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Pain Management in Resource-Limited Conflict Zones: Can Teaching Ultrasound-Guided Regional Anesthesia Help?

Aug 8, 2024, 06:40 AM by Sara Amaral, MD, DESAIC and Lena E. Dohlman, MD, MPH

Cite as: Amaral S, Dohlman L. Pain management in resource-limited conflict zones: can teaching ultrasound-guided regional anesthesia help? ASRA Pain Medicine News 2024;49. https://doi.org/10.52211/asra080124.005.

The delivery of effective pain management in low-and middle-income country (LMIC) conflict zones can be uniquely challenging. The limited availability of analgesics, inadequate patient monitoring, and lack of trained personnel, coupled with unpredictable surges of acutely injured patients, create extremely difficult situations.1,2 This article will discuss the role that ultrasound-guided regional anesthesia can have in treating patients in war-trauma hospitals in resource-poor areas.

Dr. Amaral is a Portuguese anesthesiologist who works in Brazil. Her main interests are trauma and regional anesthesia care. She has had a lifelong dream to work and teach in conflict zones and to offer help in places where few venture. Dr. Amaral successfully applied to work with Doctors Without Borders and received her first assignment at a frontline hospital in Yemen in late 2021 (Figure 1).3 A second assignment followed soon after in Afghanistan in early 2022. Her main goal at these two war trauma hospitals was to teach and improve the local medical staff’s anesthesia skills. 

Figure 1. Dr. Sara Amaral maneuvers the ultrasound machine through the hospital tents in Yemen.

The following describes some of her experiences and impressions:

Upon my arrival at the hospitals in Yemen and Afghanistan, the gravity of inadequate pain management was immediately apparent. We were presented with major trauma patients in severe acute pain and injuries at high risk for chronic pain development that we were attempting to treat with inadequate resources. Before my arrival, the pain management of these patients was mostly opioid-based. The risk of respiratory depression was a major concern due to the lack of monitoring, mechanical ventilators, and personnel skilled in the resuscitation and care of hypoventilating patients. Fortunately, both hospitals I worked in had ultrasound machines available, although they had been used exclusively for Focused Assessment with Sonography in Trauma (FAST) exams until my arrival. I assessed that regional anesthesia could be the cornerstone in redefining pain management practice amidst this challenging environment and began to guide its implementation. I will describe some of the patients we saw who benefited from the regional anesthesia we provided.

We treated several adult patients with flail chest, resulting from bomb blast explosions. Despite using high O2 flows delivered through non-rebreathing masks, many of these patients were in distress and tired, with O2 saturations dipping to the low 80s. Normally, we would have intubated and mechanically ventilated these patients, but no spare ventilators were available. We couldn’t use the only anesthesia machine for ventilation as it was needed for other cases. If we were forced to intubate these patients, we would have had to manually ventilate them until transportation to another city could be arranged, and this would, in many cases, have taken as long as a day or two. Instead, we decided to perform bilateral erector spinae plane blocks, hoping this would help. Very shortly after these blocks were in place, patients were consistently breathing comfortably on 2L/min O2 by nasal prongs, and we were able to avoid intubations. We successfully treated nearly 20 patients in this way.

Another scenario we faced was a mass casualty event involving small children on a vehicle that struck a landmine. All patients sustained severe injuries with multiple amputations. Initially, we conducted damage control surgeries on everyone, making regional blocks unfeasible at the time. However, when the surgeries ended many hours later, we decided to perform nerve blocks on all the amputated patients, most of whom were very young (ages 2-5 years old). After calculating dosages for multiple blocks in these small children and performing dozens of blocks over several hours, the infirmary transformed from a chaotic scene of crying and screaming to complete silence with all children asleep. It was a profoundly fulfilling moment. Although I felt limited in what I could do in the face of such trauma, I managed at least to provide the children with several hours of pain-free sleep and some peace. The local staff also benefitted educationally from observing and assisting with the large number of blocks performed in a short time.

