Ibironke Desalu

Low-dose intravenous ketamine improves postoperative analgesia after caesarean delivery with spinal bupivacaine in African parturients

BACKGROUND In the absence of neuraxial opiates, postoperative analgesia after caesarean delivery is limited by the duration of action of bupivacaine. This could be prolonged by the co-administration of adjuvants such as ketamine. METHODS Spinal anaesthesia was performed in 60 parturients using hyperbaric bupivacaine 15 mg. Patients were randomly allocated to receive a 2-mL intravenous injection of either ketamine 0.15 mg/kg (Group BK) or 0.9% saline (Group B) immediately after institution of spinal anaesthesia. Postoperative pain was assessed using a visual analogue scale and the time of first postoperative analgesic administration was noted. Postoperative analgesia was provided with intramuscular pentazocine and diclofenac, the total doses of which were recorded over 48 h. RESULTS The mean (SEM) time of first postoperative analgesic administration was significantly longer in Group BK (209±14.7 min) than in Group B (164±14.1 min) (P<0.001). Pain scores were significantly lower in Group BK than in Group B for 120 min after surgery (P=0.022). Patients in Group BK required significantly less diclofenac (P<0.001) and pentazocine (P<0.001) on day one after surgery. There was no difference in diclofenac (P=0.302) and pentazocine (P=0.092) consumption between the groups on the second postoperative day. The incidence of adverse effects was not different between the groups. CONCLUSION The use of intravenous low-dose ketamine as an adjuvant to bupivacaine for spinal anaesthesia for caesarean delivery was associated with longer postoperative analgesia and lower early postoperative analgesia consumption than bupivacaine alone.

Incidence, Clinical Outcome and Risk Factors of Intensive Care Unit Infections in the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria

Background Infections are common complications in critically ill patients with associated significant morbidity and mortality. Aim This study determined the prevalence, risk factors, clinical outcome and microbiological profile of hospital-acquired infections in the intensive care unit of a Nigerian tertiary hospital. Materials and Methods This was a prospective cohort study, patients were recruited and followed up between September 2011 and July 2012 until they were either discharged from the ICU or died. Antimicrobial susceptibility testing of isolates was done using CLSI guidelines. Results Seventy-one patients were recruited with a 45% healthcare associated infection rate representing an incidence rate of 79/1000 patient-days in the intensive care unit. Bloodstream infections (BSI) 49.0% (22/71) and urinary tract infections (UTI) 35.6% (16/71) were the most common infections with incidence rates of 162.9/1000 patient-days and 161.6/1000 patient-days respectively. Staphylococcus aureus was the most common cause of BSIs, responsible for 18.2% of cases, while Candida spp. was the commonest cause of urinary tract infections, contributing 25.0% of cases. Eighty percent (8/10) of the Staphylococcus isolates were methicillin-resistant. Gram-negative multidrug bacteria accounted for 57.1% of organisms isolated though they were not ESBL-producing. Use of antibiotics (OR = 2.98; p = 0.03) and surgery (OR = 3.15, p< 0.05) in the month preceding ICU admission as well as urethral catheterization (OR = 5.38; p<0.05) and endotracheal intubation (OR = 5.78; p< 0.05) were risk factors for infection. Conclusion Our findings demonstrate that healthcare associated infections is a significant risk factor for ICU-mortality and morbidity even after adjusting for APACHE II score.

