Prognosticators of Excision of Giant Intra-Oral Tumors in a Resource-Challenged Setting: A Case Report.

Minor salivary glands are widely distributed in the mucosal surface of the lips, palate, nasal cavity, pharynx, and larynx, thus can arise from any of these primary sites. Intra-oral minor salivary gland tumors (IMSGTs), while considered rare in the general population are relatively more common when compared to all the other extra-oral sites. Pleomorphic adenoma, as seen in the index patient, is the most commonly diagnosed benign IMSGT. Intra-oral minor salivary gland tumors are not uncommon and depending on their size, nature, and location can be associated with severe limitation of the Patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality. In addition to these deleterious effects, they present a major surgical challenge to the surgeon, who has to determine the safest, most feasible access to ensure complete, or near-complete excision, as well as to the anesthetist, who needs to secure a definitive airway through the nose or mouth, both of which could be significantly restricted by the presence of the tumor. The aim is to present our successful management of one of the largest intra-oral minor salivary gland tumors documented in the literature, highlighting the specific measures we undertook to tackle the peculiar surgical and anesthetic challenges we faced. It had been two years since surgery and the patient is thriving with a markedly improved quality of life and no features of recurrence. The patient is a 50-year-old male with a slowly growing painless, left palatal mass in the roof of the mouth of 10 years duration with recurrent spontaneous bloody discharge effluent and snoring. There was an associated history of dysphagia to solid with associated choking spells, a left-sided facial asymmetry with no cheek swelling, odynophagia, sore throat, or difficulty with breathing. There was ipsilateral loss of upper incisors and dental anarchy about two years before presentation. No other nasal, otologic, or ophthalmic symptoms were present. No neck swelling, stiffness, cough, or chest symptoms. The oropharyngeal physical examination was highly restricted due to the intra-oral size of the mass. Figure 1. There was facial asymmetry with a bulge of the left maxilla, left-sided levels 1b and 2 non-tender lymph node enlargements, freely mobile, not adhered to the skin. A craniofacial CT scan revealed extensive isodense heterogeneously enhancing intra-oral soft tissue mass occupying the entire palate/oral cavity and encroaching laterally on the masticator and the parapharyngeal space with erosion of the left maxillary floor and hyoid bone Figure 2. The patient had an excision biopsy of the palatal mass with a free margin. No frozen section at the time of surgery. Histology revealed Pleomorphic adenoma and was followed up for 2 years with no evidence of recurrence. Prognosticators are delay in presentation leading to an increase in size of the mass and severe limitation of the patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality, the surgeon not being overwhelmed, the skillful Anaesthesist that could maneuver the nasal cavity without us doing tracheostomy and the successful outcome of the surgery.

