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Epidural anesthesia: Views and outcomes of women in labor in a Nigerian hospital

BACKGROUND Pain during childbirth is a well known cause of dissatisfaction amongst women in labor. The use of epidural analgesia in labor is becoming widespread due to its benefit in terms of pain relief. METHOD After approval of the local Ethics Committee on Research and obtaining informed written consent, 50 American Society of Anesthesiologists (ASA) class I-II consecutive multiparous women in labor requesting pain relief were enrolled in this prospective study. After providing description of the two options of pain relief available to them, they were allocated into two groups according to their request-to receive either parenteral opioid/sedative or epidural labor analgesia. Both groups received analgesia of choice at 4-cm cervical os dilatation. The epidural group received 0.125% plain bupivacaine, while the other group received pentazocine/promethazine intravenously. The time taken to locate the epidural space, catheter-related complications encountered and the amount of intravenous fluid used were documented. RESULT The two groups were comparable in terms of socio-demographic data. The mean duration of the first and second stages of labor, respectively, were significantly shorter in the epidural group when compared with those in the non-epidural group ([P < 0.01] and [P < 0.02]). There was no difference in the rate of cesarean delivery between them - epidural analgesia (32% [8/25]) versus parenteral opioid/sedative (44% [11/25]), (OR, 0.60; 95% CI, 0.19-1.90). The maternal blood loss from delivery was minimal, with no statistical difference between the two groups (P = 0.27). The neonatal outcome was the same in both groups. Closed questionnaire showed that the overall experience of labor was much better (it was also better than expected) in the epidural group when compared with that in the non-epidural group (80% versus 4%). Eighteen (72%) women had inadequate pain relief in the non-epidural group as compared to 2 (8%) women in the epidural group. CONCLUSION The study shows that epidural labor analgesia is acceptable to women in our setting. More women in the epidural analgesia group were satisfied with the experience of labor than those who did not receive this form of analgesia than among those who received parenteral opioid/sedative.

A comparison of the haemodynamic effects of lateral and sitting positions during induction of spinal anaesthesia for caesarean section

BACKGROUND Hypotension during spinal anaesthesia occurs commonly in parturients. By influencing spread of local anaesthetic, maternal position may affect the speed of onset of sensory block and thus the haemodynamic effects. The aim of this study was to determine whether inducing spinal anaesthesia for caesarean section using plain bupivacaine in the lateral position would result in less hypotension compared with the sitting position. METHODS One hundred American Society of Anesthesiologists physical status I and II patients undergoing elective caesarean section were randomised to receive spinal anaesthesia in the lateral position (Group L) or the sitting position (Group S). Using the L3-4 interspace, patients received intrathecal plain bupivacaine, 10mg or 12 mg according to their height, after which they were placed immediately in the supine position with left uterine displacement. Maternal blood pressure was measured every minute for 10 min, every three min for 20 min and 5-minutely thereafter. Hypotension was defined as a fall in systolic blood pressure >20% or a value <90 mmHg. RESULTS There was no difference in the lowest recorded systolic blood pressure in Group L (99.2±8.9 mmHg) compared with Group S (95.4±12.3 mmHg, P=0.081). However, the lowest recorded mean arterial pressure was greater in Group L (72.9±11.2 mmHg) than in Group S (68.2±9.6 mmHg; P=0.025). The incidence of hypotension was lower in Group L (17/50, 34%) than in Group S (28/50, 56%; P=0.027). Onset of hypotension was similar between groups. CONCLUSION Hypotension occurred less frequently when spinal anaesthesia for caesarean using plain bupivacaine was induced with patients in the lateral compared with the sitting position. Values for the lowest recorded mean arterial pressure were greater but values for the lowest recorded systolic blood pressure were similar for patients in the lateral position group.

The differential impact of two anesthetic techniques on cortisol levels in Nigerian surgical patients.

