Anesthetic Plan Research Articles

Analgesic Effect of Butorphanol during Castration in Donkeys under Total Intravenous Anaesthesia.

Simple SummaryDespite the growing interest in donkey’s welfare, there is little scientific evidence in this species about the analgesic effect of the drugs most used in horses. Total intravenous anaesthesia is a valuable option for field surgery such as castration. Moreover, it is often preferred in small donkeys due to the anatomical features of their proximal airways. The aim of this study was to evaluate the effect of a low dose of butorphanol, in donkeys undergoing castration, after sedation with detomidine before total intravenous anaesthesia with a mixture of guaifenesin, ketamine and detomidine. The addition of butorphanol to detomidine produced more muscle relaxation, and reduced mean heart rate and blood pressure. This resulted in a reduced requirement for rescue analgesia, a more superficial anaesthetic plan and a shorter surgical time. It can be concluded that butorphanol allowed a more stable and superficial anaesthetic plan, probably due to its analgesic effect and synergistic action with detomidine. Due to the low dosages of drugs used and the absence of adverse effects, this protocol can be considered valuable in field conditions and for short surgical procedures, where safety equipment is not available.Pain management is necessary for all surgical procedures. Little scientific evidence about drug efficacy in donkeys is available. The aim of this study was to evaluate the analgesic effect of butorphanol in donkeys undergoing orchiectomy under total intravenous anaesthesia with guaifenesin-ketamine-detomidine. A randomized blinded prospective clinical trial (Protocol n. 2021/0000338), was carried out on 18 clinically healthy donkeys undergoing bilateral orchiectomy. Patients were assigned to Group D (n = 8) or Group DB (n = 10) if receiving intravenous detomidine or detomidine-butorphanol respectively, before induction of general anaesthesia with ketamine-diazepam. Intraoperative muscle relaxation, nystagmus, palpebral reflex, heart and respiratory rate, and non-invasive blood pressure were evaluated every 2 min; time to prepare the patient, duration of surgery and anaesthesia and recovery score were recorded. Group D had significantly longer surgical time, higher heart rate, higher systolic and mean blood pressure (p < 0.05; repeated measure ANOVA), increased muscle rigidity and expression of palpebral reflex (p < 0.05; Mann–Whitney U test) than group DB. Top-ups with thiopental were statistically higher in Group D. Butorphanol and detomidine together produced a more stable anaesthetic plan. The low dosage of opioid and alpha-2-agonists and reduced rescue anaesthesia are responsible for a safer and more superficial anaesthesia, which is mandatory under field conditions.

A case of peripartum cardiomyopathy in acute heart failure for emergency surgery.

