The efficacy and safety of an adapted opioid-free anesthesia regimen versus conventional general anesthesia in gynecological surgery for low-resource settings: a randomized pilot study.

INTRODUCTION: There is scarce data on the safety and efficacy of opioid-free anesthesia (OFA), in resource-limited settings due to the non-availability of dexmedetomidine, the reference OFA agent. We aimed to demonstrate the feasibility, efficacy and safety of a practical OFA protocol not containing dexmedetomidine, adapted for low-resource environments in very painful surgeries like gynecological surgery. METHODS: We conducted a randomized pilot study on ASA I and II women undergoing elective gynecological surgery at a tertiary care hospital in Cameroon. Patients were matched in a ratio of 1:1 into an OFA and a conventional general anesthesia (CGA) group. The OFA protocol entailed the intravenous (IV) magnesium sulfate, lidocaine, ketamine, dexamethasone, propofol, and rocuronium, followed by isoflurane and a continuous infusion of a calibrated mixture of magnesium sulfate, ketamine and clonidine. The CGA protocol was IV dexamethasone, diazepam, fentanyl, propofol, and rocuronium, followed by isoflurane and reinjections of fentanyl propofol and a continuous infusion of normal saline as placebo. The primary endpoints were the success rate of OFA, isoflurane consumption and intraoperative anesthetic complications. The secondary endpoints were postoperative pain intensity, postoperative complications, patient satisfaction assessed using the QoR-40 questionnaire and the financial cost of anesthesia. RESULTS: We enrolled a total of 36 women undergoing gynecological surgery; 18 in the OFA group and 18 in the CGA group. The success rate of OFA was 100% with significant lesser consumption of isoflurane in the OFA group, no significant intraoperative complication and better intraoperative hemodynamic stability in the OFA group. Postoperatively, compared to the CGA group, the OFA group had statistically significantly less pain during the first 24 h, no morphine consumption for pain relief, had less hypoxemia during the first six hours, less paralytic ileus, less nausea and vomiting, no pruritus and better satisfaction. The mean financial cost of this adapted OFA protocol was statistically significant lesser than that of CGA. CONCLUSION: This OFA regimen without dexmedetomidine for a low-resource setting has a promising success rate with few perioperative complications including mild intraoperative hemodynamic changes, decrease postoperative complications, pain, and opioid consumption in patients undergoing elective gynecology surgery. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov on 03/02/2021 under the registration number NCT04737473.

Pharmacodynamics of rocuronium in sickle cell patients.

BACKGROUND: Sickle cell disease is the most widespread genetic disease in the world. The chronic organ damage due to this disease could lead to variability of responses to the anaesthetic drugs. We analysed the pharmacodynamics response of rocuronium to sickle cell patients. METHODS: We observed and compared the onset time and clinical duration (time to recovery first twitch) of 0.6 mg kg-1 of rocuronium using a TOFscan® monitor, as well as the time before the first incremental dose (time to recovery second twitch), in a group of 22 homozygous sickle cell patients and a group of 23 controls, all programmed for laparoscopic surgical procedures. RESULTS: The onset time of rocuronium was longer in sickle cell patients [mean ± SD (extremes)], [6.3 ± 2.1 (1.8-10) min] than in the control group [2.5 ± 0.6 (1.4-3.5) min] (P < 0.01). The clinical duration was shorter in sickle cell patients [19.2 ± 7.1 (13-41) min] when compared to the control group [28.9 ± 6.9 (21-48) min] (P < 0.01). The time before the first incremental dose was shorter in the sickle cell patients group [27.7 ± 7.9 (19-49) min] compared to the control group [39.9 ± 8.7 (30-56) min] (P < 0.01). CONCLUSION: The onset time of rocuronium was significantly longer with a shorter duration of action in patients with sickle cell disease versus the general population.

The Practices of Anaesthesiologists in the Management of Patients with Sickle Cell Disease: Empirical Evidence from Cameroon.

