NEBULIZED MAGNESIUM VERSUS KETAMINE FOR PREVENTION OF POST-OPERATIVE SORE THROAT IN PATIENTS FOR GENERAL ANAESTHESIA.

BACKGROUND: Sore throat is a common post-operative complaint which can cause significant distress and morbidity. We tested and compared the efficacy of nebulized Magnesium and Ketamine on the incidence and severity of sore throat within the first 24 hours after general anaesthesia. OBJECTIVE: To compare the incidence and severity of post-operative sore throat at 2, 4, 8, 12 and 24 hours after extubation following pre-induction administration of nebulized Magnesium and Ketamine. METHODOS: In this randomized controlled trial, 99 adult ASA I and II patients between the ages of 16 - 65 years were administered nebulized Ketamine 50 mg, Magnesium Sulphate 250 mg or saline for ten minutes prior to induction of general anaesthesia and orotracheal intubation. Incidence and severity of post-operative sore throat were assessed at 2, 4, 8, 12 and 24 hours post extubation. RESULTS: The incidence of sore throat at 4, 8, 12 and 24 hours post tracheal extubation were significantly lower in the Magnesium (18.2%, 12.1%, 0, 0; p = 0.009, 0.006, ≤0.0001, 0.003) and Ketamine group (24.2%, 12.1%, 6.1%, 0; p = 0.041, 0.006, 0.001, 0.003) compared with the saline group (48.5%, 42.4%, 39.4%, 24.2%). Patients also had significantly less severe sore throat at 4 and 8 hours post extubation in both Magnesium and Ketamine groups (p = 0.0 11, 0.041). CONCLUSION: Pre-induction nebulization of Ketamine or Magnesium can decrease the incidence and severity of sore throat in the first 24 hours after anaesthesia.

The African Surgical OutcomeS-2 (ASOS-2) Pilot Trial, a mixed-methods implementation study

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. The working hypothesis is that patients die as a result of failure to rescue following complications in the postoperative period. The African Surgical OutcomeS-2 (ASOS-2) Trial plans to test the efficacy of increased postoperative surveillance in high risk patients for decreasing perioperative morbidity and mortality. This pilot trial aimed i) to evaluate the adequacy of data produced by the data collection strategies of the ASOS-2 Trial, ii) to evaluate the fidelity of implementation of the increased postoperative surveillance intervention, and iii) to understand the acceptability, appropriateness and feasibility of the intervention and the trial processes. Methods: The ASOS-2 Pilot Trial was a mixed-methods (quantitative-qualitative) implementation study focusing on the intervention arm of the proposed ASOS-2 Trial. The intervention is increased postoperative surveillance for high-risk surgical patients. The intervention protocol was implemented at all sites for a seven-day period. A post pilot trial survey was used to collect data on the implementation outcomes. Results: 803 patients were recruited from 16 hospitals in eight African countries. The sampling and data collection strategies provided 98% complete data collection. Seventy-three percent of respondents believed that they truly provided increased postoperative surveillance to high risk patients. In reality 83/125 (66%) of high-risk patients received some form of increased postoperative surveillance. However, the individual components of the increased postoperative surveillance intervention were implemented in less than 50% of high-risk patients (excepting increasing nursing observations). The components most frequently unavailable were the ability to provide care in a higher care ward (32.1%) and assigning the patient to a bed in view of the nurses' station (28.4%). Failure to comply with available components of the intervention ranged from 27.5% to 54.3%. The post pilot survey had a response rate of 30/40 (75%). In Likert scale questions about acceptability, appropriateness, and feasibility of the ASOS-2 intervention, 63% to 87% of respondents indicated agreement. Respondents reported barriers related to resources, trial processes, teamwork and communication as reasons for disagreement. Conclusions: The proposed ASOS-2 Trial appears to be appropriate, acceptable and feasible in Africa. This pilot trial provides support for the proposed ASOS-2 Trial. It emphasises the need for establishing trial site teams which address the needs of all stakeholders during the trial. A concerted effort must be made to help participating hospitals to increase compliance with all the components of the proposed intervention of 'increased postoperative surveillance' during the ASOS-2 Trial

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications.

BACKGROUND: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. METHODS: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. RESULTS: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. CONCLUSIONS: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. CLINICAL TRIAL REGISTRATION: NCT03044899.