Sir, Peripartum cardiomyopathy (PPCM) remains a nightmare to anaesthesiologists. Here, we report a case of PPCM in acute heart failure posted for emergency lower segment caesarean section. A thirty eight year old, morbidly obese multipara with 35 weeks gestation and gestational hypertension, presented with sudden onset of breathlessness. She did not have any significant past medical history. On examination, she was tachypnoeic, tachycardiac, hypertensive, and hypoxaemic. Auscultation revealed bilateral crepitations. She was started on bilevel positive airway pressure (BiPAP) support. Routine laboratory parameters were within normal limits. Electrocardiogram showed sinus tachycardia. Echocardiogram revealed global left ventricular hypokinesia, moderate left ventricle dysfunction, and an ejection fraction of 35%. Frusemide and nitroglycerine infusions were started. After cardiology consultation, a provisional diagnosis of peripartum cardiomyopathy was made. Emergency termination of pregnancy was decided. Under high-risk informed consent, she was taken up for anaesthesia. Our anaesthetic plan was general anaesthesia with modified rapid sequence induction. She was positioned with pillows beneath her upper chest in a ramped fashion in view of the anticipated difficult intubation. Under local anaesthesia, an arterial line and large bore venous access were placed. Careful administration of fluids was done. Patient was induced with titrated boluses of thiopentone and intubated with succinylcholine. BiPAP was maintained till the time of laryngoscopy. To suppress the haemodynamic response of laryngoscopy, Inj. metoprolol 3 mg was given. Even though intubation was completed in 15 seconds, patient desaturated to a peripheral oxygen saturation (SpO2) level of 55% which improved on positive pressure ventilation. Baby was delivered in less than 5 minutes. Early cord clamping was done to limit autotransfusion. Inj. oxytocin 20 IU was added to 500 mL normal saline and administered slowly. Analgesia was supplemented with fentanyl and paracetamol. Intraoperatively, haemodynamics remained stable. Patient was continued on frusemide and nitroglycerine infusion and shifted on ventilator support. She was extubated 6 hours later, but her cardiac function deteriorated and she was started on dobutamine support and restarted on BiPAP. Patient was shifted out of intensive care unit on fourth postoperative day and discharged on tenth postoperative day. The revised criteria for diagnosis include heart failure, secondary to left ventricular systolic dysfunction with a left ventricular ejection fraction (LVEF) <45%, occurrence towards the end of pregnancy or in the months following delivery and no other identifiable cause of heart failure. Majority are diagnosed in the first month after delivery. Its pathophysiology is still incompletely understood and is thought to be involving angiogenic, metabolic, hormonal, and oxidative stress factors. Pre-eclampsia and hypertension are strongly associated with PPCM.[1] The symptoms mimic those of normal pregnancy and the diagnosis is often missed. It is a diagnosis of exclusion. Levels of brain natriuretic peptide (BNP) and N-terminal pro-BNP are significantly elevated. Management is based on the principles of management of systolic heart failure due to other causes with caution taken to avoid drugs which cause foetal harm. Anticoagulation is recommended for all PPCM patients with an LVEF <35%.[2] The maternal outcome is variable with death occurring in 1.4% to 28%.[3] Venous thromboembolism and arrhythmias are common complications. These patients are at a risk of sudden cardiac death even after recovery. Ejection fraction at presentation best predicts recovery and ejection fraction <30% is associated with lower rates of recovery.[3] Both general and regional anaesthesia have been used in the management of these patients.[45] Our anaesthetic goals should be to maintain cardiac contractility and preload and prevent increase in afterload. Volume overload should be closely watched for and prevented. Neuraxial anaesthesia has the advantage of reducing afterload and avoiding the sympathetic response to intubation. Since our patient was in acute heart failure and unable to lie supine, we decided to administer general anaesthesia. Oxytocin can reduce and methergine can increase afterload significantly.[5] Postoperatively these patients need intensive care monitoring. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Urgent surgery for COVID-19\u2013positive pediatric patient

BackgroundWe present a case of COVID-19–positive pediatric patient for urgent urological surgery by spinal anesthesia to avoid aerosolizing procedure.Case presentationA 12-year-old, COVID-19–positive boy presented for urgent wound incision and drainage at the circumcision site. Our anesthetic plan consisted of spinal anesthesia with sedation. He was transported from the COVID-19 isolation floor to the negative pressure operating room. He was placed in lateral decubitus position and oxygen was delivered through facemask. Under sedation, spinal anesthesia was achieved at first attempt. The patient maintained spontaneous ventilation without airway intervention. Patient was recovered in the operation room then transported back to the floor.ConclusionSpinal anesthesia is a safe alternative to general endotracheal anesthesia for many pediatric urology procedures. Effective team communication and preparation are keys when caring COVID-19–positive patient in perioperative setting to avoid minimize the risk to healthcare providers.

Perioperative Management for Surgical Repair of Ebstein's Anomaly.

