S Fyneface-Ogan

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.

Comparative Effects of Single Shot Intrathecal Bupivacaine with Dexmedetomidine and Bupivacaine with Fentanyl on Labor Outcome

Background. Effective intrapartum analgesia attenuates pain, stress, and anxiety which cause release of stress hormones as well as beta-endorphins. Aim. The purpose of this study was to determine the effect of adding dexmedetomidine to hyperbaric bupivacaine for neuraxial analgesia for labor. Methods. Ninety laboring multiparous women were allocated to have single shot intrathecal bupivacaine alone (B), bupivacaine with fentanyl (BF), or bupivacaine with dexmedetomidine (BD). Sensory and motor block characteristics; time from injection to two dermatome sensory regression, sensory regression to S1 dermatome, and motor block regression to Bromage 1 were recorded. Labor pain was assessed with a 10 cm verbal pain scale. Results. Peak sensory block levels in the three groups were essentially the same (). The time for sensory and motor blocks to reach T10 dermatome and Bromage 1, respectively, was faster in group BD than in the other groups (). The time for sensory regression to S1 was significantly prolonged in the group BD (). Motor block regression time to Bromage 1 was also prolonged in the group BD (). Neonatal outcome was normal in all groups. Conclusion. Single shot intrathecal bupivacaine/dexmedetomidine significantly prolonged sensory block in laboring women.

Anaesthetic management of a super morbidly obese patient for total abdominal hysterectomy: a few more lessons to learn

BACKGROUND The prevalence of obesity is on the upward trend world-wide. This epidemic has challenging implications for anaesthetists, following the anthropometric changes associated with the disease. OBJECTIVE To highlight some of the challenges, the management and the lessons learnt during the management of this patient. METHODS This is a case report of a 52-year old super morbidly obese, diabetic, and hypertensive patient that presented for total abdominal hysterectomy. Surgery was carried out under a single-shot spinal anaesthesia with bupivacaine/fentanyl. RESULTS Under bupivacaine/fentanyl anaesthesia, she became very drowsy and had moderate to severe respiratory depression. She was arousable but had an obstructive sleep apnoea. Surgery was carried out successfully CONCLUSION A better understanding of the pathophysiology and complications that accompany obesity is needed to manage an obese patient under anaesthesia.

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.

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