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Original Research Reports: Original Clinical Research Report

Challenges of Pediatric Anesthesia Services and Training Infrastructure in Tertiary Care Teaching Institutions in Pakistan: A Perspective From the Province of Sindh

Khan, Fauzia A. MBBS, FRCA*; Haider, Saeeda MBBS, FCPS; Abbas, Nighat MBBS, FCPS; Akhtar, Navaid MBBS, FRCA§; Haq, Nur Ul MBBS, FCPS; Khaskheli, M. Saleh MBBS, FCPS; Khatri, Younis MBBS, FCPS#; Munir, Nadeem MBBS, FCPS**; Raza, Hamid MBBS, FCPS††; Siddiqui, Maqsood Ahmed MBBS, FCPS‡‡; Soomro, Ahmed Uddin MBBS, FCPS§§; Siddiqui, Safia Zafar MBBS, FCPS∥∥

Author Information
doi: 10.1213/ANE.0000000000005849

Abstract

KEY POINTS

  • Question: What are the service and training infrastructure facilities for pediatric anesthesia in Sindh province of Pakistan?
  • Findings: We have identified and documented several gaps in service provision and training of residents in this area.
  • Meaning: These data can be used to plan improvement both in service and residency training in pediatric anesthesia in the surveyed institutions.

Universal Health Coverage (UHC) by 2030 requires strengthening of anesthesia and surgical services specially in lower and middle income countries (LMICs) where often anesthesia is given a low priority in comparison to surgery.1,2 Pakistan is a country of nearly 208 million people located in Southeast Asia.3 Thirty-five percent of its population is estimated to be 15 years of age or younger.4 To ensure that the anesthesia and surgical needs of the population are met, several steps are required including documenting the existing services for pediatric anesthesia, establishing training requirements for the subspecialty, documenting availability and standardization of equipment, and ensuring a supply of essential medications. There are currently no published data available on pediatric anesthesia service and training structure from Pakistan. It is important to collect this information to identify gaps and to plan for the future.

Sindh is the second largest province with a population of 47,886,051 and a rural:urban ratio of 48:52.5 The provincial capital is Karachi, which is the largest city in Pakistan. The province has 13 tertiary care hospitals that are recognized for postgraduate training in pediatric anesthesia by the College of Physicians and Surgeons of Pakistan (CPSP), the national body responsible for accreditation of training programs in the country.6

Our primary objective in conducting this survey was to identify and document the existing service and training infrastructure for pediatric anesthesia in the teaching hospitals of Sindh. Our secondary objective was to identify the gaps and make some recommendations.

Summary of Anesthesia Service and Training Structure in Pakistan

The body responsible for postgraduate education is the CPSP, which oversees the Faculty of Anaesthesia.6 There are 2 qualifications awarded in anesthesia by examination: a fellowship (FCPS) and a membership (MCPS). The requirement for fellowship is 4 years of structured training, and for MCPS, it is 2 years. Table 1 gives the comparison between the 2 qualifications. In addition, a second fellowship is awarded in pain, cardiac anesthesia, or critical care medicine after an additional 2 years of subspecialty training. No fellowship exists for pediatric anesthesia.

Table 1. - Comparison of MCPS and FCPS Training
MCPS FCPS
Entry requirement MBBS
1-y internship
Registration with CPSP
MBBS
1-y internship
Pass FCPS 1 examination
Registration with CPSP
Length of training (y) 2 4
Type of training Unstructured Competency based
Minimum case numbers Not identified Identified
Location of training CPSP-recognized institutions CPSP-recognized institutions
Abbreviations: CPSP, College of Physicians and Surgeons of Pakistan; FCPS, Fellow of College of Physicians and Surgeons of Pakistan; MBBS, Bachelor of Medicine, Bachelor of Surgery; MCPS, Member of College of Physicians and Surgeons of Pakistan.

There are 2 cadres of staff appointed in institutions. Those with FCPS fill the academic consultant posts and have clinical, teaching, research, and administrative responsibilities. The second cadre with MCPS work in nonacademic posts and provide only clinical services.

