Evaluation of the perioperative analgesic effects of caudal block for herniotomy in children at the University College Hospital Ibadan, Nigeria.

INTRODUCTION: Caudal block is a commonly performed day case anaesthetic procedure in children for most infraumbilical surgeries worldwide [1] as it provides good analgesia in the perioperative period. In Nigeria there is paucity of data on caudal block hence the justification for this study. METHODS: This study compared the perioperative analgesic effects and safety profile of caudal block using 0.5 ml/kg body weight of 0.25% plain bupivacaine with light general anaesthesia (GA) versus inhalational GA alone in 60 children aged 2-10 years that had herniotomy using behavioural pain scale to access pain [2]. RESULTS: Showed a mean duration of surgery +/-standard deviation (SD) of 17 +/- 2 minutes for caudal, 51 +/- 6 minutes for GA (t = 60, p < 0.05, df = 59). Mean recovery times postoperatively was 6 +/- 2 minutes for caudal, 14 +/- 3 minutes for the GA (t =14, P < 0.05, df = 59). Mean postoperative pain scores was 2 +/- 0.6 for caudal, 5 +/-1 for the GA (t = 4, p < 0.05, df = 9). Time to first analgesic requirement was 170 +/- 19 minutes, 39 +/- 4 minutes for caudal and GA groups respectively (t = 37, p < 0.05, df = 59). Postoperatively 60% and 0% of patients in GA and caudal groups required opioid analgesic respectively. CONCLUSION: Children who had herniotomy under caudal block with 0.5 ml/kg of 0.25% plain bupivacaine had good analgesia with minimal complications. Caudal block in children is easy to perform and it's suitable for most day case infraumbilical surgeries.

Abdominal Pain in Adult Sickle Cell Disease Patients: A Nigerian Experience

Background: Abdominal pain is a relatively frequent occurrence in sickle cell disease. The aetiology of abdominal pain in sickle cell disease is often difficult to diagnose clinically. Despite the frequent occurrence; diagnostic dilemma; and the need for an accurate; early diagnosis; abdominal pain in sickle cell disease has not been rigorously studied. Objective: We therefore sought to describe the different presentations and patterns of abdominal pain in persons with sickle cell disease. Methods: A prospective case series of 20 patients was done in which data was collected on demographic characteristics; hemoglobin electrophoresis patterns; a description of the abdominal pain including sites; severity; and type of pain; packed cell volume and the provisional and final diagnosis. Results: Haemoglobin S patients were 17 in number constituting eightyfive percent (85) of our study population whilst the rest 3 were Hb S+C. Most patients (70) had one site of abdominal pain. The pain was mainly colicky or tightening; moderate to severe in nature and; in some cases; associated with vomiting. We did not find any significant difference between the steady state PCV and the PCV during the acute abdominal pain episodes. The final diagnosis showed that only 38.8of the patients had vasoocclusive crises and the reliability index between the provisional diagnosis and the final diagnosis was 67. Conclusion: Abdominal pain in sickle cell disease may present in different ways and it is important to recognize that the possible diagnoses are numerous. Not all cases are due to vasoocclusive crises. Early diagnosis and prompt treatment can be life saving

Abdominal pain in adult sickle cell disease patients: a nigerian experience.

BACKGROUND: Abdominal pain is a relatively frequent occurrence in sickle cell disease. The aetiology of abdominal pain in sickle cell disease is often difficult to diagnose clinically. Despite the frequent occurrence, diagnostic dilemma, and the need for an accurate, early diagnosis, abdominal pain in sickle cell disease has not been rigorously studied. OBJECTIVE: We therefore sought to describe the different presentations and patterns of abdominal pain in persons with sickle cell disease. METHODS: A prospective case series of 20 patients was done in which data was collected on demographic characteristics, hemoglobin electrophoresis patterns, a description of the abdominal pain including sites, severity, and type of pain, packed cell volume and the provisional and final diagnosis. RESULTS: Haemoglobin S patients were 17 in number constituting eightyfive percent (85%) of our study population whilst the rest 3 were Hb S+C. Most patients (70%) had one site of abdominal pain. The pain was mainly colicky or tightening, moderate to severe in nature and, in some cases, associated with vomiting. We did not find any significant difference between the steady state PCV and the PCV during the acute abdominal pain episodes. The final diagnosis showed that only 38.8% of the patients had vasoocclusive crises and the reliability index between the provisional diagnosis and the final diagnosis was 67%. CONCLUSION: Abdominal pain in sickle cell disease may present in different ways and it is important to recognize that the possible diagnoses are numerous. Not all cases are due to vasoocclusive crises. Early diagnosis and prompt treatment can be life saving.

