Impact of Pain Management Workshop on the Knowledge and Attitude of Healthcare Workers and Opioid Utilization in a Nigerian Teaching Hospital.

BACKGROUND: Pain is a public health problem requiring serious attention. One major barrier to the provision of quality pain treatment in many countries is lack of training for healthcare workers. The aim of this study was to evaluate the impact of pain education on the knowledge and attitude of healthcare workers, and opioid utilization in a university teaching hospital. METHODS: Pain management workshops were conducted for healthcare workers over a 12-month period. The modified "Knowledge and Attitudes Survey Regarding Pain" questionnaire was administered to participants pre- and post- training for each of the workshops. The total mark by each participant was entered into the Statistical Package for Social Sciences (SPSS) software version 16 software for windows (SPSS Inc., Chicago, Illinois, USA) for comparison of means for pre- and post-test. Changes in opioid utilization were evaluated. RESULTS: The pre-test and post-test questionnaires were filled by 715 and 700 participants respectively. The mean post-test score was significantly higher than the pre-test score (68% versus 49% respectively, p = 0.00001). The doctors scored significantly higher than the other groups (p < 0.0001) in the pre-test. The mean post-test scores were significantly higher than the corresponding mean pre-test scores for the various groups (p < 0.0001). Sustained increase (up to 60.4%) in total morphine utilization was observed during the training. CONCLUSION: There is a wide knowledge gap requiring regular training and re-training to achieve improved pain management and opioid utilization among healthcare workers. Inclusion of robust pain curricula in medical training programs will significantly improve pain management.

Impact of basic life support training on the knowledge of basic life support in a group of Nigerian Dental Students.

UNLABELLED: Aim and Objetive: The burden of cardiac arrest remains enormous globally. Early recognition and prompt and effective cardiopulmonary resuscitation are crucial to successful outcome following a cardiac arrest. This study assessed the impact of basic life support (BLS) training on the knowledge of a group of dental students. MATERIALS AND METHODS: Sixty-eight dental students participated in this interventional study. Using convenience sampling, pre- and post-BLS training assessment were conducted with a questionnaire. RESULTS: The mean score (standard deviation) for pretest was 4.7 (±1.47) with a range of 2-8 out a total of 10, while the mean posttest score was 8.04 ± 1.47 with a range of 3-10. The differences were statistically significant (P < 0.01). There was a marked improvement in the knowledge of the respondents with 88.2% of them having a posttest score of ≥7. CONCLUSION: The results of this study suggest that the group of dental students' knowledge of BLS was very poor prior to the BLS training. The study also showed that the BLS training had a positive influence on the BLS knowledge of the participants.

A prospective study on the effectiveness of ketamine and diazepam used for conscious sedation in paediatric dental patients' management.

AIM: The need to manage children using safe, effective and inexpensive conscious sedation materials and techniques in paediatric dentistry is high. This study evaluated the safety and effectiveness of a combination of low dose ketamine (5 mg/kg) and diazepam (0.2 mg/kg) used for conscious sedation in healthy children undergoing paediatric dental procedures at a paediatric dental outpatient clinic over a 3-year period. MATERIALS AND METHODS: All children who were scheduled for conscious sedation between 2009 and 2012 were included in the study. All children received ketamine 5 mg/kg body weight in combination with diazepam 0.2 mg/kg body weight in a single oral dose for use as conscious sedation. Patients were considered sedated when the Ramsey Score was 2 or 3. Time of onset and duration of surgical procedures were recorded. Side effects during and after discharge were recorded. RESULTS: Twenty five patients participated in the study. The effectiveness of the sedation was 84.0%. The mean time of onset of action was 10.5 ± 7.2 minutes. All cases that needed additional sedation needed this after 35?36 minutes. Three cases (12.0%) developed high temperature in the night of the day of the procedure. There was a case (4.0%) of hallucination. CONCLUSION: Ketamine and diazepam as medication for conscious sedation was considered effective. The duration of effectiveness appears to be 35 minutes. The combination is considered safe for use for conscious sedation in healthy paediatric dental outpatients undergoing minor oral surgical procedures.

Unrecognised guide wire migration during internal jugular cannulation and its retrieval--a case report.