There is evidence that regional anesthesia can minimize the risk of mortality and morbidity in resource-limited settings.4 In comparison to high-resource areas, airway problems and postoperative respiratory depression in LMICs are more likely to occur when general anesthesia with intubation is used instead of non-intubated general anesthesia or regional anesthesia. This is probably due to a lack of monitoring equipment in the operating rooms, such as ET CO2 and pulse oximeters, especially in postoperative areas. Neuromuscular blockade monitoring, reversal medication, airway rescue equipment and ventilators are often scarce or unavailable. A shortage of trained and experienced medical personnel exacerbates the problems.5,6  

A more widely used and safer option is the use of non-intubated, ketamine-based general anesthesia.7 However, the high doses of ketamine required in these scenarios often lead to a considerable incidence of nausea and vomiting after surgery, which can prolong recovery times. Ketamine also does not provide muscle relaxation, which can optimize surgical conditions. Once the ketamine wears off, pain management once again becomes a problem.

The use of opioids in LMICs can also be difficult due to shortages secondary to strict regulations in many countries concerned about opioid abuse. Inadequate training and experience in dosing of opioids in many areas combined with shortages of staff and equipment for monitoring increases the risk of postoperative respiratory depression. Regional anesthesia circumvents these issues by facilitating surgeries without the need for airway manipulation or high doses of hypnotics and opioids.

Using regional anesthesia instead of ketamine and opioids also preserves these medications for cases where regional anesthesia is not an option. In conflict zones, mass casualties can occur unexpectedly, necessitating the capacity for rapid turnover and preparation in both the operating room and post-anesthesia care unit (PACU). PACU facilities are often limited or unavailable in low-resource regions, and the potential for faster recovery with regional anesthesia is particularly valuable.8 The typically few available operating rooms and the high surgical caseload make the potential efficiency of using regional anesthesia critical for optimizing surgical throughput.9 There is also evidence that chronic pain, which is highly prevalent in these trauma injury patient populations, can be mitigated with regional anesthesia.10, 11 Controlling acute postoperative pain is important, but it is also important to minimize the risk of chronic neuropathic pain. Investing in the future psychosocial and physical rehabilitation of trauma patients is crucial as they adapt to life after amputation.

The transition to using more regional anesthesia can be challenging. Typical barriers that must be overcome are the need for more equipment and trained personnel.12 A steep learning curve requires strong motivation from the educator and the learning staff. In Dr. Amaral’s experience, there was a paradigm shift from resistance to embracing the technique as the benefits of regional anesthesia became clear (Figure 2). For local medical staff in Yemen and Afghanistan, who were accustomed to the ubiquity of pain, witnessing patients resting comfortably and smiling after traumatic injuries, perhaps for the first time in their professional lives, was profoundly gratifying (Figure 3). This significant shift served as a powerful incentive to learn. In turn, the staff’s enthusiasm greatly inspired Dr. Amaral’s dedication to teaching.

Figure 2. Teaching how to scan for a femoral nerve block in the main operating room (Yemen, 2021).
Figure 3. Dr. Mohammed performed bilateral transversus abdominis plane (TAP) blocks post-laparotomy in a patient who was a victim of a bomb explosion, guided by Dr. Amaral.

By reducing perioperative complications, enhancing pain control, and avoiding the adverse effects of opioids, regional anesthesia can serve as a critical component of perioperative care in LMICs.13 Encouraging the training and use of regional anesthesia can be an especially effective solution to the challenges of pain management in resource-limited conflict zones. We urge the global anesthesia community to support increased training of regional anesthesia techniques in LMICs.

Visit ASRA Pain Medicine Global Anesthesia SIG for available organizations for support or volunteering.

Sara Amaral, MD, DESAIC, EDRA, is an attending anesthesiologist in the department of anesthesia at Regional Hospital Afonso Guizzo in Ararangua, SC, Brazil.
Lena E. Dohlman, MD, MPH, is an assistant professor of anesthesia at Harvard Medical School/MGH in Boston, MA.

References

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