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Pain Management in the Setting
of Language Barriers and Global Health
Michelle Kuei, Danielle Savino, and Matthew Swisher
Abstract There are multiple barriers to pain management in the United States and
globally. Language, cultural and ethnic differences are significant factors with the
increasing heterogeneity of the population globally. There are social, systemic, and
biological elements to consider when examining pain disparities and creating appro-
priate pain management strategies in minority groups. Globally, in low- or middle-
income countries (LMICs), pain disparities exist largely due to limited resources.
Pain and surgical disease account for more than 30% of disease burden worldwide,
with the majority of the burden in LMICs where there are significant barriers to
pain and anesthesia care (Size et al. in Anaesthesia. 62:38–43, 2007; Lipnick MS,
Dubowitz G, Wabule A. Regional anesthesia in resource-constrained environments.
In: Atlas of ultrasound-guided regional anesthesia. Elsevier, Inc.; 2019. p. 405–1;).
Patients often have poor or nonexistent analgesic options due to lack of staff available
to administer analgesic medications, lack of opioids, education, and perceived safety
of opioids. Patients then expect undertreatment of perioperative and acute pain to be
the norm (Size et al. in Anaesthesia. 62:38–43, 2007). Regional techniques can be
helpful in these situations, however, there needs to be adequate resources and trained
professionals.
Keywords Language barriers
· Global health · Resource-limited · Limited
English proficiency
· Language discordance · Ethnic discordance · Cultural
competency
· Low-.or middle-income countries
M. Kuei · D. Savino
Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA
e-mail: mkuei@wisc.edu
D. Savino
e-mail: dsavino@uwhealth.org
M. Swisher (
B
)
Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
e-mail: mwswisher@health.ucsd.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_13
191
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192 M. Kuei et al.
1 Introduction
Language, cultural, and ethnic differences are barriers to pain management. Limited
English proficiency is associated with worse health care outcomes and disparities in
care, even when socioeconomic and insurance status are accounted for, suggesting
that language and culture play an important role. With increasing linguistic and
cultural diversity, both in the United States and globally, this becomes a signifi-
cant factor in healthcare [3, 4]. While there are limited studies addressing language
and cultural barriers to perioperative analgesia, pain management plans should be
adjusted accordingly to effectively treat patients of diverse backgrounds.
This chapter also delves into barriers to and strategies for pain control in resource-
limited settings. Anesthesia services have become a critical necessity in LMICs
where there is a huge burden of untreated surgical conditions. These conditions are
often easily treatable but have a high fatality rate due to limited access to surgical
and anesthesia care [5]. With the increase in surgical volume, perioperative pain
management becomes concurrently more important. Though pain is one of the top
causes of disability-adjusted life years globally and pain management is consid-
ered a basic human right, unreliable pain control strategies are frequently present
in resource-limited settings. Analgesia is viewed of lower priority than treatment
of other disease processes [1, 2]. Pharmacologic, non-pharmacologic, and regional
anesthesia techniques for pain control are, unfortunately, of varying availability in
LMICs.
2 Language, Cultural, and Ethnic Differences
Pain assessments are often performed via self-report, so language is important in
communicating pain. Since pain is complex, it is difficult to describe and assess
with simple ratings. Language allows patients to convey the location, quality, and
severity of their pain, in addition to associated symptoms of their pain and side
effects of pain medications. This promotes a more comprehensive pain assessment. In
predominantly English-speaking healthcare settings, studies have shown that patients
with limited English proficiency have higher pain scores and fewer pain assessments
performed. Thus, pain scales in multiple languages or pain scales that utilize images
can be beneficial to facilitate adequate treatment of pain [3]. For example, one study
found that Spanish-speaking children undergoing chemotherapy experienced pain
that was unrecognized and therefore was not treated appropriately. The authors of
this study hypothesized that the Spanish version of the pain tool should be used to
better communicate these children’s pain and avoid analgesic undertreatment [6].
Healthcare professionals caring for a patient with limited English proficiency
should assess the clinical situation, degree of language gap, available resources, and
patient preference [6]. Patients with limited English proficiency may not be able to
effectively communicate their pain needs with healthcare professionals, leading to
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Pain Management in the Setting of Language Barriers and Global Health 193
ineffective pain control, especially when interpreters are not readily available [3].
Language barriers can also lead to fewer interactions with healthcare professionals.
