Causes of deaths in the intensives care unit of Sylvanus Olympio Teaching Hospital, Lomé, Togo.

To analyze the causes of deaths in the intensive care unit (ICU) at the CHU Sylvanus Olympio (CHU SO) teaching hospital of Lomé. This retrospective study examined the files of patients who died in the ICU of CHU SO, during the 12-month period from November 2012 to October 2013. Of 732 patients admitted to the ICU, 237 died, for a mortality rate of 32.38%. Men accounted for 163 (68.8%) of the deaths, and women 74 (31.2%), for a M/F ratio of 2.2. The average age of patients who died was 41.7 years; the age group 21-30 years comprised 16% of the deaths, that 31-40 years 19.8%, and 41-50 years 17.7%. Trauma (50.64%) dominated the causes of death, including especially severe traumatic brain injury (34.18%), followed by postoperative intensive care (25.32%), including peritonitis (8%). Medical diseases accounted for 18.14% of ICU admissions. More than half the deaths (55.7%) took place in the 72 hours after ICU entry. Mortality in the ICU at CHU SO of Lomé remains very high. It affects young patients, mainly with traumatic and surgery-related pathologies.

Emergency admissions in sub Saharan Africa: example of the surgical emergency admissions unit at the Sylvanus Olympio Teaching Hospital of Lomé, Togo.

The management of patients in emergency departments is an important indicator of the quality of a healthcare system. In sub-Saharan Africa, emergency care is characterized by human and material difficulties. The purpose of this work was to assess the difficulties in managing emergencies at the surgical emergency admissions unit of Sylvanus Olympio teaching hospital of Lomé. This descriptive prospective study took place during the last 6 months of 2013. Epidemiological, clinical, and therapeutic data were collected. All admissions for acute conditions requiring urgent care were included. The study excluded patients who died at admission and patients receiving care in the medical emergency department. The study included 2880 patients, 60.3% men; the mean age was 46 years (range: 4 days to 92 years). Traffic accidents accounted for 519 cases (18%). Among patients with trauma, 23.7% had limb injuries and 17.2% head injury. Appendicitis accounted for 32.9% of the non-trauma emergencies, followed by peritonitis (27.3%), burns represented 1%. Laboratory tests were performed for 49.4% of patients, ultrasound for 14.2%, and computed tomography scans for 0.8%. Overall, 44.1% received venous catheterization, 40% volume replacement, 20% oxygen therapy, 16% blood products, 2% pressor amines, and 0.1% intubation. Analgesia was administered to 82%, antibiotic treatment (37%), and sedation to 1%. In all, 34.8% of patients underwent laparotomy, 26.6% trimming with sutures, 21.4% dressing of wounds, and 14.5% immobilization. Time to discharge was less than 24 hours for 82%, and 6.2% were transferred to intensive care. Eighteen patients died (0.6%). Management of surgical emergencies remains a major health problem in developing countries. Prevention measures and accessibility of the population to emergency care will reduce morbidity and mortality for these conditions.

Clinical profile of subdural hematomas: dangerousness of subdural subacute hematoma.

Subacute subdural hematomas are a poorly individualized nosological entity, often equated clinically to chronic subdural hematomas. Yet, their neurological deterioration which is usually rapid seems to distinguish them from chronic subdural hematomas. We wanted to show this dangerousness by establishing the clinically evolving profile of the three types of subdural hematomas. This was a prospective and retrospective study of 63 subdural hematoma (18 acute, 13 subacute, and 32 chronic) patients admitted between 2012 and 2014 in the neurosurgery unit of Lomé University Hospital. Hematomas were classified according to the elapsed time after head injury and blood density on CT. The main parameter studied was the evolution of the Glasgow Coma Score (GCS) in the 3 months following the trauma, enabling to establish an evolving profile of each type of hematoma. The average age of patients was 58.1 years for chronic subdural hematomas and 47.6 years for subacute subdural hematomas. Disease duration before admission was 13.1 days for chronic against 36.6 h for subacute hematoma. The clinical profile shows acute worsening within hours during the second week for patients with subacute hematoma, while it is progressive for patients with chronic hematoma. We noted two deaths, all victims of a subacute hematoma (one operated, one patient waiting for surgery). Iso-density hematoma on CT, especially in a young person, must be considered as a predictive factor of rapid neurological aggravation suggesting an urgent care or increased monitoring by paramedics.

