NEBULIZED MAGNESIUM VERSUS KETAMINE FOR PREVENTION OF POST-OPERATIVE SORE THROAT IN PATIENTS FOR GENERAL ANAESTHESIA.

BACKGROUND: Sore throat is a common post-operative complaint which can cause significant distress and morbidity. We tested and compared the efficacy of nebulized Magnesium and Ketamine on the incidence and severity of sore throat within the first 24 hours after general anaesthesia. OBJECTIVE: To compare the incidence and severity of post-operative sore throat at 2, 4, 8, 12 and 24 hours after extubation following pre-induction administration of nebulized Magnesium and Ketamine. METHODOS: In this randomized controlled trial, 99 adult ASA I and II patients between the ages of 16 - 65 years were administered nebulized Ketamine 50 mg, Magnesium Sulphate 250 mg or saline for ten minutes prior to induction of general anaesthesia and orotracheal intubation. Incidence and severity of post-operative sore throat were assessed at 2, 4, 8, 12 and 24 hours post extubation. RESULTS: The incidence of sore throat at 4, 8, 12 and 24 hours post tracheal extubation were significantly lower in the Magnesium (18.2%, 12.1%, 0, 0; p = 0.009, 0.006, ≤0.0001, 0.003) and Ketamine group (24.2%, 12.1%, 6.1%, 0; p = 0.041, 0.006, 0.001, 0.003) compared with the saline group (48.5%, 42.4%, 39.4%, 24.2%). Patients also had significantly less severe sore throat at 4 and 8 hours post extubation in both Magnesium and Ketamine groups (p = 0.0 11, 0.041). CONCLUSION: Pre-induction nebulization of Ketamine or Magnesium can decrease the incidence and severity of sore throat in the first 24 hours after anaesthesia.

RANGE OF MOUTH OPENING AMONG THREE MAJOR ETHNIC GROUPS IN NIGERIA.

BACKGROUND: Maximum mouth opening (MMO) is an important parameter in the assessment of several clinical situations and its measured value is documented to have racial, gender, age and anthropometric variation. OBJECTIVE: To determine the maximal mouth opening and its predictors among the different major ethnic groups in Nigeria. METHODS: Study subjects were 449 adults (232 males, 215 females), age range 18-74 years from the three major ethnic groups in Nigeria. MMO measurements and anthropometric parameters were recorded. Data analysis was done using SPSS Version 22 and variables subjected to univariate analysis to determine association and a linear regression model was performed to determine variables that could predict maximum mouth opening with p-value set at < 0.05. RESULTS: The overall mean MMO across the ethnic groups was 49.33 ± 7.91mm. Mean MMO for the Yoruba ethnic group, 53.06 ± 6.27 mm was found to be significantly higher than values obtained for Hausa tribe 52.77 ± 8.06 mm and Igbo tribe 47.59 ± 8.61 mm (p=<0.001). Age, weight and height were observed to correlate significantly with MMO. A multivariate linear regression model revealed that age and height were independent predictors of maximum mouth opening across the ethnic groups. CONCLUSION: There is ethnic variation in MMO among the 3 major ethnic groups in Nigeria with mean MMO values of 53.96 (± 6.27 mm), 52.77 (± 8.06 mm) and 47.59 (± 8.61 mm) for the Yoruba, Hausa and Igbo ethnic groups respectively. Age and height are important predictors of MMO.

AN AUDIT OF ORAL AND MAXILLOFACIAL PROCEDURES UNDER GENERAL ANAESTHESIA AT THE UNIVERSITY COLLEGE HOSPITAL IBADAN, NIGERIA.

