Anesthesia in austere environments
• Mass casualty event in which the number of cases overwhelms capacity
• Natural disaster in which the hospital is damaged or loses electricity or water
• Developing country that is disrupted by low-grade civil war
• Developing country in which health care spending is less than $5 per person per year
• Disaster (e.g., natural, industrial, terrorist) in which care is provided on site
Basic principles
A lack of trained personnel or limited evacuation options make proper patient selection and selection of the appropriate surgical procedure crucial. When patients present for elective operations, care must be taken to choose the patients in whom the most benefit is likely to be obtained with the least risk. On the other hand, when patients present for emergent operations, a surgical course must be chosen that is least likely to outstrip the medical team’s capability for perioperative care or to degrade the medical team’s ability to care for subsequent patients. For example, an extremity mangled by a landmine explosion is better amputated if the care, equipment, and time required for limb salvage and rehabilitation are not available. The process of selecting patients for surgery, or for selecting the proper surgical treatment for patients, requires collaboration among the anesthesia provider, the surgeon, and the rest of the medical team. In an austere environment, cesarean sections and amputations would be commonly performed, whereas cardiac or neurosurgical procedures would be rare (Table 179-1).
Table 179-1
Surgical Procedures in an Austere Environment
| Common Field Operations | Uncommon Field Operations |
| Abscess incision and drainage Fasciotomy Amputations Débridement of wounds or burns External fixation of fractures Emergency laparotomy Emergency caesarean section Evacuation of retained placenta |
Procedures requiring invasive monitoring Procedures requiring any postoperative intensive care Internal fixation of fractures Laparoscopy, endoscopy, arthroscopy Subspecialty surgery Note: Militaries from developed countries may have good ICU and evacuation capabilities |
