Global Health

Section Editor: Angela Enright

Anesthesia for Ambulatory Pediatric Surgery in

Sub-Saharan Africa: A Pilot Study in Burkina Faso
Yvette B. Kabr, MD,* Idriss S.S. Traor, MD, Flavien A.R. Kabor, MD, Bertille Ki, MD,* Alain I. Traor, MD,
Isso Oudraogo, MD,* Emile Bandr, MD,* Albert Wandaogo, MD,* and Nazinigouba Oudraogo, MD

BACKGROUND: Long surgical wait times and limited hospital capacity are common obstacles
to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery
might contribute to a solution to these problems. The purpose of this study was to evaluate the
safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA.
METHODS: This is a cross-sectional descriptive study that took place over 6 months. It includes
all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in
Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1
year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of
bleeding, lasting <90 minutes, and with an expectation of mild to moderate postoperative pain.
The family had to live within 1 hour of the hospital and be available by telephone.
RESULTS: During the study period, a total of 1250 patients underwent surgery, of whom 515 were
elective cases; 115 of these met the criteria for ambulatory surgery; 103 patients, with an average
age of 59.74 41.57 months, actually underwent surgery. The principal indications for surgery
were inguinal (62) and umbilical (47) hernias. All patients had general anesthesia with halothane.
Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or
nerve block in 20.77%. The average duration of surgery was 33 17.47 minutes. No intraopera-
tive complications were noted. All the patients received acetaminophen and a nonsteroidal anti-
inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery,
principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital.
CONCLUSIONS: No serious complications were associated with ambulatory surgery. Its intro-
duction could possibly be a solution to improving pediatric surgical access in low-income coun-
tries. (Anesth Analg 2017;124:6236)

A
mbulatory care means that the patient goes home
from the hospital on the same day as admission.1
Benefits include a reduction in costs, decreased risk
of nosocomial infection, and, for young children, an avoid-
ance of separation anxiety related to the unfamiliar envi-
ronment.2 In Sub-Saharan Africa (SSA), about 44% of the
population is <15 years of age.3 Pediatric surgical services
are not well developed, pediatric surgeons are rare, and
there are long delays in accessing elective pediatric surgery.4
This is certainly the case in Burkina Faso, which has only
1 specialized pediatric service at the Pediatric University
Hospital Charles de Gaulle (CHUP/CDG) in Ouagadougou.
Because of the long delays in obtaining elective pediatric
surgery, a trial of a surgical ambulatory system was begun
in June 2014. The goal was to evaluate the safety and feasi-
bility of introducing ambulatory into CHUP/CDG.
METHODS
The clinical trials identifier is NCT02766257. The date of
registration is May 6, 2016, and the principal investigator
is Yvette Kabre.
From the *Pediatric University Hospital Charles De Gaulle, Ouagadougou,
Burkina Faso; University Hospital Yalagdo Ouedraogo, Ouagadougou, Burkina
Faso; and University Hospital Souro Sanou, Bobo Dioulasso, Burkina Faso.
Accepted for publication October 12, 2016.
Funding: None.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Yvette B. Kabr, MD, 06 PO Box 10542, Ouaga-
dougou 06, Burkina Faso. Address e-mail to ykabre@yahoo.fr.
Copyright 2017 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000001780
The ethics committee of hospital approved the study.
Written, informed consent was given by the parents.
Confidentiality and anonymity were maintained.
The surgical service of CHUP/CDG consists of 3 operating
rooms, a postoperative recovery room with 4 beds, and a 24-bed
ward. To facilitate the ambulatory surgical program, a new
ambulatory care unit of 7 beds was created. The team consists
of 6 pediatric surgeons, 2 physician anesthesiologists, 14 nurse
anesthetists (2 of whom work in the recovery room), 13 operating
room nurses, and 1 nursing supervisor for the unit. Guidelines
for the ambulatory surgical program were worked out together
by the surgeons and the anesthesiologists. Eligibility criteria
included age of >1 year, American Society of Anesthesiologists
(ASA) 1 status, elective surgery with low potential for blood loss
or severe pain, lasting 90 minutes, and parents who could be
contacted by telephone and who could return to the hospital in
<1 hour. Parents gave consent for surgical procedures.
All patients were seen in a preoperative consultation by
an anesthesiologist from 3 months to 2 days before surgery,
during which eligibility for ambulatory surgery was deter-
mined. Forty-eight hours before surgery, the nurse manager
telephoned the parents with a reminder about the surgery
and to confirm the procedure.
All patients were scheduled to arrive at 6:30 am on the day
of surgery and to wait in a unit close to the operating room.
The operating and recovery rooms were the same as those
used for in-patient procedures. The anesthetic technique was
left to the discretion of the attending anesthesiologist. Patients
who had not received a nerve block or presented tachycardia
despite nerve block received 15 mg/kg of IV acetaminophen
and fentanyl intraoperatively.