Background: Ebstein's anomaly is a rare and complex heart defect that affects the tricuspid valve and is accountable for around 1% of congenital cardiac abnormalities. It is one of the most common congenital causes of tricuspid valve regurgitation. Ebstein's anomaly often is diagnosed prenatally, due to its severe cardiomegaly. Some individuals with this anomaly do not experience complications until adulthood and even then, they have mostly minor complaints like exercise intolerance. An atrial septal defect is most commonly (70-90%) associated with Ebstein's anomaly. However, ventricular septal defect (VSD) can be associated with 2-6% of the cases.&#x0D; Case presentation: This report presents a case of surgical intervention for a 38-year-old female with Ebstein's anomaly symptomatic with moderate-severe pulmonary regurgitation and foramen ovale apertum.&#x0D; Conclusions: Ebstein anomaly is a complicated form of congenital heart disease with variable clinical presentations. The anesthetic plan must also focus on maintenance of RV function and avoidance of increase in PVR. Reversible causes of increased PVR, such as acidemia, hypoxemia, and hypercarbia must be avoided. Agents that lower PVR, such as nitrates, and nitric oxide may be beneficial in patients with severe pulmonary hypertension.&#x0D; With a sound knowledge of the cardiac anatomy, accurate scheming of surgical outcomes, routine follow-ups, multidisciplinary team approach, and better management, an experienced center can ultimately improve the prognosis of such patients.

Anaesthesia and Critical Care Department at a Major Academic Centre's Adaptation to Face the COVID-19 Pandemic.

The new novel coronavirus is having a major impact on healthcare systems internationally. Hospitals are struggling to manage the sudden influx of critical patients. Anaesthesiologists and critical care physicians are front liners in the fight against COVID-19 and carry the highest risk of getting infected. Due to the rapid response of the Saudi government to the WHO’s early warning, we were fortunate at our hospital to see a slower rise in COVID-19 cases allowing us some time to prepare. We had to make room for the expected rise in highly infectious and critical patients, while at the same time protecting non-COVID-19 patients, staff and trainees. Additionally, the team continued to provide essential and specialized care to all patients in the hospital and maintain its academic and non-clinical services within the university. This review presents the different protocols, challenges and lessons learned during the development of a COVID-19 anaesthesia and critical care department plan in a major teaching hospital in Jeddah, Saudi Arabia. Our ultimate aim is to share our experience with other similar institutions.

A comparison of two different management plans for patients requiring both carotid endarterectomy and coronary artery bypass grafting.

Carotid endarterectomy (CEA) is a prophylactic operation that is used to mitigate the risk of stroke caused by embolism of atherosclerotic plaques in the carotid bifurcation. Previously, the large, multicentre, randomised, controlled GALA study found no significant differences in clinical outcomes between patients treated using general or local anaesthesia. While this study provided important insights into disease outcomes based on treatment modalities, it did not answer questions regarding the safety of CEA under local anaesthesia in patients at high risk for cardiovascular complications. Here, we examined the use of two different management plans in patients requiring both carotid endarterectomy and coronary artery bypass grafting (CABG), in terms of their effects on hospital mortality. Thirty-four patients consecutively operated on in our cardiovascular department were included in this analysis. The patients were divided into two groups based on the anaesthetic management plan. The first group consisted of patients who underwent CEA and CABG under general anaesthesia in the same session (GA group); the second group consisted of patients who initially underwent CEA under cervical block anaesthesia followed by CABG under general anaesthesia in a separate session (CB-GA group). These two groups were compared in terms of postoperative complications and hospital mortality. The incidence of postoperative myocardial infarction was higher in the CB-GA group, with four patients experiencing postoperative myocardial infarction, compared to no patients in the GA group. For patients requiring CEA and CABG, performing both operations under general anaesthesia in the same session was safer than initially performing CEA under cervical block anaesthesia followed by CABG under general anaesthesia.

Update on the safety of anesthesia in young children presenting for adenotonsillectomy.