The residency program for FCPS is standardized to 4 years all over the country and is competency based.6 For general training recognition, an institution applies to the CPSP on a predesigned format, the college then arranges a faculty visit. The inspection team reports to CPSP and recognition for training is based on these reports after discussion in the College Council.

Trainees register with CPSP after passing the part 1 FCPS examination and are assigned a supervising consultant who is a fellow of CPSP with 5 years of postfellowship experience and an employee of a recognized training institution. This consultant does not supervise the trainee directly but is responsible for obtaining feedback on clinical training of their assigned residents from other colleagues with whom the trainee works. They then prepare and submit regular written reports to CPSP on the trainee’s progress.

The competency model as proposed by CPSP is based on knowledge, technical skills, communication skills, team work, and research centered around patient care. The instructional methodology revolves around supervised clinical training, tutorials and lectures, problem-based discussions, workshops, and self-learning. The level of clinical competencies to be achieved each year is specified as either observer or assistant status, performed under supervision or performed independently. The work performed by the trainee is recorded in an e-logbook on daily basis and signed by the consultant supervisor on the operating list.

See Supplemental Digital Content 1, https://links.lww.com/AA/D768, for details on pediatric anesthesia training during residency programs.

METHODS

We conducted this cross-sectional survey between June 2018 and September 2018 in 12 teaching hospitals of the Sindh province of Pakistan that were recognized for post graduate training in pediatric anesthesia. We utilized a grant from the World Federation of the Societies of Anaesthesiologists (WFSA). The survey was conducted in English, as it is widely understood among the medical fraternity in the country. Consent for data release was taken from either the hospital chief medical officer or the head of the unit of anesthesia of the institution. Approval from the ethical committee of the Pakistan Society of Anaesthesiology, Karachi Chapter, was obtained for conducting the survey and publication of this anonymized data. Written informed consent was also obtained from all coordinators filling the data form.

We designed a questionnaire covering different aspects of pediatric anesthesia service and training (see Supplemental Digital Content 2, https://links.lww.com/AA/D769). The questions in the survey were a combination of yes/no answers and open-ended questions. The form was pretested in 2 hospitals before being used. The pretesting included 2 hospitals that were later included in the survey, but the coordinators identified for the final survey were not involved in pretesting. The questionnaire consisted of 2 parts. The first part recorded demographic data and general institutional information, and the second part recorded the information related to availability of pediatric anesthesia service as well as training structure of the residency program.

The form was e-mailed to all administrative heads of the anesthesiology departments. They or their designate (a senior faculty member) were primarily responsible for filling the form and were designated as coordinators. All coordinators had access to departmental data. A research assistant who was familiar with medical terminology was instructed and trained by one of the primary investigators (F.A.K.) in 2 live sessions. Training included familiarization with the survey form, and how to fill in any missing information. The research assistant made 2 field visits to each hospital. The completed forms were re-reviewed by F.A.K. and S.H., and coordinators were contacted for further clarifications.

Confidentiality of the information was assured, as all data were kept with the principal coordinator, and the access to raw data was limited to the 2 main coordinators. Furthermore, the names of the institutions were kept confidential, and data were stored as institution A, B, C, etc.

Statistics

All information from different institutions was transferred to Excel sheets and then imported into Statistical Package for the Social Sciences (SPSS), version 22.0 (IBM Corporation) for analysis. Frequency and percentage were computed for all categorical variables. Quantitative value was reported as mean with standard deviation and median with interquartile range (IQR).

RESULTS

Survey Return Rate

There were 13 teaching hospitals in Sindh recognized for training by CPSP. One institution refused to participate; hence, data were collected from 12 institutions, a response rate of 92%. Seven institutions were government run, and 5 were under private governance.

Preoperative Assessment

Only one private institution had a dedicated preoperative clinic for pediatric patients. In the rest, children shared the clinics with adults. The exact number of pediatric patients seen in the preoperative clinics was not available as it was not logged in the majority of hospitals.

Premedication Practice and Parental Presence in Operating Room

Premedication was routinely used for all elective surgery patients in one private institution. In 4 hospitals, premedication practice was dependent on the discretion of the consultant in charge of the list. The drug used for premedication was oral midazolam. In the rest of the hospitals, children were not premedicated due to logistical issues of running busy lists and shortage of nursing staff, although midazolam was available.

