Introduction Regional anesthesia is a safe alternative to general anesthesia. Despite benefits for perioperative morbidity and mortality, this technique is underutilized in low-resource settings. In response to an identified need, a regional anesthesia service was established at the University Teaching Hospital of Kigali (CHUK), Rwanda. This qualitative study investigates the factors influencing implementation of this service in a low-resource tertiary-level teaching hospital. Methods Following service establishment, we recruited 18 local staff at CHUK for in-depth interviews informed by the “Consolidated Framework for Implementation Research” (CFIR). Data were coded using an inductive approach to discover emergent themes. Results Four themes emerged during data analysis. Patient experience and outcomes: where equipment failure is frequent and medications unavailable, regional anesthesia offered clear advantages including avoidance of airway intervention, improved analgesia and recovery and cost-effective care. Professional satisfaction: morale among healthcare providers suffers when outcomes are poor. Participants were motivated to learn techniques that they believe improve patient care. Human and material shortages: clinical services are challenged by high workload and human resource shortages. Advocacy is required to solve procurement issues for regional anesthesia equipment. Local engagement for sustainability: participants emphasized the need for a locally run, sustainable service. This requires broad engagement through education of staff and long-term strategic planning to expand regional anesthesia in Rwanda. Conclusion While the establishment of regional anesthesia in Rwanda is challenged by human and resource shortages, collaboration with local stakeholders in an academic institution is pivotal to sustainability.

Critical care is underprioritized. A global call to action is needed to increase equitable access to care and the quality of care provided to critically ill patients. Current challenges to effective critical care in resource-constrained settings are many. Estimates of the burden of critical illness are extrapolated from common etiologies, but the true burden remains ill-defined. Measuring the burden of critical illness is epidemiologically challenging but is thought to be increasing. Resources, infrastructure, and training are inadequate. Millions die unnecessarily due to critical illness. Solutions start with the implementation of first-step, patient care fundamentals known as Essential Emergency and Critical Care. Such essential care stands to decrease critical-illness mortality, augment pandemic preparedness, decrease postoperative mortality, and decrease the need for advanced level care. The entire healthcare workforce must be trained in these fundamentals. Additionally, physician and nurse specialists trained in critical care are needed and must be retained as leaders of critical care initiatives, researchers, and teachers. Context-specific research is mandatory to ensure care is appropriate for the patient populations served, not just duplicated from high-resourced settings. Governments must increase healthcare spending and invest in capacity to treat critically ill patients. Advocacy at all levels is needed to achieve universal health coverage for critically ill patients.

Keywords postoperative Á pediatric Á pain Á RwandaTo the Editor,Research in sub-Saharan Africa has described shortages of pediatric anesthesia airway equipment, medications, training, and personnel. Previous work by our group has shown postoperative pain management of adults in Rwanda, a low income country (LIC), to be inadequate but improving. 1,2 Here, we report results of an initial study on the impact of these conditions on postoperative pain in children.With approval of the ethics committees of the Universities of Saskatchewan and Rwanda and of the hospitals, we conducted a prospective observational study from July 2019 to December 2019 of postoperative pain management in children aged 3-16 yr in the teaching hospitals in Kigali and Butare. We obtained consent from parents and assent from children in their preferred language. Participants were invited in the preoperative holding area and followed in the recovery room and ward until postoperative day 2, when the validated Faces Pain

Purpose International partnerships have an important role in capacity building in global health, but frequently involve travel and its associated carbon footprint. The environmental impact of global health partnerships has not previously been quantified. Methods We conducted a retrospective internal audit of the environmental impact of air travel for the international education programs of the Canadian Anesthesiology Society’s International Education Fund (CASIEF). We compiled a comprehensive list of volunteer travel routes and used the International Civil Aviation Organization Carbon Emissions Calculator, which considers travel distance, passenger numbers, and average operational data for optimized estimates. Comparisons were made with average Canadian household emissions and disability adjusted life years (DALYs) lost from climate change consequences. Results The total carbon dioxide emitted (CO 2 -e) for the Rwanda, Ethiopia, and Guyana CASIEF partnerships were 268.2, 60.7, and 52.0 tons, respectively. The DALYs cost of these programs combined is estimated to be as high as 1.1 years of life lost due to the effects of CO 2 -e. The mean daily carbon cost of the average Rwanda partnership was equivalent to daily emissions of 2.2 Canadians (or 383 Rwandans), for the Guyana partnership was equivalent to 1.6 Canadians (or 7.6 Guyanese people), and for the Ethiopia partnership was equivalent to 2.4 Canadians (or 252 Ethiopian people). Conclusions Air travel from these CASIEF partnerships resulted in 380.9 tons CO 2 -e but also enabled 5,601 volunteer days-in-country since 2014. The estimated environmental cost needs to be balanced against the impact of the programs. Regardless, carbon-reduction remains a priority, whether by discouraging premium class travel, organizing longer trips to reduce daily emissions, prioritizing remote support and virtual education, or developing partnerships closer to home.