Objective: High quality obstetric anaesthetic care is integral to reducing preventable maternal deaths in Low-and-Middle-Income-Countries (LMICs). We applied behavioural science to evaluate SAFE Obstetrics, a 3-day Continuing Professional Development (CPD) course, on physician and non-physician anaesthetists' practice behaviours across 3 LMICs.Methods: Seven anaesthetist Fellows from Bangladesh, Nepal and Tanzania were trained in qualitative methods and behavioural science. Structured interviews were undertaken by Fellows and two UK behavioural scientists with course participants. Interviews were based on the Theoretical Domains Framework: a comprehensive framework of influences on behaviour change. Interviews were recorded, transcribed and analysed using content and thematic analysis.Results: 78 physician and non-physician anaesthetists participated (n = 26 Bangladesh, n = 24 Nepal and n = 28 Tanzania). Participants reported positive improvements in patient-centered working, safety, teamwork and confidence. Across countries, we found similar barriers and facilitators: environmental resources, a strong professional identity and positive social influences were key facilitators of change.Conclusion: This multi-country theory-based evaluation highlighted the impact of SAFE Obstetrics on participants' clinical practice. A supportive work environment was crucial for implementing learning following training; CPD courses in LMICs must furnish participants with skills and equipment to address training implementation challenges. Building local behavioural science capacity can strengthen LMIC health intervention evaluations.

Sickle cell disease is a multisystem disease characterised by chronic haemolytic anaemia, painful vaso-occlusive crises and acute and chronic end-organ damage. It is one of the most common serious inherited single gene conditions worldwide and has a major impact on the health of affected individuals. Peri-operative complications are higher in patients with sickle cell disease compared with the general population and may be sickle or non-sickle-related. Complications may be reduced by meticulous peri-operative care and transfusion, but unnecessary transfusion should be avoided, particularly to reduce the risk of allo-immunisation. Planned surgery and anaesthesia for patients with sickle cell disease should ideally be undertaken in centres with experience in caring for these patients. In an emergency, advice should be sought from specialists with experience in sickle cell disease through the haemoglobinopathy network arrangements. Emerging data suggest that patients with sickle cell disease are at increased risk of COVID-19 infection but may have a relatively mild clinical course. Outcomes are determined by pre-existing comorbidities, as for the general population.

In high-resource settings most paediatric anaesthesia is undertaken by specialist or subspecialist practitioners. In remote and resource-poor settings it is usual for anaesthetists to care for all ages of patient, and paediatrics can therefore form a large part of the non-specialist’s workload. The chapter contains essential knowledge for the non-specialist paediatric anaesthetist, including equipment sizing, drug doses, and fluid therapy, mostly in handy ‘quick-look’ tables. The presentation and management of common perioperative comorbidities such as malnutrition and sickle cell anaemia are also discussed. The bulk of the chapter covers practical advice on anaesthesia for a range of common paediatric and neonatal surgeries.

Reducing maternal mortality remains a global priority, particularly in low- and middle-income countries (LMICs). The Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia (OB) course is a three-day refresher course for trained anaesthesia providers addressing common causes of maternal mortality in LMICs. This aim of this study was to investigate the impact of SAFE training for a cohort of anaesthesia providers in Ethiopia. We conducted a mixed methods longitudinal cohort study incorporating a behavioural questionnaire, multiple-choice questionnaires (MCQs), structured observational skills tests and structured interviews for anaesthesia providers who attended one of four SAFE-OB courses conducted in two regions of Ethiopia from October 2017 to May 2018. Some 149 participants from 60 facilities attended training. Behavioural questionnaires were completed at baseline (n= 101, 69% response rate). Pre- and post-course MCQs (n = 121, n : 123 respectively) and pre- and post-course skills tests (n 123, n = 105 respectively) were completed, with repeat MCQ and skills tests, and semi-structured interviews completed at follow-up (n = 88, n = 76, n = 49 respectively). The mean MCQ scores for all participants improved from 80.3% prior to training to 85.4% following training (P < 0.0001) and skills test scores improved from 56.5% to 83.2% (P < 0.0001). Improvements in MCQs and skills were maintained at follow-up 3-11 months post-training compared to baseline (P=0.0006, < 0.0001 respectively). Participants reported improved confidence, teamwork and communication at follow-up. This study suggests that the SAFE-OB course can have a sustained impact on knowledge and skills and can improve the confidence of anaesthesia providers and communication within surgical teams.