Parental presence in the operating room (OR) was only allowed in 4 private hospitals (33%).

Routine Preoperative Testing

Significant variation was noticed in the preoperative routine laboratory tests required in different institutions. All institutions required complete blood picture for all scheduled patients. Twenty-five percent required additional urinalysis, coagulation studies, and viral markers, and 42% asked for urea and electrolyte results routinely in all admitted patients.

Pediatric Surgical Lists and Operating Room Organization

The percentage of day care patients on pediatric lists varied widely between 5% and 70% in different hospitals. The median number of pediatric surgeries per week in the government hospitals was 20 (range, 15–40; IQR, 20–30), and in private hospitals, it was 40 (range, 10–45; IQR, 11–43). The median number of operating lists per week was 3 (range, 2–6) in government and 5 (range, 2–6) in private institutions. Fifty percent of the scheduled surgeries were relatively simple (eg, inguinal hernia repair and circumcision), 25% were laparotomies, and 25% were specialized surgery (eg, neurosurgery and cardiac surgery). Inguinal hernia repair was the most common procedure, followed by circumcision and hypospadias repair.

A dedicated pediatric OR was present only in 5 institutions (3 government and 2 private).

Staffing

Staffing was shared with adult lists, and none of the hospitals had dedicated anesthetic staff looking after pediatric patients. All consultants providing or supervising pediatric lists had postgraduate qualifications, either FCPS or MCPS, but had shared responsibilities for adult lists. Nonphysician staff (ie, nurses and technicians) were from the general pool and did not have any formal certification of pediatric training apart from learning on job.

Status of Monitoring

Table 2. - Availability of Monitors in Surveyed Institutions
Monitors Government-run institutions
(total No. 7)
n (%)
Private-run institutions
(total No. 5)
n (%)
Pulse oximeters 6 (86) 5 (100)
O2 analyzers 2 (28.5) 3 (60)
Etco 2 monitors 3 (43.8) 5 (100)
Temperature probes (pediatric) 2 (28.5) 3 (60)
Peripheral nerve stimulators 2 (28.5) 2 (40)
BIS monitor 0 1 (20)
Foley catheters (pediatric size) 7 (100) 4 (80)
Pediatric central lines 1 (14) 5 (100)
Invasive arterial monitoring lines 0 4 (80)
n is the number of hospitals where this monitoring was available.
Abbreviations: BIS, bispectral index; Etco2, end-tidal carbon dioxide.

The status of monitoring in the surveyed institutions in reference to pediatric anesthesia is given in Table 2. Pulse oximetry was available in all hospitals except one. In 50% of the government hospitals, the number of available pulse oximeters was less than the number of ORs. End-tidal carbon dioxide monitoring was available in only 3 of the 7 government institutions (44%).

Equipment

Anesthesia Machines and Circuits

Anesthesia machines and circuits with provision for pediatric/neonatal ventilation were available in only 66.6% institutions (4 government and 4 private). T piece circuit was available in 91.6% of the hospitals.

No active scavenging was available in any of the hospitals. Reliance was on air changes in the ORs.

Disposable Airway Equipment

Different endotracheal tube (ETT) sizes from 2.5 to 6.5 were available in all institutions. Cuffed ETT were also available in 83.3% of the hospitals, but their use was dependent on the discretion of the consultant conducting the list.

Laryngeal masks in all sizes were available at all premises. Pediatric Igel was available in only 50% hospitals. Pediatric videolaryngoscopes were present in only 2 institutions (16.6%): 1 public and 1 private.

Other Equipment

Table 3. - Availability of Other Equipment, n (%)
Availability of equipment Government institutions (total No. 7)
n (%)
Private institutions (total No. 5)
n (%)
NIBP with pediatric cuff 4 (57) 5 (100)
Pediatric ECG electrodes 5 (71) 5 (100)
Pediatric defibrillator pads 5 (71) 3 (60)
Regional anesthesia equipment
 Pediatric epidural needles 0 0
 Caudal epidural needles 4 (57) 2 (40)
 Intrathecal needles 0 0
 Peripheral nerve block needles 2 (28) 0
 PCA equipment (for older children) 0 2 (40)
Abbreviations: ECG, electrocardiogram; NIBP, noninvasive blood pressure; PCA, patient-controlled analgesia.

