2020 Laos Blog

In February of 2020, Dr. Tom Pajewski, MD, PhD, Associate Professor of Anesthesiology & Division Head for Neuroanesthesia and Dr. Justin Hickman, MD, CA2 Anesthesiology Resident, participated in UVA Anesthesiology’s third trip to Vientiane Laos with the Midwest Spine Foundation.

Laos (or Lao People’s Democratic Republic) is a Southeast Asian communist state landlocked and bordered by China, Burma, Thailand, Cambodia, and Vietnam. It is traversed by the Mekong River and mountainous in terrain. The population is approximately 7.5 million people. The country ranks 139th on the Human Development Index and per capita income is roughly 1800 USD per year. Subsistence agricultural comprises about half of the country’s GDP. Healthcare in Laos is covered under various insurance schemes based on government status and wealth. It is not universally provided and is predominantly a fee for service based system making complex surgery inaccessible to most. Most of the healthcare resources are found in large urban areas with minimal access to preventive care.

The complex spine surgery offered by Midwest Spine Foundation is locally sponsored within the Mittaphab Friendship Hospital in Vientiane, Laos. With recent expansion and modernization of the hospital, patients do now have access to MRI and CT imaging in Laos, whereas even a few years back they were often traveling to Thailand for such services. Currently neurosurgical interventions locally performed are limited to minor surgeries and emergent procedures. Larger complex spine surgeries such as repairs for severe congenital scoliosis and vertebral destruction by tuberculosis (Pott’s Disease), which require many levels of instrumentation and fixation of hardware, are not provided in country. Dr. Hartman’s and his team have been helping to fill

this critical need for over a dozen years with over 35 mission trips through his collaboration with the neurosurgical staff at Mittaphab Hospital.

The Neurosurgery floor of the hospital houses 2 operating rooms within the ward. The ORs are equipped with modern Drager Fabius anesthesia machines with sevofluorane vaporizers. These ventilators have monitors available but limited to only 3 lead EKG, NIBP, and pulse oximetry. Additional gas monitoring such as ETCO2, O2 sampling, anesthetic gas analyzers and invasive blood pressure monitoring however were not available. There was no intraoperative neuromonitoring available. Anesthetic drugs locally available included ketamine, fentanyl and morphine for analgesia, as well as thiopental, pancuronium and tranexemic acid. Additionally, 2 units of whole blood are made available for each patient for resuscitation (No pRBCs or other individual components are available). Phenylephrine was available for infusion by drip count (no pumps available). Furthermore, the modern convenience of intraoperative labs that we are accustomed to for such large complex spines is also not available.

Patients are cared for postoperatively in an ICU with some limited modern tools such as ventilators, portable X-Ray (which broke during our stay), point of care ABG (without H&H), and CT scanner (available usually within 30min but no radiologist for readings). Despite some modern technology, there were overall very limited ICU resources and staffing available (eg. no chest tube kits, limited number of portable monitors for vital signs, no sedation for ventilated patients). Patients are further expected to pre-purchase from local pharmacies any medications/supplies needed for their care in the postoperative period.

The patients we cared for during our February 2020 mission presented a variety of pathologies and complexities. We performed multilevel spinal instrumentations and fusions with corpectomies and cage placements for Pott’s disease involving both anterior and posterior approaches in the same case. We additionally performed large scoliosis repairs on pediatric patients with significant curvatures. The length and complexity of procedures coupled with limited monitoring capability made necessary a stronger reliance on good physical examination, heightened vigilance and early proactive treatment to prevent morbidity. Despite the complexity and risk of these cases, the experience and technical expertise of our surgical team significantly helped minimize OR time and blood losses. Providing anesthesia for such complex lifesaving surgeries requiring critical postoperative care in such a limited resource environment is truly a unique challenge and learning experience that undoubtedly helps fine tune valuable perioperative skills.