Maternal mortality rates in low-middle income countries remain high, with sub-Saharan Africa accounting for two-thirds of global maternal deaths. Inadequate staff training is one of the main contributors to anaesthesia-related deaths and the Association of Anaesthetists developed the Safe Anaesthesia from Education course in collaboration with the World Federation of Societies of Anaesthesiologists to address this training gap. We aimed to evaluate the impact of this course among Kenyan participants. Mixed methodologies and secondary analyses of anonymised data were used to study translation of learning into practice. In total, 103 participants from 66 facilities who attended courses between 2016 and 2017 were analysed. Ninety (87%) participants who were followed up completed knowledge tests. Baseline median (IQR [range]) knowledge test score was 41 (37-43 [21-46]). There was a significant improvement in median (IQR [range]) knowledge test score immediately post-course (43 (41-45 [33-48]); p < 0.001) which was sustained at 3-6 month follow-up (43 (41-45 [32-50]); p < 0.001 compared with baseline). Eighty-four of the 103 participants were observed in their workplace and capability, opportunity and motivation-behaviour framework was used to study the barriers and facilitators to practice change. Psychological capability and reflective motivation were the main factors enabling positive behaviour change such as team communication and pre-operative assessment, whereas physical and social opportunity accounted for the main barriers to behaviours such as performing the surgical safety checklist. Our study demonstrates that the Safe Anaesthesia from Education obstetric course is relevant in the low-resource setting and may lead to knowledge translation in clinical practice.

Rib fractures are associated with significant morbidity and mortality. Ultrasound-guided thoracic paravertebral catheter insertion has been described for the management of pain secondary to rib fractures. We conducted a retrospective observational study of all patients with rib fractures who had a paravertebral catheter inserted for analgesia provision over a 4-year period. Data from the Trauma Audit and Research Network were used to compare patients with rib fractures who were managed with paravertebral catheters to those managed with systemic analgesia. A total of 314 consecutive paravertebral catheters were inserted in 290 patients. Five (1.9%) catheters were removed due to ineffective analgesia. Other minor complications occurred in three cases (0.96%). The proportion of rib fracture patients managed with paravertebral catheters increased from 31/200 (15.5%) in the first year of study to 81/168 (48.2%) in the fourth; over this time-period the observed:predicted mortality ratio fell from 1.04 to 0.66. Proportional hazard regression with and without propensity score matching demonstrated a reduction in mortality associated with paravertebral catheter use, but this became statistically non-significant when time-dependent analysis was used. Paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.

SummaryThere is an urgent need to improve access to safe surgical and anaesthetic care for children living in many low‐ and middle‐income countries. Providing quality training for healthcare workers is a key component of achieving this. The 3‐day Safer Anaesthesia from Education (SAFE)® paediatric anaesthesia course was developed to address the specific skills and knowledge required in this field. We undertook a project to expand this course across five East and Central African countries (Ethiopia, Kenya, Malawi, Uganda and Zambia) and train local faculty. This study reports the outcomes from course evaluation data, exploring the impact on knowledge, skills and behaviour change in participants. Eleven courses were conducted in a 15‐month period, with 381 participants attending. Fifty‐nine new faculty members were trained. Knowledge scores (0–50 scale) increased significantly from mean (SD) 37.5 (4.7) pre‐course to 43.2 (3.5) post‐course (p < 0.0001). Skills scores (0–10 scale) increased significantly from 5.7 (2.0) pre‐course to 8.0 (1.5) post‐course (p < 0.0001). One hundred and twenty‐six participants in Malawi, Uganda and Zambia were visited in their workplace 3–6 months later. Knowledge and skills were maintained at follow‐up, with scores of 41.5 (5.0) and 8.3 (1.4), respectively (p < 0.0001 compared with pre‐course scores). Content analysis from interviews with these participants highlighted positive behaviour changes in the areas of preparation, peri‐operative care, resuscitation, management of the sick child, communication and teaching. This study indicates that the SAFE paediatric anaesthesia course is an effective way to deliver training, and could be used to help strengthen emergency and essential surgical care for children as a component of universal health coverage.

