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Rules of Thumb in Anaesthesia for Sub-Saharan Africa
Background
Anaesthesia practice in sub-Saharan Africa (SSA) faces unique challenges: limited resources, intermittent oxygen supply, equipment shortages, underdeveloped infrastructure, and late presentation of patients. These rules of thumb combine WHO and World Federation of Societies of Anaesthesiologists (WFSA) global standards with locally relevant adaptations to maximise safety and efficiency in SSA contexts.
Rules of thumb
1. Preoperative Assessment and Preparation
i. Thorough history and examination:
Essential in the absence of advanced diagnostics. Identify comorbidities, prior anaesthesia complications, medications, and allergies.
ii. Optimise chronic conditions:
Stabilise hypertension, diabetes, anaemia, and malnutrition where possible before surgery.
iii. American Society of Anaesthesiologists (ASA) classification:
Use ASA Physical Status for risk communication and planning. Where ASA I and II have lower risk compared to III-V and VI is the brain dead.
iv. Fasting:
Follow evidence-based fasting (6 h for solids, 2 h for clear fluids). Avoid prolonged fasting, especially in children, to reduce hypoglycaemia and dehydration.
Refs:
WHO Safe Surgery; ASA preoperative evaluation standards.
2. Choice of Anaesthesia Technique
i. Regional first:
Prioritise spinal/epidural and peripheral nerve blocks when safe, especially for obstetrics and orthopaedics. Regional techniques conserve oxygen and reduce airway risk.
ii. Ketamine as a workhorse:
Provides dissociative anaesthesia, preserves airway reflexes, and maintains cardiovascular stability. Ideal for emergencies and low-resource contexts.
iii. Total intravenous anaesthesia (TIVA):
Propofol or ketamine-based TIVA is a substitute where volatile agents are unavailable.
iv. Simple > complex:
Avoid techniques requiring fragile equipment or drugs with unreliable supply chains.
Refs:
WFSA standards; Dohlman et al., “Anaesthesia in resource-limited settings.”
3. Monitoring and Clinical Vigilance
i. Minimum monitoring:
Blood pressure, pulse oximetry, ECG (when available) and clinical observation (colour, chest rise, pulse quality).
ii. Pulse oximetry is non-negotiable:
At least one working oximeter per anaesthetising location; prioritise its use for high-risk patients.
iii.Clinical judgement:
When monitors fail, rely on respiratory rate, skin colour, pulse, and auscultation.
Refs
WHO-WFSA International Standards; Life box programme data.
4. Airway Management
i. Basic skills first:
Bag-valve-mask ventilation and endotracheal intubation are core competencies.
ii. Always have a plan:
A graded airway plan — manual airway manoeuvres → bag-mask → supraglottic device (if available) → intubation → surgical airway (if trained).
iii.Oxygen conservation:
Avoid over-ventilation, titrate oxygen to SpO₂ targets (≥94% for most adults; adjust in COPD, neonates).
Refs
WFSA airway guidelines; WHO oxygen access recommendations.
5. Essential Drugs and Medication Safety
i. Maintain a short essential list:
Oxygen, ketamine, propofol (if available), atropine, adrenaline, benzodiazepine, opioid (morphine/fentanyl), local anaesthetics, oxytocin, antibiotics.
ii. Paediatric dosing:
Always weight-based; keep a paediatric emergency drug chart visible.
iii.Avoid polypharmacy:
Use the fewest drugs necessary; reduce reliance on those requiring strict cold chain.
Refs
WFSA essential anaesthesia drug lists; paediatric safety reviews.
6. Obstetric and Paediatric Anaesthesia
i. Obstetrics
Spinal anaesthesia is preferred for caesarean section if not contraindicated. Always prepare for postpartum haemorrhage (PPH) with oxytocin and a blood loss plan.
ii. Children
Maintain normothermia, avoid excessive fasting, and prepare appropriate airway equipment. Paediatrics are more vulnerable to hypothermia and O maternal health guidelines; ASA paediatric fasting standards.
Refs
Refs: WHO maternal health guidelines; ASA paediatric fasting standards.
