INTERNATIONAL

Neuroanesthesia and Neurocritical Care Activities in Colombia

María Claudia Niño de Mejía, MD
Associate Professor, Neuroanesthesiology and Intensive Care
Head, Neuroanesthesia Section and Neuroanesthesia Fellowship Program
Head of Perioperative Evaluation of the Surgical Patient

Darwin Cohen, MD
Clinical Professor, Neuroanesthesiology
Hospital Universitario Fundación Santa Fe de Bogotá HUFSFB
Universidad El Bosque
Universidad de los Andes

Andrés M. Rubiano, MD, PhD (c), FACS, IFAANS
Professor, Neurosurgery and Neuroscience, Universidad El Bosque
Director for Neurotrauma and Neuroscience Institute
Bogotá, Colombia

Dr. Niño de Mejía
María Claudia Niño de Mejía, MD
Dr. Cohen
Darwin Cohen, MD
Dr. Rubiano
Andrés M. Rubiano, MD, PhD (c), FACS, IFAANS

Colombia is the second most biodiverse country in the world, with a diverse economy and continuous growth. The development of neurosurgery in Colombia dates back many centuries. Significant observations in this context were made during the Maya and Aztec cultures. The publication from the Anthropologic Institute (1971) by Drs. Jaime Gómez and Gonzalo Correal suggest the pre-Columbian practice of craniotomies with patient survival during the Chibcha culture (200 years BC to 1500 years AD). The preserved cranium with the Carbon 14 method dated back around 350 years AD. The cases studied indicated the composition of cranioplasty with clay and a high content of iron, serving as a simple example for the level of care for patients with neurological injuries, even in those times.

Perioperative Care for Traumatic Brain Injury (TBI)
Worldwide, TBI affects about 70,000,000 people per year, being the leading cause of death among the young and more economically active population (1). Mortality in low- and middle-income countries (LMICs) is higher, with up to three times the probability of dying in these regions than in more economically developed countries (2). Colombia (a country that belongs to the LMICs) has a significant traffic accident rate associated with motor-vehicles traffic (3). It is reported that of the 13.4 million vehicles registered in the country, 7.5 million of them are motorcycles with the highest rate of accident and mortality, not only in Colombia but also in the Latin American region (4). Furthermore, these accidents generate high health spending estimated at between 1.6% and 4.2% of gross domestic product, with annual costs that exceed one billion dollars. Furthermore, estimates from autopsy reports from the Colombian Institute of Legal Medicine and Forensic Sciences indicate that 70% of deaths from violence and 90% of deaths from traffic accidents are related to TBI (5).

Efforts are underway to improve the situation by characterizing the problem and proposing possible solutions adjusted to the local environment. Rubiano et al. (6) recently developed a proposal for stratified protocols for TBI treatment at different levels of complexity of care in Colombia to reduce heterogeneity in the treatment of these patients. These protocols were developed based on consensus to articulate treatment options for TBI according to the different levels of resources and the complexity of services. This protocol and other related publications have made it possible to generate recommendations that can be used to modify prevention and healthcare policies for this problem.

Impact of the COVID Crisis in Anesthesiology and Critical Care
Amidst the global crisis due to the SARS COVID-19 pandemic, the practice of anesthesiology has been seriously affected, also affecting the practice of neuroanesthesia and neurocritical care. Colombia does not escape this reality, presenting a significant decrease in the number of elective neurosurgical procedures, reducing the opportunity for residents to expose themselves to the care of these patients, affecting both practice and teaching. This has led us to use simulation and virtual education strategies and tools as the pillar to strengthen educational processes. Hand in hand with the above, it has been necessary to adjust the hospital capacity and fully equipped intensive care beds to meet the very high demand and mitigate the ravages of the pandemic.

Colombia bases the healthcare of its population on a system made up of two subsystems that complement each other: the self-sustaining (47.17% of the population), and the subsidized subsystems (another 48.44%). Less than 4% of the population covers their care privately. This system spends 7.2% of the gross domestic product (7).

