By Femi Ogunyemi (Dr)

Perhaps the commonest health reason Nigerians who can afford it go abroad is to have surgery. Indeed, if you ask anyone inside the country their greatest concern should they be hospitalised, for many, it is the prospect of surgery.

Anaesthesia and surgery is much safer today than 30 years ago.

Death during or soon after an operation is due to 3 factors: the patient has specific medical problems, the surgery is complicated by bleeding or infection, and anaesthesia related factors.

In Zimbabwe anaesthesia related death is 1:3000; in Zambia 1:1900; in the UK and USA 1:200,000. If you need surgery in Togo, you have some serious thinking to do….their figure is 1:150!

The WHO states that 50 percent of anesthesia-related deaths in Nigeria occur in pregnant women. WHO working groups have identified four potential standards for improving surgical safety:

1 Safe surgical TEAMS; 2  Safe anaesthesia; 3. Prevention of surgical site infection; 4. Measurement of surgical services. They determined 10 essential objectives for safe surgery.

The TEAM will –

1: Operate on the correct patient at the correct site; 2: Use methods known to prevent harm from administration of anaesthetics, while protecting the patient from pain; 3:  Recognize and effectively prepare for life-threatening loss of airway or respiratory function. 4: Recognize and effectively prepare for risk of high blood loss; 5: Avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk; 6: Consistently use methods known to minimize the risk for surgical site infection; 7: Prevent inadvertent retention of instruments and sponges in surgical wounds; 8: Secure and accurately identify all surgical specimens; 9: Effectively communicate and exchange critical information for the safe conduct of the operation.

Lastly,10: Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results. Note that, of these 10 objectives, the anaesthetist is directly responsible for  2, 3, 4 and 5. Government and policy makers should take the lead on Objective 10.

In furtherance of these objectives, the WHO, in 2009, published a checklist of must-dos for every surgical case: Before induction of anaesthesia. Has the patient confirmed his/her identity, site, procedure and consent? Is the site marked? Is the anaesthesia machine and medication check complete?

Is the pulse oximeter on the patient and functioning?

Does the patient have a known allergy?

Does the patient have a difficult airway/aspiration risk? Does the patient have a risk of >500 ml blood loss (7 ml/kg in children)?

Before skin incision

Confirm all team members have introduced themselves by name and role

Confirm the patient’s name, procedure and where the incision will be made

Has antibiotic prophylaxis been given in the last 60 minutes?

Anticipated critical events

To surgeon: what are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss? To anaesthetist: are there any patient-specific concerns?

To nursing team: has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns? Is essential imaging displayed?

Before patient leaves operating room

Nurse verbally confirms The name of the procedure. Completion of instrument, sponge and needle counts

Specimen labelling (read specimen labels aloud, including patient name)

Whether there are any equipment problems to be addressed. Surgeon, anaesthetist and nurse review the key concerns for recovery and management of this patient.

According to the WHO, only 31 institutions registered for the Surgery Checklist in Nigeria; only one ( UCH Ibadan ) is actually implementing it.

YOU, as a knowledge-empowered patient can: Make sure your identity, operative site, procedure are confirmed.

Ask as many questions as you need before you give YOUR CONSENT.

Request a pulse oximeter probe be put on your finger.

Tell the TEAM about any ALLERGIES. Ask if you will need antibiotics. Since 2010, in the UK and USA, the WHO checklist is done for EVERY single procedure. It is a start to making surgery safe in Nigeria.

•Dr. Femi Ogunyemi, FRCA, FWACS, is a member of the British Pain Society, American Pain Society, the North American Neuromodulation Society and the Aerospace Medical Association. He is a Diplomate of the American Academy of Pain Management and a Fellow in Pain Medicine from Emory University.