Global pediatric anesthesia-Anglophone West Africa perspective.

BACKGROUND: This article gives the pediatric anesthesia perspective from Cameroon, Nigeria, Ghana, Liberia, and Gambia, five out of six countries in Anglophone West Africa. Over 40% of the population of most of these countries are younger than 14 years and there is an increasing need for paediatric anesthesia services. FINDINGS: Workforce density ranges from 0.08 to 0.58 physician anesthesia providers per 100,000 population. There are only 13 trained pediatric anesthetists; ratios range from 0 to 0.4 per 100,000 children, thus pediatric anesthesia services are provided by various cadres of physician and non-physician anesthesia providers. Physician anesthesia training is mostly carried out by the West African College of Surgeons as well as national postgraduate colleges. Pediatric anesthesia services are provided in tertiary (teaching), secondary (general), district, faith-based, military, private hospitals and through surgical missions. Challenges include lack of trained personnel, high morbidity from late presentation to health facilities and financial constraints, lack of health insurance for pediatric anesthesia services, unavailability of appropriate equipment and consumables, a narrow range of medications, very few pediatric-specific operating theaters, and inadequate critical care services. SOLUTIONS: The lack of opportunities for sub-specialty training in pediatric anesthesia in West Africa is currently being addressed in Nigeria and Ghana. Non-governmental agencies fund programs and courses related to pediatric anesthesia and have also provided fully equipped operating theaters. Advocacy for pediatric anesthesia can be achieved through the National Surgical Obstetric Anesthesia and Nursing Plans Implementation Committee of the various countries. There is an urgent need for prioritization of health in the budgets of Anglophone West African countries and governments must deliberately provide support for anesthesia and surgical services. More international collaborations towards workforce training and creation of children's hospitals are needed.

Block performance indices of perivascular and perineural techniques of ultrasound-guided axillary block in upper limb surgeries: A comparative study.

Background: Nerve block anesthesia is a common regional anesthesia used for upper limb surgeries because of its ability to target the operative site and provision of impressive postanesthetic pain relief. This randomized, single-blinded study compared the quality of block of the perineural (PN) and perivascular (PV) techniques of axillary brachial plexus block under ultrasound guidance. Methods: Sixty-six participants were recruited into either PV or PN groups. The local anesthetic (LA) comprised 14 ml of 0.5% bupivacaine, 14 ml of 1% lidocaine, and 2 ml of dexmedetomidine (50 µg/ml). Under ultrasound guidance, 6 ml of LA was deposited around the musculocutaneous nerve for both groups. For the PV group, 24 ml was deposited dorsal to the axillary artery while 8 ml each was deposited around median, radial, and ulnar nerves for the PN group. Results: The mean total procedure time in PN group was significantly longer than in the PV group (7.82 ± 0.95 min vs. 4.79 ± 1.11 min; P = 0.001). Participants in the PN group required more needle passes (66.7% required 4 passes while 81.8% required only 2 passes in the PV group). The success rate was 100% in PN group and 93.9% in PV group (P = 0.49). Conclusion: The PV and PN techniques were comparable in terms of their success rates and total anesthesia-related times. The PN technique had higher success rate and faster block onset, but the PV provided a quicker performance time and fewer needle passes. Hence, PV technique may be preferable to PN for high-volume surgical units.