Improvement in intensive care unit: Effect on mortality

Background: The Lagos University Teaching Hospitals Intensive Care Unit (ICU) was founded in 1975. It was designed as an eight-bedded ICU, a previous review of outcome of surgical admissions in the ICU in 2002 placed mortality at 40.3%, however, presently run as a five-bed unit with new ICU equipment procured in 2012, arterial blood gas machines, patient monitors, and ventilators with sustained multidisciplinary approach to patient management. We compared the number of admissions, mortality, and discharges to the ward 1 year before (Period I) and after the upgrade of the ICU facilities (Period II). Methods: This was a retrospective study of all patients admitted into the ICU between June 2011 and May 2013. We looked at the admission register of the ICU and retrieved biometric data, diagnosis, age, pattern of units admitting patients into ICU, length of stay (LOS), and outcome of ICU care whether the patient died in ICU or was discharged to the ward. Results: There were 122 patients admitted into the ICU in Period I and 156 patients were admitted in Period II with a mean LOS of 6.3 ± 5.4 days and 7.8 ± 7.3 days, respectively. Mortality rate in Period I was 74.6% while mortality fell to 57.7% in Period II (P = 0.005). Conclusion: There was a significant improvement in the ICU outcome with the upgrade of the ICU facilities.

The outcome of anaesthesia related cardiac arrest in a Sub-Saharan tertiary hospital

Abstract Background Anaesthesia related cardiac arrest is undesirable, and different attempts have been made to reduce the mortality associated with it through continuous specialist training, and provision of state of art equipment, combined with rigorous research. Patients and methods We determined the outcome of all cardiac arrests that occurred within 24 h of a surgical procedure and anaesthesia from January 2013 to May 2014. Results There were nine anaesthesia related cardiac arrest in 4229 cases, (incidence of 21.28 per 10,000), with a mortality of 7/4229; (16.55 per 10,000). There were 60 perioperative cardiac arrests (incidence of 141.88 per 10,000), with a mortality of 55/4229 (130.05 per 10,000). There was return of spontaneous circulation in 34 (56.67%) cases, among them only 7 (20.59%) survived to hospital discharge. The independent determinant of perioperative mortality was the duration of cardiac arrest ⩾ 5 min (RR 10.50, 95% CI 2.721–40.519, p < 0.001), cardiac arrest in the absence of a witness (RR 9.56, 95% CI 2.486–36.752, p < 0.001), nonstandard time of cardiac arrest (RR 3.2, 95% CI 1.792–5.714, p < 0.001), ASA physical status ⩾ III (RR 2.017, 95% CI 1.190–3.417, p = 0.017), and emergency surger (RR 2.17, 95% CI 1.151–4.049, p = 0.011). Conclusion Anaesthesia related cardiac arrest and mortality were linked to cardiovascular depression from halothane overdose in our institution. The burden can be reduced by improving on establishing standard monitoring in the perioperative period, and a team approach to patients care.

The Effect of Pre-Incision Field Block versus Post-Incision Inguinal Wound Infiltration on Postoperative Pain after Paediatric Herniotomy

BACKGROUND: The Ilioinguinal/iliohypogastric nerve block has been shown to significantly decrease opioid analgesic requirements and side effects after inguinal herniotomy. We compared the effect of pre-incisional field block with 0.25% bupivacaine and post-incisional wound infiltration with 0.25% bupivacaine for postoperative pain control after inguinal herniotomy. PATIENTS & METHODS: This was a randomized controlled double blind study in 62 ASA I and II children aged 1-7 years scheduled for inguinal herniotomy. They were assigned to receive either pre-incision field block (group I) or post-incision wound infiltration at the time of wound closure (group II). The pain score was assessed in the recovery room using mCHEOPS score and VAS or FLACC score at home by the parents for 24 hours. RESULTS: The mean pain scores during the 2 hour stay in the recovery room, at 12 and 18 hours at home were similar in both groups, p > 0.05. However, the mean pain scores were significantly lower at 6 hours at home in group I (1.22 ± 0.57) than in group II (1.58 ±0.90), p <0.001, but significantly higher at 24 hours at home in group I (3.29 ± 0.46) than in group II (2.32 ± 0.24), p = 0.040. There was no difference in mean paracetamol requirement, and in the number of patients who required paracetamol for pain relief at home in both groups, p > 0.05. CONCLUSION: We have demonstrated that both pre-incisional ilioinguinal/iliohypogastric field block and post incisional wound infiltration provided adequate postoperative analgesia for 24 hours after inguinal herniotomy.