Les glandes salivaires mineures sont largement réparties à la surface muqueuse des lèvres, du palais, de la cavité nasale, du pharynx et du larynx, et peuvent donc survenir à partir de l'un de ces sites primaires. Les tumeurs des glandes salivaires mineures intra-orales (TGSMIO), bien que considérées comme rares dans la population générale, sont relativement plus courantes par rapport à tous les autres sites extra-oraux. L'adénome pléomorphe, tel que celui observé chez le patient index, est la TGSMIO bénigne la plus fréquemment diagnostiquée. Les tumeurs des glandes salivaires mineures intra-orales ne sont pas rares et, en fonction de leur taille, de leur nature et de leur emplacement, peuvent être associées à une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère et même une mortalité. Outre ces effets délétères, elles présentent un défi chirurgical majeur pour le chirurgien, qui doit déterminer l'accès le plus sûr et le plus faisable pour assurer une excision complète ou presque complète, ainsi que pour l'anesthésiste, qui doit assurer une voie aérienne définitive par le nez ou la bouche, tous deux pouvant être significativement restreints par la présence de la tumeur. L'objectif est de présenter notre prise en charge réussie de l'une des plus grandes TGSMIO documentées dans la littérature, mettant en évidence les mesures spécifiques que nous avons prises pour relever les défis chirurgicaux et anesthésiques particuliers auxquels nous avons été confrontés. Deux ans après l'intervention, le patient se porte bien avec une nette amélioration de sa qualité de vie et aucune manifestation de récurrence. Le patient est un homme de 50 ans présentant une masse palatine gauche en croissance lente et indolore dans le palais depuis 10 ans, avec des écoulements sanguins spontanés récurrents et des ronflements. Il y avait une histoire associée de dysphagie aux solides avec des épisodes d'étouffement, une asymétrie faciale du côté gauche sans tuméfaction de la joue, une odynophagie, un mal de gorge ou des difficultés respiratoires. Il y avait une perte ipsilatérale des incisives supérieures et une anarchie entaire environ deux ans avant la présentation. Aucun autre symptôme nasal, otologique, ophtalmique n'était présent. Aucun gonflement du cou, raideur, toux ou symptômes thoraciques. L'examen physique de l'oropharynx était fortement limité en raison de la taille intra-orale de la masse. Figure 1. Il y avait une asymétrie faciale avec une bosse du maxillaire gauche, des ganglions lymphatiques non douloureux des niveaux 1b et 2 du côté gauche, mobiles librement, non adhérents à la peau. La tomodensitométrie craniofaciale a révélé une masse tissulaire molle intraorale extensive, hétérogène, rehaussée de manière isodense occupant l'ensemble du palais/cavité buccale et empiétant latéralement sur les muscles masticateurs et l'espace parapharyngé, avec érosion du plancher du maxillaire gauche et de l'os hyoïde. Figure 2. Le patient a subi une biopsie d'excision de la masse palatine avec une marge libre. Aucune section congelée n'a été réalisée lors de la chirurgie. L'histologie a révélé un adénome pléomorphe et un suivi de 2 ans n'a montré aucun signe de récurrence. Les facteurs pronostiques comprennent le retard de la présentation entraînant une augmentation de la taille de la masse et une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère voire une mortalité, le chirurgien ne se laissant pas dépasser, l'anesthésiste compétent pouvant manœuvrer dans la cavité nasale sans avoir recours à une trachéotomie, et le succès de l'intervention chirurgicale. MOTS-CLÉS: Intraoral; Glande salivaire mineure; Excision; Tumeur; Pronostiqueurs.

Post-operative Analgesic and Opioid-sparing Effect of a Single-dose Pre-operative Oral Pregabalin in Gynaecological Surgeries.

Background: Post-operative pain treatment is a major challenge in our environment. Opioids may cause respiratory depression post-operatively. Therefore, any combination of opioid and non-opioid analgesics that provides quality post-operative pain control and reduces opioid consumption with its attendant side effects will be highly desirable. Objectives: The aim of this article is to evaluate analgesic benefits and opioid-sparing effects of pre-operative oral pregabalin in patients who undergo abdominal gynaecological surgeries. Materials and Methods: A prospective randomized double-blind placebo-controlled study is carried out at University of Ilorin Teaching Hospital, Kwara State, Nigeria. Eighty-two patients scheduled for gynaecological surgeries were randomized into two equal groups. The patients in the control and study groups received a placebo drug and oral pregabalin 150 mg, respectively, 1 h before induction of general anaesthesia. Post-operative pain intensity using a five-point Verbal Rating Scale, time to first request for analgesia, and 24 h post-operative pethidine consumptions were assessed. Mean values were compared using Student's t-test. Categorical data were compared with the χ 2 test. Level of significance was set at 5% (0.05) and power of the study was 80%. Results: Demographic characteristics were comparable between the two groups. The median pain score was 0-2 (no pain-moderate pain) throughout the study. Post-operative static and dynamic pain scores at 1, 4, and 12 h were significantly higher in the placebo group (<0.001). Twenty-four hours post-operatively, there were no significant differences in static and dynamic pain scores between the two groups (P=0.131 and P=0.384, respectively). Time to first analgesic requirement and total pethidine consumed within 24 h post-operative were 47 ± 19 vs. 258 ± 137 min (P=0.001) and 326.19 ± 62.70 vs. 192.86 ± 55.84 mg (P=0.001) in the control and study groups, respectively. The pre-operative use of pregabalin reduced post-operative opioid requirement by 40.9% in the study group. Nausea and vomiting were more common in the placebo group, whereas dizziness, blurring of vision, and sedation were more common in the pregabalin group. Conclusion: A single pre-operative dose of 150 mg oral pregabalin had significantly greater analgesic effects compared with placebo and reduced post-operative opioid requirements in patients undergoing myomectomy or total abdominal hysterectomy. It should be considered an adjuvant in multimodal pain management regimens following gynaecological surgeries.