[Anesthesia for upper limb surgery in a developing country: experience of infraclavicular and axillary blocks under neurostimulation]. / Anesthésie pour chirurgie du membre supérieur dans un pays en développement : expérience des blocs infraclaviculaire et axillaire sous neurostimulation.

ABSTRACT: Despite advances in regional anesthesia under ultrasound guidance, neurostimulation remains the primary technique in underequipped locations. MATERIAL AND METHODS: We conducted a prospective descriptive study from January to December 2010 and June 2011 to May 2012 with as our main objective the assessment of the practices of infraclavicular and axillary nerve blocks (ICB and AXB, respectively) at Sylvanus Olympio University Hospital. RESULTS: 105 patients (11.8%) received ICB) and 75 patients (8.5%) axillary blocks (AXB). The average minimum intensity of neurostimulation was 0.4 mA (range: 0.25-0.45 mA. The mean volume of 0.5% bupivacaine used was 30 ± 10 mL. The mean onset time of the block was 15 ± 10 min, and the mean duration of action 6 ± 4 hours. Postoperative pain was significantly worse in patients who received ICB compared to AXB [χ(2) = 19.034, p = 0.00001<0.05]. The cost of either type of locoregional anesthesia under neurostimulation compared with general anesthesia was 44 euros versus 105 euros. CONCLUSION: Peripheral nerve block by ICB and AXB under neurostimulation showed significant difference in terms of postoperative analgesia efficiency. Locoregional anesthesia remains too rarely practiced in underequipped countries despite its benefits and although it is particularly appropriate for these countries.

[Results of transosseous reattachment for distal rupture of the biceps tendon. Evaluation of results]. / Réinsertion transosseuse par voie antérieure des ruptures du tendon distal du biceps brachial (biceps brachii [bb]) : évaluation des résultats.

Avulsion of the distal biceps brachii tendon is an uncommon injury. This is a retrospective review of cases operated in our department by transosseous suture fixation on the radial tuberosity, using the single anterior incision. Between 2000 and 2007, a total of 10 patients with distal biceps tendon injury were included. All were men, with an average age of 39 years. The most common mechanism was passive extension against active flexion. The dominant limb was affected in all patients. Clinical diagnosis was the rule. Surgical reattachment to the radial tuberosity through the anterior approach to the elbow was performed. The preoperative period was one week in three cases, between one and three weeks in five cases, and superior to three weeks in two cases. Clinical and instrumental evaluation of the results was done. Average follow-up was 48 months. Subjective results were good in seven cases, acceptable in two cases and poor in one case. Nine patients return to their previous level activity with no limitations. The average range of motion was 0° of extension to 135° of flexion. Strength testing of the injured limbs, compared to the contralateral, using the criteria described by Baker and Bierwagen, revealed a loss of 22% of supination strength and 32% of supination endurance. There was a loss of 14% of flexion strength and 27% of flexion endurance. There were two cases of superficial surgical site infection. There were no cases of nerve damage or heterotopic bone formation. Two main factors were found to explain the poor outcomes: experience of the surgeon and a long preoperative delay. Despite the limitations of this study, we found that transosseous reattachment of the biceps' distal tendon to the radial tuberosity can restore supination. Strength and endurance for supination can be better restored by early intervention. Complications are easily avoided if surgery is performed early and by experts.

[Hematemesis in Togo: findings of a 12-month study in an intensive care unit]. / Hématémèses au Togo: expérience d'un an en réanimation.