Comparison of intravenous ephedrine with phenylephrine for the maintenance of arterial blood pressure during elective caesarean section under spinal anaesthesia.

Hypotension is a major concern of the anaesthetists whenever subarachnoid block is performed especially in obstetric patients. Vasopressors have been shown to be more effective at limiting spinal hypotension than other treatment of hypotension like preloading and left uterine displacement. The aim of the study is to compare the effect of bolus intravenous Ephedrine with Phenylephrine for the maintenance of arterial blood pressure during elective caesarean section under spinal anaesthesia. This was a randomized, double blind, controlled study of sixty two healthy parturients American Society of Anesthesiologists' (ASA) status 1 and 2 at term with singleton pregnancy who consented to subarachnoid block at University College Hospital, Ibadan, Nigeria. The parturients were preloaded with 10 ml per kg of crystalloid before the induction of spinal anaesthesia with injection of 2.5 ml of 0.5% hyperbaric Bupivacaine at L3/L4 levels. Ephedrine 5 mg (group A; n = 31) or phenylephrine 100 ug (group B; n = 31) was given for the maintenance of arterial blood pressure. Results showed that the incidence of hypotension in the 62 patients was 24.2%. Both vasopressors effectively restored both the systolic and the diastolic blood pressure. There was significant difference in heart rate between the two groups. Nausea occurred in both groups and was found in hypotensive patients, no patient vomited during the procedure. The mean APGAR Scores were similar for the two groups; no baby had Apgar score of < 8 in either group. We concluded that phenylephrine is safe and can be used as effectively as Ephedrine. Its administration results in higher blood pressure than Ephedrine in parturients undergoing Caesarean Section under spinal anaesthesia.

Palliative care and nursing.

Due to the changing pattern of disease and ageing population with chronic diseases, palliative care, a much neglected area of Medicine, has now become an important public health issue worldwide. Palliative care is applicable throughout the course of chronic life threatening illnesses and aims at reducing pain and suffering associated with these conditions. It provides pain and symptom control, psychosocial and spiritual support for patients and their families so that patients can enjoy the best quality of life till the end. Bereavement support is also provided following death and this encompasses care of orphans in conditions such as HIV/AIDS. Palliative care is provided by a team of multidisciplinary professionals (doctors, nurses, social workers etc) and volunteers working with patients and families in the hospital, home and hospices within the community. WHO policies on palliative care development contain the essential ingredients of Education, Drug Availability And Effective Government Policy. These are relevant for development of palliative care service and Research activities in Nigeria as clinicians, government officials and health educators can work together to achieve measurable outcomes.

Pain management in developing countries.

Access to pain relief is an integral part of peri-operative care jointly managed by clinicians and nursing staff. Simple regimens, relying on inexpensive drugs, are often not followed due to inadequate healthcare systems. This article describes some of the common challenges, and suggests practical approaches to overcoming them.

Preoperative analgesia in emergency surgical care in Ibadan.

Pain is the main complaint of patients presenting as surgical emergencies. However, preoperative analgesia has not been studied in developing countries. The adequacy of preoperative analgesia in 106 consecutive acute surgical cases admitted to the Accident and Emergency Department of The University College Hospital, Ibadan, was evaluated using the visual analogue scale and the verbal rating scale. In all, 58% of cases were trauma victims, and the male-to-female ratio was 2.5:1. Analgesia was not prescribed in 45.2% of the patients, 65% of whom were in severe pain. In addition, 81% who were given preoperative analgesia had 'moderate to severe' residual pain. The results showed that provision of preoperative analgesia is inadequate in emergency surgical cases in Ibadan.

Study processes of first year clinical students of the College Of Medicine, University of Ibadan, Ibadan Nigeria.