Résumé Contexte: L'anesthésie par bloc nerveux est une anesthésie régionale courante utilisée pour les chirurgies des membres supérieurs en raison de sa capacité à cibler le site opératoire et à fournir un soulagement impressionnant de la douleur postanesthésique. Cette étude randomisée à un seul insu a comparé la qualité des techniques de blocage périneural (NP) et périvasculaire (PV) du plexus brachial axillaire sous guidage échographique. Méthodes: Soixante-six participants ont été recrutés dans les groupes PV ou PN. L'anesthésie locale (AL) comprenait 14 ml de bupivacaïne à 0,5 %, 14 ml de lidocaïne à 1 % et 2 ml de dexmedetomidine (50 µg/ml). Sous la direction des ultrasons, 6 ml de LA ont été déposés autour du nerf musculo-cutané pour les deux groupes. Pour le groupe PV, 24 ml ont été déposés en position dorsale par rapport à l'artère axillaire, tandis que 8 ml ont été déposés autour des nerfs médian, radial et ulnaire pour le groupe PN. Résultats: La durée totale moyenne de la procédure dans le groupe PN était significativement plus longue que dans le groupe PV (7,82 ± 0,95 min contre 4,79 ± 1,11 min ; P = 0,001). Les participants du groupe PN ont exigé plus de passes d'aiguille (66,7 % ont exigé 4 passes, tandis que 81,8 % n'ont exigé que 2 passes dans le groupe PV). Le taux de réussite était de 100 % dans le groupe PN et de 93,9 % dans le groupe PV (P = 0,49). Conclusion: Les techniques PV et PN étaient comparables en termes de taux de réussite et de temps total liés à l'anesthésie. La technique PN a eu un taux de succès plus élevé et un début de bloc plus rapide, mais la PV a fourni un temps de performance plus rapide et moins de passes d'aiguille. Par conséquent, la technique PV peut être préférable à la PN pour les unités chirurgicales à volume élevé. Mots-clés: Bloc nerveux, périneural, périvasculaire.

Effectiveness of postoperative analgesia in the management of acute pain in day-case surgeries.

Background: Surgery is the most common source of acute pain. Aim: To determine the intensity of acute pain following day case surgery and evaluate the effectiveness of the prescribed analgesics. Methods: A descriptive observational study carried out at the main operating and the Urology Outpatient theatre suites of the University College Hospital, Ibadan. Seventy consecutive adult patients presenting for day case surgeries between July and September 2013 were recruited. The procedures were stratified as follows: peripheral, groin/perineal, urologic/endoscopy or orthopedic/plastic surgeries. The prescribed postoperative oral analgesics were paracetamol alone or in combination with diclofenac, tramadol or both. Postoperative pain intensity was assessed on arrival in the recovery room and at 6, 12, 24, 48, & 72 hours using the Verbal Intensity Pain Scale (VIPS). The pain scores were presented as mean±SD at different time intervals for each stratified surgical procedures and analgesics using tables and frequency bar charts. A mean pain score of less than 2 for each category of surgical procedures or analgesics group was considered as satisfactory pain control and thus effective analgesia. Result: The overall prevalence of moderate to worst possible pain after surgery in this study was 54.3% on arrival in the recovery room. The mean pain score was greater than 2 at 6 hours postoperative in all surgical categories except in patients who had peripheral surgeries irrespective of single or combination analgesic therapy. Conclusion: A high proportion of patients arrived in the recovery room with a high pain score; measures to improve intraoperative analgesia should be employed.

RésuméContexte: La chirurgie est la source la plus fréquente de douleur aiguë. But: Déterminer l'intensité de la douleur aiguë après un cas de chirurgie de jour et évaluer l'efficacité des analgésiques prescrits. Méthodes: Une étude observationnelle descriptive réalisée à la salle principale d'opération et les suites de théâtre ambulatoire d'Urologie au Collège Hospitalier Universitaire, Ibadan. Soixante-dix patients adultes consécutifs se présentant pour des cas de chirurgies de jour entre juillet et septembre 2013 ont été recrutés. Les procédures ont été stratifiées comme suit: chirurgie périphérique, aine / périnéale, urologique / endoscopie ou chirurgie orthopédique / plastique. Les analgésiques oraux postopératoires prescrits étaient le paracétamol seul ou en combinaison avec le diclofénac, le tramadol ou les deux. L'intensité de la douleur postopératoire a été évaluée à l'arrivée dans la salle de récupération et à 6, 12, 24, 48 et 72 heures en utilisant l'échelle d'intensité verbale de l'intensité (VIPS). Les scores de douleur ont été présentés sous forme de moyenne ± écart-type à différents intervalles de temps pour chaque procédure chirurgicale stratifiée et analgésiques en utilisant des tableaux et des graphiques à barres de fréquence. Un score de douleur moyen inférieur à 2 pour chaque catégorie de procédures chirurgicales ou de groupe analgésique a été considéré comme un contrôle satisfaisant de la douleur et donc une analgésie efficace. Résultat: La prévalence globale de la douleur modérée à la pire possible après la chirurgie dans cette étude était de 54,3% à l'arrivée dans la salle de récupération. Le score moyen de la douleur était supérieur à 2 à 6 heures postopératoires dans toutes les catégories chirurgicales, sauf chez les patients ayant subi une intervention chirurgicale périphérique, quel que soit le traitement antalgique simple ou combiné. Conclusion: Une proportion élevée de patients est arrivée dans la salle de récupération avec un score de douleur élevé; des mesures visant à améliorer l'analgésie peropératoire devraient être utilisées.