This prospective study was conducted over a 12-month period on patients who underwent upper digestive endoscopy for hematemesis in the medical intensive care unit (ICU) of the Tokoin University Hospital Center in Lomé, Togo. A total of 44 patients with a mean age of 44 years were included. The sex-ratio was 2.61. Risk factors included use of non-steroid anti-inflammatory (NSAI) in 16 patients (36.4%) and alcohol abuse in 13 (29.6%). At the time of admission to the ICU, 21 patients (47.7%) were in hemodynamic shock and 11 (25%) presented signs of portal hypertension. The underlying etiology was peptic ulcer in 18 cases (40.9%) including 13 cases of duodenal ulcer and 5 cases of stomach ulcer, rupture of esophageal varicosities in 8 (18.2%), gastric tumor in 6 (13.6%), Mallory Weiss syndrome in 5 (11.4%), gastritis in 4 (9,1%), and esophagitis in 3 (6.8%) due to peptic inflammation in 2 and mycotic infection in 1. The mortality rate was 45.5%. The main causes of hematemesis were peptic ulcer and rupture of esophageal varicosities. The death rate was high due to inadequate care facilities.

Dynamic hip screw and compression plate fixation of ipsilateral femoral neck and shaft fractures.

PURPOSE: To evaluate surgical outcomes of ipsilateral femoral neck and shaft fractures. METHODS: Between April 1997 and September 2004, 29 men and 8 women (mean age, 37 years) underwent fixation of femoral neck and shaft fractures using a dynamic compression plate plus a dynamic hip screw or screws. There were 30 femoral neck and 7 pertrochanteric fractures. Functional results were assessed according to the Friedman and Wyman classification. RESULTS: The mean follow-up period was 49 months. Of the femoral neck fractures, 34 united in a mean of 4 months; 33 of them healed anatomically and one with a 6-degree varus angulation. No osteonecrosis of the femoral head was noted. Of the femoral shaft fractures, 32 united in a mean of 6 months, 5 were non-unions (2 persisted even after revision surgery). Seven patients developed infections (5 superficial and 2 deep), which resolved with debridement and antibiotic treatment. Functional results were good in 29 patients, fair in 5, and poor in 3. CONCLUSION: The use of dynamic hip screws and compression plates for ipsilateral femoral neck and shaft fractures is reliable in achieving bone union with few complications.

[Use of ilio-inguinal iliohypogastric nerve block for herniorraphy: a prospective study in a 35-case series at the Lome University Hospital Center in Togo]. / Pratique du bloc ilio-inguinal ilio-hypogastrique pour cure herniaire: étude prospective à propos de 35 cas colligés au CHU de Lomé, Togo.

The purpose of this prospective-descriptive study was to evaluate the quality of anaesthesia and analgesic effect achieved by ilio-inguinal iliohypogastric nerve block (IINB) in patients undergoing herniorraphy. Study was carried out over a 6-month period in the Anaesthesia Intensive Care Department of the Lomé University Hospital Centre in Togo. All patients indicated for unilateral herniorraphy were enrolled. A total of 35 patients underwent herniorraphy with IINB. Mean patient age was 32 years. Farmers accounted for 57% of the population. Men accounted for 86.7%. The anaesthesia classification was ASA I or II in 88.6% of cases. Complete sensory block was obtained within 15 minutes after induction in 71.43% of cases. Additional sedation using ketamine and/or fentanyl was used in 51.43% of cases. Conversion from IINB to general anaesthesia was necessary in three cases including 2 due to extension of the surgical incision and one for the surgeon's convenience. The mean duration of the procedure was 70 minutes. Intraoperative complications included nausea in one case, dizziness in 2 cases, and bitterness in mouth in 3 cases. Postoperatively, extension to the femoral nerve was observed in 2 cases. Five patients presented a visual analogue pain scale (VAS) > or = 4 within 18 hours after the procedure. This study shows that IINB is a useful alternative to general anaesthesia for herniorraphy. Specific training is necessary to allow more widespread use.