BACKGROUND: Operating theatre time management is a constant source of tension among the healthcare professionals responsible for the use of the facility. It is important that all effort should be geared at optimal utilization of available resources and minimization of waste. AIM: To appraise time management, frequency and duration of surgical procedures, frequency and determinants of blood transfusion in oral and maxillofacial surgery. DESIGN OF THE STUDY: Prospective clinical study. SETTING: The University College Hospital, Ibadan. Nigeria. METHODOLOGY: This was a cross-sectional study of consecutive patients who had maxillofacial surgical procedures. Information was collected on number of cases scheduled per list, number of cases done per list, each patient's biodata, time intervals between patient arrival and departure from operating theatre, route and duration of intubation, type of surgical procedure, surgical time, preoperative and postoperative packed cell volume estimations, volume of blood loss and the frequency and volume of blood transfusions. RESULTS: The main points of delay were identified as the patient wait at the theatre reception and in the operating suite before intubation. Mandibulectomy procedures were the longest procedures with approximately five (5) hours, followed by maxillectomy with four (4) hours and maxillofacial trauma with three and a half (3.5) hours. Maxillectomy procedures had highest transfusion probability. The surgical time and the estimated blood loss significantly determined whether a patient would be transfused or not. The nasotracheal was the commonest route of intubation while cleft surgeries were the most frequent procedures performed followed by trauma surgeries. Majority of the patients were not transfused and two units of blood was the most frequent transfused volume for a patient. CONCLUSION: The main areas of delay have been identified as patients' waiting periods before the surgical procedures. The reasons why these delays occur need to be investigated and addressed to have an optimally functional facility. Reservation of blood for maxillofacial surgical procedures should be based on the anticipated need for blood transfusion for the particular procedure.

Inappropriate Intensive Care Unit admissions: Nigerian doctors' perception and attitude.

BACKGROUND: Nonclinical factors are said to influence decisions to admit patients into the Intensive Care Unit (ICU). We therefore assessed the perception and attitude of Nigerian doctors working in the ICU about inappropriate admissions and request for admission in the setting of a full ICU. METHODS: An anonymous, self-administered questionnaire survey was carried out among doctors working in the ICU of 17 University Teaching Hospitals, in Nigeria. A score of 0 (least usual reason) to 5 (most usual reason) was ascribed to some factors that can influence ICU admission. In addition, each of the 4 possible actions in the setting of a full ICU was graded from 0 (least likely) to 5 (most likely). The result was analyzed as appropriate. RESULTS: Sixty-four doctors participated in the survey. Inappropriate admissions were acknowledged by 96% of respondents. Perceived reasons included pressure from superiors (93.7%), referring clinicians (89.1%), and hospital management (87.5%). If confronted with request for admission in the setting of a full ICU, respondents will arrange for the discharge of fit ICU patients to the ward (95.3%), transfer patients not receiving acute care to high dependency unit or recovery room (70.3%), or create additional ICU beds (42.2%). Chi-square test showed a significant difference between single and married respondents with regard to clinical doubt (P = 0.01) and pressure from referring clinician (P = 0.02) as reasons for inappropriate admission. Respondents' gender, marital status, professional activity, and number of ICU admissions per year did not affect possible steps in the setting of a full ICU. CONCLUSION: Inappropriate ICU admissions were perceived as a common event and were mainly attributed to pressure from seniors, referring clinicians, and hospital management. Further work is necessary to determine the impact of such admissions on ICU efficiency.

PERCEPTION OF NIGERIAN ANAESTHETISTS ON INTRA-OPERATIVE DEATH.

BACKGROUND: Intra-operative death is an unusual devastating occurrence in anaesthetic practice, and it is of serious concern when it happens. OBJECTIVES: To assess the causes, the effects and the perception of Nigerian anaesthetists to intra-operative death. DESIGN: A cross-sectional and questionnaire-based study. SETTING: Five University Teaching Hospitals in South-Western Nigeria. SUBJECTS: Nurse anaesthetists, resident doctors in anaesthesia and consultant anaesthetists. RESULTS: One hundred and five anaesthetists participated in the study (72.9% response rate). Seventy seven (73.3%) of the respondents had experienced an intra-operative death with most of them having five or more years of experience (p = 0.0001). Majority 53 (68.8%) of the respondents felt that the deaths were avoidable, and most deaths occurred mainly during emergency surgery (96.1%). Forty three (55.8%) of them were psychologically disturbed, fifty six (53.3%) respondents were of the opinion that it is reasonable for the anaesthetists involved not to take partin further surgery for that day. Sixty (57.1%) respondents considered discussion at mortality meeting as appropriate after an intra-operative death. CONCLUSION: This study showed that most anaesthetists would want those involved in the intra-operative death not to take part in further surgery for that day. Adequate preventive measures should be put in place with departmental or institutional policies on what to do after such events.