Tonsillectomy with and without adenoidectomy is a frequently performed surgical procedure in children. Although a common procedure, it is not without significant risk. It is critical for anesthesiologists to consider preoperative, intraoperative, and postoperative patient factors and events to optimize safety, especially in young children. In the majority of cases, the indication for adenotonsillectomy in young children is obstructive breathing. Preoperative evaluation for patient comorbidities, especially obstructive sleep apnea, risk factors for a difficult airway, and history of recent illness are crucial to prepare the patient for surgery and develop an anesthetic plan. Communication and collaboration with the otolaryngologist is key to prevent and treat intraoperative events such as airway fires or hemorrhage. Postoperative analgesia planning is critical for safe pain control especially for those patients with a history of obstructive sleep apnea and opioid sensitivity. In young children, it is important to also consider the impact of anesthetic medications on the developing brain. This is an area of continuing research but needs to be weighed when planning for surgical treatment and when discussing risks and benefits with patients’ families.

Investments in surgical systems contribute to pandemic readiness and health system resilience.

Safe surgical care, including anesthesia, obstetrics, and trauma, is an essential component of a functional health system, yet five billion people lack access to high-quality, timely and affordable surgical care. As health decision makers are grappling with how to make appropriate investments for crisis readiness and resilience, investments in surgical care should be considered for their compounding benefits to meet a country’s diverse health goals. National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) are developed through global partnerships and multi-stakeholder consensus and provide a dynamic framework for surgical scale-up that also improves the resilience of the larger health system. Our paper applies principles from the literature on health system resilience to surgical systems and examines the unique capabilities of the surgical workforce and infrastructure to be redeployed during times of crisis, using examples from the current pandemic.

THE USE OF COOLING AND FREEZING FOR ANESTHESIA OF Phrynops geoffroanus TURTLES (PLEURODIRA: CHELIDAE) AND THE ESTABLISHMENT OF LOW INCIPIENT LETHAL TEMPERATURE

The use of hypothermia for anesthesia and euthanasia in ectothermic individuals has promoted many discussions, especially in the last four decades, and yet it continues today as a method that is prohibited or restricted to certain procedures. Despite this, some studies have shown satisfactory results in obtaining anesthetic plans, raising questions about the real possibility of using this method in research. The aim of the present experiment was to determine the time patterns to generate anesthesia and low incipient lethal temperature in Phrynops geoffroanus through cooling and freezing. Turtles reached the anesthesia grade nine within 30 minutes, making ease handling due to muscle relaxation, and, in 80 minutes, they reached anesthesia grade 11, becoming insensitive. The low incipient lethal temperature (LILT) shows that 1°C is the limit freezing from where the turtle can recover its motor activities while lower temperatures cause death. The low incipient lethal temperature was determined in a 300-minute period independently of the individual's size or weight.

Oral melatonin as part of multimodal anxiolysis decreases emergence delirium in children whereas midazolam does not: A randomised, double-blind, placebo-controlled study.

Pre-operative anxiety is a risk factor for emergence delirium in children and a multimodal approach including sedatives and nonpharmacological measures is the current strategy to tackle this anxiety. The efficacy of oral melatonin as a component of multimodal anxiolytic strategy to decrease emergence delirium is not well studied. The aim of this study was to evaluate the efficacy of a multimodal anxiolytic strategy including oral melatonin or midazolam to decrease emergence delirium after sevoflurane anaesthesia. A randomised, double-blind, parallel arm, placebo-controlled trial. Tertiary care teaching hospital from July 2019 till January 2020. Children in the age group of 3 to 8 years who received sevoflurane anaesthesia for elective ambulatory procedures. Children were randomised to receive oral premedication with either melatonin 0.3 mg kg-1, midazolam 0.3 mg kg-1 or honey as placebo. All the children received standardised nonpharmacological measures involving multiple techniques to allay anxiety. The anaesthetic plan was also standardised. The primary outcome was the incidence of emergence delirium as assessed by the Watcha scale in the postanaesthesia care unit. The secondary outcomes were pre-operative anxiety assessed using a modified Yale Preoperative Anxiety scale, patient compliance with mask induction using the Induction Compliance Checklist and postoperative sedation. Data from 132 children were analysed. Melatonin significantly reduced the incidence of emergence delirium compared to placebo: 27 vs. 50%, respectively, an absolute risk reduction of 23.3 [95% confidence interval 3.7 to 42.9), P = 0.03]. Melatonin also significantly reduced the risk of emergence delirium compared with midazolam: 27 vs. 56%, respectively, an absolute risk reduction of 29.2 (95% CI 9.5 to 48.8). The midazolam group had a similar incidence of emergence delirium as placebo. Sedation scores were similar in the three groups postoperatively. The incidence and score of pre-operative anxiety as well as the compliance with mask induction were similar in the three groups. A multimodal anxiolytic approach including oral melatonin, as opposed to oral midazolam, significantly reduced emergence delirium after sevoflurane anaesthesia. CTRI/2019/06/019850 in Clinical Trial Registry of India (www.ctri.nic.in).