Complications and outcomes following central neuraxial anesthesia in a sub-Saharan Tertiary Hospital: The legal implication

Abstract Background Complications following central neuraxial anesthesia have led to litigations and claims in developed nations, however, the incidence of litigation is low in our environment. Anesthetist practicing in Nigeria need to be aware that such complications are not uncommon. Aim and objective To determine central neuraxial anesthesia related complications and the legal implications. Method This was a prospective observational study conducted in 821 patients scheduled for surgery under central neuraxial anesthesia from February 2012 to January 2013. The choice of anesthesia depended on the indication and the duration of surgery. Results The observed complications of central neuraxial anesthesia, which may result in litigation included inadvertent high block (22.4%), paresthesia during needle placement (6.2%), inadequate block (3%), failed block (1.2%), and postdural puncture headache (1.15%). Others were seizure (0.1%), meningism (0.1%), persistent pain in the lower limb for 48 hours (0.1%), back pain (0.7%) and cardiac arrest (0.49%); three of the four cardiac arrest died. There was, however, no report of litigation or claim in this study. Conclusion We have demonstrated that complications, which may result in litigation and claim following central neuraxial anesthesia is not a rare occurrence in our institution. However, there was no record of litigation or claim in our review. Anesthetist in Nigeria need to be aware of the legal implication of such complications. When performing blocks, well recognized complications should be discussed before obtaining consent. If any untoward effect occurs, a detailed note of the findings and treatment should be documented for future reference.

Cortisol and Insulin Levels during Major Gynaecological Operations: The influence of Two Anaesthetic Techniques

Abstract BACKGROUND: Metabolic and hormonal changes are noticed within the first few hours after surgical injury. These changes are influenced by the intensity, duration, type of injury, and the anaesthetic techniques. AIM: To investigate the effects of anaesthesia on cortisol, insulin and glucose concentrations during major gynaecological surgeries. METHODS: Forty patients were randomly allotted to receive either balanced general anaesthesia (n=20) or combined spinal epidural anaesthesia extending from T5 to S5 (n=20). Blood samples were collected for cortisol and glucose at preinduction, 1, 3 and 4 hours, and for insulin at preinduction and 24 hours after incision. RESULTS: The mean cortisol concentration was significantly lower 4 hours after incision with combined spinal epidural anaesthesia (19.96 ± 11.32) μg/dl than with balanced general anaesthesia (38.94 ± 10.6) μg /dl, p = 0.018. The mean insulin concentration, 24 hours after incision decreased with combined spinal epidural anaesthesia, but increased with balanced general anaesthesia p = 0.403. The mean glucose concentrations were significantly lower with combined spinal epidural anaesthesia than with balanced general anaesthesia during the 4 hour study period p ≤ 0.05. CONCLUSION: combined spinal epidural anaesthesia extending from T5 to S5 resulted in lower cortisol, insulin and glucose concentrations during major gynaecological surgeries. This may be of benefit in patients scheduled for surgical operations below the umbilicus.

Endotracheal intubation in the prone position, in a patient with a high-velocity missile injury to the abdomen and thorax

The airway management in prone position secondary to penetrating posterior thoracic injury is challenging to the anesthetist. We described a successful endotracheal intubation under direct laryngoscopy at first attempt in the prone position in a 25-year-old male with a 6-foot hollow metal impacted in the right posterolateral thorax.

Coming in from the cold....intensive care induced anxiety state on return of consciousness

The emergence from anaesthesia is well known to be a frightening period for patients, as alteration in memory and perception often leads to confusion and resistance. Anaesthetists constantly talk patients through this period, reminding them that they have just had an operation, encouraging them to tolerate whatever airway device may be in place and thus preventing both physical and psychological trauma. In the ICU setting, return of consciousness may not be so well defined, and patients are often left in a vulnerable, confused dream-like state.