Oral morphine effectiveness in Nigerian patients with advanced cancer.

Oral morphine elixir in the immediate release form became available in Nigeria in the year 2006 after decades of use in the treatment of cancer pain in many other countries. In order to determine the effectiveness of oral morphine in Nigerian patients, 182 patients presenting with severe cancer pain at the Radiotherapy Clinic, University College Hospital (UCH), Ibadan, Nigeria, were recruited in a prospective descriptive observational study. Information on patient's demography, diagnosis, baseline intensity and character of pain, morphine dosages, and effects were collected using a semistructured questionnaire administered at recruitment and biweekly in the follow-up period. Mean (+ SD) age of the patients was 47 (+ 14.6) years and the most common types of cancer diagnosed in the study participants included cancer of the breast and uterine cervix. The pretreatment pain intensity score mean (+ SD) was 8.09 (+ 1.51). Of the 166 patients whose data were analyzed, 84.3% (95% confidence interval [CI] 77.8-89.5%) achieved a 3-point reduction in pain intensity using the 11-point Numerical Rating Scale at the end of the first week of treatment. Twenty-six patients (15.7%) required adjuvant therapy. The reduction in pain intensity was maintained throughout the 3 months follow-up period, with the mean 24-hour morphine consumption of 55.54 mg in the first month and 61.54 mg in the third month. Oral morphine significantly reduced cancer pain in Nigerian patients (P < .01). Increasing dose as required was found to enhance the effectiveness of oral morphine.

Esophageal, tympanic, rectal, and skin temperatures in children undergoing surgery with general anesthesia.

The purpose of this study was to determine the degrees of agreement between various sites of temperature measurement and examine the trend of body temperature in children during surgery under general anaesthesia. Thirty-six consecutive children who underwent surgery with general anaesthesia, had temperatures measured at the oesophagus, skin, ear canal and rectum at baseline, every 15 minutes for the first hour and every 30 minutes thereafter. Spearman correlation and Bland-Altman analyses were used to compare data and trends of mean differences assessed by line graphs. The median age of the sample was 48 months. There were 575 temperature measurements taken. The inter-method correlation coefficients was highest for the oesophageal vs rectal (r = 0.96) temperature and lowest for rectal vs skin (r = -0.11) temperature. The lowest mean difference (95% CI) in temperature at commencement of surgery was between the oesophageal and rectal sites, -0.03°C (-0.08, -0.01) while the highest mean difference (95% CI) temperature was between oesophageal and skin sites, 3.24°C (2.65, 3.85). The trend in differential temperatures between sites remained throughout the duration of surgery. Bland-Altman plots showed that the least difference (bias) at baseline (0.3°C) was between the oesophageal and tympanic temperatures while at 1 hour (0.13°C ) was between the oesophageal and rectal temperatures. The oesophageal site was the closest to rectal for monitoring core temperature while the skin was the least reliable site in the study population. In the situation where oesophageal probe is not routine or functioning, rectal or tympanic temperatures may be used.