The capacity to perform safe surgery in Rwanda, while improving, is somewhat limited secondary to and inadequate infrastructure, surgical resources, and personnel. Up to 80 % of hospitals in the southern province reported absent or insufficient pulse oximetry, and 35 % reported no or inadequate oxygen supply [5]. Approximately 80 % of surgical procedures are performed at district level hospitals, which are typically less likely to have adequate capability for blood banking, amputations, closed or open fracture repairs, inhalational anesthetic administration, and chest tube insertion [5]. Many of the major surgical procedures are therefore performed at the referral hospitals. There are two public referral hospitals in Rwanda, the larger of which is Centre Hospitalier Universitaire, Kigali (CHUK). The other is Centre Hospitalier Universitaire, Butare (CHUB). These referral hospitals are equipped with eight and four general operating rooms, respectively. As shown in Table 18.2, in 2009 approximately 4,164 and 2,488 major surgeries were performed at CHUK and CHUB, respectively [5]. Although referral hospitals have better surgical capacity than their district-level counterparts, they still have some pragmatic limitations. On occasion, either of these large referral centers may have limited or absent surgical or anesthetic supplies, such as consistent capnography, local anesthetic agents, or banked blood products.

Limited personnel are also an issue. As of 2013, Rwanda has only 10 licensed anesthesiologists; the national anesthesia residency program currently has 16 trainees. In a continuing effort to build up Rwanda’s anesthesiology capability, organizations such as ASA/CASIEF and HRH provide a significant contribution to the anesthesia workforce. These visiting anesthesiologists not only participate in daily clinical care but also teach and mentor residents and Rwandan staff. A recent surgical capacity national collaboration meeting emphasized the important role of international efforts in enhancing the education of Rwandan health care providers and therefore increasing Rwandan health care in a sustainable manner [5].

Lack of medical supplies, electricity, or appropriately trained staff is of course a problem not exclusive to Rwanda. Infrastructure analyses across sub-Saharan Africa show common themes of inadequate supplies and equipment, limited monitoring, lack of appropriate training for anesthesia providers, and few qualified anesthetists [6, 7]. In one 2006 survey among 97 non-private hospital anesthesia providers in Uganda, only 23 % stated they had the minimum monitoring requirements to conduct a safe anesthetic in an adult patient. The most frequently unavailable items included pulse oximetry and oxygen source; running water and electricity were also described as not always available [7].

This shortage of physical and personnel resources directly impacts the type of anesthesia and analgesia available for orthopedic surgery. As orthopedic procedures account for approximately 40 % of the surgical caseload at CHUB, and orthopedic surgery is amenable to regional anesthetic techniques, this chapter focuses on regional anesthesia for orthopedic surgery. Despite the decrease in postoperative opioid consumption and improvement in patient satisfaction that is associated with peripheral nerve block techniques [8], few orthopedic surgery patients in Rwanda receive such blocks. Whereas 99 % of lower extremity surgery at both CHUB and CHUK is performed under spinal anesthesia, only 10–15 % of these patients receive supplemental peripheral nerve blockade for postoperative pain control. Although approximately 55 % of orthopedic cases at CHUB involve upper extremity fractures, very few patients are offered brachial plexus blockade either for surgical anesthesia or postoperative analgesia [9]. Frequently cited reasons by Rwandan anesthesiologists are lack of needles or local anesthetic solution and lack of skills regarding peripheral nerve block techniques [1]. The low prevalence of brachial plexus blockade is particularly unfortunate given its benefits when compared to general anesthesia, including decreased postoperative pain, improved readiness for discharge, and decreased nausea and vomiting [10]. In a setting such as Rwanda, where both material and personnel resources are significantly limited, the impact of a consistent regional anesthesia service may be substantial. Economical, clinical, and training spheres may all be positively affected.