AIMS AND OBJECTIVES: The objective of this article is to report a case of unrecognised missed guide wire diagnosed two months after right internal jugular cannulation and which was successfully retrieved from the right femoral vein. PATIENT AND METHODS: The case record of a patient that had retained intravenous guide wire was reviewed with relevant literature. RESULT: A 40-yr-old female had an emergency left thoracotomy on account of haemorrhagic pleural effusion. A right internal jugular central venous catheter (CVC) insertion was performed for resuscitation and haemodynamic monitoring before induction of anaesthesia. A follow-up thoraco-abdominal Computed tomography (CT) scan taken after 8 weeks showed a pigtail intravascular metallic foreign body traversing the distal superior vena cava, right atrium, inferior vena cava, and ending at the right femoral vein. The guide wire was successfully removed via a right femoral venotomy under local anaesthesia. CONCLUSION: Intravascular loss of a guide wire is a rare complication of CVC insertion. If basic precautionary measures were taken, the loss of guide wire would have been avoided.

Review of skull base surgery in a Nigerian teaching hospital.

BACKGROUND AND OBJECTIVES: There is dearth of information on skull base surgery in Nigerians. This study was conducted to determine types of skull base lesions describe surgical approaches to the lesions and determine outcome of surgical management of the lesions over the study period. METHODS: We retrospectively reviewed the case notes of the patients who underwent skull base neurosurgical procedures between January 2001 and June 2007 in our centre. We obtained information on demography, clinical presentation, diagnosis, cranial computerised tomography findings, type of surgery, intraoperative findings and outcome of surgical management at the time of discharge from the hospital. RESULTS: Brain tumours were diagnosed in 28 patients, head injuries in 9 patients and one patient each had anterior encephalocele and frontal sinus mucocele. Eighteen patients had frontal craniotomy, three patients had temporal craniotomy and two patients had lateral rhinotomy in addition to bifrontal craniotomy. Two patients had frontoorbitotomy while retrosigmoid craniectomy was performed in one patient. Thirty three patients showed significant postoperative improvement at discharge. CONCLUSION: Brain tumour was the most common indication for skull base surgery in our centre. These tumours were mainly located in the anterior cranial fossa. Frontal craniotomy was the most common surgical approach. Non-availability of modern neurosurgical facilities confined us to the use of mainly traditional approaches. The availability of these facilities will assist in improving our management outcome in the future.

Supplemental oxygen for caesarean section under spinal anaesthesia.

BACKGROUND: Routine administration of supplemental oxygen to parturients undergoing Caesarean section under spinal anaesthesia has been criticised in recent times. OBJECTIVES: To assess the need for routine supplementary oxygen in healthy women undergoing Caesarean section under spinal anaesthesia in resource challenged setting and establish the efficacy of administration of oxygen at 4L/min. DESIGN: Simple randomized trial using sealed envelopes. SETTING: The Obafemi Awolowo University Teaching Hospital; a 580 bed hospital situated in Ile-Ife in South-western Nigeria. SUBJECTS: Seventy parturients with ASA physical status I or II undergoing Caesarean section under spinal anaesthesia. MAIN OUTCOME MEASURES: Outcome measures were arterial oxygen saturation (SaO2) and Apgar scores at one and five minutes. RESULTS: The mean pre-induction arterial oxygen saturation in the two groups were similar. There was a statistically significant difference in the mean SaO2 at one minute between the two groups, with the control group being higher (97.7% +/- 1.5% versus. 96.7% +/- 1.5%; p-value = 0.008). The mean least SaO2 during surgery was also higher in the control group (95.9% +/- 1.5% versus 94.9% +/- 2.0%, p-value = 0.015). The Apgar score of the babies at one and five minutes for the study and control group were similar. CONCLUSION: Healthy parturients undergoing Caesarean section under spinal anaesthesia do well without supplemental oxygen; administration of supplemental oxygen from the common gas outlet of anaesthetic machine with the breathing circuit and standard anaesthetic facemask at 4L/min causes relative desaturation.

The import of abdominal pain in adults with sickle cell disorder.

