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Where there are no resources: Emergency Cesarean Sections in conflict zones in West Africa performed under Ketamine Anesthesia without intubation are safe

Aim: The aim of this retrospective, observational study was to test the hypothesis that general anesthesia with i.v. ketamine and without intubation as frequently practiced in humanitarian projects in Africa can be used with relative safety for emergency cesarean sections (CS) in a partly evacuated District Hospital in Northern Ivory Coast during time of conflict. Method: We analyzed 125 consecutive CS out of which 28 had been performed under ketamine anesthesia (KA) and 97 under spinal anesthesia (SPA) for significant differences in survival to discharge and major intra-operative complications using student’s t test. KA was administered with 0,5mg Atropine i.v., 5mg Diazepam i.v. and an initial bolus of 0,5mg/kg Ketamine with additional doses of 0,25mg/kg as needed. SPA was done with 2,5 ml normobaric Bupivacaine 0,5%. Results:n: SPA=97,KA=28; survival to discharge: SPA=96,KA=28; intra op CPR: SPA=1,KA=0 (n.s.); aspiration/laryngospasm: SPA=0,KA=0; „high spinal“ (treated with mask ventilation): SPA=3,KA=0(p<0,05). The one patient not surviving to discharge was found dead in bed by the night nurse 16h post op. The patient had received a unit of blood one hour earlier. Her death does not seem to be related to the type of anaesthesia given. The patient needing CPR had presented with a ruptured uterus during labour. She arrested after our national anaestetist had chosen to perform a SPA. She received CPR for 25 min and was converted to an intubation anaesthesia with Ketamine and Vecuronium. She received 4l of crystalloids and all available 4 units of blood. The neonate was delivered with CS and was fine after some initial stimulation. After hysterectomy the mother was manually ventilated for 10h and then extubated due to a lack of resources. She recovered well and was discharged after 6 days. Conclusion: Our data suggests that KA can be applied with relative safety for emergency CS. In our experience it is the method of choice for haemodynamically instable patients especially if the local experience with intubation is minimal.