Patients with sickle cell disease are more likely to undergo surgery during their lifetime, especially given the numerous complications they may develop. There is a paucity of data concerning the management of patients with sickle cell disease by anaesthesiologists, especially in Africa. This study aimed to describe the practices of anaesthesiologists in Cameroon concerning the perioperative management of patients with sickle cell disease. A cross-sectional study was carried out over four months and involved 35 out 47 anaesthesiologists working in hospitals across the country, who were invited to fill a data collection form after giving their informed consent. The data were analysed using descriptive statistics and a binary logistic regression model. Among the 35 anaesthesiologists included in the study, most (29 (82.9%)) had managed patients with sickle cell disease for both emergency and elective surgical procedures. Most of them had never asked for a haematology consultation before surgery. Most participants (26 (74.3%)) admitted to having carried out simple blood transfusions, while 4 (11.4%) carried out exchange transfusions. The haemoglobin thresholds for transfusion varied from one practitioner to another, between <6 g/dL and <9 g/dL. Only 6 (17.1%) anaesthesiologists had a treatment guideline for the management of patients with sickle cell disease in the hospitals where they practiced. Only 9 (25.7%) prescribed a search for irregular agglutinins. The percentage of haemoglobin S before surgery was always available for 5 (14.3%) of the participants. The coefficient (0.06) of the occurrence of a haematology consultation before surgery had a significant influence on the probability of management of post-operative complications (coefficient 0.06, 10% level of probability). This study highlights the fact that practices in the perioperative management of patients with sickle cell disease in Cameroon vary greatly from one anaesthesiologist to another. We disclosed major differences in the current recommendations, which support the fact that even in Sub-Saharan countries, guidelines applicable to the local settings should be published.

Malignant hyperthermia, a rare perioperative complication: case series and literature review.

Malignant hyperthermia is a rare complication of general anesthesia appearing as an acute and potentially lethal hypermetabolic state in people carrying a genetic anomaly expressed in skeletal muscles. Malignant hyperthermia has been scarcely described in sub-Saharan Africa. Herein, we present three cases of malignant hyperthermia occurring in the perioperative period in Cameroon. The authors wish to draw attention to the clinical presentation of this rare but potentially lethal emergency, for timely diagnosis, management and follow-up geared at preventing perioperative mortality.

Anaesthesiologist-intensivist phycisians at the core of the management of critically ill COVID-19 patients in Africa: persistent challenges, some resolved dilemma and future perspective.

Unlike developed countries which have purely intensivists also called critical care physicians or intensive care physicians to manage critically ill patients like those with severe forms of COVID-19, the practice of critical care medicine in Africa is coined to anaesthesiology. Hence, anaesthesiologist-intensivist physicians are the medical specialists taking care of critically ill COVID-19 patients in Africa. Likewise, unlike intensive care units (ICUs) in high income countries, those in most African countries face the challenge of a lack of emergency drugs and resuscitation equipment, limited health infrastructure and understaffed and underfunded health care systems. The COVID-19 pandemic is an unprecedented one faced by intensivists in high-income countries and anaesthesiologist-intensivist phycisians in Africa. Infected patients with severe forms of the disease like those having grave COVID-19 complications like massive pulmonary embolism, severe cardiac arrhythmias, cardiogenic shock, septic shock, acute kidney injury or acute respiratory distress syndrome require ICU admission for better management. Both intensivists or anaesthesiologist-intensivist physicians have the peculiarity of securing the airways of critically COVID-19 patients and providing respiratory support with mechanical ventilation after laryngoscopy and endotracheal intubation when needed. In so doing, they can easily be infected from respiratory droplets or aerosols expired by the COVID-19 patients. Hence, in Africa, anaesthesiologist-intensivist phycisians have a higher risk of contracting COVID-19 compared to other health professionals. It's worth to mention that the COVID-19 pandemic struck African anaesthesiologist-intensivist phycisians and ICUs when there were neither prepared skillfully or lacked the required ICU capacity to meet the demands of thousands of severe COVID-19 African patients. These further weakened the already strained health systems in Africa. It required a lot of creativity, engineering skills and courage for these ill prepared African anaesthesiologist-intensivist physicians to provide care to these critically ill patients and improve their outcomes as the pandemic progressed. However, despites the numerous efforts made in African anaesthesiologist-Intensivist phycisians to care for critically ill COVID-19 patients, the pandemic is spreading at a rapid rate across Africa. There is an urgent need for African health authorities to anticipate on how to scale up the future high ICU capacity needs and limited ICU workforce, infrastructure and equipment to manage severe forms of COVID-19 in future. It cannot be overemphasized that these severe forms of COVID-19 are potentially fatal and are a major contributor to the death toll of the COVID-19 pandemic.