1. Dr RB Rana and Team
Nepal

2. Dr Rana RB, Dr Manandhar ML, Mr Shrestha Naba
Raj
National Academy of Medical Sciences,
Kathmandu, Bagmati Zone: Nepal (ASIA)

3. Nepal is a land-locked Asian country
which borders India to its east, south
and west and China to its north. It
covers an area of 147,181 km2 and
varies between an altitude of 60 m
and 8,848 m (Mt Everest). Current
population 27.5 million (2010
projected) with an annual growth rate
of 1.94 per cent (CBS 2009)1.

4.  MMR (2010 survey) as 229/100,000 live
births. (by training to community worker &
doctors)
 MDG5 target for 2015 is to reduce 213.
 Among these deaths, some 41% occur in a
health facility (FHD 2009).
 Workup:
◦ Producing doctors capable of providing obstetric
care including c-section and
◦ Producing anesthesia assistant to provide
anesthesia under supervision in health facility of
remote areas.

5. Anesthesia assistants (AA) are paramedical staffs
working under the government with three years
medical science background and at least 6 months
anesthesia assistant training. Now AA training is of
one year duration with the same background since
2011. These attempts will help expand and
strengthen Comprehensive Emergency Obstetric
Care sites in different areas of need. Nepal is also
attempting to improve access to surgical services
to the remote areas by availing an anesthesia
machine which is affordable, simple to use, and
requiring easy maintenance. We evaluated the
appropriateness and user friendliness of the
'Universal Anesthesia Machine' (UAM) in our
context.

6. UAM2 is a simple anesthetic British Standards3
work station that looks familiar with clear layout.
The key differences from a standard Boyle's
machine are the oxygen concentrator, drawover
vaporizer, breathing bellows and balloon valve.
The system provides continuous anesthesia
flow, reverting to drawover mode if air is
entrained or if electricity fails (O2 concentration
stops), with the vaporizer and bellows continuing
to function as normal. In both modes, oxygen
can alternately be supplied via cylinder, central
line or the side emergency inlet. Almost all parts
are designed to require minimum or no services
for maintenance4.

7. • To assess the functions of the UAM in terms
of reliable oxygen supply, anesthetic agent
flow, breathing system and scavenging
system and
• To assess the user friendliness,

8.  Four UAM machines provided by the NICK SIMONS’
Foundation, New York were distributed to four
different hospitals (two central and two peripheral
hospitals) of Nepal.
 Three to five days orientation to at least one qualified
anesthesiologist and anesthesia assistants of each of
individual sites were oriented with didactic and live
demonstration.
 All the users were also oriented with an evaluation
system by recording in the pre-set form. The
readymade forms contained the patient's
demographic information, surgical details, oxygen
monitor findings, airway management, breathing
circuit types and maintenance and recovery details as
shown in the table below.

10.  A team of anesthetist, biomedical technician and
administrator carried out follow-up visited to each site
every two months.
 Continuous communication was maintained between
follow-up visits through email and phone calls to help
for any problem and their management.
 Adequate forms to record various parameters of patient
and the machine were also made available.
 At the end of the study period, three user
anesthesiologists and 8 user AAs were asked to rate the
user perspective of layout and setting up of machine
and also the UAM response to patients' variables as
shown in figure 6. Collected records were finally
analyzed.

11. Age (yrs) / Sex Distribution
294
300
250
200
128
150
100
36 38 30
50 6 10 11 21 20 21 19
2 0
0
<1 1-5 6-10 10-15 16-50 51-60 >60
Male Female

12.  Total case 641 in 6 months and one week.
 Figure 1 shows:
◦ smallest patient was of 22 days and
◦ oldest is 85 years old.
 Elective 69% and 31% found as emergency.
 Figure 2 shows
◦ Gen Surg 35%
◦ Obstetric 17% were obstetric
 Figure 3:
◦ The original bellow was used in majority of the cases
◦ Ayre’s T-piece and Bain’s circuit
 Maintenance aurnd recovery of patients are shown in figure 4
& 5. Oxygen saturation in elective and emergency patients are
shown in figure 6. The user evaluation of the machine and the
patient parameter are shown in figure 7 and 8.

21.  It may be too early to conclude the evaluation of UAM and its
usefulness. However, the result clearly favors the acceptability
of the UAM due to its simplicity, safety, reliability and
functionality. It can be easily oriented within a week and can
be used confidently. Most of the user commented about the
handheld bellow which sticks the user with the machine and
patient (favoring ASA standard I monitoring).This initial
impression to the UAM is very positive in Nepal’s context. It is
reliable in terms of oxygen supply system, vaporizer and use
of a variety of breathing circuits. Its simplicity, versatility and
negligible maintenance cost having continuous flow and
combined drawover system in different geographic locations
(remote area) are attractive features to any resource limited
areas to serve quality anesthesia in comfortable way.

22. 1. Nepal Millennium development goals
report, Progress report 2011.
2. Fenton PM. Maternal deaths and anaesthesia
technology in the 21st century. Anaesthesia
News 2010; 273: 5-8
3. AAGBI (2009) Section 4: Standards. In: Safe
Management of Anaesthetic Related
Equipment. AAGBI, London: 8-9
4. OES Medical (2010) Universal Anaesthetic
Machine User Manual CE 0120 Doc 1973-
510