INTERNATIONAL NEUROANESTHESIA NEWS

Neuroanaesthesia and Neurocritical Care in Pakistan

Faraz Shafiq, MCPS, FCPS
Assistant Professor, Department of Anaesthesiology
Aga Khan University
Karachi, Pakistan

Fauzia Khan, LRCP, MRCS, FRCA, FCPS
Professor, Department of Anaesthesiology
Aga Khan University, Karachi, Pakistan

Veronica Gin, FANZCA, MBChB, PGDipPH
Faraz Shafiq, MCPS, FCPS
Fauzia Khan, LRCP, MRCS, FRCA, FCPS

Fauzia Khan, LRCP, MRCS, FRCA, FCPS

Pakistan is the sixth most populous country in the world. The 2017 census lists its population as 207,774,520. Sixty-seven percent of the population is rural. The health system is three-tiered. The primary healthcare is provided by the Basic Health Units and the Rural Health Centers. Secondary care is provided by the Tehsil and District Headquarter hospitals and tertiary care by the larger teaching hospitals located in the main cities.

There is a dearth of information on both neurosurgery and neuroanaesthesia practice in the country. According to a 2011 publication, there were 42 neurosurgical centers in the country, 1500 neurosurgical beds and 150 qualified practicing neurosurgeons in Pakistan, at that time. More recent numbers are not available. The first neurosurgical center in Pakistan was established in 1951 at the Jinnah Postgraduate Medical Center, Karachi, Pakistan with the arrival of Dr. O.V. Jooma from abroad. This was followed by centers in Lahore and Multan. Neuroanaesthesia as a subspecialty is still in its infancy in Pakistan. Anaesthesia in itself is still a shortage specialty. A recent publication by the World Federation of Societies of Anaesthesiology (WFSA) lists Pakistan as having 1.64 /100,000 physician anaesthesiologists. The national burden of neurosurgical cases is immense. Approximately 1400 neurosurgical cases were handled by our tertiary care institutions in 2018. The numbers at some of the government institutions is nearly five to six times this number. Generally, it is the practicing general anaesthesiologists who handle the neurosurgical cases in all institutions. The post graduate diploma in Anaesthesiology in Pakistan, i.e. the Fellowship of the College of Physicians and Surgeons of Pakistan (FCPS), requires four years of training, during which the neuroanaesthesia module is of three months duration. The training is competency-based and needs to be signed off by a supervisor. There is currently no post-fellowship neuroanaesthesia training program in the country.

Almost all teaching hospitals have established neurosurgical departments to handle major surgery, e.g. craniotomies, pituitary surgery, major spine surgery, etc. Much of the head trauma first presents to District Headquarter Hospitals. Recently, Punjab Institute of Neurosciences, the first specialized hospital facility, has been established in Lahore with ten neurology- and neurosurgery-related disciplines and 200 surgical beds.

Awake craniotomy and Deep Brain Stimulation (DBS) surgery have been recently introduced in the country. The first case of awake craniotomy was conducted at the Aga Khan University Hospital in late 2016 (Figure 1). To date, 185 cases have been done in this institution and the technique has been introduced in other national institutions like Shifa International in Islamabad, Shaukat Khanum Hospital in Lahore and South City Hospital, Karachi (Figure 2). DBS technique is also being practiced in a few other tertiary care centers. In most centers, the critical care neurosurgical beds are shared with general surgical patients. There is lack of availability of advanced monitoring like cerebral oxygenation in the majority of centers practicing neuroanaesthesia.

Ongoing educational activities are again conducted at various centers. Committee for European Education in Anaesthesiology (CEEA) courses are also run in three centers in Karachi, Lahore and Islamabad. CEEA courses are a set of six two-and-a-half day courses with one of them dedicated to neurology and neuroanaesthesia. In the last three years, Aga Khan University (AKU) has conducted regular courses on neuroanaesthesia as well as on assessment and treatment of postcraniotomy pain. We have also run workshops on anaesthesia for awake craniotomy in our institution. In addition, neurosurgical anaesthesia is a popular topic discussed at the local anaesthetic meetings.

Pakistan has only one anaesthesia journal published in the country, Anaesthesia Pain and Intensive Care (APICARE). Another published neurology journal, Pakistan Journal of Neurological Sciences, is a joint collaboration of Pakistan Society of Neurology, Pakistan Academy of Neurological Diseases and Pakistan International Neurosciences Society. A quarterly journal, it is recognized by EMRO-WHO and Pakistan Medical and Dental Council. Pakistan Journal of Neurological Surgery, another quarterly journal, is published by the Pakistan Society of Neurosurgeons and Department of LGH Lahore.

In conclusion, there is a need to develop fellowship programs in neuroanaesthesia and neurocritical care to make progress in the subspecialty. These programs should be recognized by the certification body in the country. It is also important that a future career pathway is available to these individuals in both public and private sectors. In addition, there is a need to form a core group of individuals who should then initiate a neurosurgical anaesthesia society which can specifically focus on promotion of the subspecialty. In parallel data regarding the type of cases performed, their management and outcomes should be part of a process of documentation and audits that should be published in local journals.

Figure 1

Figure 1: CME on awake craniotomy at Aga Khan University (2017)

Figure 2

Figure 2: Patient positioning during awake craniotomy

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