Students adopt several learning approaches towards achieving the perceived goal of passing their prescribed examinations. This study was carried out to determine the study processes being used by medical students of the College of Medicine, University of Ibadan on arrival at the Faculty of Clinical Sciences. One hundred and sixty five first year clinical students were studied using the modified 'Biggs' Study Process Questionnaire. Additional questions to identify local factors that would contribute to the learning were also included. There were 143 respondents (87% of the study population). The predominant study pattern among the students was the deep approach (63%). The achieving and superficial approaches were used by 8% and 29% of the students respectively. Additional analysis showed that 68%, 31% and 1% had 'good', 'average' and poor learning capacities respectively. Self interest was the principal reason why the students chose medicine as a career. Most students (76%) preferred lectures to tutorials, and only 30% found out extra information about topics taught frequently. Thirty-nine percent of the study cohort saw their teachers as role models, and 76% intended to travel abroad after graduation. Majority of 1st year clinical students of the College of Medicine, University of Ibadan adopted a deep approach to learning and have a good capacity to learn. However, most do not employ self-directed learning strategies and do not see their teachers as role models. The majority intend to travel abroad upon graduation.

Knowledge and attitudes of terminally ill patients and their family to palliative care and hospice services in Nigeria.

BACKGROUND: A palliative care and Hospice service is a neglected aspect of medical discipline especially in a developing country like Nigeria. With the global increase in incidence of cancer and HIV/AIDS and 70% of them presenting late, coupled with limited resources, for effective symptom control, palliative care therefore remains the only option left to improve the quality of life of the patients. OBJECTIVE: To assess the knowledge and attitudes of patients and their relations to palliative care and hospice services {PC&H} and to fashion out appropriate services for the patients. MATERIALS AND METHODS: A total of 130 participants were studied using a questionnaire which comprised of three parts: Socio-demographic variables, Information about Knowledge and Attitudes towards PC&H. RESULTS: Sixty nine were patients while 61 were family members. Ninety four [72.3%] had no knowledge of PC&H regardless of level of education and social status. 109 [84%] agreed that symptoms of the terminally ill patients should be treated to improve their quality of life and 75% of the participants agreed that this will be better done in a Hospice. 106 [83%] participants desire to have hospice established in every community, this again was regardless of tribe CONCLUSION: There is a gross lack of knowledge about PC&H in our community as evidenced among the participants studied. However, there is a positive attitude towards PC&H suggesting a general acceptance, since there is presently no well established Hospice in Nigeria; we recommend that government and Non governmental organizations should assist in this area. A hospital based Hospice might be a starting point.

Post-operative pain therapy: prescription patterns in two Nigerian teaching hospitals.

In order to evaluate doctors prescriptions in post-operative pain management, a precoded, structured and pretested questionnaire was administered to resident doctors working in the department of surgery in two teaching hospitals in Nigeria. The questionnaires were completed voluntarily by all the doctors involved. Fifty-five completed questionnaires were analysed. Fifty-three per cent of the doctors aimed at relieving just enough pain for the patient to be comfortable. The others aimed at complete pain relief. Drug availability was the most important factor determining what the doctors prescribed. Anaesthetists had little or no influence on their choice of drugs. Forty-five per cent of the doctors thought that they had been adequately educated in pain control. However, the level of training did not influence the response (p > 0.05). Intramuscular opioid, 6-8 hourly, was the most preferred route of drug administration. It was concluded that prescribing patterns for post-operative pain therapy in Nigeria has changed little in the last decade. The new treatment modalities, which are being utilized in developed countries, are still not being used in this country.

Ketamine anaesthesia for young children undergoing radiotherapy.

Young children with radiosensitive malignant tumours often require sedation or anaesthesia to provide immobility for radiotherapy sessions lasting several days. This paper describes the use of repeated intramuscular ketamine anaesthesia for radiotherapy in children age 1.5 to 5 years. Intramuscular ketamine 5-13mg/kg body weight was administered on 280 occasions to 15 children, the highest number of sessions per child being 30 and the least 9. The airway and cardiovascular parameters were well maintained. The time to complete recovery varied from 15 to 90 minutes (mean 52.5+/-31.7 S.D.). Involuntary movements of the tongue, mouth and limbs were observed in 8 patients (52.3%) during 63 sessions (22.5%) but only necessitated interruption of radiotherapy on 6 occasions (2.1%). Ketamine was found to be safe and effective for sedation of young children in the radiotherapy suite and minimal aneasthetic facilities were required.