BACKGROUND Surgical procedures are associated with a complexity of stress response characterized by neurohumoral, immunologic, and metabolic alterations. AIM The aim was to compare the effects on the stress response by isoflurane-based intratracheal general anesthesia (ITGA) and bupivacaine-based epidural anesthesia (EA), using cortisol as a biochemical marker. MATERIALS AND METHODS Following the approval of the Hospital Ethical Board, informed written consent from patients recruited into this study was obtained. One group received general anesthesia with relaxant technique (group A) while the other group had bupicaine epidural anesthesia with catheter placement for top-ups (group B) for their surgeries. Both groups were assessed for plasma cortisol levels - baseline, 30 minutes after skin the start of surgery and at skin closure. RESULTS There was no statistically significant difference in the baseline mean heart rate, mean arterial pressure (mean MAP) and the mean duration of surgery between the two groups; the baseline mean plasma cortisol level was 88.70 ± 3.85 ng/ml for group A and 85.55 ± 2.29 ng/ml for group B, P=0.148. At 30 minutes after the start of surgery the plasma cortisol level in the GA group was 361.60 ± 31.27 ng/ml while it was 147.45 ± 22.36 ng/ml in the EA group, showing a significant difference, P=0.001. At skin closure the mean plasma cortisol value of 384.65 ± 48.04 ng/ml recorded in the GA group was found to be significantly higher than the value of 140.20 ± 10.74 ng/ml in the GA group, P<0.002. CONCLUSION Using plasma cortisol as a measure, bupivacaine-based epidural anesthesia significantly reduces the stress response to surgical stimuli when compared with isoflurane-based tracheal general anesthesia.

Pre-Incisional Intravenous Low-Dose Ketamine Does Not Cause Pre- Emptive Analgesic Effect Following Caesarean Section under Spinal Anaesthesia

Background: Adequate postoperative pain relief is one of the commonest challenges faced by women who deliver by caesarean section. Aim: This study was aimed at finding out the effect of pre-incisional administration of low dose intravenous ketamine on the post-operative analgesia demand time. Patients and Methods: Following approval from the Hospital’s Ethical Committee, a prospective, randomised double-blind study was carried out to evaluate the pre-emptive effect of low-dose ketamine on women undergoing elective caesarean section under plain bupivacaine/fentanyl spinal anaesthesia. Results: Eighty women completed (83.33%) the study. The results were comparable in both groups for maternal age, weight, height, gestational age and parity. There was no statistical difference in the patient characteristics between the two groups under study. The mean time taken to achieve a maximal sensory level was 9.3±0.91 mins in Group-A and in Group-B 8.35±1.49 mins, p=0.260. The regression time to two segments was also the same in the two groups of women. The mean in the Group-A was 28.1±1.52 mins while the Group-B had 27.6±2.10 mins, p=0.161. The time to first analgesic request in the Ketamine Group was 193.44±26.53 mins while that for the Placebo group was 140.14±22.34 mins. The difference in the duration was statistically significant, p=0.0001. Conclusion: It is concluded that the pre-incisional administration of low-dose intravenous ketamine only demonstrated a delayed time to first analgesic request in the women who had plain bupivacaine/fentanyl spinal anaesthesia and not a pre-emptive analgesic effect.

Pattern of admissions to the University of Port Harcourt Teaching Hospital intensive care unit – a 10-year analysis

Objective. To determine the admission pattern and outcome of patients in the Intensive Care Unit (ICU) of University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria. Method. A retrospective review of all patients admitted to the ICU at the UPTH from 1996 to 2005 was carried out. Data were obtained from the ICU admission and discharge registers and nurses’ handover records. Results. A total of 1 447 patients were admitted from 15 departments. There were 658 males and 789 females (male/female ratio 1:1.2). Ages ranged from 4 months to 90 years, the median age was 30 years and the mean age was 31.7±5.6 years. The highest proportion of admissions (48.7%) was from the Department of Obstetrics and Gynaecology, and the lowest from Ophthalmology and Anaesthesia (0.1%). Postoperative cases made up 62.1% of total admissions, with post-caesarean section (CS) contributing 65.7% of these. Non-availability of beds in the ward was the reason for the majority of the post-CS admissions. Up to 41.5% of the patients admitted to the ICU had no justifiable reason for admission. Average length of stay was 8.1±2.8 days, median 4.5 days. One patient was manually ventilated for 5 hours, none was mechanically ventilated, and none had invasive cardiac monitoring. Three children had peritoneal dialysis for acute renal failure. Unconscious patients were fed enterally through a nasogastric tube, while conscious patients ate orally. Analysis of outcomes showed that 597 patients (41.3%) were transferred to the wards, while 352 (24.3%) were discharged home. The outcome was not indicated in 128 cases (8.8%), 16 patients (1.1%) left the ICU against medical advice, 1 patient (0.1%) was referred to another tertiary institution and 1 (0.1%) absconded. Three hundred and fifty-two patients died, giving a mortality rate of 24.3%. Conclusion. The highest percentage of admissions to the ICU was from the Department of Obstetrics and Gynaecology. The majority of the patients did not require intensive care but were admitted because there was no bed in the wards.