Pratique du bloc ilio-inguinal ilio-hypogastrique pour cure herniaire : etude prospective a propos de 35 cas colliges au CHU de Lome; Togo

Evaluer la qualite anesthesique et le benefice analgesique du bloc ilio-inguinal ilio-hypogastrique (BII) dans les cures herniaires. Le service d'anesthesie reanimation du CHU de Lome a servi pour cadre d'etude. Il s'agit d'une etude prospective et descriptive sur une periode de 6 mois. Tous les patients dans le cadre d'un programme pour cure herniaire unilaterale ont ete inclus dans l'etude.Au total; 35 patients ont subi la cure herniaire sous BII. L'age moyen des patients etait de 32 ans. Les cultivateurs representaient 57. Le sexe masculin representait 85;70. Dans 88;6des cas; les patients etaient de classe ASA I et II. Dans 71;43des cas; le bloc sensitif etait complet 15 minutes apres l'induction. Dans 51;43des cas; les patients avaient beneficie d'une sedation complementaire avec de la ketamine et / ou du fentanyl. Trois cas de BII ont ete convertis en anesthesie generale : 2 en raison de l'extension de l'incision chirurgicale; et 1 en raison de l'inconfort pour le chirurgien. La duree moyenne de l'intervention etait de 70 minutes. Les nausees (1 cas); les vertiges (2 cas); la sensation de bouche amere (3 cas) ont ete les complications peroperatoires observees. En postoperatoire; 2 cas d'extension au nerf femoral ont ete observes. 5 patients ont eu une EVA = 4 dans les 18 heures postoperatoires. Dans 68;57des cas; les patients sortaient au 3e jour postoperatoire. Le BII est une alternative interessante a l'anesthesie generale dans les cures herniaires. Sa vulgarisation necessite neanmoins un apprentissage a sa bonne pratique

[Knowledge and acceptance of obstetric peridural analgesia: survey of pregnant women in Togo]. / Niveau de connaissance et acceptabilité e l'analgésie péridurale: enquête auprès des femmes enceintes au Togo.

The purpose of this study was to evaluate knowledge and acceptance of obstetric peridural analgesia among pregnant women in Togo. A prospective, descriptive survey was carried out over a period of one month. A standardized survey form was used to collect data. A total of 303 pregnant women with a mean age of 27 +/- 6 years were interviewed. A proportion of primiparous and multiparous was the same, i.e., 50%. Among multiparous women, 83.5% described labor pain during previous deliveries as severe. Twelve percent of the pregnant women interviewed claimed knowledge of techniques to control labor pain. Three pregnant women reported a detailed understanding of peridural analgesia obtained from the Internet. A total of 253 women (83.5%) replied affirmatively when asked if they would opt for peridural analgesia if it was offered free of charge for delivery at the end of the current pregnancy. Acceptance was motivated by better delivery conditions for the newborn (112 women) and comfort achieved by pain relief (130 women). Refusal was motivated by a religious belief that painful delivery was in the natural order (31 women). Among the six Moslem women that refused painless delivery, two from the Djerma ethnic group stated that pain was the best expression of their femininity. The acceptance rate fell from 83.5% to 70% if peridural analgesia was offered at extra charge. Most pregnant women in Togo expressed interest in trying peridural analgesia. It is compulsory in medical indications.

[Delayed autologous transfusion: about 70 surgical patients at the Saint-Jean-de-Dieu Hospital in Afagnan, Togo]. / Transfusion autologue différée: apropos de 70 cas a l'hôpital Saint-Jean-de-Dieu d'Afagnan, Togo.

This prospective study was conducted from 2000, September the 1st to October the 31st, at the Saint-Jean-de-Dieu Hospital in Afagnan (Togo). All the 75 patients who received indication of autologous blood transfusion (ABT) accepted the protocol; 70 out of them, among whom 63% were female, benefited an ABT The age of the patients varies between 13 and 80 years old (average 33.2). Initial rate of haemoglobin was on average of 11.7 g/dl; 14% of these patients had a haemoglobin diseases. The most frequent interventions were hysterectomies (21%), bone surgery (16%), prostatectomies (11). Only one blood unit was taken from 63 patients and two units from the 7 others inducing giddiness (5) and headaches (1). During intra and postoperative periods, 41 patients were given 45 units of blood (use rate: 58%). The percentage of patients who received transfusion was 56% in gynaecological surgery 79% in orthopaedics and 88% in urology. Only one patient received an additional homologous unit of blood. The rate of haemoglobin was on average 10.2 g/dl the day after surgery. No incident in connection with the ABT was recorded. The ABT is a feasible, effective and secure method in the context of a small African hospital. It may be a solution to the problems of shortage of blood products and transfusion safety. Training and motivation are necessary for its successful implementation.

