A Tale of Two Cities: Congenital Cardiac Anesthesia in Katmandu, Nepal and Denver, Colorado, USA
By Priska Bastola1, Scott Stenquist2, Richard Ing2, and Mark Twite2
1Manmohan Cardiothoracic Centre, Maharajgunj Medical Campus, Tribhuvan University, Katmandu, Nepal
2Children’s Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
Corresponding author: Dr. Mark Twite
Mark.Twite@childrenscolorado.org
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair…”
Charles Dickens
A Tale of Two Cities, 1859
These famous opening lines penned by Charles Dickens create a sense of sweeping possibilities: the age is everything and nothing all at once. Over one hundred and fifty years later, there are still many possibilities to improve the perioperative care of children with congenital heart disease (CHD). Katmandu is the capital city of Nepal. The city is at an elevation of 4,600 feet above sea level and has a population of around 5 million people. Nepal is a landlocked country with a diverse geography including fertile plains, subalpine forests and a high mountainous range with eight of the world’s ten tallest mountains, including Mount Everest (29,029 Feet). Denver is the capital city of Colorado and sits at an elevation of 5,280 feet (exactly 1 mile) above sea level and has an estimated population of 4 million people. Colorado is also a landlocked state with a diverse geography including deserts, high plains, subalpine forests and the Rocky Mountain Range with the highest point being Mount Elbert (14,440 Ft).
Recently, we had the good fortune to host reciprocal visits of cardiac anesthesiologists from our two countries. This article highlights some of the key similarities and differences between the cardiac programs which are 7,700 miles apart. While Katmandu and Denver share geographical similarities, the same cannot be said for the socioeconomic status of the two countries. Nepal has a population of around 30 million people, with a gross domestic product (GDP) of 25 billion United States Dollars (USD) and a life expectancy of 70 years. The United States of America (USA) has a population of around 330 million people, a GDP of 20 trillion USD and a life expectancy of 79 years. The current health expenditure is 6% of GDP in Nepal and 17% of GDP in the USA, which is the highest of any country in the world. Healthcare costs in the USA are very complex and still leave gaps in coverage for many people. In contrast, Nepal has a more universal governmental healthcare model for its people. Rheumatic heart disease remains common in Nepal and heart valve replacement surgery is common, with many people receiving free or low-cost artificial heart valves though the government system. However, this also points to the lack of early detection of not just acquired heart disease but also congenital heart disease. This lack of diagnosis is largely due to the shortage of trained cardiologists, especially pediatric cardiologists, and diagnostic tools including echocardiography, computed tomography (CT) and magnetic resonance imaging scanners.
There are two cardiac centers in Katmandu. At Manmohan Cardiothoracic Center, around 100 children per year undergo cardiac surgery for congenital heart defects. A much larger number of adults undergo cardiac surgery and the facility has a total of 80 beds of which 16 are dedicated cardiac ICU beds. Manmohan has two cardiac catheterization laboratories and three cardiovascular operating rooms (CVOR). In Denver there are also two cardiac centers providing congenital heart surgery. At Children’s Hospital Colorado around 350 children per year undergo open heart surgery with another 150 having non-cardiopulmonary bypass surgery. The entire hospital has over 500 patient beds, 16 dedicated cardiac ICU beds, two cardiac catheterization laboratories and two CVORs. Children’s Hospital Colorado has ‘high tech’ operating rooms with new anesthesia machines and work stations and an electronic medical record. At Manmohan, the anesthesia machines are functional, but lack end tidal CO2 measurement and nitrous oxide. Anesthesiologists from both countries agreed that electronic medical records are convenient for finding patient information, yet are very expensive, but were unclear if they have a positive effect on anesthesia related outcomes. Disposables such as cerebral oximetry sensors are expensive and reserved for the highest risk surgeries and are not ‘routine of care’ as in most congenital cardiac surgeries in the USA. Both centers placed similar central venous lines and arterial lines with respect to brand, and location. Interestingly, no PIC lines were used at Manmohan which may reflect the fact they do not have the opportunity to operate on the high complexity neonates which require repeat procedures. Both centers used the same infusion pumps, and had ready access to disposables such as endotracheal tubes, including double lumen endotracheal tubes, glide scopes, epidural kits, etc.
Despite very different training pathways, the clinical skill sets were very comparable between physician anesthesiologists in both countries. Our Nepalese colleagues would be able to function independently as congenial cardiac anesthesiologists in the USA, although they lacked experience with high complexity cases such as single ventricle palliation procedures. Many of our Nepalese cardiac anesthesia colleagues seek training opportunities abroad when possible, often in India. The team dynamics in the operating room are different between the two countries. In Nepal, it is much more ‘old school’ with the cardiac surgeon being the ‘captain of the ship’ compared to the team consensus approach in the USA. Unfortunately, the cardiac teams in Nepal often have to undertake surgical procedures in children with very little data, other than echocardiograms, due to the lack of trained pediatric cardiologists, especially interventional cardiologists. In Nepal almost no cardiac catheterization data was obtained before surgery and even fewer interventional procedures were performed.
The conduct of anesthesia was strikingly similar between the two countries. We were all surprised at similar dosing regimens for most of our medications including antifibrinolytics. Both centers practiced early extubation for suitable cardiac cases. However, there were a few notable differences. Inhalational induction of anesthesia is very common in the USA for children with congenital heart disease (CHD), while in Nepal intravenous induction of anesthesia is used. This may reflect the ready availability of nitrous oxide in the USA and also a cultural acceptance by children and families in Nepal that a peripheral intravenous catheter will be placed prior to induction. In Nepal, during cardiopulmonary bypass, there was not an anesthetic vaporizer on the bypass machine, so a propofol infusion was used instead during the bypass portion of the case. While there is considerable interest in starting a heart transplant program in Nepal, there are significant hurdles including the lack of extracorporeal assist technologies, and the costs of long-term immunosuppression and difficulties of patient follow-up, particularly in remote rural areas.
In summary, despite the huge socioeconomic differences between our two countries, we were encouraged by the similarities in clinical practice. This raises the possibility that significant improvements in care could be made with modest investments in equipment and disposables in Nepal and more importantly by partnering institutions together to exchange ideas and educational opportunities. Perhaps we now live in the ‘best of times’ if we seize the possibilities to foster global relationships between congenital cardiac anesthesiologists and bring our collective wisdom and hope to all children with CHD. It may take organizations like the Congenital Cardiac Anesthesia Society, to promote and foster international relationships, so that our common goal of excellent perioperative care of children with CHD can become a global reality.
Below: Cardiac anesthesiologists in action. Katmandu, Nepal
