Neuroanesthesia and Neurocritical Care in Uganda
Betty Nantongo, MBChB, MMED
Anaesthesiologist, Dept of Anaesthesia
CURE Children's Hospital, Mbale, Uganda
John Paul Ochieng, MBChB, MMED, FCA
Lecturer, Dept of Anaesthesia
Busitema University, Busitema, Uganda
Moses Ssenyonjo, MBChB, MMED (3rd Year)
Resident Anaesthesiologist, Dept of Anaesthesia
Mbarara Regional Referral Hospital, Mbarara, Uganda
Peter Kaahwa Agaba, MBChB, MMED, FCA
Lecturer, Dept of Anaesthesia and Emergency Medicine
Makerere University, Kampala,Uganda
Uganda is a low-middle-income country in sub-Saharan Africa bordered by Kenya in the east, Tanzania and Rwanda in the south, the Democratic Republic of Congo in the west, and South Sudan in the north. Uganda has approximately 47 million people with an approximate land mass area of 241,037 km2. Kampala, the capital city of Uganda, has 1.35 million people. In addition, the country has ten other administrative areas designated as cities, with 25.7% of the population living in urban areas.
The public health service system is classified from the top, with the higher level; specialized, national, and regional referral hospitals, to the lower community-level health centers. All the five specialized hospitals and the five national referral hospitals are located in the capital city. The 14 regional referral hospitals are evenly distributed in the country but mainly in the urban areas. Private For Private (PFP) and Private Not-For-Profit (PNFP) health institutions and hospitals are also evenly distributed throughout the country (Figure 1). PNFPs primarily provide a higher level and specialized health services, while PFPs offer various levels of health services but mainly at the lower level of care.
The Practice of Neuroanesthesia and Critical Care
The public health service system is organized, so that speciality and subspecialty surgeries are performed in regional, national, and specialized hospitals. However, the provision of speciality and subspecialty surgical services is dependent on the availability of specialized surgical human resources and special surgical equipment. As a result, the only public health service facilities able to provide neurosurgical services are Mbarara Regional Referral Hospital (RRH), located in Mbarara city in Western Uganda, and Mulago National Specialized Hospital situated in the capital city, Kampala. In addition, several PFP hospitals, primarily located in Kampala, the capital, provide neurosurgical services. However, the scale of these neurosurgical services is small compared to that offered by the above two public hospitals.
CURE Children's Hospital of Uganda, located in Mbale City in eastern Uganda, is a specialized neurosurgical PNFP hospital. It provides a considerably large amount of neurosurgical service focusing on pediatric neurosurgery.
Mulago National Specialized Hospital is the teaching hospital for Makerere University. This hospital is well supported by clinical and academic departments of anesthesiology and neurosurgery. With support from the government through the Ministry of Health (MoH), the hospital has managed to establish elaborate neurosurgical, neuroanesthesia, and neurocritical care services (Figures 2/3). The average number of neurosurgical procedures performed is 900 - 1000 cases per year. The most common indication for these surgeries is trauma. However, other common neurosurgical procedures performed include CSF diversion surgeries, neuro-oncological surgery, and pediatric neurosurgery. The surgeries are performed by neurosurgeons, neurosurgery trainees, and general surgery trainees.
Anesthesia is provided by a team of physician anesthesiologists, trainees, and non-physician anesthesia providers. The physicians and trainee anesthesiologists provide anesthetics for the more complex neurosurgical procedures. In contrast, the non-physician anesthesia providers direct anesthesia for the less complicated neurosurgical procedures under the supervision of the anesthesiologists. Almost all the cases are done under general anesthesia with inhalational agents, with a few exceptions, carried out using total intravenous anesthesia (TIVA) or a scalp block, and monitored anesthesia care. Intraoperative monitoring includes the standard monitors with invasive pressure. The intraoperative neurophysiologic monitoring (IONM) is reserved for specific cases such as posterior fossa tumors and spine surgeries; currently, IONM is provided by one anesthesiologist in the country who has received this training.
The neurosurgical ward has a high dependence unit (HDU) staffed by neurosurgeons. The hospital general intensive care unit (ICU) admits all critical neurosurgical patients, including those who require intensive postoperative care. The majority of patients admitted to the general ICU are neurotrauma patients.