Pediatric brain tumors in Nigeria: clinical profile, management strategies, and outcome.

INTRODUCTION: Although modern neuroimaging has facilitated early care of brain tumors in children worldwide, there are, however, few published reports on clinical profile, treatment, and outcome of brain tumors in children from our subregion. PURPOSE: We aimed to retrospectively study the clinical profile and outcome of pediatric brain tumors in a tertiary referral center from a developing country. METHODS: Forty pediatric patients with histologically verified brain tumors managed by the authors over a 13-year period (May 1994-April 2006) were studied. Patients' data from clinical, radiological, and pathology records were analyzed using the statistical package for social sciences version 16. RESULTS: The mean age was 9.75 years (range 1-15 years). Twenty-two males, 18 females. Common presenting symptoms were headaches (23 patients, 57.5%) and seizures (15 patients, 37.5%). Hyperreflexia (72.5%) and focal motor deficits (62.5%) were the most common neurologic signs. The mean interval from onset of symptoms to neurosurgical diagnosis was 13.4 months (95% CI). All patients had tumor resection, while 11 (27.5%) patients received adjuvant radiotherapy. Hydrocephalus occurred in 19 (47.5%) patients and was associated with early presentation (X2 = 10.65, p < 0.01). Low-grade astrocytoma (25%) and medulloblastoma (25%) were the most common tumors. Survival at 1 and 5 years were 56 and 47%, respectively. CONCLUSION: Focal motor signs and elevated intracranial pressure are the salient presenting features of brain tumors in children seen in Nigeria. Those of them with hydrocephalus are likely to present early. The outcome for pediatric brain tumors remains poor.

Morphine-sparing effect of intravenous paracetamol for post operative pain management following gynaecological surgery.

OBJECTIVE: The study evaluated the morphine sparing effect of intravenous Paracetamol and the incidence of side effects in the recovery room following lower abdominal gynaecological surgery. METHOD: Fifty six, ASA I and II patients undergoing lower abdominal gynaecological surgery were randomized into two groups, which were either given (A) intravenous (I.V) Paracetamol 1g diluted to 20 mls with normal saline or (B) I.V normal saline 20 mls at the beginning of the skin closure. In the re covery room pain intensity was evaluated and the time of first request for analgesic was noted. Intravenous morphine 2mg bolus was titrated to . Pain relief was evaluated at rest and on movement until pain score at rest Numerical rating score (NRS) < or = was achieved. Total dose of morphine was noted, morphine side effects, adequacy of analgesia and patient's satisfaction were assessed. RESULTS: The mean time of first analgesic request was prolonged significantly in Group A 40.9 +/-18.9 minutes vs. 11.4 +/- 5.5 minutes in Group B ( P = 0.00), with significant difference in morphine consumption 7.1 +/- 1.6 vs. 12.2 +/- 2.1 (P = 0.01) respectively. Morphine related side effects were higher in placebo group (33.3%) compared with (11.1%) in paracetamol group. More patients in the paracetamol group compared with the placebo group felt pain relief was adequate (66.7% vs 44.4%) and also more patients were satisfied with the regimen in paracetamol group compared with placebo group (96% vs 29.6%). CONCLUSION: Intravenous Paracetamol improved analgesia and reduced the amount of morphine consumption in the immediate postoperative period with reduced opioid side effects and better patient satisfaction.

Comparison of intravenous ephedrine with phenylephrine for the maintenance of arterial blood pressure during elective caesarean section under spinal anaesthesia.