Dose related effects of oral clonidine pre-medication on bupivacaine spinal anaesthesia.

INTRODUCTION: The duration of action of sub-arachnoid block is short, and one of the ways to overcome this is the use of oral clonidine. METHODS: 108 patients of ASA I and II, aged 18 to 65 years undergoing lower abdominal surgeries under spinal anaesthesia were randomized into three groups.. Control group A (n=36) no oral clonidine pre-medication, Group B (n=36) and group C (n=36) received 100 µg and 200 µg of oral clonidine pre-medication respectively, 1hr before spinal anaesthesia. Haemodynamic parameters were recorded. Sensory block, degree of motor blockage, and sedation were assessed. RESULTS: Clonidine prolonged the mean duration of motor block by 189.98±26.93 min (100µg) and 191.89±28.13 min (200µg) compared to 117.92±25.13 min in the control group p<0.05. The mean duration of analgesia was 188.19±35 min (100µg) and194±24.58 min (200µg) in the clonidine groups compared to 115.89±26.66 min in control group p<0.05. All the patients were awake in the control group while 71.43% and 100% were drowsy in groups B and C respectively. CONCLUSION: Oral clonidine produces better clinical effects on the onset and duration of Bupivacaine spinal anaesthesia.

EFFICACY AND SAFETY OF ORAL KETAMINE PREMEDICATION IN CHILDREN UNDERGOING DAY CASE SURGERY.

BACKGROUND: Oral premedication for paediatric age group is an uncommon practice amongst anaesthetists in Nigeria. Both parents and the child suffer some form of emotional or psychological distress. AIM: To determine the efficacy and safety of oral formulated ketamine for premedication in children scheduled for ambulatory surgeries. METHODS: Seventy three children aged 1 - 6 years with American Society of Anesthesiologists (ASA) physical status I-II were prospectively studied. They were assigned randomly to receive either 5 mg/kg (Group A), 10 mg/kg (Group B), or no ketamine (Group C).The children were observed for acceptance of premedication, sedation and anxiolysis at 10, 20 and 30 minutes after drug administration. Behavior/response of each child at the time of separation from parents, intravenous access, and acceptance of facemask for induction, postanaesthetic arousal state and complications were also recorded. RESULTS: There were 73 children in this study with a mean age of 37.4±18.0 months. The groups were comparable in age. The studied agent was tolerated by both groups that received premedication with no significant difference (P 0.73). Adequate sedation and anxiolysis were observed in groups A and B, (52%, 84%) and (68%, 88%) respectively. However, more children in group B (82.6%) had satisfactory behaviour at separation from parents and a better acceptance of anaesthetic face mask (64%) at induction than those in groups A and C (33.3%, 21.7%, respectively). No side effect was recorded in either of the premedication groups or the control group. CONCLUSION: Oral ketamine is acceptable and safe premedication for children. It provided good sedation, relieved anxiety and had no side effect in the children at the studied doses.

Effect of wound infiltration with bupivacaine on pulmonary function after elective lower abdominal operations.

BACKGROUND: Subcutaneous or intrafascial wound infiltration of local anaesthetic with systemic opioids has been shown to enhance patient comfort with improved analgesia and reduced opioid requirements. OBJECTIVE: To demonstrate improved pulmonary function when postoperative analgesia was provided by combined bupivacaine wound infiltration and systemic opioid. METHODS: In a prospective, randomized, placebo-controlled study, 46 patients (23 per group) scheduled for elective gynaecological surgery under general anaesthesia had subcutaneous and intrafascial wound infiltration of 40 ml, 0.25% bupivacaine (study patients) or 40 ml 0.9% saline (control) just before the end of surgery. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and peak expiratory flow rate (PEFR) were done before surgery and at 6, 12 and 24 hours postoperatively. Student's T and chi-square tests were used for tests of significance set at P < 0.05. Postoperative analgesia was provided with intramuscular morphine 0.15 mg/kg 4 hourly and 10mg/kg of intravenous paracetamol as rescue analgesia. RESULTS: PEFR, FVC and FEV1 were reduced in both the control and study groups but the reduction was greater in the control group. CONCLUSION: Bupivacaine wound infiltration produced statistically significant elevations in pulmonary function tests results at all assessment periods.