Attitude of anaesthetists to intra-operative catastrophes: a questionnaire survey

Abstract Background: Although anaesthetic deaths are uncommon, most anaesthetists are likely to be involved with an anaesthetic catastrophe at some point in their careers. This experience may have significant psychological impact on the staff concerned. Formal incident reporting accompanies anaesthetic deaths, and in addition involved personnel frequently need professional counseling. Objective: To determine the impact and attitude of Nigerian anaesthetists towards an intra-operative death. Method: A structured-questionnaire survey of 65 Nigerian physician anaesthetists, of all grades, attending a National Anaesthetic Scientific forum, was carried out to collect relevant information using a descriptive study design. Nurse anaesthetists were excluded from the study Data was analysed using simple mathematical correlates. Results: The response rate was 86%. Out of a total mortality of 77, 48 (62%) were unanticipated. Emergency procedures accounted for 61 (79%) of these mortalities. Only 32 (41%) of the critical incidents were formally reported. Forty-eighty (86%) of the respondents were psychologically affected by the intraoperative catastrophes reported. In order of frequency of incidence, lingering memories of the event accounted for 38%, depression 28% and cardiac dysrhythmias 2% amongst others. Most of the 49 (88%) respondents that were psychological affected did not have any form of debriefing. Conclusion: Critical incident reporting should be encouraged, whilst anaesthetic departments should have departmental guidelines for managing the aftermath of critical incidents, and ensuring psychological support for their practitioners. Trainees should undergo a training module in psychological debriefing following critical incidents as part of their curriculum. Medical Defence Organizations should be established in developing countries with appropriate government legislation.

Charcoal-roasted plantain and fish vendors in Port Harcourt: A potential anaesthetic high risk group?

Summary A survey of charcoal-roasted plantain and fish (CRPF) vendors in Port Harcourt, Nigeria was carried out to determine if they were a potential anaesthetic high risk group. Questionnaires which contained vendors biodata and educational qualification including information on hours of exposure as well as number of years in the business and respiratory symptoms if present were filled by the authors in the presence of the vendors. Oxygen saturation and heart rate were recorded using the Nonnin 9250 portable battery-operated oximeter. Results were programmed into Microsoft EXCEL work sheet and data analysed. A total of 102 vendors were visited at their place of work over a three month period. Two declined to be interviewed leaving 100 vendors. All vendors were women aged 16 to 60 years (mean 34.3 years). More than half of the vendors (52%) had secondary level education. Seventeen per cent were part-time vendors while 83% were full-time. Number of years of exposure ranged from 1 to 30 years (Mean 6.4 years). The daily duration of exposure ranged from 4 to 14 hours (mean 7.7 hours). Mean oxygen saturation was 97%, while mean pulse rate was 85bpm. There were no significant respiratory symptoms. We conclude from this survey that outdoor cooking or roasting with charcoal less than 14 hours daily for less than 10 years may not be enough to cause respiratory problems or pose any significant anaesthetic risk.

Prophylactic Infusions of Phenylephrine and Ephedrine during Combined Spinal Epidural Anaesthesia for Caesarean Section: A Comparative Study