Availability of other equipment besides airway equipment is shown in Table 3.

Regional Anesthesia

Equipment specific to pediatric regional anesthesia is shown in Table 3. Caudal anesthesia was practiced in all institutions for infraumbilical surgery. Use of other blocks like epidural, transversus abdominis plane block (TAP), or brachial plexus block was very rarely practiced. The exact numbers for these blocks were not available.

Anesthetic Medications

All essential anesthetic drugs listed in World Health Organization (WHO) essential medication list were available, except for halothane and ephedrine. Halothane was no longer used because of availability of better alternatives like isoflurane and sevoflurane. Ephedrine was not licensed in the country by the drug control authority. Consistent supply of potent narcotics like morphine, fentanyl, and pethidine was an issue in all hospitals since the government issues a set yearly quota to all hospitals, and after this quota is consumed, it is not replenished until the next calendar year. Tramadol and nalbuphine were alternate analgesics used for both intraoperative and postoperative pain relief.

Neonatal Surgery

Neonates were not operated on in 2 institutions. In the other 10 institutions, there were variations in the number of neonatal procedures performed, and the case load varied. The median number of neonatal surgeries performed per month was 7 (range, 1–20; IQR, 3–15) in these institutions.

The common neonatal surgeries performed were inguinal hernia repair, laparotomy/stoma formation for anorectal malformations, and ventriculo-peritoneal shunt insertion.

Postanesthesia Recovery Room (Postanesthesia Care Unit) Service and Staffing

All patients were recovered in the adult recovery area. None of the hospitals had dedicated pediatric nursing staff in their postanesthesia care units (PACUs).

Pain Management

Pain scales for assessment of pediatric pain were not displayed in any of the recovery rooms of the surveyed hospitals. Postoperative pain was documented as the fifth vital sign in only 7 hospitals (58%; 3 government and 4 private). There was no dedicated acute pain service for pediatric patients in any of the hospitals. In hospitals where an acute pain service existed, children were managed by the general team along with adult patients.

A protocol for management of pediatric pain was present in only one institute.

Oral analgesics such as paracetamol and ibuprofen syrup were available for use in all institutions except one. Use of rectal suppository (diclofenac) for intraoperative and postoperative pain management was present in 10 institutions. Intravenous paracetamol was freely available and was used as an analgesic.

Transdermal patches were not available in any institution. Patient-controlled analgesia was only used in older children in one institution.

There was inconsistent supply of morphine and fentanyl for postoperative pain relief after major surgery, and alternative drugs like nalbuphine and tramadol were used.

Pediatric Critical Care Services

There were separate pediatric and neonatal units present in 6 hospitals (4 private and 2 government). The number of beds in these units varied between 4 and 10. Two hospitals had neonatal units but no pediatric intensive care unit (ICU), and one had a shared pediatric/neonatal unit. In 3 hospitals, pediatric patients went to a general ICU or were transferred out of the hospital if critical care was needed. All 3 of these hospitals were government owned.

Dedicated forms for documentation were used in all neonatal intensive care units (NICUs).

Pediatric Anesthesia Training Infrastructure

All teaching hospitals in this survey were recognized teaching centers by the CPSP; however, 2 of the government institutions were only training MCPS candidates. They had recently been recognized for FCPS; hence, data on FCPS training were not available from them.

Pediatric surgical lists per week, approximate number of pediatric surgical case workload per week, the number of anesthesia residents completing a pediatric module, and exposure to pediatric critical care are shown in Table 4.