Comparative study of the haemodynamic effects of propofol and thiopentone in modified electroconvulsive therapy in Nigerians.

BACKGROUND: Electroconvulsive therapy provokes abrupt changes in systemic haemodynamics. We compared the effects of propofol and thiopentone on haemodynamic responses of patients scheduled for ECT between September 2008 and March 2009 in two Nigerian tertiary hospitals. METHODS: In a prospective, randomized study, 40 patients scheduled for ECT were allocated into 2 groups of 20 each. Anaesthesia was induced with either 1mg/kg propofol (PG) or 5 mg/kg thiopentone (TG) and 0.5mg/kg suxamethonium prior to ECT. Heart rate (HR), blood pressure- systolic (SBP), mean arterial (MAP) and diastolic (DBP) were taken before ECT and at 1 and 5 minutes postictal. The means of the increases in haemodynamic parameters were compared. RESULTS: There were significant increases in mean HR in both groups at 1 and 5 min and the increases were comparable between the 2 groups (p = 0.784). The increases in SBP were not significant in both groups and were comparable (p = 0.988). The increases in mean DBP were not significant in both groups but it was significantly greater in TG (p = 0.012). Increase in MAP was significantly greater in the TG at 1 min (p = 0.028). CONCLUSION: Propofol at 1 mg/kg and thiopentone at 5 mg/kg used for modified ECT in this study resulted in significant increases in heart rates. However, a significant increase in mean arterial pressure with thiopentone and a significantly greater increase in diastolic blood pressure when the two agents are compared confer some superiority on propofol over thiopentone in attenuating haemodynamic responses to ECT.

Examination malpractice in our medical schools: prevalence and import on tomorrow's doctors.

UNLABELLED: AIMS AND OBJECTIVES. The objective of this paper is to estimate the prevalence of examination malpractice among medical students; its import on medical education and future doctors. MATERIALS AND METHODS: Structured questionnaires were administered to consenting medical students of participating four medical colleges in Nigeria. Data was collated and analysed using SPSS version 11. RESULTS: Three hundred and eighty two students responded. There were 210 males and 172 females (M: F-1.2:1); age range 19-45 years, mean 24.86 ± SD. Majority 304(79.6%) were in the 5th and final years. At secondary and tertiary levels, 67(18.1%) and 79(22.2%) were respectively involved in cheating. Mode of cheating included seeking examination materials, 10(2.6%); copying answers between examination rooms, 18(4.8%); copying assignments, 290(77.7%) and copying laboratory results 206(56.6%). Clinical examinations not performed were described as "normal" by 206(56.6%). Motivation for cheating included previous failures and escape punishment in 6(3.3%) and 31(10.4%) respectively. While 46(12.8%) tried to induce lecturers to change grades, 97(25.8%) would not inform the authority if they suspected that examination leaked. CONCLUSION: Examination malpractice in High schools and Tertiary institutions also includes the medical students. Educating pupils from the elementary schools on effects of cheating, inclusion of this practice in the medical curriculum as part of Medical Ethics and Institutional culture of Integrity among doctors are recommended. Stiffer punishment for offenders would reduce the practice among the students.

Appropriate practice of anesthesia: A plea for better training.

