Women Anesthesiologists in Sub-Saharan Africa in the Pre-COVID Era: A Multinational Demographic Study.

BACKGROUND: Gender imbalance and poor representation of women complicate the anesthesiology workforce crisis in sub-Saharan Africa (SSA). This study was performed to obtain a better understanding of gender disparity among medical graduates and anesthesiologists in SSA. METHODS: Using a quantitative, participatory, insider research study, led by female anesthesiologists as the national coordinators in SSA, we collected data from academic or national health authorities and agencies. National coordinators were nominees of anesthesiology societies that responded to our email invitations. Data gathered from 13 countries included information on medical graduates, anesthesiologists graduating between 1998 and 2021, and number of anesthesiologists licensed to practice in 2018. We compared data between Francophone and Anglophone countries, and between countries in East Africa and West Africa/Central Africa. We calculated anesthesiology workforce densities and compared representation of women among graduating anesthesiologists and medical graduates.Data analysis was performed using linear regression. We used F-tests on regression slopes to assess the trends in representation of women over the years and the differences between the slopes. A value of P < .050 was considered statistically significant. RESULTS: Over a 20-year period, the representation of female medical graduates in SSA increased from 29% (1998) to 41% (2017), whereas representation of female anesthesiologists was inconsistent, with an average of 25%, and lagged behind. Growth and gender disparity patterns were different between West Africa/Central Africa and East Africa. Representation of female anesthesiologists was higher in East Africa (39.4%) than West Africa/Central Africa (19.7%); and the representation of female medical graduates in East Africa (42.5%) was also higher that West Africa/Central Africa (33.1%). CONCLUSIONS: On average, in SSA, female medical graduates (36.9%), female anesthesiologists (24.9%), and female anesthesiology residents projected to graduate between 2018 and 2022 (25.2%) were underrepresented when compared to their male counterparts. Women were underrepresented in SSA, despite evidence that their representation in medicine and anesthesiology in East African countries was rising.

Cheyne-Stokes respiration and cardiovascular oscillations ending abruptly when deploying transfemoral aortic valve.

A 86-yr-old man was referred for transfemoral aortic valve implantation. Transthoracic echocardiography revealed a severe stenosis (mean gradient: 58 mmHg, aortic valve area: 0.4 cm2), and after multidisciplinary discussion, the risk of surgery was judged too high (logistic Euroscore: 51%), and the patient was proposed for a transfemoral aortic valve implantation (TAVI). On arrival in the operating room, the patient, fully conscious, was noted to have Cheyne-Stokes breathing (CSB), which persisted after 40% oxygen administration. TAVI procedure was successful, and the CSB pattern was interrupted within 8 s. To the best of our knowledge, this report is the first to show an acute disappearance of CSB, occurring only seconds after TAVI and restoration of a normal hemodynamic situation. To explain such rapid changes in breathing pattern, we hypothesize a role played by the acute release of pulmonary hypertension and pulmonary volume overload.NEW & NOTEWORTHY Acute disappearance of Cheyne-Stokes breathing after transfemoral aortic valve implantation suggests a reflex pathway originating from the fall in pulmonary vessels congestion.

Twenty Years of Collaboration Between Belgium and Benin in Training Anesthesiologists for Africa.

Belgium has been collaborating for 20 years with Abomey-Calavi University in Cotonou, Republic of Benin, to train anesthesiologists for Sub-Saharan, French-speaking African countries. With 123 graduates from 15 countries and 46 residents still in training, this program has succeeded in reversing the trend of a decreasing anesthesiology workforce in those countries, thus improving the quality of anesthesia and patient safety. Belgian government sources, as well as hospitals and anesthesia teams, provided most of the financial resources. Reasons for success, positive outcomes, and shortcomings are discussed, as well as future perspectives and threats. Failure to enroll enough female residents (15%) and brain drain (18% of alumni) are of concern. Alumni are capable of importing and adapting modern technology and practice. Graduates increase the impact of the Cotonou program by getting involved in teaching nonphysician anesthesia providers and by supporting new anesthesiology training programs being launched in several countries. Other African countries with training programs, by following this example, could accelerate anesthesiology progress by accepting foreign residents from the region. The role of anesthesiologists as anesthesia team leaders must be better defined, and residency training programs adapted accordingly. Continuing international support remains of critical importance, especially in the form of resident rotations to high-income countries. The development of structured anesthesiology programs should be encouraged by African governments as developing anesthesia is a prerequisite for surgical development in every discipline.

