Global Surgery & Anesthesia

In the rural district hospital Kalukembe, in Huila Province, Angola, there are no physicians. Advance practice nurses run the hospital and perform 80% of the operations. They use 40ml 1/2% lidocaine (diluting 20ml of 1% with 20ml of saline): 20mls for the vertical skin incision, 20ml for the fascia / peritoneal insicion). Once the cord is clamped, then a single dose of weight appropriate IV ketamine is given for the closure. Approximately 500 C-sections / year are accomplished this way with satisfactory results.

I would stay away from Ketamine, except in circumstances where there is no consideration of obstructed labor. I used it once and, because it does not relax the uterus, the uterus was tonically contracted and I was unable to free the fetal head from the pelvis without greatly extending the uterine incision. The mom and baby survived --just barely. Spinal anesthesia is an excellent method for rural hospitals, as long as an IV preload of normal saline is given beforehand, the injection is made slowly, and the mom is watched constantly for respiratory depression. Pulse oximetry would be a big help.

Excellent Robert, excellent and interesting. The world is finally waking up to tricks of rural surgery! When I was training to be A Nigerian Specialist in general medical practice (now family Medicine)at Mkar Christian hospital Gboko Benue state Nigeria 28 years ago, ALL of us gps used ketamine for ALL our caesarian sections whether elective or emergency and NONE of the paitients had any adverse effect. It is adjudged the safest intravenouus anaethesia in the hand of no-anaesthetists. And how did we do it?
The skin is infiterated with 1% lignociane 20 ml. fascia too is infiltertsted with 20ml 1% lignocaine. Just before we enter into the peritoneal cavity we give 2ml of 40mg/ml of ketamine slowly and then we move very very fast! as patient sleeps we RAPIDLY cut through the lower segment of the uterus and deliver the head and baby is delivered in less than 2 minutes so there is no sedation of the baby. We then sew the uterus back and move Rapidly to closure before the ketamine sedation wears off. We deliver another 2 ml of ketamine if there are signs of arousal. Total time from skin to cutting of cord-3 mins; till ...

Excellent Robert, excellent and interesting. The world is finally waking up to tricks of rural surgery! When I was training to be A Nigerian Specialist in general medical practice (now family Medicine)at Mkar Christian hospital Gboko Benue state Nigeria 28 years ago, ALL of us gps used ketamine for ALL our caesarian sections whether elective or emergency and NONE of the paitients had any adverse effect. It is adjudged the safest intravenouus anaethesia in the hand of no-anaesthetists. And how did we do it?
The skin is infiterated with 1% lignociane 20 ml. fascia too is infiltertsted with 20ml 1% lignocaine. Just before we enter into the peritoneal cavity we give 2ml of 40mg/ml of ketamine slowly and then we move very very fast! as patient sleeps we RAPIDLY cut through the lower segment of the uterus and deliver the head and baby is delivered in less than 2 minutes so there is no sedation of the baby. We then sew the uterus back and move Rapidly to closure before the ketamine sedation wears off. We deliver another 2 ml of ketamine if there are signs of arousal. Total time from skin to cutting of cord-3 mins; till end of skin closure- 45 minutes dead.I did that almost every day for 24 months. 28 years later, the skills are still with me

I worked in South Sudan for Medicins sans Frontieres in a busy OB service. While I routinely did spinal anesthesia for all C sections, sometimes the situation was urgent and I opted for ketamine. Local is important, but you can get through to the uterus with 100 mg or so of ketamine and once the cord is cut, you can add a benzodiazepine and a narcotic for added measure. I did have general anesthesia capacity but no resources for recovery so if the spinal wouldnt work, I used a total intravenous technique with no difficulties. It is important to add atropine from with beginning to deal with significant secretions and prevention of laryneal spasm.

CLIFF ROBERSON, CRNA
MSF South Sudan