Anesthesia during deployment of a military forward surgical unit in low income countries: A register study of 1547 anesthesia cases

Autoři: Quentin Mathais aff001;  Ambroise Montcriol aff001;  Jean Cotte aff001;  Céline Gil aff001;  Claire Contargyris aff001;  Guillaume Lacroix aff001;  Bertrand Prunet aff002;  Julien Bordes aff001;  Eric Meaudre aff001
Působiště autorů: Department of Anesthesiology and Intensive care, Military Hospital Sainte-Anne, Toulon, France aff001;  Service Médical de la Brigade des Sapeurs Pompiers de Paris, Paris, France aff002;  French Military Health Service Academy Unit, Ecole du Val-De-Grâce, Paris, France aff003
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223497



Military anesthesia meets unique logistical, technical, tactical, and human constraints, but to date limited data have been published on anesthesia management during military operations.


This study aimed to describe and analyze French anesthetic activity in a deployed military setting.


Between October 2015 and February 2018, all patients managed by Sainte-Anne Military Hospital anesthesiologists deployed in mission were included. Anesthesia management was described and compared with the same surgical procedures in France performed by the same anesthesia team (hernia repair, lower and upper limb surgeries). Demographics, type of surgical procedure, and surgical activity were also described. The primary endpoint was to describe anesthesia management during the deployment of forward surgical teams (FST). The secondary endpoint was to compare anesthesia modalities during FST deployment with those usually used in a military teaching hospital.


During the study period, 1547 instances of anesthesia were performed by 11 anesthesiologists during 20 missions, totaling 1237 days of deployment in nine different theaters. The majority consisted of regional anesthesia, alone (43.5%) or associated with general anesthesia (21%). Compared with France, there was a statistically significant increase in the use of regional anesthesia in hernia repair, lower and upper limb surgeries during deployment. The majority of patients were civilians as part of medical support to populations.


In the context of an austere environment, the use of regional anesthesia techniques predominated when possible. These results show that the training of military anesthetists must be complete, including anesthesia, intensive care, pediatrics, and regional anesthesia.

Klíčová slova:

Anesthesia – General anesthesia – Local and regional anesthesia – Orthopedic surgery – Surgical and invasive medical procedures – Surgical repair – Epidural block – Femoral block


1. French Military Doctrine: Medical Support to Operations. DIA-4.0.10_SOUTMED-Ops.N_176/DEF/CICDE/NP, July 31, 2014.

2. French Military Doctrine: Medical Aid to the Population. DIA3.10.3.1_AMP.N_097/DEF/CICDE/NP, May 15, 2009.

3. Gordon S. The military physician and contested medical humanitarianism: a duelling entity? Soc Sci Med. 2014;120:421–9. doi: 10.1016/j.socscimed.2014.04.025 24928172

4. Bilski TR, Baker BC, Grove JR, Hinks RP, Harrison MJ, Sabra JP, et al. Battlefield casualties treated at Camp Rhino, Afghanistan: lessons learned. J Trauma. 2003;54 (5):814–21. doi: 10.1097/01.TA.0000046627.87250.1D 12777893

5. Chambers LW, Rhee P, Baker BC, Perciballi J, Cubano M, Compeggie M, et al. Initial experience of US Marine Corps forward resuscitative surgical system during Operation Iraqi Freedom. Arch Surg. 2005;140(1):26–32. doi: 10.1001/archsurg.140.1.26 15655202

6. Chambers LW, Green DJ, Gillingham BL, Sample K, Rhee P, Brown C et al. The experience of the US Marine Corps’ Surgical Shock Trauma Platoon with 417 operative combat casualties during a 12 month period of operation Iraqi Freedom. J Trauma. 2006;60(6):1155–61. doi: 10.1097/01.ta.0000220340.91356.7e 16766956

7. Brethauer SA, Chao A, Chambers LW, Green DJ, Brown C, Rhee P, et al. Invasion vs insurgency: US Navy/Marine Corps forward surgical care during Operation Iraqi Freedom. Arch Surg. 2008;143(6):564–9. doi: 10.1001/archsurg.143.6.564 18559749

8. Ramasamy A, Harrisson S, Lasrado I, Stewart MP. A review of casualties during the Iraqi insurgency 2006-A British field hospital experience. Injury. 2009;40(5):493–7. doi: 10.1016/j.injury.2008.03.028 18656190

9. Barbier O, Pasquier P, Racle M, Baudoin Y, Malgras B. Dynamic Insights on Surgical Activity in a New Modern Warfare: the French Role 2 in Bangui, Central African Republic. Mil Med. 2017;182(3):e1756–61. doi: 10.7205/MILMED-D-16-00121 28290955