Mid-term survival after transcatheter aortic valve implantation: Results with respect to the anesthetic management and to the access route (transfemoral versus transapical).

CONTEXT: Several studies have analyzed the long-term survival after transcatheter aortic valve implantation (TAVI). However, no previous studies have looked at survival beyond 1-year with respect to the type of anesthesia. AIMS: The aim was to evaluate the mid-term survival after TAVI with respect to the type of anesthesia (general anesthesia [GA] vs. local anesthesia ± sedation [LASedation]) or the type of procedure (transfemoral [transfem] vs. transapical TAVI) performed. SETTINGS AND DESIGN: Retrospective cohort study. SUBJECTS AND METHODS: This retrospective study included TAVI's between January 2009 and June 2013. Patients were divided into three groups: transfem TAVI under GA, transfem TAVI under LASedation and transapical TAVI. A total of 176 patients were eligible. The following clinical outcomes were evaluated: (1) Mortality, (2) Major cardiovascular complications, (3) Conduction abnormalities and arrhythmias, (4) Acute kidney injury, (5) Aortic regurgitation, (6) Neurologic events, (7) Vascular complications, (8) Pulmonary complications, (9) Bleeding, (10) Infectious complications, (11) Delirium. STATISTICAL ANALYSIS USED: A Kruskal-Wallis test was performed to test significance between the three groups for quantitative variables. Categorical variables were compared using a Chi-square test. Survival was estimated using Kaplan-Meier method. RESULTS: There was no statistically significant difference between the survival of both transfem TAVI's (P = 0.46). The short-term outcome of the transfem TAVI groups was better than the transapical arm, but their mid-term survival did not show any significant difference (P = 0.69 transapical vs. transfem GA; P = 0.07 transapical vs. transfem LASedation). CONCLUSIONS: Our results demonstrate that the type of anesthesia and the access route do not influence mid-term survival after TAVI.

Fibrinogen concentration significantly decreases after on-pump versus off-pump coronary artery bypass surgery: a systematic point-of-care ROTEM analysis.

OBJECTIVES: Studies have emphasized the importance of normal fibrinogen concentrations in surgical patients. The primary hypothesis of this study was that fibrinogen levels significantly decrease in on-pump coronary artery bypass graft (CABG) surgery versus off-pump coronary artery bypass graft (OPCAB) surgery. The second objective was to show that ROTEM (TEM International, GmbH, Munich, Germany) rapidly detects these abnormalities compared with standard tests. DESIGN: A prospective, nonrandomized study. SETTING: A university hospital. PARTICIPANTS: Forty-two and 62 patients in the CABG and OPCAB groups, respectively, undergoing first-time bypass surgery were included. INTERVENTIONS: CABG versus OPCAB surgery. MEASUREMENTS AND MAIN RESULTS: Routine coagulation tests and ROTEM values were measured before anesthesia (T0), after the first dose of heparin (T1), after protamine (T2), upon intensive care unit arrival (T3), and 4 hours postoperatively (T4). The outcome measures were followed until 4 hours postoperatively. Fibrinogen concentrations were significantly lower in the CABG versus the OPCAB group at T2 (170 ± 44 v 243 ± 73 mg/dL, p < 0.001) and T3 (179 ± 42 v 232 ± 68 mg/dL, p < 0.001). This was confirmed by significantly lower FIBTEM maximal clot firmness values at T2 (9 ± 4 v 14 ± 5 mm, p < 0.001) and T3 (9 ± 4 v 13 ± 6 mm, p < 0.001). In the CABG group, patients received significantly more transfusions of all blood products except fresh frozen plasma. CONCLUSIONS: Fibrinogen concentration significantly decreases after cardiopulmonary bypass. ROTEM helps in its fast detection.

An increase in endogenous erythropoietin concentrations has no cardioprotective effects in patients undergoing coronary artery bypass graft surgery.

