In October 2004, Kybele visited Orioni Maternity Hospital located in the Georgian capital, Tbilisi. This private maternity hospital performs approximately 1,600 deliveries per year. The facility is eight years old and is a multi-profile clinic, providing antenatal, postpartum and infant care. Dr. David Gagua, the chief obstetrician, provided information through a translator. He said that the cesarean section rate is 12-13% in his hospital with 12 obstetricians and one operating room. He considers the anesthesia team to be “pioneers” in obstetric anesthesia; there are five anesthesiologists dedicated to providing obstetric patient care. They perform roughly 25-35 epidurals and 120-140 deliveries per month. The cost of an epidural is approximately 80 lari ($42.00 US dollars) including the anesthesia fee. Epidural use is limited by fear in some patients as well as cost – the average monthly salary in Georgia is only $30.00 USD.
Dr. Giorgi Gongadze, the chief of obstetric anesthesia, gave Kybele a tour of the facility and described the practice. The “epidural kit” is a Portex kit that consists of only a needle and catheter – the glass loss of resistance syringe is reused. Some of the staff still use a double catheter technique with lumbar epidural and caudal analgesia. Lidocaine 10% is the only local anesthetic available and is diluted for intermittent dosing. Cesarean sections are done primarily with general anesthesia (95%) utilizing ketamine and oxygen. There is an antiquated Russian anesthesia machine with a halothane vaporizer but this is rarely used due to fear of uterine atony. Spinal needles and bupivacaine are not available. 

  

A team of 12 arrived in Tbilisi, Georgia September 9-23, 2006 including Medge Owen (Wake Forest), Brittany Clyne (Charlotte, NC), John Schultz (Duke), Virgil Manica (Tufts-NEMC), Melvin Seid (Winston-Salem, NC), Lisa Councilman-Gonzales (Texas A&M), Wendy Gore-Hickman and Anita Harding (Canada), Simon Millar and Rod Hamilton (Scotland), and Philippe and Hanka Gautier (Belgium). Thirteen hospitals were visited in Gori, Tbilisi, and Kutaisi, Georgia and two medical education conferences were presented, one in Tbilisi and one in Kutaisi. Both were well-attended (120 physicians) and quite interactive between the attendees and the presenters. Approval was obtained by the Ministry of Health in Georgia for Kybele to bring bupivacaine, ephedrine, and phenylephrine for teaching demonstrations. Currently these drugs are either not available or available only on the black market. Health officials have asked for our help to gain approval for long-acting local anesthetics and ephedrine in their country, providing a great step forward in the development of regional and obstetric anesthesia. 

The team was split into groups of 2-3 to enable multiple hospitals to be visited each day. The anesthesia conditions were much worse than expected. In Georgia, anesthesia monitors were limited or non-existent. In fact, we observed entire surgeries performed with only an occasional finger on the pulse by the anesthesiologist. In other words, there were no blood pressure monitors, oxygen monitors (pulse oximeters) or ECG! A few hospitals were well-equipped, but conditions for women in the maternity houses were universally poorer. Other common practices observed during cesarean sections in multiple hospitals were pre-medication with valium, no pre-oxygenation to prevent oxygen desaturation during anesthesia induction, no lateral tilt of the patient to prevent aortocaval compression, intravenous ketamine and succinylcholine used routinely for induction of general anesthesia, no aspiration prophylaxis, no cricoid pressure and mask ventilation during induction of general anesthesia, no end-tidal CO2 available for confirmation of endotracheal tube placement, and poor sterile technique. We hope to help alter these practices to improve safety and the adherence to standard evidence-based guidelines.  

 

We had the opportunity to demonstrate and teach state-of-the-art patient care with appropriate monitoring and compassion during the hospital visits, and we were featured on a Georgian television program providing analgesia for a primiparous patient who delivered in comfort with her husband by her side. The film team was personally moved by this experience because they had all had poor birthing experiences. Regional anesthesia supplies, text books, and other teaching materials were donated. 

We were wonderfully received by our hosts, who went to great lengths to ensure an unforgettable experience for the team. We were visible at the national level in Georgia through the media and with meetings with high-ranking government officials. There is a lot of enthusiasm for a return visit next year. Following our visit, Dr. Manana Kshutashvili of Tbilisi, Georgia wrote, “I hope we will remain friends and will continue partnership...I hope the next visit will be even more fruitful as we have received request from West Georgia to include towns like Zugdidi, Sachkhere, Tkibuli, and of course Kutaisi.”  And Dr. Tengiz Asatiani wrote, “I can say that Kybele in general was very successful and will have a big impact on development of regional anesthesia in hospitals where this method was not used widely.”  

On September 17 the team traveled by bus to Yerevan, Armenia. Six hospitals were visited in Yerevan, each by groups of 2-3 team members who gathered information and did extensive clinical teaching in regional anesthesia. A two-day medical education conference was presented and was attended by 76 physicians. Very lively discussion ensued during the conference, educating both the presenters and the attendees. Anesthesia conditions in Armenia were also worse than expected. Anesthesia monitors were available in some hospitals and the operating rooms appeared very modern and well-equipped, but observation during working hours identified that the monitors were infrequently used during general anesthesia. As in Georgia, general anesthesia was the most common anesthesia for cesarean section and similar practices were observed. Some patients were placed on a succinylcholine infusion without additional ketamine doses, placing the patients at high risk for being paralyzed but awake during surgery! In fact, many patients were told that they could experience recall during cesarean section because anesthesia is considered dangerous. Many practices are left over from Russian days, including the diagnosis of myopia as an indication for a primary cesarean section (“if the eyes are weak, the uterus is weak”).  

We were wonderfully received by our hosts who provided us with daily feasts and cultural excursions after our hospital visits, making our experience extremely memorable. The hospitality of the Armenian people is truly incredible. There was enthusiasm for us to return to present future medical education conferences. Following our visit, Dr. Armen Varosyan wrote, “I also would like to thank you very much for your visit and especially for the medical conference, which was very useful for our audience. Your efforts to share your knowledge and experience with our specialists were greatly appreciated by all attendees of the conference, and most of them would like to have more occasions in the future to meet with you.” 

Amid national political turmoil, an 8 member Kybele team arrived in Georgia November 9-17, 2007. The first patient-controlled epidural analgesia (PCEA) infusion in Georgia was administered by Kybele team members to a laboring patient in Orioni Hospital in Tbilisi. Numerous infusion pumps and adminstration sets were donated to Georgia on this trip by Novant-Forsyth Medical Center in Winston-Salem, North Carolina. Since the previous Kybele visit, Orioni has implemented the use of spinal anesthesia for cesarean section following the national approval of bupivaciane. Drs. Lisa Councilman and Virgil Manica endured a 6 hour drive over poor road conditions and in bad weather to Batumi, Georgia, on the Black Sea coast. They spent the week working in several hosptitals demonstrating spinal anesthesia for OBGYN procedures and giving multiple conferences. They were graciously received. We continue to identify culltural and local issues impacting wormen's health care in Georgia. Future trips and conferences will be planned to further education in safe obstetric anesthesia. Our primary goal is education; we hope to lower maternal morbidity and mortality by teaching during the acute management of the parturient and newborn. This goal is in accordance with the Georgian health services, the WHO and UN agencies. 

The next trip to Georgia is planned for September 2008. Please contact Dr. Brittany Clyne for more information (bbclyne@hotmail.com).  August 2008 Update:  The October 2008 trip has been momentarily postponed due to instability within the country of Georgia.