Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices

Background: Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric proceduralsedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. Methods: This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Results: Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. Conclusions: The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

A comparative study of ketofol and fentafol for evacuation of retained products of conception (ERPC)

Background: Intravenous balanced anesthesia (IVA) is desirable during the evacuation of retained products of conception (ERPC) to avoid the use of inhalational anesthetics agents that may cause uterus relaxation, the possibility of bleeding, and the risk of uterus perforation. Objectives: The aim of this study was to compare the efficacy and safety of ketofol (a mixture of propofol and ketamine) versus fentafol (a mixture of propofol and fentanyl) during the ERPC. Methods: A double-blind, randomized comparative study was conducted among a total of 60 women of childbearing age categorized as grades I and II according to the American Society of Anesthesiologist (ASA), presented for ERPC. The patients were selected and randomized blindly into two groups (K group and F group), with 30 patients in each group. The K group was given ketofol (1ml containing 5mg of propofol and 5mg of ketamine) and F group was given fentafol (1ml containing 5mg propofol and 5mcg fentanyl). An intravenous loading dose of ketofol or fentafol was given slowly, with doses ranging from 1ml to 2ml/10kg, to reach level 5 or 6 of the Ramsay Scale of Sedation (RSS), followed by small incremental doses which were given when RSS dropped to 4. Hemodynamic parameters, success, and side effects were assessed throughout the procedures. Results: K group demonstrated a significant increase in heart rate (HR) and blood pressure (BP), compared to significant decreases in the F group. Decreases in oxygen saturation (SpO2) and respiratory rate (RR) were observed more in the F group. However, no patients developed hypertension, hypotension, apnea, hypoxemia or serious adverse effects. Ketofol showed less propofol consumption and a short recovery time. Conclusions: Both ketofol and fentafol offer optimum conditions for ERPC. Ketofol is characterized by more stable hemodynamic parameters, a smaller dosage and faster recovery

Accès d'euphorie au réveil d'une sédation avec le propofol

L'objectif de cette revue était de rapporter les effets hallucinatoires survenus chez un sujet de 30 ans, au réveil d'une sédation au propofol pour endoscopie digestive. Le propofol est un hypnotique intraveineux d'utilisation courante lors des anesthésies pour gestes de courte durée comme les procédures diagnostiques en radiologie et en endoscopie. Le réveil post-anesthésie est qualifié « de très bonne qualité », cependant des effets hallucinatoires et psychodysleptiques ont fait l'objet de quelques écrits dans la littérature. Nous rapportons un cas d'accès d'euphorie post-anesthésique après sédation au propofol pour une endoscopie digestive

Expériences visuelles au cours de la chirurgie de la cataracte sous anesthésie péribulbaire

But. Décrire les expériences visuelles des patients au cours de la chirurgie de la cataracte sous anesthésie péribulbaire. Patients et méthodes. Nous avons mené une étude transversale pendant une période d'un mois au CHU-IOTA (Bamako). Étaient inclus les adultes opérés de la cataracte sous anesthésie péribulbaire sans sédation. Les patients étaient interrogés 1 à 4 heures après l'intervention sur les sensations visuelles de l'œil opéré, durant la chirurgie. Résultats. Deux cent sept (207) patients (105 hommes et 102 femmes) ont été retenus. Leur âge moyen était de 62,94 ans ± 12,5. L'acuité visuelle préopératoire des patients était comprise entre 1/10 et la perception lumineuse. Cent cinquante-huit (76,3%) patients ont rapporté des phénomènes visuels observés pendant l'intervention. Il s'agissait de la lumière (rapportée par 76,3% de patients), des couleurs (31,9%), des instruments (22,7%), des doigts du chirurgien (25,1%), de l'eau (27,1%) et des mouvements vagues (19,8%). Parmi eux, 38% étaient effrayés par ces sensations visuelles. Conclusion. Plus de trois-quarts de patients ont des expériences visuelles au cours de la chirurgie de la cataracte sous anesthésie péribulbaire. Certains sont effrayés par ces phénomènes visuels. Il est important de faire un counseling préopératoire approprié afin de réduire le stress des patients