BACKGROUND: The role of the anesthesiologist is often unknown among patients. But, the situation where the anesthesiologist is uncertain of his/her function gives more cause for concern. METHODS: A questionnaire survey on the appraisal of anesthetic practices was carried out over 5 months using the style of clinical practice. RESULTS: One-third of the anesthesiologists who responded to the survey attached little importance to the work they did by not communicating the same to their patients while 45.2% did not discuss the intraoperative findings with the surgeons. Although 57 (59.4%) of the respondents usually visit their patients on the ward preoperatively, only 16 (21.6%) discussed the proposed anesthetic procedure with the patients. Thirty-nine (40.2%) respondents claimed that they do not wear ward coats to the ward at the preoperative visit. Less than 20% consistently conducted a postoperative visit. The majority of the respondents would treat all patients as important, irrespective of social status, while 74.5% of them considered obtaining informed consent for anesthesia from patients as significantly important. CONCLUSION: The current practice of anesthesia has been found wanting in several aspects. Knowledgeable discussion by anesthesiologists with surgeons as well as enlightenment of patients and their relatives about their work will improve the quality of anesthesia care remarkably. Changes in the anesthesia training curriculum to reflect these deficiencies would be helpful.

Pediatric day case surgery: experience from a tertiary health institution in Nigeria.

BACKGROUND: The general observation that children achieve better convalescence in the home environment supports the need for adoption of day case surgery, which is gaining considerable acceptance in developing countries. Pediatric surgical service is in great demand in developing countries, and in-patient beds and surgical supplies are insufficient. METHOD: A prospective collection of data on all pediatric day surgeries (PDSs) by the pediatric surgical unit University of Ilorin Teaching Hospital (UITH, Ilorin, was done. Parents had pre-operative outpatient briefing and postoperative interviews on the second and ninth days for consultation regarding post-operative complications and events at home. Study period was between April 2005 and September 2007 (2(1/2) years). RESULTS: Of the 660 elective cases, 449 (68.02%) children were recruited as day cases. The male-to-female ratio was 14.3:1. Age ranged between 20 days and 15 years with a mean of 37.6 months and standard deviation (SD) of 34.4 months. Congenital hernias/ hydroceles were the highest indications (71.2%), followed by lump/ masses (12.9%), undescended testes (8.7%), umbilical hernias (4.8%) and thyroglossal duct cyst (2.5%). In 98.9% of cases, the parents resided within 20 km radius of the hospital, and 91.5% of them could reach the hospital within 1 hour. Fathers and mothers of 80.1% and 77.1% of children, respectively, had above-primary education. More than half of the fathers (55%) were civil servants, while 30% were self-employed. The mothers were civil servants in 37.3% of cases, and 34% were self-employed. The average number of outpatient clinic visits before surgery was 2-3 visits (41.2%) with mean interval to surgery of 4-5 weeks (60.3%). Logistics (investigations and availability of operation list) and patient's fitness for surgery were statistically significant delay factors (P= 0.001). CONCLUSION: Parents reported 14 children to be irritable at home due to pain, while the others reported satisfactory day case experience. No unplanned admission or mortality was recorded, and only 3 (0.8%) parents would not recommend day case surgery to other people. CONCLUSION: Pediatric day case surgery is feasible for well-selected and monitored cases in our environment. Term neonates with informed parents are suitable for pediatric day case surgery. There is a need for a day case center to reduce waiting list at UITH.

Complications and indications for intensive care unit admission after thyroidectomy in a University Teaching Hospital.

BACKGROUND: Routine admission of all post-thyroidectomy patients into intensive care unit (ICU) within the first 24-48 hours is advocated and practised in some hospitals. However, clinicians today are faced with the need to improve patient outcome at minimal costs. AIMS: To determine the incidence of life-threatening complications necessitating (ICU) admission following thyroidectomy; and to identify any pre-operative risk factors for ICU admission in patients with goitre. SETTING: University of Ilorin Teaching Hospital, Ilorin, Nigeria. DESIGN: Retrospective study. METHODOLOGY: A retrospective study of all patients who were admitted to the ICU following thyroidectomy, over a period of 10 years (January 1993- December 2002), was carried out. Their records were analysed for indication for admission, therapeutic intervention instituted and outcome. RESULTS: A total of 196 case notes out of the 210 thyroidectomies performed within the study period could be retrieved for analysis. Twenty patients (10.2%) required ICU admission for various indications. Sixteen of the admissions were elective based on recognition of the need immediately after extubation in the theatre, while the remaining 4 patients were emergency admissions transferred from the post-surgical ward at variable periods within the first 24-hours post-operatively. The most common reason for ICU admission was recurrent laryngeal nerve (RLN) palsy, which occurred in 13 patients (6.6%). There was one mortality in the elective admissions and no mortality in emergency admissions. No patient died or suffered disability on account of failure to get admitted to ICU. CONCLUSION: It is safe to discharge the majority of patients back to post-surgical ward for nursing care immediately after thyroidectomy. Most of our patients were discharged to the post-surgical ward without any life-threatening complication.