Objective To assess the performance of reusable pulse oximeter probe and microprocessor box combinations, of varying price-points, in the context of a low-income pediatric setting. Methods A prospective, randomized cross-over study comparing time to biologically plausible oxygen saturation (SpO(2)) between: (1) Lifebox LB-01 probe with Masimo Rad-87 box (L + M) and (2) a weight-appropriate reusable Masimo probe with Masimo Rad-87 box (M + M). A post hoc secondary analysis comparison with historical usability testing data with the Lifebox LB-01 probe and Lifebox V1.5 box (L + L) was also conducted. Participants, children aged 0 to 35 months, were recruited from pediatric wards and outpatient clinics in the central region of Malawi. The primary outcome was time taken to achieve a biologically plausible SpO(2) measurement, compared using t tests for equivalence. Results We recruited 572 children. Plausible SpO(2) measurements were obtained in less than 1 minute, 71%, 70%, and 63% for the M + M, L + M, and L + L combinations, respectively. A similar pattern was seen for less than 2 minutes, however, this effect disappeared at less than 5 minutes with 96%, 96%, and 95% plausible measurements. Using a +/- 10 second threshold for equivalence, we found L + M and M + M to be equivalent, but were under-powered to assess equivalence for L + L. Conclusions The novel reusable pediatric Lifebox probe can achieve a quality SpO(2) measurement within a pragmatic time range of weight-appropriate Masimo equivalent probes. Further research, which considers the cost of the devices, is needed to assess the added value of sophisticated motion tolerance software.

The Association of Anaesthetists of Great Britain and Ireland and the then Uganda Society of Anaesthesia established the Uganda Fellowship Scheme in 2006, to provide scholarships to encourage doctors to train in anaesthesia in Uganda. We conducted an evaluation of this programme using online questionnaires and face-to-face semi-structured interviews with trainees who received scholarships, as well as with senior surgeons and anaesthetists. Focus group discussions were held to assess changes in attitudes towards anaesthesia over the last 10 years. Interviews were recorded, transcribed and analysed using the constant comparative method. A total of 54 Ugandan doctors have received anaesthesia scholarships since 2006 (median funding per trainee (IQR [range]) £5520 (£5520-£6750 [£765-£9000]). There has been a four-fold increase in the number of physician anaesthetists in Uganda during this time. All those who received funding remain in the region. The speciality of anaesthesia is undergoing a dramatic transformation led by this group of motivated young anaesthetists. There is increased access to intensive care, and this has allowed surgical specialities to develop. There is greater understanding and visibility of anaesthesia, and the quality of education in anaesthesia throughout the country has improved. The Uganda Fellowship Scheme provided a relatively small financial incentive to encourage doctors to train as anaesthetists. Evaluation of the project shows a wide-ranging impact that extends beyond the initial goal of simply improving human resource capacity. Financial incentives combined with strong 'north-south' links between professional organisations can play an important role in tackling the shortage of anaesthesia providers in a low-income country and in improving access to safe surgery and anaesthesia.

This chapter provides an overview of some helpful principles for the anaesthetist, including cultivating a culture of good practice and safety in the operating room, preoperative investigation (including cardiopulmonary exercise testing), preoperative fasting, and prophylaxis of venous thromboembolism.

OBJECTIVE:To gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries.DESIGN:Focus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach.SETTING:Community, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care.PARTICIPANTS:Healthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors.RESULTS:We conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability.CONCLUSIONS:Pulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations.TRIAL REGISTRATION NUMBER:NCT02941237.

