The limitations of healthcare in developing countries, in addition to a lack of specialists, may include scarce infrastructure, poorly equipped hospitals, the unavailability of blood products, the malnutrition of patients, uncertainty in preoperative patient evaluation and perioperative hypothermia. We describe the impact of these conditions on anaesthesia at the Sushma Koirala Memorial Plastic and Reconstructive Hospital in the developing country of Nepal, where seven teams of the University Department of Anaesthesiology, Cologne, Germany, provided anaesthesia for the surgical repair of cleft lip, maxilla and palate during a series of 3 week commitments from November 1998-2001.
The hospital, surrounded by small mountain villages and agricultural terraces, 1400 m above sea level on the promontory of the Himalayas, was originally founded for leprosy patients. Since 1998, when it was taken over by Interplast Germany, Dr H.D. Pape, retired Professor of Oromaxillofacial Surgery at the University of Cologne, has been in charge of the hospital focussing on cleft surgery. The hospital consisted of a 150 m2 single-story building with two operating theatres. Each patient family shared one bed on the concrete floor of the patient building or in the nearby 'hotel'. There was neither heating nor air-conditioning in the patient building. Water was provided from a mountain creek. Two emergency generators ensured electricity backup during daily power cuts. Anaesthetic equipment included a Stephan machine designed solely for manual ventilation, with oxygen and nitrous oxide cylinders and a halothane vaporizer. Neither a gas analyser nor an ECG monitor were available. The waste gas pipe was directed outside through a hole in the flysheet. Our teams supplied two pulse oximeters as well as anaesthetic drugs and materials. Oxygen, nitrous oxide, halothane and infusion fluids were obtained from India. A surgeon, a local surgical resident and four nurses staffed the hospital.
More than 90% of patients and their relatives travelled overland by bus, requiring an average 10 h ride to the hospital. Ten families had undertaken journeys of up to 18 h and one family even walked for 5 days over the mountains. The children wore ragged clothes and had no shoes; they also had dirty feet and hands. Only 11% of the patients spoke some English. The charges for hospital care were the equivalent of a day's wage per patient and the accompanying family. Those unable to afford this fee received free treatment. Preoperative patient evaluation had to be restricted to history, with the aid of an interpreter, and a physical examination. No laboratory tests or radiographs were available.
A total of 175 children, of whom 103 were males, were operated on with the assistance of our teams. Sixty-two children were between 4 months and 2 yr of age; the remaining children were equally distributed until 16 yr of age. Our patients' body weight and height ranged from 5 to 52 kg and from 63 to 170 cm, respectively. About one-third of the children were treated for cleft lip only, another one-third for cleft lip, maxilla and palate, and the remaining one-third for other cleft combinations. A total of 123, 22 and 30 children were designated to ASA classes I, II and III, respectively. Those allocated to ASA II had moderate malnutrition and/or mild bronchitis; those in ASA III had severe malnutrition and/or severe bronchitis. In two cases surgery had to be postponed for acute bronchitis. Two children had a history of rheumatic fever, one child had cardiac disease of unknown nature and one child suffered from untreated epilepsy. Abdominal distension was a common finding.
The children were premedicated with midazolam 0.5 mg kg−1 orally 30 min before the induction of anaesthesia. In children up to 6 yr of age, anaesthesia was induced with halothane and nitrous oxide in oxygen via a facemask. Intravenous (i.v.) induction with propofol 2.0-2.5 mg kg−1 was used in most children over 6 yr of age. Mivacurium 0.2 mg kg−1 or vecuronium 0.1 mg kg−1 were used to facilitate orotracheal intubation. Anaesthesia was maintained with nitrous oxide 66% and halothane 1.0-1.5% in oxygen or by a propofol infusion (0.1-0.2 mg kg−1 min−1) supplemented with fentanyl 2-5 μg kg−1 or alfentanil 20-50 μg kg−1. A throat pack was always inserted and a single dose of ampicillin 25 mg kg−1 and piperacillin 25 mg kg−1 given i.v. Blood pressure, heart rate and peripheral oxygen saturation were monitored using a manual blood pressure cuff and oximeter. The estimated intraoperative blood loss never exceeded 10-20% of the estimated circulating blood volume. Pain therapy in children under 12 yr of age included rectal acetaminophen 10-20 mg kg−1 given after induction of anaesthesia and supplemented postoperatively by pirinitramide (piritramide) 0.1-0.15 mg kg−1 i.v. and acetaminophen 10-20 mg kg−1 orally. Children over 12 yr of age received pirinitramide (piritramide) 0.1-0.2 mg kg−1 and metamizol 10-15 mg kg−1 i.v., postoperatively. The children were monitored until the following morning. Wounds were inspected every morning until the patients' discharge on the sixth postoperative day. Insufficient heating in winter and the lack of air-conditioning in summer resulted in an extremely variable operating room temperature. The lowest recorded temperature was 11°C in January and February, causing the patient's temperature (external auditory meatus) to fall by an average of 0.8°C. Warmer conditions prevailed during April, May, October and November. No severe wound infections were observed. Laryngospasm occurred in two infants after extubation. Postoperative vomiting was not a general problem. One child vomited a handful of worms. Another child required surgical wound revision for postoperative bleeding.
The incidence rate of cleft malformations in Asian countries has been reported to be about 1 : 600 compared with 1 : 350 in Western countries . In Nepal, many of these patients reach adulthood without ever receiving treatment. According to the somatograms of the National Center for Health Statistics , our children had, on average, 22% less body weight and were 10% shorter than American children of comparable age. Thus, half our patients appeared malnourished, which is in accordance with the data of Liu and Richard . However, owing to ethnic and environmental differences in the Nepalese population, the data of  and  may not be useful references. In Western countries, recommendations for cleft lip closure require children to be at least 10 weeks old, weigh at least 4.5 kg and have a haemoglobin concentration >10.0 g dL−1[4,5]. The palate and maxilla are closed at the end of the first year of life . With this approach, blood transfusion is rarely necessary . In Nepal, we did not accept children under the age and weight of 4 months and 5 kg, respectively. Owing to a lack of equipment, their haemoglobin concentrations remained unknown. We therefore refrained from attempting lip and palate closure in one session as described for developing countries  to minimize the chance of every third patient requiring blood. Therefore, in children under 3 yr of age, i.e. almost 50% of our patients, the surgeon preferred to close the palate first and the lip several months later. The objective was to avoid the parents neglecting palate closure in view of a cosmetically pleasing result at the lip. Only in certain very small children did the surgeon close the lip at the first session for the sake of economizing blood loss.
Although our population of 175 children may be too small for a statistically valid conclusion, none of the team members ever felt they were taking unacceptable risks. This impression is supported by the fact that, outwith this report, another 180 adults with cleft malformations were operated upon successfully in our hospital. The low incidence of problems specific to paediatric anaesthesia, which may be related to endotracheal intubation, lung ventilation, fluid balance, laryngospasm and hypothermia, is in part explained by the relatively advanced age of our Nepalese patients.
While continuing to improve the hospital facilities, we feel that the degree of complexity should remain limited. As long as both financial resources and servicing expertise for 'high-tech' equipment are lacking, we prefer to use simple equipment. Sophisticated electronic equipment should be confined to gadgets small enough to fit into the teams' air luggage, e.g. portable pulse oximeters. Likewise, the selection of patients, the technique of anaesthesia and the surgical approach should be adapted to the local conditions. It was a challenge as well as a rewarding experience to both experienced and trainee anaesthesiologists to work successfully under conditions clearly different from their home hospital environment.
Department of Anaesthesiology; University of Cologne; Cologne, Germany
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