If the language gap is substantial and/or there is a patient preference for interpretation
services, a medical interpreter should be used [7]. Interpreters do not completely erad-
icate language barriers. However, they do improve communication between health-
care professionals and patients. However, healthcare professionals often underuti-
lize dedicated interpreter services, instead, substituting their own limited language
knowledge for clinical encounters. It can be viewed as more time consuming to
treat patients with language discordance and use interpreter services [4]. In a study
of hospitalized Spanish-speaking obstetrics/gynecology patients, it was found that
use of interpreters was associated with better pain control, timely response to pain
needs, ease of receiving pain medications, and perceived helpfulness of healthcare
professionals as stewards of analgesic therapeutics [8].
The presence of a language-concordant healthcare professional or dedicated inter-
preter is associated with improved quality and outcomes, including decreased pain
and improved physical and psychological well-being [4]. In a study of pain manage-
ment in breast cancer patients, it was reported that Spanish speakers reported greater
pain severity, distress, and barriers to pain management than English speakers. They
also endorsed greater misconceptions about the doctor-patient relationship and pain
management, likely due to poor communication with healthcare professionals [9].
Good communication allows healthcare professionals to set pain expectations and
discuss different alternatives for pain management/treatment [8].
Another study investigated the association between parental English proficiency
and pain management in pediatric surgical patients. It was found that children of
limited English proficiency parents had fewer pain assessments and higher levels of
pain recorded prior to receiving opioid analgesics compared with children of English
proficient parents. However, children of limited English proficiency parents with ≥2
interpreter encounters each day had lower pain scores after medication administration
and were more likely to receive opioids at pain levels similar to children with English
proficient parents. These findings suggest that more frequent use of professional
interpreters when assessing pain could reduce the disparity in pain management.
This study also found that children with limited English proficiency parents used
the nonverbal face pain scale more and the numeric pain rating scale (NRS) less
than children with English proficient parents. Again, certain pain scales may be
more appropriate for limited English proficiency patients, which should be taken
into consideration for more effective pain assessment[10].
Studies have shown that pain ratings are only comparable between nurses and
patients when the nurse is language concordant with the patient [11]. In a study
exploring nurses’ perspectives on caring for patients with limited English proficiency,
language barriers were identified as the biggest obstacles in providing adequate,
appropriate, and timely care. Communication was identified as the most important
component of a nurse’s role in the care of hospitalized patients. Certain situations
were identified where the use of interpreters is not feasible, including when patients
are under the influence of anesthesia or severe pain and anxiety. Often in the perioper-
ative setting, especially with emergency surgery, interpreter services can be difficult
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194 M. Kuei et al.
to access. In these situations, there is the potential for novel technologies to assist in
the management of language barriers [12].
In addition to recognizing increasing language diversity, there is growing hetero-
geneity of cultures and ethnicities. It is therefore important to understand how this
diversity impacts pain management as well. There are persistent ethnic disparities
in the prevalence, treatment, progression, and outcomes of pain-related conditions
despite advances in pain management. These inequities have been demonstrated
across a broad array of treatment settings. Ethnic minorities frequently receive inad-
equate or substandard healthcare. These patients may be less likely to receive pain
medications, receive lower doses of pain medications, and have longer wait times
in the emergency department. Their pain is also often underestimated by healthcare
professionals. They are also less likely to be included as an active participant in deci-
sions relevant to their medical treatment [11, 13, 14]. Understanding the institutional-
ized structure and mechanisms driving these differences in medical management is an
important factor that might result in reductions in the disparities relevant to adequate
pain treatment of ethnic minorities. There are sociocultural, healthcare system struc-
tural, and physiological factors that convalesce to complicate pain management.
Because pain is a subjective experience, it can be easily influenced by any of these
factors [11, 15].
Healthcare professionals are more likely to be responsive to pain communication
with people from a concordant culture and are less likely to understand pain commu-
nication communicated by people from other cultures. Culture can determine how
pain is perceived, experienced, and communicated. Different cultures have different
expectations and may accept pain as a normal part of life/their medical condition
and not a clinical problem that requires treatment. Other cultures may also display
diverse pain coping strategies that can influence the pain experience. Each cultural
and ethnic group has its own norms for the communication of pain and distress, both
verbal and non-verbal. Some cultures and ethnic groups may display more emotion
in the presence of pain, while others may be more stoic and downplay the pain.
Patients may not ask for pain medications because they think it will be brought to
them if they need it, or that non-verbal indicators would be sufficient to convey their
pain. Patients may think that it is disrespectful or viewed as complaining to ask for
pain medications, or that their pain should be more severe before conveying it to
the healthcare professionals. Some cultures prefer alternative and complementary
pain treatments to pain medications. Other sociocultural factors include family tradi-
tions, religious beliefs, and previous experiences. People who are more acculturated
report similar levels of pain to people of the country to which they have emigrated
[11, 15, 16].