Pediatric AnesthesiaVolume 28, Issue 5 p. 380-381 EDITORIAL Visiting teams: Experts or colleagues? Isabeau A. Walker, Isabeau A. Walker Great Ormond Street Hospital, London, UK UCL Institute of Child Health, London, UKSearch for more papers by this authorVernon Mark Gacii, Vernon Mark Gacii Kenyatta National Hospital, Nairobi, Kenya Department of Anaesthesia, School of Medicine, University of Nairobi, Nairobi, KenyaSearch for more papers by this authorLuke B. Nasedra, Luke B. Nasedra Department of Anaesthesia, Intensive Care and Hyperbaric Services, CWM Hospital, Suva, Fiji College of Medicine, Nursing and Allied Health Science, Fiji National University, Suva, FijiSearch for more papers by this authorRobert J. McDougall, Robert J. McDougall rob.mcdougall@rch.org.au orcid.org/0000-0003-2237-7231 Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Vic., Australia Department of Paediatrics, University of Melbourne, Melbourne, Vic., AustraliaSearch for more papers by this author Isabeau A. Walker, Isabeau A. Walker Great Ormond Street Hospital, London, UK UCL Institute of Child Health, London, UKSearch for more papers by this authorVernon Mark Gacii, Vernon Mark Gacii Kenyatta National Hospital, Nairobi, Kenya Department of Anaesthesia, School of Medicine, University of Nairobi, Nairobi, KenyaSearch for more papers by this authorLuke B. Nasedra, Luke B. Nasedra Department of Anaesthesia, Intensive Care and Hyperbaric Services, CWM Hospital, Suva, Fiji College of Medicine, Nursing and Allied Health Science, Fiji National University, Suva, FijiSearch for more papers by this authorRobert J. McDougall, Robert J. McDougall rob.mcdougall@rch.org.au orcid.org/0000-0003-2237-7231 Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Vic., Australia Department of Paediatrics, University of Melbourne, Melbourne, Vic., AustraliaSearch for more papers by this author First published: 05 June 2018 https://doi.org/10.1111/pan.13371 Funding information The study was funded by departmental resources. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume28, Issue5May 2018Pages 380-381 RelatedInformation

Hypoxemia measured by pulse oximetry predicts child pneumonia mortality in low-resource settings (LRS). Existing pediatric oximeter probes are prohibitively expensive and/or difficult to use, limiting LRS implementation. Using a human-centered design, we developed a low-cost, reusable pediatric oximeter probe for LRS health-care workers (HCWs). Here, we report probe usability testing. Fifty-one HCWs from Malawi, Bangladesh, and the United Kingdom participated, and seven experts provided reference measurements. Health-care workers and experts measured the peripheral arterial oxyhemoglobin saturation (SpO2) independently in < 5 year olds. Health-care worker measurements were classed as successful if recorded in 5 minutes (or shorter) and physiologically appropriate for the child, using expert measurements as the reference. All expert measurements were considered successful if obtained in < 5 minutes. We analyzed the proportion of successful SpO2 measurements obtained in < 1, < 2, and < 5 minutes and used multivariable logistic regression to predict < 1 minute successful measurements. We conducted four testing rounds with probe modifications between rounds, and obtained 1,307 SpO2 readings. Overall, 67% (876) of measurements were successful and achieved in < 1 minute, 81% (1,059) < 2 minutes, and 90% (1,181) < 5 minutes. Compared with neonates, increasing age (infant adjusted odds ratio [aOR]; 1.87, 95% confidence interval [CI]: 1.16, 3.02; toddler aOR: 4.33, 95% CI: 2.36, 7.97; child aOR; 3.90, 95% CI: 1.73, 8.81) and being asleep versus being calm (aOR; 3.53, 95% CI: 1.89, 6.58), were associated with < 1 minute successful measurements. In conclusion, we designed a novel, reusable pediatric oximetry probe that was effectively used by LRS HCWs on children. This probe may be suitable for LRS implementation.