Motorcycle crash characteristics in Nigeria: implication for control.

Despite being the second most common cause of road traffic injuries (RTIs) in Nigeria, no study had examined the peculiarities of motorcycle crash site characteristics in Nigeria. We examined and interviewed 363 motorcycle RTI patients in three tertiary hospitals in southwest Nigeria. All the motorcycles are small with capacities between 80 and 125cm3. 68.9% of the patients sustained their injuries while working or going to work and 23.4% on their way to school. 176 (48.5%) of the crashes were with moving vehicles and in 83 (22.3%) cases, either the motorcycle or the other vehicle is moving against the traffic. 37.8% of all crashes occurred at junctions with no roundabout versus 5% at junctions with roundabout. Some risky practices of the patient included carrying more than 2 persons (15.02%), travelling without headlight at night (31.7%) and not wearing helmets (96.5%). This study showed that risky behavior among motorcycle riders, chaotic traffic and road design faults accounted for most of the motorcycle crashes. The implications for the prevention and control of motorcycle injuries were discussed.

Pediatric day case surgery: Experience from a tertiary health institution in Nigeria

Background : The general observation that children achieve better convalescence in the home environment supports the need for adoption of day case surgery, which is gaining considerable acceptance in developing countries. Pediatric surgical service is in great demand in developing countries, and in-patient beds and surgical supplies are insufficient. Method : A prospective collection of data on all pediatric day surgeries (PDSs) by the pediatric surgical unit University of Ilorin Teaching Hospital (UITH, Ilorin, was done. Parents had pre-operative outpatient briefing and postoperative interviews on the second and ninth days for consultation regarding post-operative complications and events at home. Study period was between April 2005 and September 2007 (2½ years). Results : Of the 660 elective cases, 449 (68.02%) children were recruited as day cases. The male-to-female ratio was 14.3:1. Age ranged between 20 days and 15 years with a mean of 37.6 months and standard deviation (SD) of 34.4 months. Congenital hernias/ hydroceles were the highest indications (71.2%), followed by lump/ masses (12.9%), undescended testes (8.7%), umbilical hernias (4.8%) and thyroglossal duct cyst (2.5%). In 98.9% of cases, the parents resided within 20 km radius of the hospital, and 91.5% of them could reach the hospital within 1 hour. Fathers and mothers of 80.1% and 77.1% of children, respectively, had above-primary education. More than half of the fathers (55%) were civil servants, while 30% were self-employed. The mothers were civil servants in 37.3% of cases, and 34% were self-employed. The average number of outpatient clinic visits before surgery was 2-3 visits (41.2%) with mean interval to surgery of 4-5 weeks (60.3%). Logistics (investigations and availability of operation list) and patient's fitness for surgery were statistically significant delay factors (P= 0.001). Conclusion : Parents reported 14 children to be irritable at home due to pain, while the others reported satisfactory day case experience. No unplanned admission or mortality was recorded, and only 3 (0.8%) parents would not recommend day case surgery to other people. Conclusion: Pediatric day case surgery is feasible for well-selected and monitored cases in our environment. Term neonates with informed parents are suitable for pediatric day case surgery. There is a need for a day case center to reduce waiting list at UITH

Cervical plexus block for thyroidectomy: experience with a giant goitre: case report.

Local or regional anaesthesia has long been recognised as a useful anaesthetic option for thyroidectomy. A few authors have reported the successful use of local infiltration anaesthesia for thyroidectomy in our environment. The technique is said to be particularly suitable for simple giant goitres. Cervical plexus block has also been found useful for this operation in other parts of the world. However, we are unaware of any report on the use of cervical plexus block for thyroidectomy in our environment. We used bilateral superficial cervical plexus block for thyroidectomy in a 20-year old girl with a simple multinodular goitre. Surgery was performed with the patient in the classical thyroidectomy position. Though the patient was lightly sedated during the operation, the anaesthetist maintained communication with her throughout the procedure. Anaesthesia was generally effective, except for minor complaints of pressure symptoms during mobilization of the gland and postural aches. These, the patient described as tolerable. Surgery, which lasted 2 hours 45 minutes, was uneventful. The patient was allowed oral fluid intake within 2 hours postoperatively. Superficial cervical plexus block is simple, safe, effective and cheap for thyroidectomy for Simple Giant Goitre.

