No ventilator, no electric power, no oxygen, no drugs (hardly)… Anesthesia in low income countries. Heroes or thoughtless

Errando, C.L.

doi:10.1016/j.redare.2021.05.007

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"apellidos" => "Hidalgo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621002152" "doi" => "10.1016/j.redar.2021.05.024" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621002152?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192922000865?idApp=UINPBA00004N" "url" => "/23411929/0000006900000005/v1_202206100555/S2341192922000865/v1_202206100555/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "Editorial article" "titulo" => "No ventilator, no electric power, no oxygen, no drugs (hardly)… Anesthesia in low income countries. Heroes or thoughtless" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "258" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "C.L. Errando" "autores" => array:1 [ 0 => array:3 [ "nombre" => "C.L." "apellidos" => "Errando" "email" => array:1 [ 0 => "errando013@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Can Misses, Ibiza, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sin respirador, sin electricidad, sin oxígeno, sin fármacos (casi)… Anestesia en países con pocos recursos económicos. ¿Héroes o inconscientes?" ] ] "textoCompleto" => "“[The] successful use [of an anaesthetic] requires a radical change in the conservative mental attitude of the anaesthetist”<a class="elsevierStyleCrossRef" href="#bib0005">1</a>.“A review of the history of anaesthesiology frequently shows how the techniques, drugs, devices and systems used in clinical practice have changed and been improved over the years - sometimes as a steady progression, and at other times as a giant leap. The same can be said regarding acceptance or neglect of certain techniques and drugs among anaesthesiologists. Some drugs that were widely used over a certain period of time and then abandoned have now taken on a new lease of life; drugs that had been practically forgotten due to their side effects are being used again… Even now, with our vast clinical anaesthesia arsenal, something always comes up that, despite being "old", is given an overhaul, or adapted, or accepted from another perspective and added to the general arsenal or to certain selective indications in our broad field”<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.Ketamine was first used as an anaesthetic in humans in 1966<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. From the start, it was controversial<a class="elsevierStyleCrossRef" href="#bib0020">4</a>, especially in the United Kingdom, where indications for the drug were not derived from clinical trials, and it was prescribed indiscriminately<a class="elsevierStyleCrossRefs" href="#bib0005">1,3</a>. The adverse effects of ketamine when used in isolation, together with poor understanding of its mechanism of action, contributed to this situation. But by the 1990s, ketamine had been used millions of times in numerous surgeries<a class="elsevierStyleCrossRef" href="#bib0025">5</a>.In this issue of the Spanish Journal of Anaesthesiology and Resuscitation, Villalonga et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> show us how in situations of limited resources and pressing healthcare demands, returning to (relatively) easy-to-use drugs and techniques allows anaesthesiologists to carry out not only the minor interventions described in their report, but also, in our opinion, other more major surgeries. Take, for example, some of the drug combinations used in opioid-free anaesthesia. The role of ketamine in multiple indications is indisputable<a class="elsevierStyleCrossRefs" href="#bib0005">1,4,7,8</a>: as an adjuvant in various indications, or in combination with other agents in the treatment of intraoperative and postoperative acute pain (it reduces acute tolerance to analgesia and the hyperalgesia caused by opioids, particularly those with an ultrashort half-life such as remifentanil). It is used for its neuroprotective properties, as an antiemetic, as a sedative, as an anaesthetic/analgesic in insufficient regional or neuraxial blockade, for induction and maintenance of anaesthesia in patients with shock due to various causes, and for the treatment of chronic pain, etc., not forgetting indications that have not yet been fully developed or are not yet based on scientific evidence (chronic pain by certain routes of administration, topical, subcutaneous and neuraxial). Its growing use as an antidepressant in psychiatry deserves special mention<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a>. Stress and depression are associated with neuronal atrophy, characterised by loss of synaptic connections in key cortical and limbic brain regions. Briefly, ketamine, an N-methyl-Daspartate (NMDA) receptor antagonist that produces rapid antidepressant actions in treatment-resistant depressed patients, rapidly increases spine synapses in the PFC and reverses the deficits caused by chronic stress. This is thought to occur by disinhibition of glutamate transmission, resulting in a rapid but transient burst of glutamate, followed by an increase in brain-derived neurotrophic factor release and activation of downstream signalling pathways that stimulate synapse formation<a class="elsevierStyleCrossRef" href="#bib0050">10</a>. Thus, ketamine can be used to treat depression refractory to other therapies.Returning to the article that gave rise to this editorial, some of the clinical uses of ketamine that are thought to be "modern or novel" had already been introduced by the 1970s, when it was used as an anaesthetic in underdeveloped countries, in war zones, and in natural disasters<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. All these situations are characterised by adverse healthcare conditions, such as a lack of specialized personnel, adverse climatic conditions, irregular supplies or total shortage of resources, lack of postoperative care, etc.The use of ketamine in these circumstances, and in the situation reported by Villalonga et al.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>, would not have been possible if the People's Republic of China had succeeded in having it classed as an illegal drug. In 2014, the Chinese authorities, after discovered widespread abuse of ketamine as a recreational drug, lobbied the Economic and Social Council (ESC) of the United Nations to class the drug as an internationally controlled substance, according to the Convention on Psychotropic Substances of 1971 (Schedule I)<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>. Under the Convention, if approved by the ESC, ketamine would only be available (manufactured, packaged, marketed, distributed, sold, exported, etc.) in countries that have adequate national control/supervision measures, and would be banned in all other countries. This triggered a major, worldwide campaign (which in Spain, unfortunately, attracted very little attention) instigated by the medical and scientific community<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> to prevent this change in international law. Fortunately, 29 countries, including Spain, presented their arguments and declared themselves in favour of greater international control, but against the inclusion of ketamine in Schedule I. Several countries drew attention to the use of ketamine in low-income countries; specifically, the United Kingdom argued, among other things, that 5.5 billion people living in countries with limited or no access to controlled medicines would be deprived of one of their principle, if not only, anaesthetics<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a>.Therefore, as in many aspects of life, and in field of anaesthesia in its broadest sense, we need to be aware of our past and our origins in order to make the most of the knowledge already accumulated instead of trying to drive through “progress” that is, in fact, not progressive. In the words of Villalonga et al. "Many young [and not so young, I dare add] specialists today who would be capable of performing anaesthesia for a liver transplant would have found it hard to practice anaesthesia in Heshima hospital”. I agree with his recommendation that residents in training should be taught to think outside the box and to use alternative approaches to cope with situations they would not usually find in the operating room. Mentorship is probably rarely used in this regard, although it would be limited to a few. In conclusion, it is largely in our hands as high-income countries to help these heroes succeed without putting themselves or their patients at risk." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Errando CL. Sin respirador, sin electricidad, sin oxígeno, sin fármacos (casi)… Anestesia en países con pocos recursos económicos. ¿Héroes o inconscientes? 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ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Revista Española de Anestesiología y Reanimación has received its first journal Impact Factor (JCR) in 2023. Instructions for authors - Submit an article

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

© Clarivate Analytics, Journal Citation Reports 2022

Impact factor 2023

0.9

Citescore

CiteScore measures average citations received per document published.

Citescore 2023

1.8

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.239

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

362

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Journal Information

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Vol. 69. Issue 5.