10. Malgras B; Barbier O, Pasquier P, Petit L, Polycarpe A, Rigal S, et al. Initial deployment of the 14th Parachutist Forward Surgical Team at the beginning of the operation Sangaris in Central African Republic. Mil Med. 2015;180(5):533–8. doi: 10.7205/MILMED-D-14-00212 25939107

11. Le TD, Gurney JM, Nnamani NS, Gross KR, Chung KK, Stockinger ZT, et al. A 12-Year Analysis of Nonbattle Injury Among US Service Members Deployed to Iraq and Afghanistan. JAMA Surg. 2018;153(9):800–807. doi: 10.1001/jamasurg.2018.1166 29847675

12. Chmátal P, Bohonek M, Dobiásová M, Hasek R, Cernohous M. A humanitarian mission in southern Iraq: utilization of the 7th Field Hospital of the Army of the Czech Republic—a report on its medical activities and working conditions. Mil Med. 2005;170(6):273–5.

13. Lagrew J, Eugenio L, Nelson SC, Hauff NM, Kaesberg JL, Lambert ME, et al. Pacific Partnership 2010: Anesthesia Support Aboard the USNS Mercy Humanitarian Civic Assistance. Mil Med. 2012;177(8):939–46. doi: 10.7205/milmed-d-12-00044 22934374

14. Woll M, Brisson P. Humanitarian Care by a Forward Surgical Team in Afghanistan. Mil Med. 2013;178(4):385–8. doi: 10.7205/MILMED-D-12-00411 23707821

15. Bonnet S, Bertani A, Savoie PH, Mathieu L, Boddaert G, Gonzalez F, et al. Humanitarian Surgical Care Provided by a French Forward Surgical Team: Ten Years of Providing Medical Support to the Population of the Ivory Coast. Mil Med. 2015;180(10):1075–82. doi: 10.7205/MILMED-D-14-00688 26444470

16. Wong EG, Trelles M, Dominguez L, Gupta S, Burnham G, Kushner AL. Surgical skills needed for humanitarian missions in resource-limited settings: common operative procedures performed at Médecins Sans Frontières facilities. Surgery. 2014;156(3):642–9. doi: 10.1016/j.surg.2014.02.002 24661767

17. Trelles M, Stewart BT, Hemat H, Naseem M, Zaheer S, Zakir M, et al. Averted Health Burden over 4 Years at Médecins Sans Frontières (MSF) Trauma Centre in Kunduz, Afghanistan, prior to Its Closure in 2015. Surgery. 2016;160(5):1414–1421. doi: 10.1016/j.surg.2016.05.024 27407057

18. Ariyo P, Trelles M, Helmand R, Amir Y, Hassani GH, Mftavyanka J, et al. Providing Anesthesia Care in Resource-limited Settings: A 6-year Analysis of Anesthesia Services Provided at Médecins Sans Frontières Facilities. Anesthesiology. 2016;124(3):561–9. doi: 10.1097/ALN.0000000000000985 26881395

19. White RL, Cohen SP. Return-to-duty rates among coalition forces treated in a forward-deployed pain treatment center: a prospective observational study. Anesthesiology. 2007;107(6):1003–8. doi: 10.1097/01.anes.0000290605.55736.e1 18043069

20. Mercer SJ, Whittle CL, Mahoney PF. Lessons from the battlefield: human factors in defence anesthesia. Br J Anaesth. 2010;105(1):9–20. doi: 10.1093/bja/aeq110 20551025

21. Donat N, Schaal JV, Masson Y, Hoffmann C, Cirodde A, Nau A, et al. Anaesthesia in deployed settings. Anesth Reanim. 2017;3:440–449.

22. NATO: Chapter 16: Medical Support. NATO Logistics Handbooks, 1997. Available at; accessed February 1, 2019.

23. WHO (World Health Organization). 2013. WHO Model List of Essential Medicines. 18th List (April 2013) Final Amendments—October 2013.

24. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN. Disease control priorities, third edition: volume 1. Essential surgery. Washington DC: World Bank, 2015

25. Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT, et al. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet. 2015;385(9983):2209–19. doi: 10.1016/S0140-6736(15)60091-5 25662414

26. Cozowicz C, Poeran J, Zubizarreta N, Mazumdar M, Memtsoudis MG. Trends in the Use of Regional Anesthesia: Neuraxial and Peripheral Nerve Blocks. RAPM. 2016;41(1):43–9. doi: 10.1097/AAP.0000000000000342 26650430

27. Buckenmaier CC 3rd, Lee EH, Shields CH, Sampson JB, Chiles JH. Regional anesthesia in austere environments. RAPM. 2003;28(4):321–7. 12945026

28. Bourgouin S, Goudard Y, Montcriol A, Bordes J, Nau A, Balandraud P, et al. Feasibility and limits of inguinal hernia repair under local anaesthesia in a limited resource environment: a prospective controlled study. Hernia. 2017;21(5):749–757. doi: 10.1007/s10029-017-1631-x 28676927

29. Koscielniak-Nielsen ZJ. Ultrasound-guided peripheral nerve blocks: what are the benefits? Acta Anaesthesiol Scand. 2008;52(6):727–37. doi: 10.1111/j.1399-6576.2008.01666.x 18477070

30. Walker KJ, McGrattan K, Aas-Eng K, Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database Syst Rev. 2009;(4):CD006459. doi: 10.1002/14651858.CD006459.pub2 19821368

31. De Oliveira GS Jr, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials. Anesth Analg. 2014;118(2):454–63. doi: 10.1213/ANE.0000000000000066 24445643

32. Wilensky RJ. Military Medicine to Win Hearts and Minds: Aid to Civilians in the Vietnam War. Lubbock, TX: Texas Tech University Press, 2004.

33. Raju M. Psychological aspects of peacekeeping operations. Ind Psychiatry J. 2014;23(2):149–156. doi: 10.4103/0972-6748.151693 25788805

34. Agazio J. Army nursing practice challenges in humanitarian and wartime missions. Int J Nurs Pract. 2010;16(2):166–75. doi: 10.1111/j.1440-172X.2010.01826.x 20487062

35. D’Aranda E, Bordes J, Bourgeois B, Clay J, Esnault P, Cungi PJ, et al. Fraction of Inspired Oxygen Delivered by Elisée™ 350 Turbine Transport Ventilator With a Portable Oxygen Concentrator in an Austere Environment. J Spec Oper Med. 2016;16(3):30–35. 27734439

36. Wilder A. Aid and stability in Pakistan: lessons from the 2005 earthquake. Disasters. 2010;34:S406–26. doi: 10.1111/j.1467-7717.2010.01209.x 20846352

37. Drifmeyer J, Llewellyn C. Military training and humanitarian and civic assistance. Mil Med. 2004;169(1):23–9. doi: 10.7205/milmed.169.1.23 14964497

38. Kelly J. Following professional codes of practice and military orders in austere military environments: a controversial debate on ethical challenges. J R Army Med Corps. 2015;161:i10–i12. doi: 10.1136/jramc-2015-000545 26621807

39. Jenkins CL, Elliott AR, Harris JR. Identifying ethical issues of the Department of the Army civilian and Army Nurse Corps certified registered nurse anesthetists. Mil Med. 2006;171(8):762–9. doi: 10.7205/milmed.171.8.762 16933819

40. Tobin J. The challenges and ethical dilemmas of military medical officer serving with peacekeeping operation in regard to the medical care of local population. J Med Ethics. 2005;31(10):571–4. doi: 10.1136/jme.2004.008839 16199596

41. Reade MC. Medical assistance to civilians during peacekeeping operations: wielding the double-edged sword. Med J Aust. 2000;173(11–12):586–9. 11379496

42. Forrester JD, Forrester JA, Basimouneye JP, Tahir MZ, Trelles M, Kushner AL, et al. Sex disparities among persons receiving operative care during armed conflicts. Surgery. 2017;162(2):366–376. doi: 10.1016/j.surg.2017.03.001 28400124

43. Gyedu A, Abantanga F, Boakye G, Gupta S, Otupiri E, Agbeko AE, et al. Barriers to essential surgical care experienced by women in the two northernmost regions of Ghana: a cross-sectional survey. BMC Womens Health. 2016;16:27. doi: 10.1186/s12905-016-0308-4 27230890

44. Vlassoff C. Gender inequalities in health in the Third World: uncharted ground. Soc Sci Med. 1994;39(9):1249–59. doi: 10.1016/0277-9536(94)90357-3 7801162

45. Moss NE. Gender equity and socioeconomic inequality: a framework for the patterning of women’s health. Soc Sci Med 2002;54:649–61. doi: 10.1016/s0277-9536(01)00115-0 11999484

46. Bansal T, Hooda S. Anesthetic Considerations In Paediatrics Patients. JIMSA. 2013;26(2):127–31.

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2019 Číslo 10