Structurally, predominantly minority neighborhoods are less likely to stock
opioids in their pharmacies. However, even when access is equal, different ethnic
groups still use different amounts of pain medications. Certain ethnic groups
will underreport pain and have a fear of medication dependency, tolerance, and
side effects. Gaps in communication of pain occur from sociocultural beliefs,
misperceptions, and language barriers [11, 15].
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Pain Management in the Setting of Language Barriers and Global Health 195
In a study of oncology patients at various treatment sites, it was found that
65% of minority patients (Hispanic and nonwhite backgrounds) received inadequate
pain treatment compared with 50% of nonminority patients. Minority patients also
received better pain management at community-based treatment settings. Various
factors likely contribute to these findings, including concern for potential drug abuse,
inability to pay for pain medications, barriers in accessing healthcare and filling
prescriptions, and difficulty in healthcare professionals assessing pain due to differ-
ences in language and culture. Certain minority groups may also fear aggressive
medical treatment and side effects of analgesics or lack assertiveness in seeking
healthcare, thus making them less likely to report pain and reluctant to pursue pain
management with stronger analgesics. Awareness of the risk for inadequate pain
management in minority groups can be beneficial in improving pain assessment and
treatment in these groups. There is also a need for patient education relevant to pain
management in minority groups and public health education as it relates to pain
[17, 18].
Biologically, ethnic differences in pain tolerance have been documented in a
variety of pain-related conditions. This has been shown both clinically and in experi-
mental pain studies across different ethnicities around the world. In general, those of
ethnic minority backgrounds relative to the country in which they live demonstrate
increased pain sensitivity in comparison to those of ethnic majorities. They have
lower pain thresholds to various types of nociceptive stimulation, including thermal,
ischemic, and pressure/mechanical pain. It has been suggested that endogenous pain-
regulatory systems may account for ethnic differences in pain perception [11, 18, 19].
Furthermore, there are also biological ethnic differences in drug metabolism, dosing
requirements, therapeutic responses, and side effects of analgesics. However, more
studies need to be performed to elucidate the associated genetic factors [11, 15, 19].
Some studies have shown that western approaches to multi-disciplinary pain treat-
ments are designed and delivered in a way that are more likely to benefit certain
ethnic and cultural groups. Pain treatments and assessment tools should be cultur-
ally tailored to patients’ backgrounds to improve outcomes. Healthcare professionals
need to recognize the wide variation in pain expression and communication across
cultures and ethnic groups. Cultural competence training amongst healthcare profes-
sionals is important. Healthcare professionals should develop knowledge and appre-
ciation on culturally specific beliefs and attitudes held by their patients, even if
they are not scientifically grounded. These medical professionals can then use this
knowledge to adjust their patients’ pain management plan. Further research should
explore beliefs and expectations of pain management in different cultural groups to
allow for integration with evidence-based pain management [11, 15, 16, 18, 20]. In
addition, culturally appropriate treatment strategies that integrate cultural practices,
philosophies, products, or environments should be considered as pathways to facil-
itate behavior change and provide a framework for patient-focused interventions.
This can be achieved through social networks of community workers and recruiting
individuals from the community with knowledge and training in pain management
[15]. Studies have also shown that patients are more likely to actively participate in
their treatment with healthcare professionals of the same background [19].
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196 M. Kuei et al.
Medical professionals should be flexible in the way they approach pain manage-
ment and treat pain in a culturally appropriate manner without biases and stereo-
typing. It has been shown that education focused on disparities in pain manage-
ment led to increased physician confidence in their ability to identify potential
barriers when treating minorities and increased confidence in their ability to imple-
ment strategies to minimize biases. Training healthcare professionals in communi-
cation skills, use of interpreters, and cultural competence are important interventions
[11, 15, 16, 18, 20].
The mechanisms underlying ethnic and cultural differences in pain experiences
are multifactorial and complex, thus more studies need to be performed to clarify
the intricate variables and how to best address them. It is unknown which factors, if
intervened upon, would have the greatest impact. Equalizing pain treatment across
all patient groups will assume a place of increasing prominence as society grows
more ethnically and culturally diverse. The increasing prevalence of pain can have
debilitating socioeconomic and health ramifications for the individual and society.