Post operative pain therapy: a survey of prescribing patterns and adequacy of analgesia in Ibadan, Nigeria.

OBJECTIVE: To establish prescribing patterns for post operative pain therapy, it's adequacy, as well as patients' satisfaction with the prescriptions. DESIGN: A survey of doctors' prescriptions for post operative pain therapy over a six month period. SETTING: The University College Hospital Ibadan, Nigeria, the oldest teaching hospital in the country. SUBJECTS: All consecutive adult elective general surgical patients operated on over a six month period, who were on admission for at least 72 hours after surgery. Patients with prolonged post operative unconsciousness or those unwilling to answer the questionnaire were excluded. INTERVENTION: The anaesthetic charts, recovery room and treatment sheet were reviewed to complete a structured, pretested and precoded questionnaire. Two other questionnaires were administered to patients at 24 and 48 hours post operatively to review the effect of the analgesic prescribed. RESULTS: 149 patients met the inclusion criteria. Moderate to unbearable pain was reported in 68.7% of the patients at 24 hours and 51.7% of patients by 48 hours. Post operative analgesics were to be given via only the intramuscular route in all cases. There was a limited range of drugs to choose from; pethidine, pentazocine and dipyrone were the only drugs available. Pethidine was prescribed four hourly in 2.7%, six hourly in 46.9% and eight hourly in 25.9%, of the cases. Eighty five percent of the patients who were given dipyrone complained of moderate to unbearable pain post operatively. Inadequate doses of analgesics were generally given. Despite the high incidence of pain, 63.9% of patients still reported that they were very satisfied with their pain relief. CONCLUSION: Prescription patterns for post operative pain relief have not changed to include many of the new methods presently available. Only one route of administration is still used for a limited range of opioid and non-opioid drugs. Patients still experience a high incidence of moderate to unbearable pain in the post operative period. This can be improved by prescribing drugs at shorter intervals to reflect their pharmacokinetics and using newer techniques of drug administration.

Pain assessment in Nigerians--Visual Analogue Scale and Verbal Rating Scale compared.

The usefulness of 2 methods of pain assessment was determined in a cohort of Nigerians who had pain as a symptom and were receiving physiotherapy for various indications. The English and Yoruba versions of two Pain Rating Scales, the Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS) with 1 to 4 or 1 to 5 intensity scales (VRS-4 or VRS-5) were employed for the assessment of pain in 100 patients. The mean pain score on the 4-point VRS scale was 2.49 +/- 0.72, for the 5-point VRS 2.1 +/- 1.18 and for the VAS 4.93 +/- 2.5. Correlation analysis for corresponding groups of patients showed a significant positive relationship between the VAS and VRS-4 (r = 0.68 P < 0.001) VAS and VRS-5 (r = 0.64 P < 0.001) indicating that both VAS and VRS constitute useful tools for pain assessment in Nigerian patients.

Post-operative pain control--prescription pattern and patients' experience.

The prescription pattern for post-operative pain and patients' experience with pain relief were studied in 200 adult patients who had anaesthesia and surgery at the University College Hospital, Ibadan. Intermittent intramuscular injection of analgesics were prescribed for 192 patients (96%) while other routes were intravenous injections (2%), intravenous infusion (1%) and intermittent epidural injection (1%). Moderate to severe pain was reported by 46% and 49.5% of the patients immediately after surgery and before subsequent analgesic doses were due respectively. Pain disturbed patients from sleeping, moving in bed and coughing. It also made patients cry (20%), feel depressed (23%), anxious (12.5%) and angry (14.5%). Despite the high incidence of pain and the associated disturbances, 178 patients (89%) still found overall pain relief satisfactory.

Non-cardiac surgery and anaesthesia in children with congenital heart disease.

