Multimodal Spinal Anesthesia in Somalia: Evidence, Implementation Considerations, and a Safety Framework for Resource-Limited Settings - A Narrative Review.

BACKGROUND: Safe anesthesia remains difficult to deliver in many resource-limited settings because of shortages of trained providers, monitoring equipment, oxygen, essential medicines, recovery facilities, and critical-care support. Spinal anesthesia is widely used for cesarean delivery and selected lower abdominal, urologic, perineal, and lower-limb procedures. Its contemporary use extends beyond the intrathecal injection to include patient selection, dose planning, hemodynamic management, multimodal analgesia, monitoring, postoperative observation, and rescue readiness. OBJECTIVE: This narrative review examines the available evidence, implementation considerations, and minimum safety requirements for multimodal spinal anesthesia in Somalia and comparable resource-limited settings. METHODS: A structured narrative literature search was conducted using PubMed/MEDLINE, Google Scholar, ScienceDirect, Cochrane-related sources, WHO and WFSA resources, and relevant global surgery literature. Sources addressing spinal or neuraxial anesthesia, obstetric anesthesia, multimodal analgesia, anesthesia safety, low-resource surgery, and Somalia's anesthesia and critical-care context were considered. Evidence was synthesized thematically and categorized as published clinical evidence, international safety standards, contextual interpretation, or proposed implementation recommendations. FINDINGS: Spinal anesthesia may reduce dependence on some components of general anesthesia infrastructure for appropriately selected patients, but it is not inherently safe. Minimum requirements include a trained provider, patient assessment, blood-pressure and oxygen-saturation monitoring, intravenous access, oxygen, vasopressors, airway rescue equipment, postoperative observation, and protocols for hypotension, failed block, high spinal block, and conversion to general anesthesia. Cesarean delivery represents an important area for standardization. Intrathecal adjuvants should be selected according to each facility's monitoring and recovery capacity. CONCLUSION: Somalia-specific evidence on spinal anesthesia outcomes remains limited. The proposed framework should therefore be considered evidence-informed rather than locally validated. Prospective local audits are needed before claims regarding effectiveness, affordability, or improved outcomes can be made.