Unsedated flexible upper gastrointestinal endoscopy: need for routine oxygen monitoring?

BACKGROUND: To determine the incidence of oxygen desaturation and whether routine oxygen monitoring is necessary during unsedated diagnostic flexible upper gastrointestinalendoscopy. METHODS: A prospective study involving 54 consecutive in and out patients who had diagnostic upper gastrointestinal endoscopy at the endoscopy suit of the Jos University Teaching Hospital, Jos, Nigeria between March 2007 and October 2007. The patients were reviewed before the procedure and classified according to the American Society of Anesthesiologists' (ASA) classification into classes I, II, III and IV Endoscopy was carried out after topical pharyngeal anaesthesia using 10% lidocaine spray and oxygen saturation was monitored throughout the procedure. RESULTS: There were 30 males and 24 females, with a male, female ratio of 1.25:1. The mean age was 46.7 with a range of 17 to 81 years. Mild to moderate desaturation occurred in 10 (18.5%) of the patients while severe desaturation occurred in 7 (12.9%) of the patients. All cases of severe desaturation lasted less than 30 seconds and no supplementary oxygen was needed. There were no significant statistical correlations between desaturation and gender, age, duration of procedure or ASA status of the patients. CONCLUSION: Routine oxygen monitoring may not be necessary in patients undergoing unsedated diagnostic upper gastrointestinal endoscopy and who do not have respiratory disease.

Anaesthetic management of mentosternal contractures where resources are limited.

OBJECTIVE: Perioperative airway management in postburn mentosternal contractures often pose great challenges to the anaesthetist as well as the plastic surgeon. This is more so where resources are limited. METHOD: Patients with postburn mentosternal contracture who had surgery between January 2000 and December 2006 at the Jos University Teaching Hospital, Jos Nigeria were retrospectively reviewed. The information obtained from the anaesthetic chart as well as the patients' case notes included demographic data, type of anaesthetic induction and maintenance as well as the type of airway management. RESULTS: There were 15 patients (12 males and 3 females), aged between 6 and 65 years. A total of 17 procedures were performed on the patients. Five of the patients were induced with ketamine and maintained with the same drug until adequate release was achieved. In five others the release were done under inhalational anaesthesia using a facemask after induction with ketamine. Six of the cases had laryngeal mask airway (LMA) inserted while one patient had a tracheostomy under local anaesthesia. After adequate release endotracheal tubes were inserted except in those who had LMA which were maintained to the end of the surgery. The rest of the procedure was then continued under general inhalational anaesthesia. CONCLUSION: Fixed flexion deformities in postburn mentosternal contractures could present serious airway challenges to the attending anaesthetist during contracture release and skin cover. This could be overcome by the use of ketamine, inhalational anaesthesia as well as the use of LMA before contracture release.

Anaesthetic management of mentosternal contractures where resources are limited

Objective: Perioperative airway management in postburn mentosternal contractures often pose great challenges to the anaesthetist as well as the plastic surgeon. This is more so where resources are limited. Method: Patients with postburn mentosternal contracture who had surgery between January 2000 and December 2006 at the Jos University Teaching Hospital, Jos Nigeria were retrospectively reviewed. The information obtained from the anaesthetic chart as well as the patients' case notes included demographic data, type of anaesthetic induction and maintenance as well as the type of airway management. Results: There were 15 patients (12 males and 3 females), aged between 6 and 65 years. A total of 17 procedures were performed on the patients. Five of the patients were induced with ketamine and maintained with the same drug until adequate release was achieved. In five others the release were done under inhalational anaesthesia using a facemask after induction with ketamine. Six of the cases had laryngeal mask airway (LMA) inserted while one patient had a tracheostomy under local anaesthesia. After adequate release endotracheal tubes were inserted except in those who had LMA which were maintained to the end of the surgery. The rest of the procedure was then continued under general inhalational anaesthesia. Conclusion: Fixed flexion deformities in postburn mentosternal contractures could present serious airway challenges to the attending anaesthetist during contracture release and skin cover. This could be overcome by the use of ketamine, inhalational anaesthesia as well as the use of LMA before contracture release

Intensive care unit admissions in the Jos University Teaching Hospital.