More pain research needs to be conducted and translated into practices and policies
with a focus of reducing disparities in pain management [11, 15, 18, 20].
3 Pain Management in Global Health
Historically, pain management in resource-limited areas has been overlooked by the
global medical community as more emphasis and resources are funneled toward
issues deemed more pressing including communicable diseases [21]. Unfortunately
this has led to a large gap in both knowledge/clinical training and resources for
pain management, leaving many LMICs to either find alternative strategies for pain
control or forgo the expectation of controlling pain altogether [21, 22]. With the
lack of emphasis on pain management in LMICs, many barriers to appropriate pain
management have developed, including lack of resources, education discrepancies,
government policies, fear of opioid adverse effects, and more [23].
While pain management has in the past been neglected as an essential part of global
health, there is hope for the future. As the global surgical burden increases, there
will ultimately be an increased need for adequate perioperative pain management.
Luckily, in recent years there has been a shift in global agendas to include both acute
and chronic pain management as a fundamental human right [21, 24]. Organizations
such as the WorldHealth Organization (WHO) have emphasized the need to prioritize
pain management and palliative care as part of universal health coverage [23, 25, 26].
The array of perioperative pain management strategies in LMICs around the world
is difficult to encompass succinctly. This wide disparity is largely secondary to the
fact that most LMICs are limited to what is available at the local patient, provider, and
system levels [24, 27]. It is important to grasp the magnitude of discrepancy that exists
from a resource allocation standpoint to understand pain management in LMICs.
For example, morphine is a relatively inexpensive medication that has been declared
essential by the WHO [23]. Despite this statement, its availability remains skewed.
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Pain Management in the Setting of Language Barriers and Global Health 197
It has been noted that the richest 10% of countries in the world continue to hold
approximately 90% of distributed morphine equivalent opioids [21, 24]. Tramadol
is a commonly utilized analgesic with more access to this weak opioid in LMICs
due to its less direct effects [28]. Due to the lack of availability of opioids for many
patients worldwide, other non-opioid strategies are often used. Additionally, even
when opioids are available, many healthcare professionals in LMICs feel uncom-
fortable administering/prescribing them due to lack of understanding and experience
utilizing them [23].
Non-opioid analgesics have long been a mainstay of perioperative pain manage-
ment in countries of all resource levels. In fact, they are the first step noted in the
WHO analgesic ladder for both acute and chronic pain management [29]. While it is
difficult to ascertain exact data on the overall use of non-opioid analgesics throughout
LMICs, paracetamol and diclofenac are often mentioned as part of the non-opioid
analgesic ladder [22, 30]. Their use in treatment regimens is contingent on each
community’s access to non-opioid analgesics and may vary greatly.
Ketamine has long been relied on in LMICs as a means for both anesthesia and pain
management. The organization, Médecins Sans Frontières/Doctors Without Borders,
estimates that more than 50 countries globally depend on ketamine as part of multi-
modal analgesic plans, usually given concomitantly with tramadol and diclofenac
for maximal effect [31]. In addition to ketamine’s use as a perioperative analgesic in
LMICs, it is crucial to note that ketamine remains vital as the primary anesthetic for
many resource-limited countries [31, 32].
Many LMICs have developed resourceful, individualized adjuncts to medica-
tions as components of multimodal perioperative pain management pathways. For
example, acupuncture has long been a staple of Eastern medicine and is used in
countries of all resource levels [33]. Its ability to decrease both postoperative opioid
requirements and postoperative nausea/vomiting makes it an ideal complementary
medicine when considering multimodal pain management. Other studies have shown
that approaches, such as talking with friends can be a successful option for nonphar-
macologic pain management. One study from Ethiopia in 2019 found this to be the
most common method of non-pharmacologic postoperative pain control with 88.3%
of patients using it within 6 hours after surgery [34]. While these different methods
of nonpharmacologic pain management are certainly important adjuvants in LMICs,
they are not appropriate substitutes to pharmacologic pain management.
LMICs face significant barriers when it comes to providing adequate pain manage-
ment, in both the acute and chronic setting. The first barrier that should be addressed
is the historical lack of initiative in pain management with the past several decades
focusing mainly on communicable diseases. With the expected exponential increase
in surgical and anesthetic services worldwide, pain management has started to r eceive
more recognition [22]. Along the same lines, the lack of resources, specifically opioid
availability, in LMICs often severely limits the available approaches to pain manage-
ment [21, 22]. In addition to lack of resources, limited training in pain management
and lack of pain protocols have also been cited as a significant barrier to adequate
pain control in LMICs. Several studies based in Rwanda have demonstrated that a
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198 M. Kuei et al.
fear of medication side effects and concern for incorrect decision making has nega-
tively impacted evidence-based practice. One study found that only 46% of medical
personnel interviewed had training in acute pain management [21]. Other barriers to
pharmacologic pain management in LMICs include cultural beliefs about pain, fear
of addiction, and government regulations of opioid administration.