Table 4. - Exposure of Anesthesia Residents to Pediatric and Neonatal Anesthesia Services and Pediatric Critical Care
Hospital No. of pediatric surgery lists/wk Total No. of residents (FCPS trainees) in the program Average No. of pediatric cases operated/wk Duration of pediatric anesthesia rotation Exposure to neonatal anesthesia Pediatric critical care facility in the hospital
Aa 2 34 20 3 mo Yes General
Ba 3 33 30 1 mo No General
Ca 6 17 20 2 mo No Pediatric
Da 2 25 15 2 mo Yes General
Ea 3 7 30 2 mo/y Yes General
Fa 3 Only MCPS trainees 40 Only recognized for MCPS training Yes Neonatal and general
Ga 1 Only MCPS trainees 20 Only recognized for MCPS training Yes General
Hb 5 34 40 3 mo Yes Pediatric and neonatal
Ib 6 18 45 3 mo Yes Pediatric and neonatal
Jb 3 5 12 3 mo Yes General
Kb 2 26 40 3 mo Yes Pediatric and neonatal
Lb NA 6 10 3 mo Yes Pediatric and neonatal
Abbreviations: FCPS, Fellowship of College of Physicians and Surgeons of Pakistan; MCPS, Membership of College of Physicians and Surgeons of Pakistan; NA, exact number not available.
aGovernment institutions.
bPrivate institutions.

There was a variation in the level of residents rotating in pediatric anesthesia and also in the organization of pediatric anesthesia rotations. In some institutions, the residents completed a continuous 3-month block of rotation in pediatric anesthesia, whereas in others, the rotation was broken into periods of 1 or 2 months, and the residents were exposed to pediatric anesthesia at different residency levels.

The amount of faculty supervision on pediatric lists also varied from institution to institution. In several hospitals, 1:1 faculty/resident ratio for managing the operating lists was not feasible due to shortage of number of faculty. In these facilities, anesthesiologists with MCPS were present to help out the residents in case of emergency. None of the hospitals had dedicated consultants practicing only pediatric anesthesia; they were generalists with interest in pediatric anesthesia.

The survey inquired about handling of complications, the support available to the trainees in case of complications, and the discussion that occurred in the department after a complication. In all training centers, consultants took the responsibility for complications, and these were discussed in departmental meetings. Some institutions did not have formal morbidity and mortality meetings, but problems were discussed in their morning meetings.

DISCUSSION

Our survey results showed that while all WHO recommended drugs were generally available, there was an overall deficit in the availability of some basic and specialist pediatric equipment and a wide variation in the organization of services and training infrastructure for pediatric anesthesia across Sindh province. These identifiable deficits in service provision and training are likely to negatively impact the safety and quality of surgical and anesthesia care and adversely affect patient outcomes.

The pertinent points are highlighted in the following discussion.

Pediatric Anesthesia Services

Lack of basic monitoring and other equipment in some hospitals meant unsafe anesthesia practice. This could be overcome by having essential lists for both monitoring and basic anesthetic equipment, endorsed by the health ministry as well as the National Anesthesia Society.

Lack of availability of core opioid analgesics results in substitution of longer-acting drugs like nalbuphine or tramadol for intraoperative and postoperative analgesia.7 This means longer recovery time and longer PACU stay. Drugs like morphine and fentanyl are tightly controlled by the government, which issues a set quota for the whole year. Nickerson et al8 have stressed the importance of advocacy on the part of anesthesia providers to have more control on access to narcotics, and national societies have a part to play in this.

Deficient postoperative pain assessment and management was found in our survey. Apart from overcoming staffing issues, this could be improved with availability of protocols and guidelines for effectively using available analgesic drugs. In addition, awareness sessions and workshops are needed to train the recovery and ward staff on importance of pain assessment and management in children.

There was wide variation in the organization of service. One of the limiting factors in reorganization of services, especially in government run-institutions, is shortage of faculty at consultant level. WFSA recommends 5 physician anesthesia providers (PAPs)/100,000 population to meet the Lancet Commission recommendations for a specialist surgical workforce by 2030.9 With 1.64 PAP/100,000 population, Pakistan is far behind. This is an issue that should be taken up on an urgent basis by the government in collaboration with the national society and the training and accreditation body and requires both short- and long-term solutions. One solution is to expand the middle cadre workforce, the MCPS diploma holders, and provide them with a career structure and give them specific teaching and training responsibilities in addition to service work. Day care surgery was underutilized in our survey in comparison to high-income countries (HICs).10,11 Introducing separate day care surgery units could have an economic benefit for both patients and institutions and less burden on hospital systems.