Clinical audit of knowledge and practice of epidural labour analgesia amongst obstetricians in south-west Nigeria.

Epidural analgesia (EA) is the most ideal method for pain relief during labour. We sought to highlight the current knowledge and practice of the obstetricians regarding epidural labour analgesia (ELA). An audit was conducted amongst obstetricians in two teaching hospitals in the south west of Nigeria. Most of our respondents received lectures about ELA but about half of them rated the lectures as inadequate. Though 37.8% and 53.3% of respondents are of the opinion that there is interference with labour and increased incidence of instrumentation following epidural analgesia in labour respectively, however 84.4% agreed that the technique is not associated with adverse neonatal or maternal outcome and 97.8% will prefer their patients having epidural labour analgesia. We are of the opinion that education regarding ELA, both during and after obstetric speciality training, be improved, and well-established interpersonal relationship between obstetricians and anaesthetists will be needed to achieve this.

Tramadol as a prophylactic analgesic for hysterosalpingography in African women.

Hysterosalpingography (HSG) is a contrast investigation of the female reproductive tract. A major drawback to its use is pain during and after the procedure. This study was designed to evaluate the usefulness of Tramadol in alleviating the pain of the procedure and to assess the influence of tubal pathology on the degree of pain experienced. We studied 84 women; the patients were assigned randomly into two groups, group A and B. The first group, Group A (n=40) had premedication with intravenous Tramadol (100 mg) and IV hyoscine N butylbromide (20 mg), The Group B (n=44) had premedication with IV hyoscine N butylbromide (20 mg) only. The mean numeric rating pain score was 6.25 for the Tramadol group and 6.26 for the control group, P>0.05. This study does not show a significant decrease in pain perception during HSG in African women premedicated with Tramadol.

Mirizzi syndrome caused by a bile pseudocyst.

BACKGROUND: Mirizzi syndrome caused by bile pseudo cyst presents diagnostic and management challenges to the surgeon. OBJECTIVE: To emphasize to clinicians the need to always recognize and correct associated liver derangements before surgery so as to prevent the usual accompanying high morbidity/mortality associated with Mirizzi syndrome. CASE REPORT: We report an unusual and previously unreported pathology of post-cholecystectomy Mirizzi syndrome in a 35 year old female who developed a bile pseudo-cyst and which may possibly qualify for Mirizzi syndrome type 5--highlighting the need for maximum pre, -intra, and post-operative challenges for improved prognosis. The patient was lost from reactionary haemorrhage due to limited facilities. CONCLUSION: There is a crying need in developing countries to have Critical Care centers and for Clinicians to recognize the necessity for adequate pre, intra and post-operative care of these high risk patients.

Effect of breastfeeding during venepuncture in neonates.

BACKGROUND: Evidence suggests that infants feel pain, and painful experiences may lead to subsequent increased pain sensitivity. Owing to concerns regarding the potential adverse effects of pharmacological interventions in newborns, effective alternatives for pain control are being sought. AIM: The Neonatal Infant Pain Scale (NIPS) was used to determine the analgesic effect of breastfeeding during venepuncture. METHODS: The study was of cross-over design where each neonate served as his/her own control. Median pain scores during venepuncture when neonates were being breastfed (BF) were compared with those when neonates were not being breastfed (NBF). The site of venepuncture and number of previous venepunctures were noted. Pain was assessed using NIPS. RESULTS: In all, 38 term neonates (25 male, 13 female) were recruited. Mean (SD) age and weight were 8.42 (8.74) days and 2.89 (0.67) kg, respectively. The median pain score (interquartile range) of the neonates when breastfed was 1.50 (1-2), and 4.00 (2-6) when not breastfed (p=0.0001). The Kruskal-Wallis H-test did not show statistically significant differences between the BF and NBF groups when the number of previous punctures (p=0.57, p=0.27) and site of venepuncture (p=0.71, p=0.77) were considered. CONCLUSION: Using NIPS, it has been demonstrated that breastfeeding is analgesic in neonates during venepuncture and previous venepuncture/s and site of venepuncture do not seem to affect pain scores. Breastfeeding should be the first-choice analgesic during painful procedures in neonates.

