BACKGROUND: 

There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death.

METHODS: 

A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included.

RESULTS: 

Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7–25.6).

CONCLUSIONS: 

The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.

中文翻译：

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与医师和非医师麻醉提供者进行的程序性镇静相关的术后结果：来自前瞻性、观察性非洲手术结果研究的结果

背景： 

非洲对基本外科服务的需求未得到满足。有限的麻醉服务是一个促成因素。非医师麻醉提供者用于协助提供麻醉和程序镇静，以进行必要的手术。非洲手术镇静后结果的数据很少。我们调查了非洲非医生和医生进行程序性镇静后的术后结果。我们假设镇静提供者的培训水平可能与术后严重并发症和死亡的发生率有关。

方法： 

对代表 25 个非洲国家的住院成人手术患者的前瞻性队列进行了二次分析。主要结局是院内严重术后并发症和死亡的复合崩溃。我们使用逻辑回归评估了接受由非医生（与医生）进行的程序性镇静与复合结果之间的关联。我们使用反概率治疗加权倾向评分法来调整潜在的混杂变量，包括患者年龄、血红蛋白水平、美国麻醉医师协会 (ASA) 生理状态、糖尿病、手术紧迫性、手术严重程度、手术指征、手术学科、手术团队资历、医院专业水平、使用公共或私人资金的医院资金系统。所有仅接受手术镇静的患者都包括在内。

结果： 

336 名患者符合纳入标准，其中 98 名 (29.2%) 接受了非医师提供的镇静剂。非医师组 98 人中的 10 人（10.2%）和医师组 238 人中的 5 人（2.1%）发生严重的术后并发症和死亡。由非医师提供的程序性镇静与住院结局之间的估计关联是严重并发症和/或死亡的几率增加 8 倍，优势比（95% 置信区间 [CI]）为 8.3（2.7-25.6 ）。

结论： 

该次要数据分析中的少量观察表明，将程序性镇静的任务从医生转移到非医生以增加获得护理的机会可能与非洲严重的术后并发症和死亡有关。研究重点是确定导致与程序镇静相关的不良结果的因素，以使这种做法更安全。