Analgesic efficacy of dexmedetomidine versus fentanyl as an adjunct to thoracic epidural in patients undergoing upper abdominal surgery: a randomized controlled trial

Background: This randomised, double-blind study was designed to assess the analgesic efficacy of dexmedetomidine as compared with fentanyl as an adjunct to local anaesthetic in thoracic epidural for upper abdominal surgeries. Methods: Forty adult patients of American Society of Anesthesiologists grade I­II undergoing upper abdominal surgery were randomly allocated into two groups to receive 50 µg fentanyl or 50 µg dexmedetomidine as an adjunct to 10 ml 0.125% bupivacaine via thoracic epidural. Anaesthesia was induced with morphine, propofol and vecuronium and maintained by isoflurane with 60% nitrous oxide in oxygen. In the postoperative period patient-controlled analgesic pumps were used to deliver similar types of mixtures via the epidural catheter. Patients were evaluated for rescue analgesic requirements, haemodynamic stability, postoperative pain, sedation and any adverse events. Results: The groups were comparable regarding intraoperative analgesic requirements, recovery times and postoperative pain scores. The total consumption of rescue analgesia was significantly less in the dexmedetomidine group as compared with the fentanyl group (p = 0.049). Two patients in the fentanyl group had vomiting and one had pruritus. None of the patients had bradycardia, hypotension, excessive sedation or respiratory depression. Patients receiving epidural dexmedetomidine were more satisfied with the technique than those receiving fentanyl (p < 0.001). Conclusion: It was concluded that the addition of dexmedetomidine with 0.125% bupivacaine in thoracic epidural provides effective perioperative analgesia with greater patient satisfaction compared with fentanyl

Prise en charge de l'ostéopériostite chronique dentaire chez l'enfant: à propos d'un cas

L'ostéopériostite est un état inflammatoire aigu ou chronique du périoste et de l'os sous-jacent. Le but du traitement de l'adolescent est la dent causale d'avulser pour empêcher des complications septiques dentaires point de départ dentaire pour Staphylococcus aureus sensible à la méthicilline. Nous rapportons le cas d'une jeune fille de 10 ans anxieuse sans antécédents médicaux significatifs avec une ostéite de Garré évoluant depuis plusieurs mois. Le patient a été mis sous antibiotiques et examiné une semaine après la disparition des signes cliniques. Une technique, le type d'anesthésie Akinosi a été réalisée sous sédation consciente car l'anesthésie générale nécessite une préparation plus intense avant le traitement et une période de récupération plus longue après le traitement. Il a permis de pratiquer sans douleur à l'ouverture de pression de la chambre pulpaire de la première molaire mandibulaire gauche et de faciliter le drainage. L'avulsion de la dent causale se pratique alors en racine de séparation pour préserver le capital osseux

The osteoperiostitis is an acute or chronic inflammatory condition of the periosteum and the underlying bone. the goal of treatment of the teenager is avulsed causal tooth to prevent septic complications dental starting point for methicillin-sensitive staphylococcus aureus. we report the case of a young 10 year old girl anxious without significant medical history with osteitis of garré evolving for several months. The patient was put on antibiotics and review one week after resolution of clinical signs. one technique the type of anesthesia akinosi was performed under conscious sedition because general anesthesia requires a more intense preparation before treatment and a longer recovery period after treatment. it allowed to practice without pain to the pressure opening of the pulp chamber of the mandibular first molar left and facilitate drainage. the avulsion of the causal tooth is then practiced separation roots to preserve the bone capital.

Anesthesie tronculaire pour la chirurgie d'urgence de la main : les pratiques dans les services d'urgence