OBJECTIVE: Preliminary data showed an increase in endogenous erythropoietin (EPO) concentrations after acute normovolemic hemodilution (ANH) in patients undergoing coronary artery bypass graft (CABG) surgery. Numerous studies have shown the organ protective properties of EPO. The aim of this study was to investigate the cardioprotective effects of these increased EPO concentrations that resulted from ANH during cardiac surgery. DESIGN: A prospective, randomized, blind study. SETTING: A university hospital. PARTICIPANTS: A total of 93 patients undergoing isolated CABG surgery with or without cardiopulmonary bypass (CPB). INTERVENTIONS: Subjects with CPB were randomized into the control (C) or ANH group. Those in the off-pump coronary artery bypass group underwent no treatment. In the ANH group, a precalculated amount of blood was withdrawn and replaced by colloids after the induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Hemodynamic parameters were recorded intra- and postoperatively. Troponin concentrations were measured as a routine parameter postoperatively. Upon intensive care unit arrival, the EPO levels were higher in the ANH group than in the C group. There was no significant difference between the troponin values of the C and the ANH groups at 4 hours postoperatively. CONCLUSIONS: In patients undergoing CABG surgery on CPB, an increase in endogenous EPO concentrations in the physiologic range has no cardioprotective effects.

Anaphylactic shock in a beta-blocked child: usefulness of isoproterenol.

Like adults, children taking beta-blockers are at risk for serious hemodynamic instability in case of anaphylaxis. We report a case of severe bradycardia associated with anaphylactic shock after aprotinin in a beta-blocked child, which was resistant to intravenous epinephrine and vascular filling but was treated successfully with isoproterenol.

Concentration of transfusion resources on a few pathologies and a few patients: analysis of the comprehensive in-hospital patient database.

BACKGROUND: Blood is a sparse commodity. Transfusion needs increase while the number of donors decreases. These constraints incite Belgian authorities to pay more attention to transfusion financing. This implies pathologic knowledge of the epidemiology of in-hospital transfusion and the consumption of blood products. STUDY DESIGN AND METHODS: This study is a retrospective analysis of in-hospital stays from the year 2000 and includes data from all 124 Belgian hospitals. The database contains information on diagnoses, procedures, and all-patients refined diagnosis-related groups (APRDRGs) but also on expenses linked to blood products transfused and to transfusion-related pharmaceutical products. RESULTS: Three percent of surgical patients used 55.7 percent of transfusion resources and 75.4 percent of transfusion costs were associated with 24 APRDRGs. In the medical group, 3 percent of the patients accounted for 80.2 percent of transfusion costs and 20 APRDRGs consumed 71.9 percent of transfusion resources. The variables with the highest impact on the proportion of patients transfused were severity, pathology, and age. The effect of hospitals remained significant but had less impact. No substitution of blood products by transfusion-related pharmaceutical products was observed in our analysis. CONCLUSION: Our study confirms that transfusion now centers on a limited number of pathologic entities and, within those, in small subsets of patients. This implies that the costs linked to setting up and running the transfusion system can no longer be shared by a large number of patients who receive transfusions but rely increasingly on patients at higher risks of more unpredictable needs. The system must nevertheless be able to cope with them at any time.

A second-generation blood substitute (perflubron emulsion) increases the blood solubility of modern volatile anesthetics in vitro.

UNLABELLED: Perfluorocarbon-based emulsions increase the blood solubility of isoflurane, enflurane, and halothane, with a maximal effect reported for the less soluble isoflurane. Current volatile anesthetics are less soluble and may be more affected by this phenomenon. Perflubron (Oxygent(TM)) is a perfluorocarbon-based emulsion in late-stage clinical testing in surgical patients for use as a temporary oxygen carrier. We tested the hypothesis that perflubron increases the solubility of isoflurane, sevoflurane, and desflurane, as reflected by their blood/gas partition coefficient (lambda(Bl:g)). Fresh whole-blood samples were drawn from eight volunteers and mixed with perflubron to obtain concentrations of 1.2%, 1.8%, and 3.6% by volume (equivalent to in vivo doses of 1.8 to 5.4 g/kg, which represent up to twice the intended clinical dose range). By using the double-extraction method, we demonstrated increased lambda(Bl:g) for isoflurane, sevoflurane, and desflurane. However, the solubility in blood does not really change, because volatile anesthetics are actually partitioning into perflubron. Increasing the amount of emulsion in the blood consequently increases the amount of gas carried, as reflected by the measured linear correlation between the lambda(Bl:g) values of all three volatile anesthetics and perflubron doses. Even though the increase ranges from 0.9 (desflurane) to 2.6 (sevoflurane) times the normal value, the apparent lack of clinical implications in current trials with perflubron may trigger further in vivo experiments. IMPLICATIONS: Perflubron increases the in vitro solubility of volatile anesthetics when present in the blood at clinically relevant concentrations. Volatile anesthetics actually partition into the emulsion, but the solubility in the blood does not change. Further studies are needed to assess whether perflubron will affect the pharmacokinetics of volatile anesthetics in vivo.