Currently, there are no national recommendations related to pediatric anesthesia by the National Anesthesia Society (ie, Pakistan Society of Anaesthesiologists [PSA]). Practice recommendations for pediatric anesthesia are available from HIC.12 These can be modified for use in Pakistan.

There are limited data available on the pediatric anesthesia practice and training from other countries in Asia and specifically Southeast Asia. One recent publication from China addressed the current pediatric anesthesia practice in its country.13 The survey concentrated on the techniques, and we were unable to compare our findings, as our methodology was different. Another article from Bangladesh described issues and challenges of pediatric anesthesia in a single institution in a military hospital.14 One recent article from our institution described the pediatric anesthesia severe adverse events leading to anesthetic morbidity and mortality. The authors concluded that increased access to anesthetic drugs and practice improvements resulted in a decline in perioperative cardiac arrests.15

Pediatric Anesthesia Training Infrastructure

Assessment in any medical disciplines requires an infrastructure in terms of list numbers and available equipment and supervision, as well as elements of how the training is delivered, such as quality, content and frequency of lectures, workshops, case-based discussion, simulation training, clinical skills training, etc. Our survey focused only on the provision of infrastructure and not the quality.

We noticed a variation in patient load, availability of equipment, and advanced monitoring between private and government institutions. This can have a possible negative effect on the training of postgraduates enrolled in the programs.

CPSP recommends a 3-month mandatory rotation in pediatric anesthesia for all residency programs training for FCPS. Competency in these programs is assessed by the consultant supervisor based on reports provided by supervising clinical faculty. Public sector hospitals had an adequate volume of cases but lacked some basic and advanced monitoring equipment as well as inadequate supervision of trainees due to shortage of academic faculty. Several of these institutions had fragmented training structure. One proposed solution could be combined training programs with pairing of private and public hospitals. Again, our literature search did not identify national or regional publications on the training of residents specific to pediatric anesthesia. Two publications from India emphasized the need and importance of improving pediatric anesthesia programs in its country.16,17

Strengths and Limitations of the Survey

The main strength of our survey is that there was no previous published information on teaching institution-based practice in reference to pediatric anesthesia services in Pakistan, and this is a first such attempt to do so. Our survey instrument was simple and self-constructed, but we tried to get as much information as possible on the form and reconfirmed all the information. Free text space was provided after every section for related comments. We also piloted it before using it.

There are some limitations. The survey was based on departmental and institutional data and was not a survey of individual practice or patient outcomes. It was only conducted in CPSP-recognized teaching institutions approved for training for the FCPS program in anesthesia. It does not reflect on pediatric anesthesia practice nationally, as pediatric anesthesia is practiced in other nonteaching institutions at the district level, but those hospitals are not assigned residents. The reason for limiting this survey to the teaching hospitals and to Sindh province only was because we did not have the logistical and financial support available to include all the district hospitals of the province, which total approximately 170. We limited it to one province, since in the current health care model in the country, care is the responsibility of the provincial government and differs among the provinces.

One major critique on our survey is the lack of input from the trainees themselves, which is critical in determining the quality of training that is delivered and how the residents perceive their training. We also did not include all the structural elements needed for training like lectures, tutorials, workshops, etc. In spite of these limitations, we have managed to provide some basic documentation regarding the subspecialty for other investigators to build on.

CONCLUSIONS

Our survey has demonstrated the need to develop pediatric services in all perioperative areas, as well as to provide standardization of services in teaching institutions in Sindh. Several gaps have been identified, such as lack of standardization and guidelines even in the same hospitals, unavailability of both basic and advanced monitoring and equipment especially in government-owned institutions, erratic supply of narcotic analgesics, and lack of postoperative pain assessment and treatment. Some solutions have been suggested. The infrastructure in terms of pediatric anesthesia training needs further improvement. Both short- and long-term solutions are needed to deal with these deficits.

Recommendations by this group have been shared with all teaching hospitals and training bodies.