OBJECTIVE: To determine the pattern of admissions to the intensive care unit (ICU) of the Jos University Teaching Hospital (JUTH), a tertiary level referral hospital. METHOD: This is a retrospective study of the record of patients admitted between January 1994 and December 2002 to the ICU of the Jos University Teaching Hospital. The information obtained from the admission/discharge record as well as the patients' case notes included demographic data, working diagnosis, type of treatment, length of stay (LOS) in the ICU and outcome. RESULT: A total of 738 patients were admitted over this period and comprised 403 males (54.6%) and 335 females (45.6%) giving a male: female ratio of 1.2:1. The age ranged from one day to 98 years with a mean of 28.3 +/- 19.8 years. Postoperative surgical patients accounted for 48.2% of all admissions, while 15.2% were medical cases. Other indications for admissions included polytrauma (9.5%), Obstetrics and Gynaecological complications (16.1%) and burns (11%). The length of stay (LOS) in the unit ranged from 1 to 56 days, with a mean of 4.5 +/- 5.1 days. A total of 241 patients died while on admission giving an overall mortality of 42.8%. Postoperative surgical admissions accounted for 38.6% of deaths followed by burn and polytraumatised patients with 23.2% and 11.6% respectively. The lowest mortality of 8.7% was in the obstetrics and gynaecology patients. CONCLUSION: The pattern of admission into the unit and the outcome of treatment has not significantly changed after 1-2 decade of an initial report. There is need to increase the number and quality of equipment to cope with the increasing need for ICU care, as well as draw up a policy on the type of cases to be managed in order to improve the out come of care.

Management of Conjoined Twins : a Report of Two Sets

Background: Conjoined twinning is a rare congenital anomaly. We present here; our experience in the management of two sets of conjoined twins at a Teaching Hospital in north central Nigeria. Method: Data of conjoined twins managed at the Jos University Teaching Hospital in 1987 and 2004 were retrospectively collated and analyzed. Result: Two sets of pyopagus tetrapus conjoined twins were managed within the period; one was a set of triplets. The conjoined pairs in both sets of twins were females. None of the twins was diagnosed prenatally. Both sets of conjoined twins were delivered spontaneously by vaginal route. Emergency surgical separation was undertaken in both sets be- cause of deteriorating anencephaly in one twin in the first set and anorectal malformation and intestinal obstruction in one twin in the second set. Both sets of twins died after separation. Conclusion: Our experience showed that separation of conjoined twins may be associated with high mortality. Sepsis and electrolyte imbalance appear to be the major causes of morbidity and mortality; particularly when the resultant skin defects are large

Intra-operative cardiac arrest--a tropical experience.

In order to determine the pattern of intra-operative cardiac arrests in a developing country, we reviewed 40 consecutives cases of cardiac arrests at the Jos University Teaching Hospital between January 1993 and December 1997. During this period 15,060 minor cases and 9800 medium/major surgical procedures were performed and an arrest rate of 1:15,060 for minor cases and 1:251 for medium/major cases were obtained. The age ranged between one day and 65 years with a mean of 29.8 years and a male/female ratio of 1:1.3 as there were 18 males and 22 females. Twenty-five (62.5%) arrests occurred outside work hours while fifteen (37.5%) cases arrested during work hours. The surgical procedures with high arrest rates in this study were: emergency laparotomy 8 (20%), emergency caesarian sections 7 (17.5%), thoracotomy 6(15%), emergency craniotomy 5(12.5%), emergency hysterectomy 4(10%) and therapeutic bronchoscopy for foreign bodies in the airway 4(10%). The arrests occurred in 30(75%) emergency procedures as opposed to 10(25%) elective cases. Only in 3 out of the 18, 318 day case procedures did the patients arrest. One patient arrested during local infiltration of lignocaine while the other 39(97.5%) arrested under general anaesthesia. There was no arrest with spinal anaesthesia. The predisposing factors for a patient to arrest on the operating table in our environment include emergency major surgery, poor risk patients with ASA 111 and above, surgery performed outside work hours, under general anaesthesia administered by nurse anaesthetists or junior anaesthetic residents. The success rate at resuscitation is highest with patients with ASA 1 & 11, operations performed during work hours and by senior surgeons and anaesthetists.