Evaluation of the Effects of Peritonsillar Infiltration of Tramadol-Ketamine Combination Versus Tramadol Alone on Posttonsillectomy Pain in Children.

Introduction: Tonsillectomy is associated with significant pain and post-operative pain control is often unsatisfactory. This study sought to evaluate the effect of peritonsillar infiltration of tramadol-ketamine combination, tramadol alone and ketamine alone on post-tonsillectomy pain in children. Patients and Methods: A randomized double-blinded interventional study involving 90 patients aged 3-15 years of American society of anesthesiologists I or II physical status scheduled for elective adenoidectomy, tonsillectomy or adenotonsillectomy at JUTH was conducted. Patients were randomized into one of three groups: group I received tramadol 2mg/kg, group II received ketamine 1mg/kg plus tramadol 2mg/kg and group III received ketamine 1mg/kg only all made up to 2mls with normal saline and 1ml given per tonsillar bed. All patients had standard general anaesthesia with endotracheal intubation and monitoring. Data was analyzed using Epi-info version 7.1.5 with p £ 0.05. Result: The analysis of data showed that the mean ages of the participants in group I, II and III were 5.70±2.00, 5.69±3.22 and 4.47±2.01 years respectively (p-value=0.091). Group II had significantly lower pain scores, longer time to first request of analgesia, earlier oral intake and discharge from the hospital compared to the group that received either tramadol or ketamine alone. Minimal side effects were noted across all the groups in the study. Conclusion: Peri-tonsillar infiltration of tramadol-ketamine combination immediately after tonsillectomy (but before extubation of patients) significantly decreased post-tonsillectomy pain without increasing the incidence of side effects compared to tramadol or ketamine alone in children undergoing adenotonsillectomy.

Meperidine-Ketorolac Combination Provides Better Analgesia than Meperidine Alone in Postoperative Patients.

BACKGROUND: Our study objective was to assess if multi-modal analgesia with meperidine-ketorolac combination provides superior analgesia or reduces opioid requirement following surgery compared to Meperidine alone. DESIGN: Double-blind randomized controlled trial. SETTING: Postoperative pain control in orthopedic ward after spinal anesthesia. PATIENTS: American Society of Anesthesiology (ASA) risk I or II (ASA I/II) patients who had lower limb implant surgery (88) at our center from September 2014 to July 2015. INTERVENTIONS: Patients were randomly assigned to receive either 1 mg/kg of intravenous (IV) meperidine and 30 mg of IV ketorolac (treatment group) or 1 mg/kg of IV meperidine (control group) post-surgery, administered every hour for the first 6 hours during the first 24 hours post-surgery. In addition, patients received intravenous meperidine on an 'as needed basis' during the first 24 hours of the postoperative period. MEASUREMENTS: Outcomes were time-to-first analgesia request postoperatively; cumulative opioid dose in first 24 hours post-surgery; frequency of side effects; and patient satisfaction with pain relief using a Likert scale. Numerical rating scale (NRS) pain scores hourly for the first 6 hours, then the 8th, 12th, 16th, 18th and 24th hour post-surgery were assessed. RESULTS: There was a significant delay in time of first request for analgesia (460 min vs 225 min; P=0.03) and a reduction in opioid consumption in 24 hours (299 mg vs 325 mg; P=0.01) in the meperidine/ketorolac group compared with the meperidine alone group which were both statistically significant. Patient satisfaction with pain relief was better in the treatment group (P=0.01). Additionally, there were fewer side effects in the treatment group than in the control group but this was not statistically significant. CONCLUSIONS: Adding ketorolac to meperidine reduced postoperative pain, reduced patient daily opioid requirement, increased patient satisfaction with pain relief, without increasing the frequency of side effects. Therefore, IV ketorolac addition to opioids may be a reasonable option in multimodal analgesic protocol.

Ease of laryngeal mask airway insertion comparison of propofol versus thiopentone and lignocaine in adult patients

Background: A patient is required to be fully relaxed and airway reflexes should be adequately suppressed to allow for smooth insertion of a laryngeal mask airway (LMA).Propofol and a variety of other induction agents and their combinations have been tried to ease its insertion. The use of cheaper alternatives in our environment is highly desirable. Aims and objectives: To compare the ease of insertion of LMA in patients given propofol alone versus thiopentone with lignocaine, as well as assessing the cost effectiveness of these agents in our hospital setting. Methods: This is arandomised single blind prospectivestudy carried out in a Public Tertiary Academic Health Institution. Sixty-four ASA I and II patients equally randomized into 2 groups scheduled for short (not lasting more than one hour) elective gynaecological, orthopaedic, urological and general surgical procedures were recruited into this study. Patients were premedicated with 1g.kg-1 fentanyl intravenously and pre-oxygenated for five minutes. This was followed by an induction dose of either 2.5mg.kg-1propofol (group A) or a sequence of 2mg.kg-1 lignocaine and 5mg.kg-1thiopentone (group B) given by a trained assistant. With the patients in the sniffing position, LMA insertion was attempted immediately after induction of anaesthesia by the anaesthetist (researcher) who observed the ease of LMA insertion using presence or absence of adverse airway responses to LMA insertion such as coughing, gagging, laryngospasm, head and limb movement or inadequate jaw relaxation. These responses were graded as; no response, mild response, moderate response and severe response. Overall assessment of the ease of LMA insertion was then done combining these graded adverse airway responses as; excellent if there were no adverse airway responses, good if responses were mild, satisfactory if responses were moderate and poor if responses were severe with additional anaesthetic required to allow LMA insertion.Results: The average age in group A was 36.5±14 whereas in group B it was 38.7±05 with the p=0.493.There were 22 (56.4%) male patients in group A compared to 17 (43.6%) male patients in group B with p=0.528; whereas, there were 10 (40.0%) female patients in group A compared to 15 (60.0%) female patients in group B with p=0.326. Excellent LMA insertion were observed in 28 (87.5%) patients in group A compared to 27 (84.4%) patients in group B (P= 0.893); Good LMA insertion in 2 (6.3%) patients in group A compared to 1 (3.1%) patient in group B (p= 0.564); Satisfactory in 2 (6.3%) patients in group A compared to 4 (12.5%) patients in group B (p= 0.655).Conclusion: Thiopentone together with Lignocaine provided optimum conditions for laryngeal mask airway insertion comparable to that provided by propofol alone

Nigerian surgical outcomes - Report of a 7-day prospective cohort study and external validation of the African surgical outcomes study surgical risk calculator.

