Outcome Measurement at a Ugandan Referral Hospital: Validation of the Mbarara Surgical Services Quality Assurance Database.

BACKGROUND: Five billion people lack access to surgery. Accurate and complete data have been identified as essential to the global scale-up of perioperative care. This study retrospectively validates the Mbarara Surgical Services Quality Assurance Database (SQUAD), an electronic outcomes database at a Ugandan secondary referral hospital. METHODS: SQUAD data were compared to paper records from August 2013 to January 2017. To assess data entry accuracy, two researchers independently extracted 24 patient variables from 170 charts. To assess completeness of patient capture, SQUAD entries were compared to a sample of charts returned to the Medical Records Department, and to a sample of entries in ward and operating room logbooks. Two-tailed binomial proportions with 95% CI were calculated from the comparative results of patient observations, against a predefined accuracy of 0.85-0.95. RESULTS: Agreement between completed validation observations from charts and SQUAD data was 91.5% (n = 3734/4080 data points). Binomial tests indicated that 15 variables had higher than 95% accuracy. A total 19 of 24 variables had ≥ 85% accuracy. The completeness of SQUAD patient capture was 98.2% (n = 167/170) of charts returned to the Medical Records Department, 97.5% (n = 198/203) of operating logbook entries, and 100% (n = 111/111) of ward logbook entries, respectively. CONCLUSION: SQUAD closely reflects the primary surgical and anaesthetic data at a Ugandan secondary hospital. Data accuracy of key variables and completeness of population capture were comparable to those of databases in high-income countries and outperformed those of other low- and middle-income countries.

Tracheal Resection for Symptomatic Tracheal Stenosis During Pregnancy.

A 31-year-old multipara was diagnosed with tracheal stenosis that developed after intubation after an intentional benzodiazepine overdose in the first trimester of pregnancy. Tracheal dilations only temporarily improved her dyspnea at rest. A definitive repair by tracheal resection and reconstruction was performed at 28 weeks' gestation. Her symptoms resolved, and she delivered vaginally at 36 weeks' gestation after spontaneous labor.

Ultrasound guided transversus abdominis plane versus sham blocks after caesarean section in an Ugandan village hospital: a prospective, randomised, double-blinded, single-centre study.

BACKGROUND: Transversus abdominis plane (TAP) block provides 12-24 h of analgesia to the parietal peritoneum and abdominal wall, and are best used combined with oral or intravenous medications. Despite ease of use, a large margin of safety, and a high success rate, TAP blocks remain under used in settings where patients could most benefit from their use. Previous studies have used oral or intravenous narcotics for supplementation. However, the efficacy of TAP blocks in low-resourced settings where patients do not have dependable access to these medications is unknown. This study examines TAP block analgesic efficacy after caesarean section in a poorly resourced setting. We compared the post-operative status of 170 women with self-administered paracetamol-diclofenac with or without TAP blocks. We hypothesised that the block would decrease pain at 8 h, 16 h, and 24 h at rest, with coughing and upon standing. METHODS: Between Oct 31, and Dec 28, 2013, 180 women were enrolled and randomly assigned to receive either TAP or sham blocks after caesarean section. Bi-institutional (Mbarara Regional Referral Hospital and Massachusetts General Hospital) institutional review board approval was obtained for this single-centre study. After informed written consent, patients received TAP or sham blocks after caesarian section. Inclusion criteria for enrolment were: age 18 years or older, weight at least 50 kg, no allergies to study medications, otherwise healthy (American Society of Anesthesiologists classification status I or II), and having undergone elective, urgent, or emergent caesarian section under spinal anaesthesia without sedation. Under ultrasound guidance, 20-25 mL of 0·25% bupivacaine (epinephrine 1:400 000) were injected near the triangles-of-Petit. Sham blocks consisted of a transducer with a needleless syringe pressed over each flank. In the post-anaesthesia recovery area, all patients received 1000 mg paracetamol and 50 mg diclofenac, orally, to be continued on an 8-h schedule for 3 days. A skilled (masked) research nurse collected all data. The primary outcomes measured were numerical rating scale at 8 h, 16 h, and 24 h at rest, with coughing, and upon standing. The association between the pain scores at each time and type of treatment (TAP vs sham blocks) was assessed using general linear model with repeated measures. Demographics were compared using the two sample t-test (appendix). FINDINGS: 170 patients completed the study; 86 in the sham group and 84 in the study group. Demographics (age, weight, and parity) were similar between both study groups. One participant from the sham group was missing parity information (appendix). Preliminary data analysis showed reduced pain scores at all times, and with all degrees of movement for the TAP group (appendix). The largest reduction in pain was at 8 h (resting 33%, coughing 36%, and standing 44%). With time, the pain scores of the TAP group changed a little, whereas a decreasing trend can be noted in the sham group. No adverse events occurred. INTERPRETATION: This study show a significant improvement in pain scores for obstetric patients receiving a transversus abdominis plane block in comparison to standard of care in a low income, limited resource setting. The use of these blocks shows the use of an easy, inexpensive, and achievable pain control option. Especially in resource-limited areas, this approach could allow for better pain management and a new standard of care for the world's most common operative procedure. FUNDING: Eleanor and Miles Harvard Medical School Shore Fellowship Grant, and Massachusetts General Hospital, DACCPM Faculty Development Grant.

Clinical implications of the transversus abdominis plane block in adults.

The transversus abdominis plane (TAP) block is a relatively new regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall. It has a high margin of safety and is technically simple to perform, especially under ultrasound guidance. A growing body of evidence supports the use of TAP blocks for a variety of abdominal procedures, yet, widespread adoption of this therapeutic adjunct has been slow. In part, this may be related to the limited sources for anesthesiologists to develop an appreciation for its sound anatomical basis and the versatility of its clinical application. As such, we provide a brief historical perspective on the TAP block, describe relevant anatomy, review current techniques, discuss pharmacologic considerations, and summarize the existing literature regarding its clinical utility with an emphasis on recently published studies that have not been included in other systematic reviews or meta-analyses.