Hypotension is a major concern of the anaesthetists whenever subarachnoid block is performed especially in obstetric patients. Vasopressors have been shown to be more effective at limiting spinal hypotension than other treatment of hypotension like preloading and left uterine displacement. The aim of the study is to compare the effect of bolus intravenous Ephedrine with Phenylephrine for the maintenance of arterial blood pressure during elective caesarean section under spinal anaesthesia. This was a randomized, double blind, controlled study of sixty two healthy parturients American Society of Anesthesiologists' (ASA) status 1 and 2 at term with singleton pregnancy who consented to subarachnoid block at University College Hospital, Ibadan, Nigeria. The parturients were preloaded with 10 ml per kg of crystalloid before the induction of spinal anaesthesia with injection of 2.5 ml of 0.5% hyperbaric Bupivacaine at L3/L4 levels. Ephedrine 5 mg (group A; n = 31) or phenylephrine 100 ug (group B; n = 31) was given for the maintenance of arterial blood pressure. Results showed that the incidence of hypotension in the 62 patients was 24.2%. Both vasopressors effectively restored both the systolic and the diastolic blood pressure. There was significant difference in heart rate between the two groups. Nausea occurred in both groups and was found in hypotensive patients, no patient vomited during the procedure. The mean APGAR Scores were similar for the two groups; no baby had Apgar score of < 8 in either group. We concluded that phenylephrine is safe and can be used as effectively as Ephedrine. Its administration results in higher blood pressure than Ephedrine in parturients undergoing Caesarean Section under spinal anaesthesia.

Clinical comparison of cardiorespiratory effects during unilateral and conventional spinal anaesthesia.

BACKGROUND: Spinal anaesthesia is widely employed in clinical practice but has the main drawback of post-spinal block hypotension. Efforts must therefore continue to be made to obviate this setback OBJECTIVE: To evaluate the cardiovascular and respiratory changes during unilateral and conventional spinal anaesthesia. METHODS: With ethical approval, we studied 74 American Society of Anesthesiologists (ASA), physical status class 1 and 2 patients scheduled for elective unilateral lower limb surgery. Patients were randomly allocated into one of two groups: lateral and conventional spinal anaesthesia groups. In the lateral position with operative side down, patients recived 10 mg (2mls) of 0.5% hyperbaric bupivacaine through a 25-gauge spinal needle. Patients in the unilateral group were maintained in the lateral position for 15 minutes following spinal injection while those in the conventional group were turned supine immediately after injection. Blood pressure, heart rate, respiratory rate and oxygen saturation were monitored over 1 hour. RESULTS: Three patients (8.1%) in the unilateral group and 5 (13.5%) in the conventional group developed hypotension, P= 0.71. Four (10.8%) patients in the conventional group and 1 (2.7%) in the unilateral group, P= 0.17 required epinephrine infusion to treat hypotension. Patients in the conventional group had statistically significant greater fall in the systolic blood pressures at 15, 30 and 45 minutes when compared to the baseline (P= 0.003, 0.001 and 0.004). The mean respiratory rate and oxygen saturations in the two groups were similar. CONCLUSION: Compared to conventional spinal anaesthesia, unilateral spinal anaesthesia was associated with fewer cardiovascular perturbations. Also, the type of spinal block instituted affected neither the respiratory rate nor the arterial oxygen saturation.

Goldenhar syndrome: a case report and literature review.

The case of a 24-year-old female Nigerian with features of Goldenhar syndrome is presented and the challenges of management especially with reference to reconstructive facial surgery and general anaesthesia are discussed.

Surgical management of tuberculum sellae meningioma in a patient with a twin pregnancy: case report.

BACKGROUND: Meningioma in twin pregnancy is rare. The tumor has an accelerated growth during the pregnancy and may enlarge or become symptomatic during this period. This relationship makes management of patients with this tumor quite challenging. CASE DESCRIPTION: We describe a case of a rapidly deteriorating 35-year-old woman harboring an extensive tuberculum sellae meningioma who underwent craniotomy during the 24th week of pregnancy because of rapid deterioration. The surgical procedure and postoperative period were relatively uneventful. CONCLUSION: To the best of our knowledge, this is the first reported case of surgical management of a meningioma in a patient carrying a twin pregnancy (one missed abortus). When indicated, craniotomy is a safe and effective treatment option for huge frontobasal tumors during the second trimester of pregnancy.

The diagnostic dilemma of intraoperative hyperpyrexia in a malaria endemic area.

Malignant hyperthermia (MH) is a serious and feared complication of general anaesthesia. The diagnosis of MH may pose a diagnostic dilemma, as its two most common signs tachycardia and hyperthermia are also common features of infections, transfusion and drug reactions. We report three cases of hyperthermia occurring during anaesthesia posing diagnostic dilemma in which two of the cases appear to be due to malaria. It is therefore suggested that all patients undergoing anaesthesia in a malaria endemic area should be investigated and treated for malaria if indicated preoperatively even when asymptomatic to prevent such diagnostic confusion.