BACKGROUND: Surgical outcomes study for individual nations remains important because of international differences in patterns of surgical disease. We aimed to contribute to data on post-operative complications, critical care admissions and mortality following elective surgery in Nigeria and also validate the African Surgical Outcomes Study (ASOS) surgical risk calculator in our adult patient cohort. MATERIALS AND METHODS: We conducted a 7-day, national prospective observational cohort study in consented consecutive patients undergoing elective surgery with a planned overnight hospital stay following elective surgery during a seven-day study period. The outcome measures were in-hospital postoperative complications, critical care admissions and in-hospital mortality censored at 30 days. Also, we identified variables which significantly contributed to higher ASOS surgical risk score. External validation was performed using area under the receiver operating characteristic curve (ROC) for discrimination assessment and Hosmer-Lemeshow test for calibration. RESULTS: A total of 1,425 patients from 79 hospitals participated in the study. Postoperative complications occurred in 264(18.5%, 95% CI 16.6-20.6), 20(7.6%) of whom were admitted into the ICU and 16(6.0%) did not survive. Total ICU admission was 57 (4%), with mortality rate of 23.5% following planned admission and overall in-hospital death was 22(1.5%, 95% CI 0.9-2.2). All prognostic factors in the ASOS risk calculator were significantly associated with higher ASOS score and the scoring system showed moderate discrimination (0⋅73, 95% CI 0.62-0.83). Hosmer-Lemeshow χ2 test revealed scale was well calibrated in the validation cohort. CONCLUSION: NiSOS validates the findings of ASOS and the ability of the ASOS surgical risk calculator to predict risk of developing severe postoperative complications and mortality. We identified failure-to-rescue as a problem in Nigeria. Furthermore, this study has provided policy makers with benchmarks that can be used to monitor programmes aimed at reducing the morbidity and mortality after elective surgery. We recommend the adoption of the ASOS surgical risk calculator as a tool for risk stratification preoperatively for elective surgery.

Paediatric admissions and outcome in a general intensive care unit.

BACKGROUND: It is believed that intensive care greatly improves the prognosis for critically ill children and that critically ill children admitted to a dedicated Paediatric Intensive Care Unit (PICU) do better than those admitted to a general intensive care unit (ICU). METHODS: A retrospective study of all paediatric (< 16 years) admissions to our general ICU from January 1994 to December 2007. RESULTS: Out of a total of 1364 admissions, 302 (22.1%) were in the paediatric age group. Their age ranged from a few hours old to 15 years with a mean of 4.9 ± 2.5 years. The male: female ratio was 1.5:1. Postoperative admissions made up 51.7% of the admissions while trauma and burn made up 31.6% of admissions. Medical cases on the other hand constituted 11.6% of admissions. Of the 302 children admitted to the ICU, 193 were transferred from the ICU to other wards or in some cases other hospitals while 109 patients died giving a mortality rate of 36.1%. Mortality was significantly high in post-surgical paediatric patients and in patients with burn and tetanus. The length of stay (LOS) in the ICU ranged from less than one day to 56 days with a mean of 5.5 days. CONCLUSION: We found an increasing rate of paediatric admissions to our general ICU over the years. We also found a high mortality rate among paediatric patients admitted to our ICU. The poor outcome in paediatric patients managed in our ICU appears to be a reflection of the inadequacy of facilities. Better equipping our ICUs and improved man-power development would improve the outcome for our critically ill children. Hospitals in our region should also begin to look into the feasibility of establishing PICUs in order to further improve the standard of critical care for our children.

Paediatric admissions and outcome in a general intensive care unit

Background: It is believed that intensive care greatly improves the prognosis for critically ill children and that critically ill children admitted to a dedicated Paediatric Intensive Care Unit (PICU) do better than those admitted to a general intensive care unit (ICU). Methods: A retrospective study of all paediatric (< 16 years) admissions to our general ICU from January 1994 to December 2007. Results: Out of a total of 1364 admissions, 302 (22.1%) were in the paediatric age group. Their age ranged from a few hours old to 15 years with a mean of 4.9 ± 2.5 years. The male: female ratio was 1.5:1. Postoperative admissions made up 51.7% of the admissions while trauma and burn made up 31.6% of admissions. Medical cases on the other hand constituted 11.6% of admissions. Of the 302 children admitted to the ICU, 193 were transferred from the ICU to other wards or in some cases other hospitals while 109 patients died giving a mortality rate of 36.1%. Mortality was significantly high in post-surgical paediatric patients and in patients with burn and tetanus. The length of stay (LOS) in the ICU ranged from less than one day to 56 days with a mean of 5.5 days. Conclusion: We found an increasing rate of paediatric admissions to our general ICU over the years. We also found a high mortality rate among paediatric patients admitted to our ICU. The poor outcome in paediatric patients managed in our ICU appears to be a reflection of the inadequacy of facilities. Better equipping our ICUs and improved man-power development would improve the outcome for our critically ill children. Hospitals in our region should also begin to look into the feasibility of establishing PICUs in order to further improve the standard of critical care for our children