7. Postoperative Care and Recovery
i. Pain management: Use multimodal approaches
Use multimodal approaches — NSAIDs, paracetamol, regional blocks. Reserve opioids for severe pain, mindful of availability and monitoring needs.
ii. Complication vigilance
Watch for hypoxia, aspiration, haemorrhage, and sepsis.
iii. Transport safety
Patients may travel long distances; ensure stable recovery and reliable monitoring during transfers.
Refs
WHO perioperative safety and analgesia guidance.
8. Use of Infection Control and Equipment
i. Sterilisation is critical
Hand hygiene, sterile drapes, and proper autoclaving reduce infection risk.
ii. Reusable equipment
Master safe cleaning and sterilisation of reusable airway devices, laryngoscopes, and syringe.
Refs
WHO infection prevention standards.
9. Emergency Preparedness
i. Expect the worst
Plan for haemorrhage, cardiac arrest, laryngospasm, anaphylaxis.
ii. Crash Cart
Maintain a basic resuscitation kit — bag-mask, airway tools, IV fluids, adrenaline, atropine, ketamine, and antibiotics. Check regularly.
iii. Team drills
Practice emergency scenarios monthly; use simple laminated algorithms.
Refs
WHO Safe Surgery; WFSA crisis management resources.
10. Workforce, Training, and Collaboration
i. Task sharing
Non-physician anaesthesia providers (nurse anaesthetists, clinical officers) deliver most anaesthesia in SSA. Ongoing training and mentorship are essential.
ii. Team communication
Use briefings and readbacks to clarify plans and roles.
iii. Quality improvement
Track simple metrics (e.g., checklist use, oximeter availability, perioperative deaths) and run PDSA cycles.
Refs
WHO-WFSA workforce advocacy; West African training experiences.
11. Guideline Frameworks to Anchor Practice
i. WHO Safe Surgery Saves Lives initiative:
Use the Surgical Safety Checklist.
ii. WFSA/WHO International Standards for Safe Anaesthesia Practice
Minimum standards for monitoring, staffing, and drugs.
iii. ASA guidelines (adapted for LMICs):
Apply core principles pragmatically, emphasising patient safety with available resources.
Refs
WHO surgical safety; WFSA global standards; ASA preop/intraop guidance.
Conclusion
Anaesthesia in SSA requires adaptability, creativity, and mastery of fundamentals. By combining WHO checklists, WFSA global standards, safe use of ketamine and regional techniques, and a strong focus on teamwork and infection control, clinicians can deliver safe anaesthesia despite resource constraints. A “back-to-basics” approach — oxygen, oximetry, airway plan, essential drugs, and clear communication — saves lives.
Further readings
- World Health Organization (WHO). WHO Surgical Safety Checklist and Implementation Manual. Geneva: WHO; 2009.
- Gelb AW, Morriss WW, Johnson W, et al. International standards for a safe practice of anesthesia 2018. Canadian Journal of Anesthesia. 2018;65(6):698–708. doi:10.1007/s12630-018-1111-5.
- American Society of Anesthesiologists Statement on ASA Physical Status Classification System. Anesthesiology Open 1(1):p e0002, January 2026. | DOI: 10.1097/ao9.0000000000000002
- World Federation of Societies of Anaesthesiologists (WFSA). Global Anesthesia Workforce and Standards Resources. WFSA; 2018. Available at: https://www.wfsahq.org.
- Dohlman L, Kwikiriza A, Hoeft MA. Providing anesthesia in resource-limited settings. Current Anesthesiology Reports. 2019;9(2):178–186. doi:10.1007/s40140-019-00323-2.
- Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: An estimation from reported data. The Lancet. 2010;376(9746):1055–1061. doi:10.1016/S0140-6736(10)60392-3.
- Walker IA, Obua AD, Mouton F, et al. Paediatric anaesthesia in developing countries: Challenges, strategies and solutions. Paediatric Anaesthesia. 2011;21(4): 387–392. doi:10.1111/j.1460-9592.2011.03545.x.
- World Health Organization (WHO). Safe Surgery Saves Lives: Second Global Patient Safety Challenge. Geneva: WHO; 2009.
- Lifebox Foundation. Pulse Oximetry and Safe Anesthesia. Lifebox; 2022. Available at: https://www.lifebox.org.
- World Health Organization (WHO). Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. Geneva: WHO; 2016.