Cardiorespiratory changes during upper gastrointestinal endoscopy.

OBJECTIVES: To determine the changes in oxygen saturation, blood pressure and heart rate during various endoscopic procedures and to find out the risk factors for these changes. METHODS: Forty patients without cardiorespiratory disorders were recruited. Oxygen saturation, blood pressure and pulse rate were monitored during endoscopy using pulse oximeter and automated blood pressure monitor. These were recorded from baseline until 5 minutes after the procedure. The important variables, which were evaluated in relation to these changes, included age, gender, duration of the procedure and drug/dosages. RESULTS: Baseline mean oxygen saturation was 96.8 +/- 1.55%. It decreased significantly to 94.53 +/- 3.30%(p= 0.002) during insertion of probe. Mild to moderate hypoxia was found in 19 (47.5%) patients. Severe hypoxia was found in 5 (12.5%) patients. The variables that reached statistical significance for desaturation were age greater than 50 years and duration longer than 27 minutes. Changes in pulse rate were significant post-sedation, during probe insertion, during scoping, at removal of probe and immediately post-procedure (p < 0.02). The mean change in systolic blood pressure was not significant throughout the procedure when compared to baseline, however 14 (35%) patients developed transient hypertension. CONCLUSIONS: Mild to moderate hypoxia is common during endoscopic procedures and of no serious consequence. However severe hypoxia is less common. We recommend a non-invasive monitoring in patients with age greater than 50 years and procedure longer than 27 minutes.

Clinical comparison of cardiorespiratory effects during unilateral and conventional spinal anaesthesia.

BACKGROUND: Spinal anaesthesia is widely employed in clinical practice but has the main drawback of post-spinal block hypotension. Efforts must therefore continue to be made to obviate this setback OBJECTIVE: To evaluate the cardiovascular and respiratory changes during unilateral and conventional spinal anaesthesia. METHODS: With ethical approval, we studied 74 American Society of Anesthesiologists (ASA), physical status class 1 and 2 patients scheduled for elective unilateral lower limb surgery. Patients were randomly allocated into one of two groups: lateral and conventional spinal anaesthesia groups. In the lateral position with operative side down, patients recived 10 mg (2mls) of 0.5% hyperbaric bupivacaine through a 25-gauge spinal needle. Patients in the unilateral group were maintained in the lateral position for 15 minutes following spinal injection while those in the conventional group were turned supine immediately after injection. Blood pressure, heart rate, respiratory rate and oxygen saturation were monitored over 1 hour. RESULTS: Three patients (8.1%) in the unilateral group and 5 (13.5%) in the conventional group developed hypotension, P= 0.71. Four (10.8%) patients in the conventional group and 1 (2.7%) in the unilateral group, P= 0.17 required epinephrine infusion to treat hypotension. Patients in the conventional group had statistically significant greater fall in the systolic blood pressures at 15, 30 and 45 minutes when compared to the baseline (P= 0.003, 0.001 and 0.004). The mean respiratory rate and oxygen saturations in the two groups were similar. CONCLUSION: Compared to conventional spinal anaesthesia, unilateral spinal anaesthesia was associated with fewer cardiovascular perturbations. Also, the type of spinal block instituted affected neither the respiratory rate nor the arterial oxygen saturation.