The CURE Children's Hospital of Uganda started in 2001, initially as an orthopedic children's hospital introducing neurosurgery in 2005. Subsequent high volumes of neurosurgical patients led to the hospital being transitioned to a specialized pediatric neurosurgical hospital, offering 95% pediatric neurosurgery that is fully sponsored by donors and 5% privately funded adult practice. The hospital is a global leader in minimally invasive neurosurgery for hydrocephalus, a combination of endoscopic third ventriculostomy with choroid plexus cauterization. Most cases treated include hydrocephalus 65-75%, spina bifida 15-20%, brain tumors, and other congenital abnormalities in children.
The hospital had an increased number of neurosurgeries from about 500 cases to over 1500 per year, with a projection of over 1800 by the end of 2021. The hospital offers free donor-funded health care to all patients below 18 years, thus, removing the financial barrier to treatment. A neurosurgeon always performs surgeries with neurosurgery trainees or medical officers. Anesthesiologists and non-physician anesthesia providers offer anesthesia. There is no fellowship-trained neuroanesthesiologist available in Uganda; however, they recognize a need for such fellowship training to address the increased complexity of cases like brain tumors. The hospital has a four-bed neuro-ICU, and a six-bed HDU managed by the neurosurgeons and anesthesiologists (Figure 1).
Mbarara Regional Referral hospital is the teaching hospital for Mbarara university of science and technology and other surrounding medical institutions. It serves as a regional referral for the Southwestern part of Uganda, including Eastern DR Congo and Rwanda.
The average number of neurosurgeries done is about 420 cases per year; 60% are surgeries due to trauma cases, 20% are neuro-oncology, and 20% are pediatric neuro cases such as spina bifida and hydrocephalus surgeries. Currently, there are two neurosurgeons, one neurosurgery fellow, and general surgery residents to perform neurosurgeries. Anesthesia is provided by anesthesiologists, anesthesia residents, non-physician anesthesia providers, and trainees, depending on the complexity of the surgery. Currently, IONM is not performed. Neurocritical care is provided in a general ICU, and there is no dedicated HDU for neurological patients.
Training and Education
In Uganda, there is no established common standard of practice regarding who should provide anesthesia and critical care for neurosurgery. Anesthesiologists are involved directly or indirectly in managing more complex surgeries like brain tumors, vascular procedures, and spine surgeries. Departments of Anesthesiology in Makerere University and Mbarara University offer three years postgraduate training in anesthesiology and critical care for graduates of the bachelor of medicine and bachelor of surgery program. Undergraduate training programs in most universities have mandatory clinical exposure in anesthesia. During postgraduate training, there is a varying duration of rotation in neurosurgery where residents are exposed to neuroanesthesia and neurocritical care principles and management.
In both the public and private hospitals, most of the anesthetics are provided by officers whose training is an advanced diploma in anesthesia. A prerequisite for advanced anesthesia training is a nursing or clinical medicine diploma. No fellowship program in neuroanesthesiology exists, and nobody governs neuroanesthesiology practice. The practice of neurophysiology is minimal, and most hospitals do not have access to IONM. CURE children's hospital plans to train two neurophysiologists and start IONM practice within the next two years.
Partnerships and Collaborations
There are different partnerships between hospitals and other organizations in and out of the country. The different partnerships have significantly contributed towards access to equipment and skills transfer in neuroanesthesia and neurocritical care.
Challenges and Shortcomings
There is no ready access to subspecialty training in neuroanesthesia and neurocritical care despite the unmet demand for physicians in these areas, especially in the northern and eastern regions of the country. Neurosurgical care and its supporting services are resource-intensive, and the profits are not readily apparent, so investment from both the private and public sectors is lacking. There is a need for leadership and organized research collaborations in Uganda involving local neuroanesthesia and neurocritical care stakeholders.
Dowhaniuk, N. Exploring country-wide equitable government health care facility access in Uganda. International Journal for Equity in Health 2021;20(1), 38. https://doi.org/10.1186/s12939-020-01371-5