February 2017 Volume 124 Number 2 www.anesthesia-analgesia.org 623

Copyright 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
 Anesthesia for Ambulatory Pediatric Surgery in Burkina Faso
After surgery, when recovery room discharge criteria
were met, the patients were transferred to the ambula-
tory surgery unit where they were monitored for 4 hours.
Discharge criteria included the following: normal vital
signs, (ie, pulse, blood pressure, respiratory rate, tempera-
ture, and oxygen saturation); no excessive somnolence; no
nausea and vomiting; no bleeding; minimal pain; and no
respiratory abnormalities. Discharge readiness was con-
firmed by anesthesiologists.
Written discharge instructions were given to the parents
and reviewed with them by the nurse in the ambulatory
care unit. All patients received postoperative analgesia with
15 mg/kg of acetaminophen every 6 hours and a nonsteroi-
dal anti-inflammatory drug (either a 200 mg/10 kg niflumic
acid suppository every 12 hours or 10 mg/kg of ibuprofen
orally every 8 hours). These were begun in the hospital and
continued as necessary for a maximum of 5 days at home.
The telephone numbers of the surgeon and the anesthesi-
ologist were provided to the parents.
This was a descriptive, cross-sectional study conducted
over 6 months, between June and November 2014. All
patients seen by surgery and anesthesia staff who met the
criteria for ambulatory surgery were included.
Variables collected included age, gender, surgical indi-
cation, type of anesthesia, drugs utilized, duration of sur-
gery, and intraoperative and postoperative complications.
Qualitative variables were expressed as frequency; quanti-
tative variables were expressed as means standard devia-
tion. Comparisons were made using the 2 test; the risk
was set at 5%.
RESULTS
Epidemiology
During the study period, 1250 patients had surgical proce-
dures, 515 of which were elective. Of these patients, 115 met
the criteria for ambulatory surgery. Seven patients failed to
show up for their surgery, and 5 patients were rejected on
the morning of surgery because of purulent rhinitis. One
hundred and three patients underwent surgery. Thus, out-
patient surgery represented 20% of elective surgeries and
8% of total interventions. There were 79 male and 24 female
patients. The average age was 59.7 41.5 months.
General anesthesia
only
Figure. Distribution of patients according
to the type of anesthesia. n=36 (35%)
Intubation
n=27
(26%)
624
www.anesthesia-analgesia.org
Copyright 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Surgical Indications
Sixty-two patients had inguinal hernias, 47 had umbilical
hernias, 2 had epigastric hernias, 1 required a skin graft, and
1 had a bladder stone. Some patients had 2 pathologies: 9
had inguinal and umbilical hernias, and 1 patient had an
epigastric hernia as well as an umbilical hernia.
Anesthetic Technique
Anesthetic Drugs. Seventeen (16.5%) patients had an
inhalation induction with halothane; 86 (83.5%) had an IV
induction with propofol. Anesthesia was maintained with
halothane for all patients. Fentanyl was given to 46 (44.7%)
patients: 36 had not received a nerve block, and 10 had
received a nerve block but had developed tachycardia.
No patients received a muscle relaxant; bupivacaine
0.25% without epinephrine was the local anesthetic used.
Types of Anesthesia. The different types of anesthesia
used are summarized in the Figure. All patients received
general anesthesia. Sixty-seven patients also received
regional anesthesia, which was given after the induction of
general anesthesia. In 53 patients (79.2%), this was caudal
anesthesia; in 14 (20.8%) patients, a nerve block was given
(9 paraumbilical and 5 ilioinguinal/iliohypogastric). Two
patients received antibiotic prophylaxis of 50 mg/kg of
amoxicillin-clavulanate for skin grafting and bladder stone.
No patients received prophylaxis for postoperative nausea
and vomiting. The mean duration of surgery was 33 17.4
minutes.
Complications. No intraoperative complications occurred.
In the recovery room and ambulatory unit, 12 (11.7%)
patients presented complications: 8 had nausea and
vomiting, 2 had high temperatures (38.9C and 39.2C,
subsequently determined to be from malaria, and 2 were not
easily rousable. The Table shows the nausea and vomiting
in relation to the type of anesthesia administered. Seven
of the 8 who had nausea and vomiting received fentanyl.
Eight of the 12 were admitted to the hospital, 4 with nausea
and vomiting, 2 with increased temperature, and 2 with
General anesthesia
n=103 (100%)
General anesthesia +
regional anesthesia
n=67 (65%)
Mask Intubation Mask
ventilation ventilation
n=7 (7%)
n=9 (9%) n=60
anesthesia & analgesia