DISCLOSURES

Name: Fauzia A. Khan, MBBS, FRCA.

Contribution: This author conceived the study design; contributed to the survey tool; helped oversee the collection of data; helped in analyzing data; and wrote the initial draft of, edited, and approved the manuscript.

Name: Saeeda Haider, MBBS, FCPS.

Contribution: This author reviewed and edited the protocol, helped in constructing the survey tool, helped oversee the collection of data, helped in analyzing the data, and edited and approved the manuscript.

Name: Nighat Abbas, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Navaid Akhtar, MBBS, FRCA.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Nur Ul Haq, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: M. Saleh Khaskheli, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Younis Khatri, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Nadeem Munir, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Hamid Raza, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Maqsood Ahmed Siddiqui, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Ahmed Uddin Soomro, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

Name: Safia Zafar Siddiqui, MBBS, FCPS.

Contribution: This author reviewed the protocol, helped collect data, and reviewed and approved the final manuscript.

This manuscript was handled by: Angela Enright, MB, FRCPC.

    REFERENCES

    1. Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
    2. Walker I, Wilson I, Bogod D. Anaesthesia in developing countries. Anaesthesia. 2007;62(suppl 1):2–3.
    3. Pakistan Bureau of Statistics [Internet]. Pbs.gov.pk. Population Census. 2019. Accessed June 20, 2020. http://www.pbs.gov.pk/content/population-census.
    4. Siddiqui S, Vervoort D, Peters AW, et al. Closing the gap of children’s surgery in Pakistan. World J Pediatr Surg. 2019. Accessed May 14, 2020. https://wjps.bmj.com/content/2/1/e000027.
    5. Sindh-Wikipedia. 2019. Accessed June 20, 2020. https://en.m.wikipedia.org/wiki/Sind.
    6. College of Physicians and Surgeons of Pakistan. 2019. Accessed June 20, 2020. https://cpsp.edu.pk/.
    7. Khan TH. Availability of essential drugs in Pakistan (editorial). Anaesth Pain Intensiv Care. 2009;13:1–3.
    8. Nickerson JW, Pettus K, Wheeler KE, et al. Access to controlled medicines for anesthesia and surgical care in low-income countries: a narrative review of international drug control systems and policies. Can J Anaesth. 2017;64:296–307 [published correction appears in Can J Anaesth. 2017;64(5):558].
    9. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The WFSA global anesthesia workforce survey. Anesth Analg. 2017;125:981–990.
    10. Macq C, Seguret F, Bringuier S, et al. Photograph of anesthesia activity over one year in France. Ann Fr Anesth Reanim. 2012;31:835–839.
    11. Rabbitts JA, Groenewald CB, Moriarty JP, Flick R. Epidemiology of ambulatory anesthesia for children in the United States: 2006 and 1996. Anesth Analg. 2010;111:1011–1015.
    12. American Society of Anesthesiologists. Statement on practice recommendations for paediatric anaesthesia developed by Committee on Pediatric Anesthesia. Accessed May 14, 2020. https://www.asahq.org/standards-and-guidelines/statement-on-practice-recommendations-for-pediatric-anesthesia.
    13. Bin Z, Huan G, Xiangyong Z, et al. Current pediatric anesthesia practice in general in China: a national survey. Transl Perioper Pain Med. 2018;5:19–26.
    14. Azad AK, Ullah MS. Issues and challenges of pediatric anesthesia in Bangladesh. J Anesth Crit Care Open Access. 2018;10:203–206.
    15. Khoso N, Ghaffar WB, Abassi S, Khan FA. Pediatric anesthesia severe adverse events leading to anesthetic morbidity and mortality in a tertiary care center in a low- and middle-income country: a 25-year audit. Anesth Analg. 2021;132:217–222.
    16. Rao KL, Batra YK. We need to develop pediatric anesthesiology in India! J Indian Assoc Pediatr Surg. 2015;20:8–9.
    17. Sen I, Dave N, Bhardwaj N, Juwarkar C, Beegum S. Specialised training in paediatric anaesthesia: need of the hour. Indian J Anaesth. 2021;65:17–22.
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