4 Regional Techniques in Global Health
Unfortunately, there is minimal available data that addresses acute pain in LMICs
and therefore identifying specific areas or surgical procedures requiring improve-
ment is challenging. Studies are typically performed at healthcare centers with better
resources and may poorly represent the acute pain situation in more rural settings
where conditions are likely worse [1]. A survey conducted in Nigeria on postop-
erative pain demonstrated that 68.7% of patients reported moderate to unbearable
pain 24 hours after surgery [35]. In addition to post-surgical pain, pain related to
traumatic events accounts for a significant portion of the disease burden in LMICs
and often requires pain management techniques similar to what might be required
in the perioperative environment. Regional techniques are helpful in these situations
[1].
Perioperative anesthesia-related morbidity and mortality is higher in LMICs due
to lack of anesthesia infrastructure, trained professionals, equipment, basic monitors,
safety protocols, and medications. There is often a lack of access to functioning anes-
thetic machines, basic airway equipment, capnography, monitors of neuromuscular
blockade, and even oxygen. Previous research has demonstrated that there is a lower
mortality rate with regional anesthesia compared to general anesthesia when used in
these limited resource settings. For example, a study performed at Doctors Without
Borders facilities, demonstrated that spinal anesthesia and regional anesthesia were
associated with lower odds of perioperative death compared with general anesthesia
with intubation [36]. Regional anesthesia helps avoid life-threatening perioperative
airway and respiratory complications, especially in obstetrics. It can also improve
pain control, shorten recovery room length of stay, and increase operating room
efficiency, which all contributed to decreased healthcare costs. Regional anesthesia
can decrease the need for opioids, which are in short supply in LMICs. It can also
provide a less resource-intensive option than general anesthesia. Regional anesthesia
is most beneficial for obstetric, trauma, and orthopedic patients, which represent the
most common surgical cases in low- and middle-income countries [37–39]. Further-
more, during the COVID-19 pandemic, regional anesthesia has been recommended
over general anesthesia to avoid aerosolization from airway management procedures.
Minimizing aerosolizing can improve system health through decreasing infection in
healthcare professionals who are already in short supply [37].
Neuraxial anesthesia is relatively easy to teach and perform, cost-effective, safe,
and efficacious. It can be used for surgeries at and below the umbilicus. The equipment
needed is minimal and less expensive than what is required for general anesthesia.
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Pain Management in the Setting of Language Barriers and Global Health 199
However, there is limited access to spinal needles that reduce the risk of post-dural
puncture headaches. When there is a shortage of spinal needles, introducer needles
from IV cannulas can be utilized [37, 40]. The shift to neuraxial anesthesia from
general anesthesia for cesarean sections was slower in LMICs. In west Africa, anes-
thesia professionals were not providing spinal anesthesia due to personal preference
and levelof expertise. However, a retrospective study from Nigeria, demonstrated that
there is a trend toward increasing spinal anesthesia utilization for cesarean sections
[41]. A retrospective analysis on anesthetic procedures performed at healthcare facil-
ities with medical professionals from Doctors Without Borders over a 6-year period
was conducted. The study found that the most common type of anesthetic technique
was spinal anesthesia (45.56%) and the most common procedure performed was
cesarean section (35.54%) [36].
Anesthesia contributes disproportionately to maternal mortality in LMICs, mainly
due to airway complications. A systematic reviewof obstetric morbidity and mortality
in low- and middle-income countries showed that general anesthesia tripled the odds
of maternal death as compared with neuraxial anesthesia. General anesthesia also
doubled the odds of perinatal death and was associated with an increased risk of post-
partum hemorrhage and low Apgar scores compared with neuraxial anesthesia [42].
Neuraxial anesthesia in obstetrics can provide safe anesthesia by avoiding airway
manipulation, which decreases the risk of aspiration and desaturation. However,
there needs to be education on physiological changes with neuraxial anesthesia to
avoid high spinals and intraoperative hypotension [43].