Anesthetic management for tracheal stent removal with severe scar stenosis

A 28-year-old patient, ASA Grade II, was admitted to the hospital with dyspnea for the last few months. Upon bro choscopy, tracheal stenosis was observed and the symptoms were temporarily relieved by balloon dilation. The patient was then given argon knife treatment and the bronchial lesions were resected through a bronchoscope. Then two tracheal stents were placed to relieve the symptoms of dyspnea which too failed and had to be removed. Since the patient had a history of traumatic brain injury more than a year ago and underwent tracheal intubation, tracheostomy, invasive ventilator ventilation, and extubation after the condition improved. Stent removal had significant anesthetic challenges due to the small size of the lumen. After going through a few anesthesia plans, a high-frequency jet ventilator was used to maintain oxygen saturation. The procedure was successful and the patient showed a good prognosis. Key words: Dyspnea; Bronchoscopy; Tracheal intubation; Mechanical ventilation Citation: Yang T, Mudabbar MS, Fu Q, Liu B. Anesthetic management for tracheal stent removal with severe scar stenosis. Anaesth. pain intensive care 2021;25(3):391–394. DOI: doi.org/10.35975/apic.v25i3.1521 Received: January 21, 2021; Reviewed: March 1, 2021; Accepted: March 9, 2021

P.159 Glucose-6-phosphate dehydrogenase deficiency in pregnancy: What’s the anaesthetic plan?

P.159 Glucose-6-phosphate dehydrogenase deficiency in pregnancy: What’s the anaesthetic plan?

Barriers and enablers to country adoption of National Surgical, Obstetric, and Anesthesia Plans

Barriers and enablers to country adoption of National Surgical, Obstetric, and Anesthesia Plans

Reimagining Universal Health Coverage: Safe and Affordable Surgery

UN sustainable development goals (SDGs) and universal health coverage (UHC) are significant health goals the world needs to achieve. Despite concerted efforts to attain UHC, the world is still lagging. Compared to the sizable number of resources put into the treatment of well-known communicable diseases, such as HIV/AIDs, tuberculosis, and malaria, surgery is relatively underutilized despite its potential. Scaling up surgical interventions, however, is crucial since it can save many people’s lives and help avert the economic losses incurred due to diseases. Moreover, increased surgical capacity in low-to-middle-income countries (LMICs) could prove useful in overcoming pandemics, such as COVID-19. To upgrade the surgical capacity of the LMICs, it is essential to incorporate National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) into their national health policies. In this paper, the illustrative cases of two countries that adopted NSOAPs with a different model. Zambia and Pakistan, are examined. We conclude by giving recommendations to countries that are yet to adopt NSOAPs.

So Good It Hurts?

So Good It Hurts?

Anesthetic Management of Acute Ischemic Stroke in the Interventional Neuro-Radiology Suite: State of the Art.

