerve
  stimulator
Replacement bulbs for
laryngoscope
Needles
Insulated block needles
Spinal needles
Nasal cannulas and oxygen
masks
End-tidal [CO.sub.2] device     Easy Cap II; Nellcor-Puritan-Bennett,
                                Mallinckrodt, St. Louis, Mo.
Central line kit
Intraosseous needle
Cleaning and reuse supplies     Basin, chlorine bleach (household
                                variety), 70% isopropyl alcohol.

IV = Intravenous.

RELATED ARTICLE: KEY POINTS

* The issue that is foremost in providing anesthetic care in developing countries is the type of anesthesia machine that is available.

* Because of inherent problems with the host's hospital oxygen supply, an emergency supply (either an E or H cylinder) should be available in all operating rooms and the recovery room.

* The intraoperative monitoring should be similar to that used routinely at home.

* The preoperative evaluation should identify associated medical conditions such as congenital heart disease that may affect penoperative care, especially in an environment with limited facilities for dealing with perioperative complications.

* Conservation of supplies is of high importance and many supplies that are considered disposable can be disinfected, sterilized, and reused.