The effect of parental presence at induction of anaesthesia on the behaviour of unsedated Nigerian children presenting for day-case anaesthesia.

The effect of parental presence at induction of anaesthesia on one hundred and eighteen children presenting for day-case inguinal operations and the behaviour of the attending parents at induction were studied. Of the 24 children aged 5 years and below whose parents at were present at induction, 25% were distressed, while 80% of 36 children of this age group whose parents were absent showed distress. Better behaviour was observed among the children who were above 5 years of age. When parents were present 7% of 28 children cried while 20% of 30 children cried when parents were absent. In both age groups induction heart rates were significantly higher in the children whose parents were absent. All parents except one who cried and another one who was too anxious, were helpful at induction and they would welcome the same opportunity to be present at the children's induction.

Acute isovolaemic haemodilution in two Jehovah's Witnesses presenting for major intracranial surgery.

The Jehovah's Witnesses (JWS) is a religious sect with strong convictions against acceptance of blood and its products for medical care, including surgery. We present two cases of JWS, aged 24 and 19 years old, who had craniectomy for trauma and craniotomy for tumour excision, respectively. A team approach was employed in the care of both patients. During exhaustive preoperative discussions they re-affirmed their religious convictions but agreed to some modifications. Both patients accepted Acute Isovolaemic Haemodilution (AIH). However one of them insisted on non-discontinuation of the line used in collecting the blood from the vein, as that would constitute blood storage. The preoperative Packed Cell Volume (PCV) was 45% and 41% for the trauma and the tumour patients respectively. Two units of blood (1000 ml) were collected from each patient resulting in post donation PCV of 40% and 33%. The intraoperative blood loss was 300 ml and 2000 ml, respectively, and the units and crystalloid fluids were transfused for replacement. Postoperative PCV were 42% and 25%. The latter improved to 30% over the following two weeks with oral haematinics. The two cases are discussed in the light of the experience gained.

Management of cancer pain--a survey of current practice in West Africa.

A comprehensive management plan for cancer pain is yet to be formulated in the West African sub region despite the priority that the World Health Organisation (WHO) has devoted to the problem over the past decade. As a prerequisite to our cancer pain management curriculum development a structured questionnaire on cancer pain management practice was administered to 80 Fellows attending the Annual Scientific Conference of the West African College of Surgeons in 1996. They were asked how often they treated cancer patients, the causes of cancer pain, their methods of assessment and therapeutic measures and complications of management techniques. Forty-four fellows from Nigeria, Ghana, Liberia and Sierra Leone, all consultants and trainers, responded to the questionnaire. About 80% of them treated cancer patients all the time. Specific anti-cancer therapy such as surgery, chemotherapy and hormone therapy were available in the four countries but radiotherapy was only available in two centers in Nigeria. The respondents estimated that 70-90% of their patients had severe pain at presentation. Pain was thought by 52% of respondents to be due to cancer and its treatment while 47% thought it was due to cancer and the fear of dying. Pain assessment was mostly by the verbal rating scale, only 20% included psychological measurement in their schedules. Oral preparations of strong opioids were not available in most countries andfor severe pain, the parenteral route was employed. Only 18% knew about the 'by the clock' dosing schedule. The study revealed that the standard of practice of the respondents falls below accepted practice. There is thus an urgent need for the formal education of personnel involved in the care of these patients.

Case report: difficult spinal anaesthesia for caesarian section in two obese pregnant patients.

Two obese patients presented for Caesarean Section for poor progress in labour. Spinal anaesthesia was chosen because of obesity, gravidity and worry about possible related airway problems in both patients. In both cases the needle seemed to be short. In case 1, no cerebrospinal fluid (CSF) was obtained, and she was subsequently done under General Anaesthesia (GA); in case 2, CSF was obtained when the needle was pressed firmly into the patients back but flow stopped if the pressure was released. These case reports serve to illustrate that although spinal anaesthesia for obese pregnant patients may seem the safer alternative, mechanical difficulty may be considerable and eventually a GA may be considered in spite of possible risk of difficult intubation.

Ketamine anaesthesia for young children undergoing radiotherapy.