Objectif : Cette etude a pour objectif d'evaluer la pratique du bloc tronculaire pour une chirurgie de la main dans le cadre de l'urgence chirurgicale dans deux centres hospitaliers a Antananarivo. Materiels et methodes : C'est une etude prospective multicentrique sur une periode de trois mois. Etaient inclus tous les malades entres aux urgences ayant presente une plaie post-traumatique de la main et necessitant une reparation chirurgicale. Le bloc tronculaire du poignet etait realise par un medecin anesthesiste avec du Xylocaine 2pour tout les malades. Les complications eventuelles; une sedation associee; les circonstances de survenue et les lesions anatomiques etaient repertoriees. Resultats : Nous avons recueilli 152 plaies post-traumatiques de la main ayant necessite une intervention chirurgicale d'urgence durant cette periode d'etude. Parmi les blesses de la main; 82 malades ont pu beneficier d'un bloc tronculaire au niveau du poignet (53;94). On note une association avec une sedation par voie IV chez 29 malades. Les complications observees etaient : nausees et vomissements chez 8 patients. Conclusion : La pratique de l'ALR doit etre chose courante dans les services des urgences dans les pays a faibles ressources materiels. Le bloc tronculaire du poignet lors des interventions chirurgicales d'urgences de la main presente peu de risque pour le patient. Sa bonne maitrise est le garant de sa reussite et evite les incidents

Thoracic epidural for post-thoracotomy pain: a comparison of three concentrations of sufentanil in bupivacaine

ABSTRACT. Background:The aim of this prospective, double blind, randomised trial was to compare the analgesic and adverse effectsof three concentrations of the thoracic epidural sufentanil with bupivacaine in patients undergoing thoracotomy.Methods:We studied 60 (randomised) patients who were to receive a 10 ml bolus dose of sufentanil, 1µg/ml, 2 µg/ml and3 µg/ml, in bupivacaine 0.125%, via thoracic epidural. Postoperatively, pain at rest, on coughing and with ambulation wasassessed using a visual analogue scale (VAS) and observer verbal ranking score (OVRS) at 2, 6, 12 and 24 hours. Adverseeffects were simultaneously assessed.Results:There was no significant difference in the baseline characteristics between the three groups. The number of patientswith episodes of unsatisfactory pain, i.e. a VAS scores ≥ 40 and OVRS ≥ 2, at each of the four assessments postoperatively,was significantly higher with sufentanil 1 g/ml than with sufentanil 2 µg/ml or µ3 g/ml (p < 0.05). In the 3 µg/ml sufentanilgroup, four patients (20%) had a sedation score ≥ 3 compared with one (5%) and no (0%) patients in the 2 µg/ml and1 µg/ml sufentanil groups, respectively (p < 0.05). In addition, 30% patients experienced pruritus in the 3 µg/ml sufentanilgroup compared with 10% and 5%, respectively, in the 2 µg/ml and 1 µg/ml sufentanil groups. In the sufentanil 3 µg/ml,2 µg/ml and 1 µg/ml groups, 30%, 20% and 5% patients, respectively, had emetics symptoms (p < 0.05).Conclusions:We conclude that a thoracic epidural bolus of 10 ml sufentanil 2 µg/ml with bupivacaine 0.125% provides theoptimal balance between pain relief and side-effects following thoracotomy

Pratique du bloc ilio-inguinal ilio-hypogastrique pour cure herniaire : etude prospective a propos de 35 cas colliges au CHU de Lome; Togo

Evaluer la qualite anesthesique et le benefice analgesique du bloc ilio-inguinal ilio-hypogastrique (BII) dans les cures herniaires. Le service d'anesthesie reanimation du CHU de Lome a servi pour cadre d'etude. Il s'agit d'une etude prospective et descriptive sur une periode de 6 mois. Tous les patients dans le cadre d'un programme pour cure herniaire unilaterale ont ete inclus dans l'etude.Au total; 35 patients ont subi la cure herniaire sous BII. L'age moyen des patients etait de 32 ans. Les cultivateurs representaient 57. Le sexe masculin representait 85;70. Dans 88;6des cas; les patients etaient de classe ASA I et II. Dans 71;43des cas; le bloc sensitif etait complet 15 minutes apres l'induction. Dans 51;43des cas; les patients avaient beneficie d'une sedation complementaire avec de la ketamine et / ou du fentanyl. Trois cas de BII ont ete convertis en anesthesie generale : 2 en raison de l'extension de l'incision chirurgicale; et 1 en raison de l'inconfort pour le chirurgien. La duree moyenne de l'intervention etait de 70 minutes. Les nausees (1 cas); les vertiges (2 cas); la sensation de bouche amere (3 cas) ont ete les complications peroperatoires observees. En postoperatoire; 2 cas d'extension au nerf femoral ont ete observes. 5 patients ont eu une EVA = 4 dans les 18 heures postoperatoires. Dans 68;57des cas; les patients sortaient au 3e jour postoperatoire. Le BII est une alternative interessante a l'anesthesie generale dans les cures herniaires. Sa vulgarisation necessite neanmoins un apprentissage a sa bonne pratique