Post-anaesthetic respiratory complaints following endotracheal anaesthesia in lower abdominal obstetric and gynaecology surgery.

BACKGROUND: Postanaesthetic respiratory complications represent a significant negative aspect of surgical care. OBJECTIVE: To assess the incidence and possible associated risk factors for postanaesthestic respiratory complaints following endotracheal anaesthesia in lower abdominal surgery in obstetric and gynecology patients in our hospital. SETTING: A Teaching Hospital in Nigeria. DESIGN: Prospective study METHODOLOGY: All consenting adult patients, aged 16-45 years, undergoing caesarean section and major gynaecological abdominal operations, under general anaesthesia with endotracheal intubation, over a period of 8months, were studied. Postoperative respiratory symptoms, (sorethroat, hoarseness and cough), were assessed in the ward, by direct questioning method, daily for 5 days. Those presenting with cough had their chest examined, and fever (T degrees > 37 degrees C), was noted. Patients with positive chest signs had radiological examinations of the chest done for confirmation. RESULTS: A total of 202 patients were studied. Out of these, 152 (75.2%) patients had various forms of postoperative respiratory complaints. Overall, it was observed that caesarean section patients were more likely, than gynaecology patients, to report these respiratory complications in the postoperative period (88.4% vs. 58.9%). This difference was statistically significant (p < 0.05). The incidence of sorethroat directly correlated with the size of the endotracheal tube used (r = 0.936). There was a statistically significant difference in the incidence of sorethroat between the caesarean section patients and gynaecology patients (p < 0.00), particularly with endotracheal tube sizes larger than 7.5mm ID (p < 0.03). Duration of intubation, which was slightly longer in gynaecology patients (mean = 72.48 +/- 30.62), and number of intubation attempts, did not have statistically significant effect on the incidence of respiratory complaints. CONCLUSION: The use of small endotracheal tube sizes (< 8.5mm) should be preferred in women, particularly in obstetric anesthesia (6.5-7.5mm), to minimize the incidence of postoperative respiratory complications.

Day case surgery: experience in a tertiary health institution in Nigeria.

BACKGROUND: Previous studies on day case surgery in Nigeria have focused mainly on the immediate peri-operative care of the patients within the service hospital. OBJECTIVE: To assess patients' satisfaction and postoperative complications within the first seven days following day case surgery. METHODS: A post discharge patient's survey was conducted on the 7th Postoperative day in 102 consecutive patients who had undergone day care surgery. Patients were interviewed about their postoperative experiences, type of complications and treatment applied, and visits to hospitals or community health facilities/providers. They were also asked to comment on their satisfaction or otherwise of day case treatment. RESULTS: There were 32 occasions of treatment provided to 24 patients (23.5%) after discharge. Seventy-two patients (70.6 %) reported one or more complications, with pain being present in all of them. Some patients received treatment more than once, and for more than one complaint. Pain was the most common reason for seeking treatment. There was no mortality. Eighty-six (84.3%) patients expressed satisfaction with day case treatment, while 10 (9.8%) patients (9.8%) expressed dissatisfaction and 6 (5.9%) patients were indifferent. CONCLUSION: Day surgery provided satisfactory outcome for the majority of our patients, with low complication rates.

Pre-hospital care of the injured in South Western Nigeria: a hospital based study of four tertiary level hospitals in three states.