Background: Hypotension is the most common adverse effect in parturients after spinal anaesthesia for Caesarean section. Despite various pharmacological and non-pharmacological methods used in its prevention and treatment, vasopressors have become very important in the management of this form of hypotension. Objective: This study was aimed at comparing the efficacy and safety of prophylactic intravenous infusions of phenylephrine and ephedrine at preventing maternal hypotension during Combined Spinal Epidural anaesthesia (CSE) for Caesarean section. Methods: Sixty ASA I and II patients scheduled for elective Caesarean section, were randomly allocated into two groups. Patients in Group I received Phenylephrine 80 μg/min while patients in Group II received Ephedrine 1 mg/min immediately after the subarachnoid 10 mg plain bupivacaine injection while the epidural catheter was being inserted and secured. All the patients received a crystalloid preload of 1 litre of 0.9% normal saline prior to the induction of CSE. Results: The overall incidence of hypotension was 8.5% (6.7% in the phenylephrine group and 10.3% in the ephedrine groups). The lowest systolic (105.8 ± 9.2 mmHg) and diastolic arterial pressures (60.9 ± 8.9 mmHg) occurred in the ephedrine group while the lowest heart rates occurred in the phenylephrine group. The mean umbilical artery pH was 7.3 while Apgar scores at 1st and 5th min were essentially the same in the two groups. Conclusion: Prophylactic intravenous infusions of phenylephrine and ephedrine are safe and effective at reducing the incidence and severity of hypotension during combined spinal epidural anaesthesia for elective Caesarean section with no associated neonatal acidosis.

Assessment of Knowledge of Cardiopulmonary Resuscitation of Pregnant Women among Physician Obstetric Care Givers in the South-South of Nigeria

Background: Obstetricians are usually well prepared for and knowledgeable about the challenges of the birthing process. Cardiac arrest during pregnancy is uncommon, and many never encounter it throughout their practice. Objectives: The aim of this study was to evaluate the knowledge of maternal cardiopulmonary resuscitation of various cadres of physician obstetric care givers in five tertiary institutions in the south-south of Nigeria. Methodology: Questionnaires detailing years of experience of the physician caregivers, level of care involved in, previous experience with pregnant women requiring cardiopulmonary resuscitation, as well as formal training in cardiopulmonary resuscitation were distributed during Obstetrics Clinical Meetings in 5 tertiary hospitals. The questionnaire also evaluated knowledge of maternal resuscitation following cardiac arrest and awareness of Advanced Life Support in Obstetrics (ALSO) as well as International Liaison Committee on Resuscitation (ILCOR) guidelines. Data obtained were entered into Microsoft Excel and results expressed in simple percentages. Results: Out of 260 questionnaires distributed, 253 were returned (response rate 97.31%). There were 78 Consultant Obstetricians, 63 Senior Registrars, 70 Registrars and 42 House-Officers. Although 76% of the respondents have participated in the resuscitation of the pregnant woman, only 3 (1.19%) had formal training in cardiopulmonary resuscitation. Only 5 (1.98%) physician obstetric care givers were able to rank correctly the steps taken during maternal cardiopulmonary resuscitation following a cardiac arrest. The correlation between the knowledge of maternal resuscitation and the years of experience was not significant (r= - 0.314; p=0.143). Conclusion: Majority of Physician Obstetric care givers in tertiary hospitals in the south-south of Nigeria do not have appropriate knowledge of cardiopulmonary resuscitation of the pregnant woman following cardiac arrest. Keywords: Cardiopulmonary resuscitation, pregnant women, Physician Obstetric Care Givers, Knowledge

Out-of-pocket health expenditure: a preliminary survey of impact on households of patients in the intensive care unit of a tertiary hospital in Nigeria

Background: Patients are often required to make direct out-of-pocket payments for medical care in hospitals in Nigeria. atients admitted into the Intensive Care Unit of the University of Port Harcourt Teaching Hospital from 1st July to 31st December 2008 recorded relationship to patient, payment pattern, household monthly income bracket, amount spent since admission, sources of funds for payment and effects of expenditure on households as well as effects of continued stay in the ICU. Results: Sixty-four relatives were interviewed out of 76 admissions. Representatives were spouses (34.4%), siblings (31.3%), children (18.8%), parents (12.5%) and colleagues (3.1%). Income brackets/month were: no income (12.5%), N 200, 000 (9.4 %). Twenty-four households (37.5%) had spent N 100,000 since admission. Sources of funds were personal savings (48.4%), borrowing (40.6%), payment by employers (6.3%) and sale of assets (4.7%). Six households (9.4%) felt no impact of the expenditure at the time; but this was reduced to 4 (6.3%) with continued stay. Affected households reported financial hardships resulting in reduction in spending for other projects (31.3%), feeding difficulties (25.0%), inability to pay house rent (18.8%) and dropping out of school (15.5%). Conclusion: Direct out-of-pocket health expenditure by households of ICU patients causes depletion of personal savings and borrowing resulting in financial hardship. Key words: Out-of-pocket health expenditure, intensive care patients, impact on households.