This review discusses the general anesthetic approach of endovascular stroke therapy and highlights recent advances and considerations for optimal intraoperative management of acute ischemic stroke. Recent randomized controlled trials have shown no differences in clinical outcomes between monitored anesthesia care with sedation compared with general anesthesia for endovascular stroke therapy. The COVID-19 pandemic has complicated decision-making in the neurointerventional setting. Advances in imaging techniques have extended the window of treatment for endovascular therapy. Optimal time to intervention, hemodynamic stability, novel imaging techniques, and careful consideration of anesthetic plan can impact patient outcomes in reperfusion stroke therapy.

SUCLA 2 deficiency and mitochondrial cytopathy-Do we have a safe anaesthesia plan yet?

SUCLA 2 deficiency and mitochondrial cytopathy-Do we have a safe anaesthesia plan yet?

The use of high flow nasal oxygen in a patient with Duchenne muscular dystrophy with severe restrictive lung disease requiring dental extractions: a case report

Presentation: A 22-year-old man with Duchenne muscular dystrophy (DMD) presented for removal of impacted third molars in his baseline health status. Comorbidities included decreased mobility, restrictive lung disease [forced vital capacity (FVC) 35% at baseline], adrenal insufficiency, and obstructive sleep apnea. Anesthetic challenge: General anesthetics are problematic in this population. The airway is typically compromised by macroglossia. Patients have reduced functional residual capacity, so time to desaturation after induction is reduced; in patients with FVC&lt;50% there is high risk of postoperative pulmonary complications. Those with FVC&lt;30% face further increased risk. The use of depolarizing neuromuscular blockade is contraindicated due to the risk of hyperkalemia. Residual nondepolarizing neuromuscular blockade could compromise postoperative pulmonary status further. Controversy remains regarding use of inhaled anesthetics, but they are generally avoided given the risk of rhabdomyolysis. In addition, DMD patients often have cardiomyopathy, further complicating management. The overall challenge was to avoid general anesthetics in this patient. How it was done: After a full discussion with the patient and family, we decided sedation with local anesthetic was the safest anesthetic plan. As a safeguard, inhaled anesthetics were removed, the machine was flushed, and filters were placed in the circuit; a Glidescope was available. We proceeded with moderate sedation with propofol and dexmedetomidine infusions. Given his reduced pulmonary function and need for oral access, the patient was placed on high-flow nasal cannula to provide supplemental oxygen and provide positive end-expiratory pressure. Opioids were kept to a minimum: 50 mcg fentanyl was given with local anesthetic injection. The anesthetic and dental teams talked the patient through his discomfort for much of the procedure. Music of the patient’s choosing was played. Overall the patient did well with a combination of sedation, local anesthesia, and coaching by the surgery and anesthesia teams. He was discharged same day without noted complications of anesthesia. Conclusion: Preparation for this apparently “simple” case in a complex patient was key to our success. By addressing the known pulmonary changes in DMD, we employed high-flow nasal cannula in a dental surgery—a new use for this device. By using all the tools available to us as anesthesiologists we were able to avoid an intubation and the possibility of a prolonged hospital stay for our patient.

Anaesthetic Managemetnt of Surgical Resecton of A Giant Mediastinal Mass – A Case Report

Giant mediastinal mass tumors have been associated with perioperative respiratory and circulatory life- threatening complications during induction of general anaesthesia and initiation of positive pressure ventilation leading to sudden cardiac arrest known as MMS, ‘Mediastinal mass syndrome’ (4, 5,6). A detailed meticulous preanaesthetic evaluation and a well thought out anaesthetic plan can avoid life-threatening events during management of these patients. We report a successful anaesthetic management of a 12 yrs old pediatric patient with a left sided giant mediastinal germ cell tumor, posted for complete surgical resection. We followed the guiding principles for anaesthetic management of such cases, maintaining propped up position, avoiding muscle relaxants, maintaining spontaneous breathing, keeping cardiac team and perfusion team ready to cannulate and institute CPB in case of sudden cardiorespiratory collapse, adapting to low volume ventilation and titrated and step wise induction of anaesthesia.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola.

The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible. Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided. Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.