Anesthesiology, V 127 • No 2 215 August 2017 J OHN Snow was one of the founding fathers of anesthesia in the late nineteenth century and a pioneering epidemiologist. He recorded the details of more than 5,000 anesthetics during more than 12 yr of practice and stressed the importance of accurate drug administration and patient monitoring.1 In 1949, Mackintosh2 published an analysis of anesthetic deaths and discussed common lessons learned, such as safe positioning of unconscious patients, the appropriate use of thiopentone, and the dangers of cylinder misconnections. He encouraged the investigation of perioperative deaths as a means to improve anesthesia safety. In the modern era, Lunn and Devlin3 worked together as anesthesiologist and surgeon to examine the whole patient journey, recognizing that factors in anesthesia, surgery, and perioperative care required consideration if improvements in outcomes were to be made. Eichorn4 gathered data that supported mandatory standards for anesthetic monitoring, the basis of the American Society of Anesthesiologists standards and guidelines today.5 A recent meta-analysis and systematic review of perioperative mortality and anesthesiarelated deaths shows the positive impact of safety interventions over the past 80 yr.6 However, this article also suggests that improvements have not been matched in poorer parts of the world. Indeed, in countries with a low human development index (defined by life expectancy, education, and per capita income indicators), anesthesia mortality has remained unchanged since the 1950s.7 It is particularly refreshing therefore to read the work of Sileshi et al.8 in this edition of ANESTHESIOLOGY and their demonstration that it is possible to gather high-quality outcome data to improve anesthesia services in a middle-income country. Sileshi et al.8 developed a data collection tool to prospectively monitor perioperative mortality rate in a tertiary nongovernmental referral hospital in Kenya. They recorded 24-h, 48-h, and 7-day mortality, as well as case-specific perioperative data including type of surgery and anesthesia, American Society of Anesthesiologists status, and use of essential monitors and the World Health Organization Surgical Safety Checklist. The team at Kijabe recorded a lower perioperative mortality compared with other studies in lowand middle-income countries, and, importantly, they recorded an improvement in outcomes over the study period. Few anesthesiaand surgeryrelated deaths actually occur in the operating room. Although harm may start there, death often takes place on the ward or intensive care unit some days later. Timing of data collection is therefore important. Early (immediate) deaths within 24 h will describe those dying of overwhelming illness, anaphylaxis, total spinal, airway disaster, or cardiac arrest; later follow-up will detect those who were initially resuscitated from a catastrophic event and those developing multiorgan failure from sepsis, aspiration, and so forth. Data collection and follow-up of patients in a resource-constrained system are extremely difficult and therefore the measurement needs to be practical. Sileshi et al.8 are to be congratulated on their use of innovative methods to solve these challenges in data collection. The authors trained anesthesia providers to collect data electronically, which provided better returns than a traditional paper-based system. The system was designed to allow intermittent data upload to cope with irregular Internet connectivity. The authors found it difficult to capture 7-day follow-up, but since mobile phone technology is almost universal in Kenya, they used a local research officer to capture the 7-day information by phone. The hospital in Kijabe has pioneered the development nurse anesthesia training in Kenya and has developed a model of task sharing between physician and nurse providers. Their outcomes are likely to be due in part to external funding and Measuring Perioperative Mortality

Background The burden of treatable surgical diseases in children in low- and middle-income countries (LMICs) is greater than that of malaria, HIV/AIDS and TB combined. World Health Organisation member states are required to scale up access to emergency and essential surgery for children by 2030 as part of universal health coverage. There is a critical shortage of anaesthetists trained to look after children in LMICs. The aim of this project was to deliver the Safer Anaesthesia From Education (SAFE) Paediatric course in East and Central Africa, and to evaluate the impact of this training programme. Methods The SAFE Paediatric anaesthesia course is a three-day short course developed by GOSH paediatric anaesthetists in collaboration with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), World Federation of Societies of Anaesthesiologists (WFSA) and Association of Anaesthesiologists of Uganda (AAU). It focuses on common paediatric surgical conditions encountered in LMICs. A one-day Train-The-Trainer (TTT) course was also established to train future SAFE faculty. Results A total of nine SAFE courses were delivered. ‘SAFE fellows’ conducted follow-up interviews in Uganda, Zambia and Malawi. 46/57 (81%) faculty members who completed the TTT course taught on a subsequent SAFE course. 381 delegates completed the course. Mean MCQ scores increased from 37.6/50 pre-course to 43.4/50 post-course and skills scores increased from 5.8/10 to 8/10 (p<0.001). Follow-up showed significantly higher mean MCQ (pre-course 37.6/50, follow-up 41.5/50) and skills test scores (pre-course(5.8/10), follow-up(8.2/10)). All interviewed delegates reported increased confidence in providing paediatric anaesthesia. Conclusion The SAFE paediatric anaesthesia course provides high quality education for anaesthetists in LMICs. Knowledge and skills improve and are retained at follow-up. SAFE course training results in changes in paediatric anaesthesia practice and improved patient outcomes. Delivery of the SAFE training through UK/LMIC anaesthesia health partnerships builds links between paediatric anaesthetists internationally.