[Practice of the thromboembolic disease prophylaxis: a survey among surgeons and anaesthetists in Togo]. / Pratique de la prophylaxie de la maladie thromboembolique veineuse: enquête auprès des chirurgiens et anesthésistes au Togo.

OBJECTIVE: The aim of this study was to analyse the current practice of postoperative venous thromboembolism (VTE) prophylaxis among anaesthetists, nurse anaesthetist and general surgeons in Togo. METHOD: A total of 160 questionnaires were distributed to anaesthetists and surgeons with varying subspeciality interests. RESULTS: One hundred and three (64%) (3 anaesthetists, 51 nurse anaesthetists and 49 surgeons) returned the questionnaire. Of these, 16% thought that VTE was as common in Togo as in the western countries. Selective VTE prophylaxis was used by 78% of the prescriptors. In order of frequency, indications for selective VTE prophylaxis were obesity, increased risk of VTE related to surgery and past medical history of VTE. Orthopaedic surgery, caesarean section and vascular surgery were most frequently considered as high-risk surgery for VTE event. When prophylaxis was indicated, low molecular weight heparin was prescribed by 87% of prescriptors. In most cases, VTE prophylaxis duration was less than a week. In 92% of institutions, there was no written protocol for VTE prophylaxis. VTE-related morbidity was reported by 34% of the prescriptors over the past year, and 30% of these cases were fatal; 60% of the prescriptors observed these complications one week after the surgery. CONCLUSION: The practice of VTE prophylaxis in Togo is not sufficient. It is necessary to promote the training of practitioners, particularly of physicians.

Deaths associated with anaesthesia in Togo, West Africa.

This study attempts to determine the anaesthetic death rate, the causes of deaths and the avoidable mortality rate (AMR) in consecutive cases. The number of anaesthetics given was 1464: 30 cases died within 24 h. The incidence of 24-h perioperative deaths per 100 anaesthetics was 2.57. In all, 50% of deaths were observed in obstetric surgery; 47% of deaths were associated with cardiovascular management, 30% with respiratory management; 93% of deaths were identified as avoidable. The AMR was 1.5% (anaesthetic AMR: 0.75%, administrative AMR: 0.68%, surgical AMR: 0.07%). Insufficient or no blood available is the only factor for administrative AMR.

[Maternal deaths and anesthetics in the Lomé (Togo) University Hospital]. / Mortalité maternelle: implication anesthésique au CHU de Lomée (Togo).

AIM: To assess the results of anesthesia practices in a department particularly inadequately staffed with physicians specializing in anesthesiology. SETTING AND METHODS: This six-month prospective study (from January through June 2002) took place in the anesthesiology/intensive care unit of the obstetrics and gynecology department of Lomé University Hospital Center. A case report file was completed for each patient, and all anesthetics administered in the obstetrical department (labor and delivery room) were recorded and considered. We examined the perinatal deaths among women who underwent surgery. RESULTS: Anesthetics were administered to 318 women during cesarean delivery (306) and uterine scar repair (12). Nearly all patients (98%) were classified in categories 1 or 2 of the ASA physical status classification system (healthy or mild systemic disease). General anesthesia was induced in 95.9% of the women and spinal bloc used for 4.1%. Thiopental was used most often, and certain drugs, including succinylcholine and ephedrine, were not available as needed. Intraoperative monitoring was essentially nonexistent. Emergency situations accounted for 89.6% of these surgical procedures. Of the 16 cases requiring transfusions, an inadequate supply of blood products or the patient's inability to obtain blood was reported in 14 of the cases. Twelve deaths occurred, for a mortality rate among surgical patients of 3.8%. The principal causes of death were respiratory complications of anesthesia and of pregnancy-related toxemia and the unavailability of hypertonic solutions and blood products. CONCLUSION: The results of this survey show that anesthetics play a role in maternal mortality in Togo. Good practice guidelines adapted to this setting must therefore be developed.