An innovative safe anesthesia and analgesia package for emergency pediatric procedures and surgeries when no anesthetist is available.
BACKGROUND
Adequate pain control through sedation and anesthesia for emergency procedures is a crucial aspect of pediatric emergency care. Resources for administering such anesthesia are extremely limited in many low-income settings.


METHODS
Non-anesthetist providers in Western Kenya were trained in the use of a ketamine-based sedation and anesthesia package for non-anesthetists, Every Second Matters for Mothers and Babies-Ketamine™ (ESM-Ketamine). Data on use and safety of this package for emergent and urgent pediatric procedures was collected. Providers were surveyed as to what they would have done for similar procedures if the ESM-Ketamine package were unavailable.


RESULTS
Ninety procedures were completed for 77 pediatric patients utilizing the ESM-Ketamine package. Of these, 29 (32.2 %) cases were orthopedic reductions, 19 (21.1 %) were incision and drainage, and 19 (21.1 %) were debridement and irrigation of burns. Remaining cases included cesarean section, repair of perineal tear, foreign body removal, arthrocentesis, laceration repair, exploratory laparotomy, excision of mass, paracentesis, and circumcision. There were no serious adverse events in any of the cases, 17 % experienced minor adverse events including hypersalivation, hallucinations, or brief, self-resolving, oxygen desaturations. Providers were surveyed for 80 of the 90 cases as to what they would have done in the absence of the ESM-Ketamine package: in 26 cases (32.5 %), they reported they would proceed with the procedure without any anesthesia or analgesia; in 15 (18.75 %), they reported they would significantly delay the procedure while waiting for an anesthetist; in 13 (16.25 %), they reported they would attempt referral to another facility; and in 26 (32.5 %), they reported they would try using an alternate form of analgesia, primarily acetaminophen, ibuprofen, diclofenac, and/or diazepam. All surveyed providers reported they would use the ESM-Ketamine package again in similar cases.


CONCLUSIONS
The ESM-Ketamine package, through the use of a simplified protocol and checklist, allows for safe analgesia and anesthesia in children by non-anesthetists in a resource-limited setting for selected emergent and urgent procedures. This package addresses a significant gap in the availability of anesthesia services in low-income settings that would otherwise result in significant delays to procedures or proceeding with painful procedures with inadequate analgesia.
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 910, Boston, MA, 02114, USA. krschwartz@mgh.harvard.edu.|Harvard Medical School, Boston, MA, 02115, USA. krschwartz@mgh.harvard.edu.
Kevin R
KR
Schwartz
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 910, Boston, MA, 02114, USA.
Karla
K
Fredricks
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 910, Boston, MA, 02114, USA.
Zaid
Z
Al Tawil
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 910, Boston, MA, 02114, USA.
Taylor
T
Kandler
African Institute for Health Transformation, Sagam Community Hospital, Luanda, Kenya.
Stella A
SA
Odenyo
African Institute for Health Transformation, Sagam Community Hospital, Luanda, Kenya.
Javan
J
Imbamba
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 910, Boston, MA, 02114, USA.|Harvard Medical School, Boston, MA, 02115, USA.
Brett D
BD
Nelson
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 910, Boston, MA, 02114, USA.|Harvard Medical School, Boston, MA, 02115, USA.
Thomas F
TF
Burke
Anesthesia; Ketamine; Low-income; Non-anesthetist; Pediatric analgesia; Resource-limited; Sub-Saharan Africa