Neuraxial techniques also provide analgesia after the cesarean section. There
is poor labor analgesia in resource-limited environments. In a study of laboring
women in Nigeria, 85.1% of women stated would want labor analgesia. However,
only 38.9% of women received labor analgesia [44]. Therefore, more education
and training programs can be beneficial. In Ghana, a program was implemented to
teach local anesthesia professionals how to perform spinal anesthesia for cesarian
sections. This training paradigm consisted of didactic and practical training, focusing
on preanesthetic evaluation, management of an inadequate block, sterile technique,
local anesthetic dosage, treatment of side effects, complication management, and
hemodynamic monitoring. After the training, the use of spinal anesthesia for cesarian
sections increased from 6% to 89% over 3 years, then to 97% in 5 years. This research
suggests that spinal anesthesia can be efficiently provided in resource-limited settings
with the development of appropriate protocols, staff education, and the availability of
basic equipment and medications. The study authors also developed and implemented
a single-shot spinal labor analgesia protocol. However, this protocol was not sustain-
able due to a s hortage of anesthesia professionals [45]. Unfortunately, epidurals are
rarely used in LMICs due to a paucity of epidural kits, infusion pumps, and trained
staff to monitor and manage the epidural infusion and monitor for complications.
Epidural catheter insertion is also more complicated to perform, more costly, and
associated with more potential complications than spinals [45]. Epidural boluses can
be performed manually if infusion pumps are the limiting factor. Single shot spinal
analgesia can be utilized instead of epidurals, although single shot spinal analgesia is
associated with a limited duration. Intrathecal opioids can be a reasonable alternative
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200 M. Kuei et al.
to epidurals as well, however the availability of preservative-free opioids may limit
more widespread implementation [46, 47].
Despite frequent use of spinal blocks, peripheral nerve blocks are not routinely
performed in LMICs. In a survey of Nigerian anesthesiologists, spinal anesthesia was
regularly utilized. Whereas the majority of anesthesiologists reported either never
or rarely performing an epidural or peripheral nerve block. When peripheral nerve
blocks were performed, a nerve stimulator was typically used to appropriately target
nerve structures [48].
In LMICs, there is widespread interest in performing peripheral nerve blocks, but
insufficient training and lack of appropriately trained medical professionals. These
medical professionals need to be educated on how to utilize ultrasound imaging,
indications and contraindications to various regional techniques, and how to manage
potential complications. There needs to be enough staff to follow-up with patients
after their regional anesthetic, particularly if there are epidurals or nerve catheters
involved. Anesthesia professionals are often poorly supported and difficult to recruit
and retain in LMICs. There is a need for more in-depth training and regional anes-
thesia fellowships in LMICs to learn peripheral nerve and fascial plane blocks and
for ultrasound training [37]. In a multicenter study in the Democratic Republic of
the Congo and Ethiopia, 41 medical professionals were taught femoral, popliteal and
forearm nerve blocks. Following this training program, this group demonstrated an
ability to consistently provide regional anesthesia and were able to perform almost
1000 analgesic blocks with high success rates and no complications. The success
of this program demonstrates that it is feasible to perform regional techniques in
resource-limited areas successfully and safely [2]. Another study performed at a
Nigerian healthcare center demonstrated that peripheral nerve blocks have been
used successfully for orthopedic surgeries, particularly upper extremity surgeries.
In this case, brachial plexus blocks were frequently utilized as the primary anesthetic
thereby avoiding the need for general anesthesia and airway instrumentation [49].
Various techniques may be successfully utilized to provide regional anesthesia
in LMICs including ultrasound-guided, landmark-based, or nerve stimulation. The
preferred technique is locally dependent upon the equipment and trained medical
professional availability. The safety profile associated with various nerve blocks
and localization techniques may vary significantly. Generally, distal blocks and the
use of ultrasound are associated with the highest safety profile. Lack of equipment
may remain a barrier to the routine performance of peripheral nerve blocks. Sterile
ultrasound gel and probe covers are usually unavailable in resource-limited settings.
Thus, when performing ultrasound-guided nerve blocks, the provider should insert
the block needle through a sterile-prepped area of skin away from the ultrasound
probe as to not contaminate the needle. Probe covers can also be substituted with
sterile gloves and adhesive dressings. Ultrasound gel in general can be difficult to
obtain, so there may need to be substitutions with other lubricants/gels [2]. Some
equipment, like block/spinal needles, are utilized after their expiration date. Specific
peripheral nerve block needles that are blunted, insulated, and echogenic can be
difficult to obtain, so instead, spinal needles or hypodermic needles can be utilized.
It is assumed that sharper needles, like spinal needles, may be more likely to injure
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