Anesthesia in austere environments

Published on 07/02/2015 by admin

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Last modified 07/02/2015

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Anesthesia in austere environments

Craig C. McFarland, MD and C. George Merridew, MBBS, FANCZA

For many anesthesia providers, the delivery of an anesthetic in an austere environment implies that the provider has volunteered for a humanitarian mission in a developing country or is in the military and practicing in field conditions—synonymous with an austere environment. However, any time a situation arises in which medical capability is significantly below standards that are typically available in developed countries, the provider is indeed practicing in an austere environment. Such austere environments include the following:

Graduates of Western anesthesia training programs can cope well in such situations, provided that they understand the basic requisites of disaster management and the pharmacology and physiology of anesthesia. The latter allows the provider to choose among several options for delivery of a safe anesthetic—general anesthesia using a parenteral versus an inhalation technique or a regional anesthetic.

Basic principles

The austere environment is characterized by a relative lack of medical supplies, supplemental O2 electricity, trained health care personnel, or evacuation options. Each of these deficiencies requires proper planning to make medical care in an austere environment successful. When resupply is not a reliable option, a medical team may be forced to carry all of their supplies with them. This puts a premium on reusable items and on equipment with a low weight and a small footprint.

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

ICU, Intensive care unit.

Having a limited supply of supplemental O2 or electricity places a premium on optimal use of anesthetic techniques that permit spontaneous ventilation, preserve hypoxic pulmonary vasoconstriction, and minimally depress consciousness. If a regional anesthesia technique is appropriate for the surgical procedure, it meets these criteria. If general anesthesia is required, one must weigh the risks and benefits of a parenteral (intramuscular versus a total intravenous anesthetic) versus an inhalation technique.

Options for anesthesia

Regional anesthesia

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