For the year 2017, it was estimated that Colombia had 2,708 anesthesiologists for a population of more than 48,000,000 inhabitants. Education in anesthesiology is on the rise, with 23 certified training programs in which neuroanesthesia is an obligatory rotation in 73% of cases.

Regarding the supply of intensive care, the health ministry showed that the country had about 1,200 intensivists by 2020, and as of April 24, 2021, a total of 12,623 intensive care beds. This shows an increase of more than double the 5,000 beds that existed prior to the start of the pandemic (8).

Teaching and Training in Neuroanesthesia and Neurocritical Care
Colombia is the first Latin American country with an advanced training program in neuroanesthesia approved by the ICPNT (International Council of Perioperative Neuroscience Training) since 2020. The Colombian Society of Anesthesiology (SCARE) has considered this a significant achievement. It will help the growth of neuroanesthesia as a sub-specialty in Colombia and throughout the subcontinent. In addition, specialists from other countries can access this fellowship certified by ICPNT and the Hospital Universitario Fundación Santa Fe de Bogotá (HUFSFB).

Despite these important achievements, there is an apparent shortage of neuroanesthesiologists and neurointensivists in Colombia. Under the leadership and direction of Dr. Claudia Niño, the neuroanesthesia fellowship has been an advanced training program for the anesthesiologists at the HUFSFB since the late '90s. More than 21 specialists from Colombia, Venezuela, Ecuador, Panama, and the Dominican Republic obtained this non-formal qualification resulting in a better healthcare force in neuroanesthesia and neurocritical care along with the other specialists trained from abroad (9).

The program has also served as a reference center for the neuroanesthesia training fellowships of other programs in Latin America, being an elective rotation center for fellows from Panama, Mexico, and the Dominican Republic. This program will continue working to provide the teaching and growth of the specialty to reduce the gap in requirements to improve the outcome of patients who are victims of surgical brain injuries, such as TBI.

References

  1. Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, Agrawal A, Adeleye AO, Shrime MG, Rubiano AM, Rosenfeld JV, Park KB. Estimating the global incidence of traumatic brain injury. J Neurosurg. 2018:1-18. doi: 10.3171/2017.10.JNS17352.
  2. GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019 Jan;18(1):56-87. doi: 10.1016/S1474-4422(18)30415-0
  3. Selveindran S, Samarutilake GDN, Vera DS, Brayne C, Hill C, Kolias A, Joannides AJ, Hutchinson PJA, Rubiano AM. Prevention of road traffic collisions and associated neurotrauma in Colombia: An exploratory qualitative study. PLoS One. 2021;16(3):e0249004.
  4. Dunne J, Quiñones-Ossa GA, Still EG, Suarez MN, González-Soto JA, Vera DS, Rubiano AM. The Epidemiology of Traumatic Brain Injury Due to Traffic Accidents in Latin America: A Narrative Review. J Neurosci Rural Pract. 2020;11(2):287-290.
  5. Hernandez H, Moreno SL. Comportamiento de las lesiones de causa externa, 2018. Forensis, Datos para la Vida, 2018: 16-66.
  6. Rubiano AM, Vera DS, Montenegro JH, Carney N, Clavijo A, Carreño JN, et al. Recommendations of the Colombian Consensus Committee for the Management of Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol [BOOTStraP]). J Neurosci Rural Pract. 2020 Jan;11(1):7-22.
  7. Suárez-Rozo LF, Puerto-García S, Rodríguez-Moreno LM, Ramírez-Moreno J. La crisis del sistema de salud colombiano: una aproximación desde la legitimidad y la regulación. Gerencia Y Políticas De Salud, 2017: 16(32), 34-50.
  8. Gutierrez A. El país registra la mayor cifra de ocupación de camas UCI tras superar 80% de la capacidad. Diario La República. Julio 13 de 2021: Available at: https://www.larepublica.co/economia/el-pais-registra-la-mayor-cifra-de-ocupacion-de-camas-uci-tras-superar-80-de-la-capacidad-3159182.
  9. SCARE web site: https://scare.org.co/noticias/primer-programa-de-neuroanestesia-con-acreditacion-internacional-en-latinoamerica/.

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