Table. Distribution of Nausea and Vomiting
According to the Type of Anesthesia
Types of Presence of Nausea Absence of Nausea
Anesthesia and Vomiting and Vomiting Total
GA + RA 1 (1%) 66 (64%) 67 (65%)
GA only 7 (6.8%) 29 (28.2%) 36 (35%)
Total 8 (7.8%) 95 (92.2%) 103 (100%)
Odds ratio, 0.06; confidence interval, 0.0074; 0.5337 (P < .01).
Abbreviations: GA, general anesthesia; RA, regional anesthesia.
somnolence. No phone calls reporting complications were
received from parents after discharge.
DISCUSSION
The ambulatory surgery rate at CHUP was 20% of all
elective surgeries. This is very low compared with the
international literature: in 2010 in France, the pediatric
ambulatory surgery rate was 60.4%.5 The low rate in
Burkina Faso is attributable to a deliberately very selec-
tive definition of eligibility criteria for this study. Only
ASA 1 children, 1 year of age, were eligible, although in
France, patients are eligible at 6 months of age and ASA
1, 2, or 3 status.6
Of the 115 patients accepted for ambulatory sur-
gery, 7 failed to arrive on the morning of surgery, and 5
were canceled because of purulent rhinitis. It has been
shown that giving general anesthesia to a child with a
cold multiplies the risk of respiratory complications by
a factor of 8 to 10. 7
The anesthetic management was determined by the brev-
ity of the surgery, the necessity for a rapid emergence, and
the need for good postoperative pain control. Comparisons
between anesthetic agents do not lead to any practical rec-
ommendations.8 Sevoflurane is recognized as the inhaled
agent of choice for children9 but only halothane was avail-
able at CHUP. Postoperative nausea and vomiting were the
most frequent complications. These were mainly seen in
patients who received fentanyl. Vomiting can prolong hos-
pital stay, and this justifies prophylactic treatment in ambu-
latory surgery.10 The use of regional anesthesia reduces the
need for intraoperative and postoperative narcotics.11 Our
study reconfirmed this important advantage.
Eight (7.8%) patients were converted from ambulatory
surgery to inpatient status. This compares favorably with
the rate in the literature of 0.9% to 9.4%.12 With additional
experience with ambulatory surgery, we would expect to
be able to reduce our rate because we exercised a great
deal of caution during this feasibility study. Postoperative
pain is a common complaint after minor surgery13 and
may contribute to the admission rate. Our pain protocol
seemed to be very effective because there were no com-
plaints of pain either in the hospital or by telephone from
the parents. However, it is possible that pain reporting
was minimized parents because in this African region,
pain is expected and tolerated.
CONCLUSIONS
The results of the ambulatory trial at CHUP are encourag-
ing. Morbidity was low and inconsequential, consisting
mostly of postoperative nausea and vomiting that could
probably have been prevented by prophylactic treatment.
February 2017 Volume 124 Number 2 www.anesthesia-analgesia.org 625
Copyright 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Expansion of the list of surgeries could be achieved by
prudently enlarging the criteria used in this study.
We have shown that, in the context of an SSA childrens
service, the introduction of ambulatory surgery is a realistic
and viable way to increase surgical capacity and to reduce