BACKGROUND: The aetiology, clinical correlates and outcome of abdominal pain in Nigerian adults with sickle cell disorder (SCD) have not been extensively reported. OBJECTIVE: To determine the prevalence of abdominal vasoocclusive crisis in sickle cell patients with abdominal pain and their clinical correlates if any. METHODS: Clinical records of adults with SCD (Hb SS and Hb SC) attending the Haematology Outpatients' Clinic of the Obafemi Awolowo University Teaching Hospitals Complex, Southwest Nigerian, over a ten-year period, were reviewed. Demographic, clinical and laboratory data with respect to abdominal pain were retrieved. Data were analysed using appropriate descriptive and inferential statistics. RESULTS: A total of 154 records (128 Hb SS and 26 Hb SC) were available for assessment. The patients mean ages were 22.5 +/- 7.3 years (Hb SS patients) and 24.2 +/- 9.7 years (Hb SC patients) (p > 0.05). The prevalence of abdominal pain was 39.1% and 30.8% in Hb SS and Hb SC respectively (p > 0.05). Pain was commonly in the epigastrium; dull in 35% Hb SS, but peppery/burning in 37.5% Hb SC. All patients with abdominal vaso-occlusive crisis (VOC) had diffuse/generalised dull abdominal pains. A diagnosis of gastritis/peptic ulcer disease was made in 50% of Hb SC patients and 28% of Hb SS patients. Abdominal VOC was diagnosed in 26% Hb SS, but none in Hb SC patients. The size of the liver or spleen and the haematocrit of Hb SS patients did not correlate with the frequency of abdominal pain generally or abdominal VOC specifically. CONCLUSION: The prevalence rates and patterns of abdominal pain in Hb SS and Hb SC patients appear similar. Abdominal VOC characterised by diffuse/generalised dull abdominal pain occurred in only Hb SS patients and may be a marker of disease severity in these patients.

Caesarean section: intra-operative blood loss and its restitution.

OBJECTIVES: To determine the rate of blood loss and its restitution during Caesarean section and make recommendations to improve our practice. DESIGN: Prospective study. SETTING: Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria from 1st January 2005 to December 2005. SUBJECTS: All term Caesarean sections performed during the period. RESULTS: Six hundred and forty one patients met the inclusion criteria. The mean maternal age was 30.42 years +/- 5.5 (Range 16-44 years). Fifty seven patients (8.9%) were transfused. Major blood loss (>1000 ml) was reported in 7.6% of the patients. The main causes of major blood loss during surgery were placental disorders and pre-eclampsia. The main indications for transfusion were placental disorders, pre-eclampsia and breech presentation. The packed cell volume, status of the anaesthetist and the ASA grading were other factors, which had statistical association with blood transfusion. The risk of major blood loss and transfusion were negligible in patients presenting for foetal distress, cephalo-pelvic disproportion and breech presentation. CONCLUSION: The rate of blood transfusion during Caesarian section is high. Antepartum haemorrhage and pre-eclampsia were predictable indications for major blood loss and transfusion. Major blood loss and transfusion rate were negligible in patients presenting with foetal distress, cephalo-pelvic disproportion and breech presentation.

Perception of labour pain among the Yoruba ethnic group in Nigeria.

In Nigeria, it is generally assumed that labour is well tolerated and pain relief is not usually considered an important part of intra-partum care. This prospective study was carried out to assess mothers' perception of labour pain and determine any factor that may influence it. During the period of study, 281 women who delivered at Wesley Guild Hospital Ilesa, Nigeria were interviewed within 2 h of delivery to assess the severity of labour pain and desire for analgesia. Perception of labour pain was assessed using a 3-point verbal rating. The majority (68.3%) of women described labour pain as severe with only 5.3% describing it as mild. More than 86% of the women would want the pain relieved. Perception of pain was not influenced by age, parity and educational level. Management of pain in labour should form an important part of intra-partum care as is the case in developed countries.

Burkitt's lymphoma of the head and neck region in a Nigerian tertiary hospital.