Pre-hospital care in developing worlds has been found to be grossly deficient compared to high income countries. The pre-hospital care given to road accident victims attending the casualty departments of four tertiary level hospitals in South Western Nigeria was assessed using a one-page pro-forma. 1996 patients with injuries from road crashes were seen in the hospitals, only 172 had any form of pre-hospital care, just 160 were transported in ambulances and none had any form of organized pre-hospital care. The mean arrival time in the hospital after crashes was 93.6 minutes and there was a high rate (29.5%) of inter-hospital referral. For every Revised Trauma Score (RTS), the Probability of survival (Ps) of the patients was higher than the Ps of patients from high income countries.

Medical problems in geriatric surgical patients.

Age is often a marker for co-morbid illness that may complicate attempts at surgery, hence careful preoperative assessment and vigorous treatment of the pre-operative medical condition with adequate post-operative supports are needed for safe surgery. In our series, a fifteen months study period, six hundred and Ninety five patients were operated upon out of which forty four patients were 65 years old and above (6.3% ); Age ranged between 65 years and 80 years (mean age of 70 years). The patients with medical problems were sixteen (36.4% ) out of which urinary tract infection was the most common (43.8% ). The most common anaesthetic technique was spinal anaesthesia in 45.5%, the most common operative procedure was herniorrhaphy (36.4% ); followed by prostatectomy (26.5% ). Three of the patients presented with wound infection; mortality was 2.3%, which occurred in a patient who died of multiple organ failure.

Anaesthesia-related complications: follow-up programme.

BACKGROUND: The subject of postoperative complication and prevention has continued to generate interest in the last decade. Unfortunately, very few data are available locally to assess the extent of the problems and measures designed to address them. OBJECTIVE: This prospective study was designed to identify the anaesthesia-related postoperative complications at the University of Ilorin Teaching Hospital, through a follow-up programme. SETTING: The study was conducted at the University of Ilorin Teaching Hospital, Nigeria between August, 1999 and February, 2000. METHOD: A total of 172(67 male and 105 female) patients who underwent various types of surgical operations under general anaesthesia were followed up postoperatively for five days. Clinical progress including complications related to anaesthesia were recorded. RESULTS: There were 105 female and 67 male patients with a mean age of 35.27 (range 10-70) years. Of the total number only 7(9.88%) had no complications of any kind. The remaining 155(90.12%) had complications ranging from transient episode of shivering in the recovery room to severe respiratory tract infection. The commonest postoperative complication observed was respiratory tract infection, which occurred in 29.65% of patients. This was followed by pyrexia (Temp > 37 degrees C) (27.91%), nausea/vomiting (23.36%) and sore throat (19.77%). Ocular complication and urinary retention ranked lowest in the list of complications, each occurring in one patient (0.58%). CONCLUSION: This study has shown that despite recent advances in anaesthetic techniques and the introduction of newer anaesthetic drugs, the incidence of postanaesthetic complications has not changed significantly in our environment.

Postoperative pain management following caesarean section in University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria.

OBJECTIVE: To assess the common methods of analgesia used in our hospital following caesarean section, their effectiveness and patient satisfaction. DESIGN: A prospective descriptive study. SETTINGS: The study was conducted at the University of Ilorin Teaching Hospital (UITII), Ilorin, Nigeria over a period of 18 months (February 1999 - July 2000). METHODOLOGY: We studied prospectively the methods used for postoperative analgesia in 88 consecutive patients who had elective caesarean section under general anaesthesia. Pain assessment was carried out by direct questioning method using a 4-point verbal rating scale of none, mild, moderate and severe, in the recovery room, and on the mornings of days 1 and 2 postoperatively. Patients' satisfaction of pain relief was assessed on day 2 on a 2-point scale of satisfactory or unsatisfactory. The postoperative drug sheets and medication charts were also reviewed and analysed. RESULTS: Surgeon-prescribed, nurse-administered intermittent intramuscular administration of analgesics was the method used for postoperative pain control in all the patients. Pentazocine was prescribed in 86.4% of patient while the remaining 13.6% had Tramadol. Most of the patients (95%) experienced some degree of pain in the immediate postoperative period. The first 24 hours postoperatively was particularly painful for the patients with 79.6% and 54.6% reporting moderate to severe pain in the recovery room and on day 1 respectively. However, despite the high incidence of pain most of the patients (85.2%) still expressed satisfaction with the level of pain relief. CONCLUSION: Pain remains a significant problem following surgical operations in our environment.