long surgical wait times. Good organization and strict crite-
ria, agreed on by everyone, are essential. Assessing postop-
erative pain and parental satisfaction will contribute to the
success of this activity. E
DISCLOSURES
Name: Yvette B. Kabr, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Idriss S.S. Traor, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Flavien A.R. Kabore, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Bertille Ki, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Alain I. Traore, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Isso Ouedrago, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Emile Bandre, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Albert Wandaogo, MD.
Contribution: Participation in the drafting and approval of the
final document.
Name: Nazinigouba Ouedraogo, MD.
Contribution: Participation in the drafting and approval of the
final document. All authors have read and approved the final
manuscript.
This manuscript was handled by: Angela Enright, MB, FRCPC.
REFERENCES
1. Massa H, Hubert S, Carles M, Racoules-Aim M. Anesthsie
du patient ambulatoire. EMC (Elsevier Masson SAS, Paris),
Anesthsie-Ranimation, 36-635-A- 10, 2010.
2. Baujard C, Roulleau P. Anesthsie pour chirurgie ambu-
latoire en pdiatrie. Le praticien en anesthsie-ranimation.
2005;9:209215.
3. Loris SA. La population jeune en Afrique: risque ou opportunit?
Population Reference Bureau 2007. Available at http://www.
prb.org/pdf07/africasyouthpop fr.pdf. Accessed July 7, 2015.
4. Bickler SW, Rode H. Surgical services for children in develop-
ing countries. Bull World Health Organ. 2002;80:829835.
5. Marie A, Dadure C, Seguret F, Capdevila X. One year of anaes-
thesia in France: a comprehensive survey based on the national
medical information (PMSI) database. Part 2: out-hospital
patients. Anaesth Crit Care Pain Med. 2015;34:199204.
6. ADARPEF: Publications - Recommandations - Chirurgie ambu-
latoire de lenfant. Available at: http://www.adarpef.fr/site/
activites/recommandations/chirurgie-ambulatoire.htm. Mise
en ligne 20/05/2009. Accessed April 03, 2015.
7. ADARPEF - Publications - Confrences - Enfant enrhum.
Available at: http://www.adarpef.fr/site/activites/confer-
ences/enfant-enrhume.htm. Mise en ligne le 25/05/2009.
Accessed April 03, 2015.
8. Souhayl D. Particularit de la chirurgie ambulatoire en pdiat-
rie. Le Praticien en anesthsie reanimation 2014;18:341344.
9. Lerman J, Davis PJ, Welborn LG, et al. Induction, recovery,
and safety characteristics of sevoflurane in children under-
going ambulatory surgery. A comparison with halothane.
Anesthesiology. 1996;84:13321340.
 Anesthesia for Ambulatory Pediatric Surgery in Burkina Faso

10. Dadure C, Raux O, Rochette X. Capdevila. Anesthsie ambula-
toire pdiatrique. 51e Congrs national danesthsie et de rani-
mation. Mdecins. Confrences dactualisation. 2009.
11. Brennan LJ. Modern day-case anaesthesia for children. Br J
Anaesth. 1999;83:91103.
12. Dadure C, Raux O, Rochette X. Capdevila. Anesthsie ambula-
toire pdiatrique. 51e Congrs national danesthsie et de rani-
mation. Mdecins. Confrences dactualisation. 2009.
13. Fortier J, Chung F, Su J. Unanticipated admission after ambula-
tory surgerya prospective study. Can J Anaesth. 1998;45:612619.

626
www.anesthesia-analgesia.org anesthesia & analgesia
Copyright 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.