BACKGROUND: Burkitt's lymphoma is endemic in Nigeria; it forms about 39% of all childhood cancers. In recent times more of these cases are being seen presenting first to the Ear Nose and Throat clinic. OBJECTIVE: This study is designed to look at the pattern of presentation of head and Neck Burkitt's lymphoma at a Nigerian Tertiary hospital and to evaluate current treatment modality. DESIGN: It is a retrospective study of all confirmed Burkitt's lymphoma of the head and neck region seen at the Obafemi Awolowo University Teaching Hospital Ile Ife (OAUTHC) between 1986 and 2002. PATIENTS AND METHODS: The medical records of all the patients with the histopathologically confirmed Burkitt's lymphoma over a 17-year period (1986-2002) were evaluated. The proportion of the tumor affecting the Head and neck region were noted. The data extracted were entered into a questionnaire and analysis of data was done using the SPSS 10.0 software. RESULTS: A total of 196 cases of Burkitt's lymphoma were seen over the period out of which 140 (71.4%) were in the head and neck region. There was a male preponderance with the incidence of 72% and 28% in females. The peak age incidence was found to be within the first decade of life. The most common sites that were affected are; the jaw (65.9%), nasal and paranasal sinuses (12.2). Majority of the patients presented with advanced disease. Combination Chemotherapy comprising Cyclophosphamide, Oncovin, Methotrexate and Prednisolone (COMP) was the mainstay of management. The treatment outcome was only favorable in 36.6%. Default rate was (11.7%) while the mortality rate was (12.6%). Relapse\recurrence was found in (5.1%) of cases. Frank drug resistance was found in (2.6%). Blindness was found to be a major morbidity associated with this disease. Septicemia and severe anemia were found to be the major causes of mortality. Some complications of treatment were noted. DISCUSSION: The importance of the findings in this work was discussed in line with the existing literature. CONCLUSION: Head and neck remain the mostly affected parts in Burkitt's lymphoma in this environment. Presentation with advanced disease is the bane. This partly explains high morbidity and mortality in affected children.

Kidney transplantation in a developing economy: challenges and initial report of three cases at Ile Ife.

BACKGROUND: Kidney transplantation (KT) is globally adjudged the best alternative treatment for end stage renal disease (ESRD) in preference to life-long dialysis. This form of therapy was hitherto unavailable in Nigeria until our hospital and a private hospital embarked on a KT programme despite our depressed economy, and inadequate facilities. We present the initial report of KT performed in our hospital and the challenges of KT in our developing society. CASE REPORTS: Three patients with ESRD had living related KT between June 2002 and April 2003. The first patient died with functioning graft six and a half months post transplantation from complications of Diabetes mellitus and sepsis, while the remaining two still enjoy a good quality of life 35 months post transplantation. There were problems with procurement and monitoring of immunosuppressive drugs in the three patients. This report also illustrates the common causes of ESRD in Nigeria and some of the complications of KT. To our knowledge, these are the first reported cases of KT in Nigeria. CONCLUSION: Kidney transplantation is cost effective and offers a good quality of life for ESRD patients. Poverty, inadequate facilities and lack of donors are major problems facing KT in our society. Although KT requires high technical and material resources, with proper training, commitment and adequate funding, it is feasible, safe and cheaper on a long term basis for the management of patients with ESRD in a developing economy like ours. There is a need for government funding of KT programmes in developing countries.

Anaesthesia for neonatal surgical emergencies in a semi-urban hospital, Nigeria.

OBJECTIVE: To establish the techniques of anaesthesia for neonatal surgical emergencies in a semi-urban hospital in Nigeria, assess their adequacy and make recommendations to improve our practice. DESIGN: Retrospective study. SETTING: Obafemi Awolowo University Teaching Hospital, Ile-lfe, Nigeria, from January 1990 to December 2000. SUBJECTS: One hundred neonates aged one to twenty eighty days. RESULTS: One hundred neonatal surgical emergencies were operated but only 76 case notes were available for review. Three hundred and fifty eight elective neonatal surgeries were done during the same period. The ASA classification were: ASA IE=10, 2E=25, 3E=28, 4E =12 and 5E=1. The mean weight was 2.66+/ 0.52 kg. Over 95% of the cases were done under general anaesthesia. Anorectal malformations and intestinal obstruction were the most common indications for surgery (64.5%). Nurse anaesthetists gave over 50% of the anaesthetics. Peri-operative adverse events such as tachycardia, respiratory distress, aspiration and hypothermia were recorded in 11.8% of the cases. Mortality was 39.2%. CONCLUSION: General anaesthesia is still the main technique of anaesthesia and mortality following surgery is still high. Efforts should be made to train appropriate personnel to provide improved care and thereby reduce morbidity and mortality.

