The Case for Oxygen in Global Surgical Care.

To the Editor, The recent article about a lack of available oxygen for surgery in lowand middle-income countries (LMICs) highlights an imperative public health concern [1]. As mentioned, oxygen is a paramount component of safe surgery. Sadly, it is not ubiquitous in many operating theatres in LMICs and this deficiency needs to be addressed quickly. Particularly surprising was the delayed addition of oxygen as an essential medicine by the World Health Organisation (WHO) in 2013. Amongst the plethora of techniques for which oxygen is key, pre-oxygenation is a good example of the necessity for a steady supply—helping lead to favourable operative outcomes in certain patient groups. The aim of pre-oxygenation is to replace bodily nitrogen stores with oxygen, hence prolonging the duration of apnoea before desaturation occurs. This can typically be achieved through 3 min of normal tidal breathing, or eight vital capacity breaths. As pulse oximetry tends to pick up signs of desaturation late, pre-oxygenation allows more time for any issues to be recognised and addressed, helping improve safety and outcomes. Whilst there are no clear indications for when pre-oxygenation must be utilised, strong supporting evidence emphasises its use in rapid sequence inductions, critical illness, obese patients, paediatric surgery and during pregnancy. The three key requisites for pre-oxygenation are (1) high inspired oxygen concentration, (2) a firm seal around the delivery device and (3) adequate alveolar ventilation. Lack or dysfunction in any one of these components will mean that pre-oxygenation is either inadequate or not possible; such is the case in many LMICs without adequate availability of oxygen [2]. A recent report in the Lancet, focusing on healthcare delivery in Sierra Leone, found that for a population of 6.1 million people, there were four practising anaesthesiologists in addition to 70 nurse anaesthesiologists [3]. Perhaps with this knowledge then it is not quite as surprising that another recent study analysing surgical capacity in the same country, which included ten of the countries seventeen government hospitals, found that 40 % of operations had no supply of oxygen, whilst the remaining 60 % only had an interrupted supply [4]. This is by no means isolated to Africa; a study which looked at 21 facilities in Papa New Guinea found that only 30 % of procedures had uninterrupted oxygen supply [5]. In addition to the deficiency of oxygen itself, monitoring was also an issue with a lack of pulse oximeters and oftentimes anaesthetic machines. Whether the absence of oxygen is due to a shortage of resources and equipment or due to shortfalls in broader infrastructure needs more investigation. Given the evidence behind the value of this precious surgical commodity and its severe paucity in many LMICs, it is vital that changes are made to correct this deficiency. A significant investment in time and money is essential to help raise awareness of this problem and fund the necessary changes and supplies. & Salil B. Patel salil.patel@students.pcmd.ac.uk