Children with Congenital Heart Disease (CHD) presenting for non-cardiac surgery have various physiological and functional abnormalities and thus pose great challenges to the anaesthetist. This one year prospective study was undertaken to determine the incidence of CHD in children presenting for non-cardiac surgery, the type of lesions and anaesthetic course. Five patients (1.5%) out of a total of 324 children aged from birth to twelve years who had surgery during the study period were found to have CHD, ventricular septal defect (VSD) being the commonest cardiac lesion. Surgery was for cataract extraction and herniorrhaphy. Although all the children had been previously treated or were on current treatment for additional medical problems, surgery under closely monitored balanced general anaesthetic technique was found to be safe.

Anaesthetic manpower development in West Africa.

Advances in surgery have been possible worldwide largely due to specialized manpower, innovations in modern anaesthetic techniques and drugs. Shortage of specialist manpower in anaesthesia has continued in West Africa despite various available local postgraduate training programmes. This paper examines the impact of the West African Postgraduate Medical College (WAPMC) training programme on anaesthetic manpower development in the West Africa subregion. Data collected from the records of the WAPMC revealed that from April 1992 to October 1996 a total number of 2,963 candidates attempted the primary examination of the various surgical faculties compared to 93 candidates for anaesthesia--a ratio of 32 prospective surgeons to one anaesthetist. The end point of the training produced 292 Fellows in the five-year period with only six in anaesthesia, i.e., 1 anaesthetist to 49 surgeons. Although the diploma programme of the same College produced 56 graduates in the study period, 53.6% of them were pursuing the Fellowship programme in tertiary institutions. Suggestions are proposed to redress the ever-widening gap between the number of specialist surgeons and anaesthetists in the West Africa subregion.

Post operative nausea and vomiting in Nigerians.

A retrospective survey of postoperative nausea and vomiting (PONV) in the recovery room over a five year period was conducted, followed by a prospective study of 200 adult patients to estimate the incidence and predisposing factors to nausea and vomiting during the first 24 hours after anaesthesia and surgery in Nigerians. In the retrospective study only records of 61 patients (0.79%) out of the 7714 post anaesthetic recovery room charts reviewed revealed documentation of vomiting. These were 20 males (32.8%) and 41 females (67.2%). In the prospective study, the incidence of post operative nausea and vomiting within twenty four hours of surgery was 41.6% and 19.6%, respectively. But only two out of 39 patients (one per cent) vomited within the first three hours in postoperative period. The frequency of vomiting varied from one to 15 times and women had significantly more emetic symptoms than men (p < 0.05). Preoperative administration of pethidine and morphine was associated with postoperative nausea and vomiting. It is suggested that Nigerian women should be considered for prophylactic anti-emetic therapy, especially when narcotic analgesic are to be employed in their anaesthetic management.

Complications following sedation of paediatric oncology patients undergoing radiotherapy.

Sedation is often required to achieve immobilisation of small children during radiotherapy to avoid irradiation of normal tissues during the course of treatment. At the University College Hospital, Ibadan radiotherapists provide sedation for such patients with administration of parenteral and/or oral promethazine, diazepam, chlorpromazine and paraldehyde. This retrospective review of 84 children aged 1 month to 6 years who received sedation for radiotherapy over a period of twenty-one to twenty-eight days showed that 48% had complications. These included injection cellulitis (85.3%), injection abscess (4.87%), paresis of the lower limb (7.3%), aspiration pneumonia (2.4%). Anaesthetists in developing countries should be encouraged to extend their expertise in caring and resuscitation of sedated or unconscious patients to the radiotherapy unit. This will allow for the use of a wider variety of sedative agents and better monitoring as well as minimise or eradicate complications.

Surgery of toxic goitre in non-euthyroid patients: a preliminary report.

In recent years, the cost of medical care has skyrocketed and since medical treatment is not free, some drugs are now beyond the reach of some patients. One of such drugs is the antithyroid drug, carbimazole, which has been priced beyond the reach of our thyrotoxic patients. We have therefore been forced to operate on these patients whenever they present, even while thyrotoxic. The principle of our management is to anticipate the development of thyroid crises and to prevent its occurrence post-operatively by using saturated solution of potassium iodide (SSKI) or Lugol's iodine, propranolol, diazepam, and hydrocortisone. This is a preliminary report of the first twelve consecutive patients so treated.