Knowledge about pulse oximetry among medical and nursing staff.

The use of the pulse oximeter is becoming popular in developing countries. The introduction of the requirement into hospitals is not usually accompanied by appropriate staff training. Therefore 25 health care professionals at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, were studied to assess their knowledge about the pulse oximeter. A questionnaire was designed to assess this. A 100% response rate was achieved from staff participating in the study. Most (92%) of the participants (medical (M) 44%, nursing (N) 52% and medical student (MS) 4% had seen the equipment before, being used in the hospital. Only 28% claimed to have been trained in its use though. The answers to the clinical questions generally reflected a poor understanding of the principles of pulse oximetry. The aim of improving patient's care by introducing such equipment can only be achieved by accompanying its introduction with staff training on the use of this equipment.

Anaesthesia as a career--the influence of undergraduate education in a Nigerian Medical School.

Sixty-seven final year medical students of the Obafemi Awolowo University, Ile-Ife, Nigeria were questioned to find out the influence of undergraduate education on their choice of future career. Eighty per cent of them found anaesthesia interesting and important but none would pick anaesthesia as a first choice for future career. One-third of the students studied did not even consider it. The students made several suggestions on how to improve undergraduate medical training. The author also suggests measures for general improvement in all aspects of anaesthetic practice in Nigeria with a view to attracting more residents into this specialty.

A comparison of the efficacy of alfentanil and remifentanil analgesic infusions for spinal surgery.

The use of alfentanil infusion was compared with that of remifentanil infusion for spinal cord surgery in a retrospective review. The aim was to compare the outcome when methohexitone was used as the only hypnotic agent in the two groups. Over a 3-year period, 5 patients (group 1) had Alfentanil infusion and 11 patients (group 2) had remifentanil infusion for analgesia during spinal cord surgery. Results showed that remifentanil lead to a faster onset of recorvery than alfentanil. It also provided better haemodynamic stability than alfentanil without excesive hypotension (p > 0.05). Our experience here indicated that remifentanil provided better flexibility of use with less tachycardia and respiratory depression than alfentanil for spinal surgery.

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.

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.

Practice and acceptance of day-care surgery in a semi-urban Nigerian hospital.

OBJECTIVE: To determine the acceptability and practicability of day-care surgery in a semi-urban area of Nigeria. DESIGN: A twelve- month prospective study. SETTING: Wesley Guild Hospital, Ilesa, Nigeria. PATIENTS: Sixty seven consecutive patients with ASA I-II status and aged three months to 97 years were studied. INTERVENTION: Patients were operated as day-cases using general or local anaesthesia. MAIN OUTCOME MEASURES: Practicability, post-operative problems and acceptability. RESULTS: The mean age of patients studied was 27.26 years (SD 23.89), with males accounting for 61% of the 67 cases. Fifty eight per cent and 42% had general and local anaesthesia respectively. While all patients had post-operative support from family members, less than seven per cent had access to telephone or family doctor services. About 80% of the patients lived within 10 km from the hospital. Intermediate operations accounted for 60% of the cases, while minor ones accounted for 40%. The mean operating time was 30 minutes. Postoperative pain was the only significant problem encountered. This, however, decreased in the patients with time. Complication rate was 10.5%. CONCLUSION: A significant number of patients accepted and approved of the day stay surgery. Medical and surgical practitioners in semi-urban regions are encouraged and charged to accept the practice of short stay surgery.

Management of pain after surgery--a short review.

In the last decade, methods for the relief of pain following surgery have received attention. Acute postoperative pain management has evolved to include many other treatment modalities, apart from the traditional method of intramuscular opioids in the postoperative period. Changes made include the introduction of other routes of analgesic administration, introduction of new analgesics as well as the introduction of different methods of producing analgesia. In Nigeria, many of the new techniques being used abroad have not been introduced into our routine practice. It is intended to review the present situation and suggest methods of improvement.