Young children with radiosensitive malignant tumours often require sedation or anaesthesia to provide immobility for radiotherapy sessions lasting several days. This paper describes the use of repeated intramuscular ketamine anaesthesia for radiotherapy in children age 1.5 to 5 years. Intramuscular ketamine 5-13mg/kg body weight was administered on 280 occasions to 15 children, the highest number of sessions per child being 30 and the least 9. The airway and cardiovascular parameters were well maintained. The time to complete recovery varied from 15 to 90 minutes (mean 52.5+/-31.7 S.D.). Involuntary movements of the tongue, mouth and limbs were observed in 8 patients (52.3%) during 63 sessions (22.5%) but only necessitated interruption of radiotherapy on 6 occasions (2.1%). Ketamine was found to be safe and effective for sedation of young children in the radiotherapy suite and minimal aneasthetic facilities were required.

Pathological fracture complicating epidural local anaesthetic opioid infusion for cancer pain.

Two cases of severe bone pains from metastatic cancer, without clinical or radiological evidence of fractures on admission, are presented. Pain control and mobilization were achieved initially with local anaesthetic-opioid epidural infusion. Subsequent loss of analgesia prompted a re-examination, which revealed pathological fractures of the femur. Internal fixation of the fractures resulted in good control such that strong opioids were no longer required.

Intra-operative cardiac arrests.

This is a review of patients who had cardiac arrest in the operating suites at the University College Hospital (UCH), Ibadan between January 1994 and December 1998. The main objectives of the study were to evaluate the incidence of intraoperative cardiac arrests, identify associated factors and, in particular, those factors that might be essential for better prognosis. The study was retrospective, descriptive and cross-sectional. The figures were retrieved from the theatre records, the intensive care records, case notes and pathology reports. During the study period, 6,356 operations were performed. There were 35 cardiac arrests giving an incidence of 55 per 10,000 operations. Of the 35 cases, 18(51.4%) were males while 17(48.6%) were females. The age range was 4 months to 84 years (mean 32.5 years) with wide distribution through the decades. Of the twenty-four patients (68.6%) that were done as emergency cases, four patients (17.1%) recovered fully. Of the 11(31.4%) elective cases, 5 (41.7%) made full recovery. Ten patients (28.6%) were ASA I & II, while 25 (71.4%) were graded ASA status III to V. The factors associated with cardiac arrest in this study included emergency operation and the ASA status.

Pain assessment in Nigerians--Visual Analogue Scale and Verbal Rating Scale compared.

The usefulness of 2 methods of pain assessment was determined in a cohort of Nigerians who had pain as a symptom and were receiving physiotherapy for various indications. The English and Yoruba versions of two Pain Rating Scales, the Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS) with 1 to 4 or 1 to 5 intensity scales (VRS-4 or VRS-5) were employed for the assessment of pain in 100 patients. The mean pain score on the 4-point VRS scale was 2.49 +/- 0.72, for the 5-point VRS 2.1 +/- 1.18 and for the VAS 4.93 +/- 2.5. Correlation analysis for corresponding groups of patients showed a significant positive relationship between the VAS and VRS-4 (r = 0.68 P < 0.001) VAS and VRS-5 (r = 0.64 P < 0.001) indicating that both VAS and VRS constitute useful tools for pain assessment in Nigerian patients.

Post operative nausea and vomiting in Nigerians.

A retrospective survey of postoperative nausea and vomiting (PONV) in the recovery room over a five year period was conducted, followed by a prospective study of 200 adult patients to estimate the incidence and predisposing factors to nausea and vomiting during the first 24 hours after anaesthesia and surgery in Nigerians. In the retrospective study only records of 61 patients (0.79%) out of the 7714 post anaesthetic recovery room charts reviewed revealed documentation of vomiting. These were 20 males (32.8%) and 41 females (67.2%). In the prospective study, the incidence of post operative nausea and vomiting within twenty four hours of surgery was 41.6% and 19.6%, respectively. But only two out of 39 patients (one per cent) vomited within the first three hours in postoperative period. The frequency of vomiting varied from one to 15 times and women had significantly more emetic symptoms than men (p < 0.05). Preoperative administration of pethidine and morphine was associated with postoperative nausea and vomiting. It is suggested that Nigerian women should be considered for prophylactic anti-emetic therapy, especially when narcotic analgesic are to be employed in their anaesthetic management.