Local anaesthesia for appendicectomy: one surgeon's experience

Background: Appendicectomy can be performed under general; regional and local anaesthesia but the anaesthetic risks are least with the later. Where it is appropriate to perform a procedure under local anaesthesia therefore; this method should be readily utilized. This report aims to share one surgeon's experience with local anaesthesia for appendicectomy. Method: A prospective study was carried out at the Mile One Hospital; a private clinic in Port Harcourt; Nigeria. Patients with acute appendicitis admitted for appendicectomy between July 1999 and December 2002 were assessed and recruited into the study based on criteria such as weight less than 70 kg and option for local anaesthesia. Lignocaine (0.5) in a dose of 3-4mg/kg body weight was infiltrated in the line of incision (Lanz) superficially and then into deeper planes. Those who would not tolerate lignocaine alone were sedated with 10mg of diazepam and 30mg of pentazocine. Patients who still would not tolerate the procedure were converted to general anaesthesia with ketamine. The appendix was removed with the stump unburied. Results: Out of 78 patients with acute appendicitis 35 (44.85) were considered suitable for local anaesthesia. Only 31 eventually tolerated the procedure; 7 of these patients requiring sedation. General anaesthesia was resorted to in 4 patients who failed to tolerate local anaesthesia with sedation. Five patients (16.13) developed surgical site infections; 10 (32.26) had nausea intra-operatively while 7 (22.58) had subcutaneous emphysema in the immediate postoperative period. The mean operative time was 39minutes. There was no mortality

Urologic day-care surgery : scope and problems in a developing country

Objective Due to the numerous economic and social benefits associated with the practice of day-care surgery; it is gaining widespread acceptance worldwide and across all specialties. We therefore determined the spectrum of procedures and the difficulties faced during implementation of day-care urologic surgery in a tertiary-care center in Nigeria. Patients and Methods This was a prospective study of all consecutive urologic day cases seen at the urology unit of Jos University Teaching Hospital; Nigeria; from January 2003 to December 2004. A total of 270 patients aged between 2 weeks and 100 years (median 55 years) with a male to female ratio of 14:1 were seen during the study period. The parameters studied were the presenting symptoms; diagnosis; treatment modalities; anesthesia; complications and whether or not the patients were converted to be in-patients or readmitted after discharge as well as the reasons for such conversion or readmission. The statistical analysis was done using the Epi-info 2004 system; version 3.2.2. Results The main conditions seen were urethral stricture in 89 (32.5) patients; benign prostatic hyperplasia in 86 (31.8); carcinoma of the prostate in 26 (9.6); carcinoma of bladder in 15 (5.6) and male infertility in 10 (3.7) patients. The procedures carried out were mainly urethroscopy/ urethrocystoscopy in 103 (38.2) patients; visual internal urethrotomy in 48 (17.8) and trucut prostatic biopsy in 33 (12.2) patients. Sedation was used in 142 (52.9); sedation and local anesthesia in 53 (19.7); local anesthesia alone in 9 (3.3); general anesthesia in 22 (8.1) and other combinations or omissions in entry in 41 (15.2) patients. Circumcision was performed on 3 neonates (1.1) without anesthesia. There was a cancellation rate of 15.6(n=42) mainly due to the inability of the patients to come (24 patients; 57.1); inadequate materials in the theatre (9 patients; 21.4); power failure (4 patients; 9.5); strike action (3 patients; 7.1) and financial difficulties (2 patients; 4.8). We had a conversion rate to in-patients of 1.9(n=5) for various reasons. No further complications or readmissions after discharge were encountered. Conclusion Urethrocystoscopy is the most frequently performed procedure and urethral stricture the most common diagnosis in our day practice. Cancellation of cases and conversion to in-patients remain our major challenges. The education of patients and physicians; as well as the provision of adequate material and infrastructure are recommended in order to provide the maximum benefit from urologic day-surgery practice