Where Are They Now? Evolution of a Nurse Anesthesia Training School in Ghana and a Survey of Graduates.

Ghana, like other countries in sub-Saharan African, has limited access to surgery. One contributing factor is the inadequate number of anesthesia providers. To address this need, Kybele, Inc., a US-based non-governmental organization, partnered with the Ghana Health Service to establish the third nurse anesthesia training school (NATS) in Ghana. The school, based at Ridge Regional Hospital (RRH) in Accra, opened in October 2009. This paper describes the evolution of the training program and presents the curriculum. Second, the results of a voluntary survey conducted among the first four classes of graduates (2011-2014) are presented to determine their perceived strengths and gaps in training and to identify employment locations and equipment availability. Seventy-five of 93 graduates (81%) responded to the survey. The graduates reported working in 39 hospitals across 7 of the 10 regions in Ghana. Six providers (8%) worked alone and 16 (21%) were one of only two providers. Fifty-three providers (71%) had no physician anesthesiologist at their facility. Most providers had access to basic anesthesia equipment; however, there was limited access to emergency airway equipment. While most graduates felt that their training had prepared them for their current positions, 21% reported experiencing a patient death during anesthesia. The NATS at RRH has been sustained and most of the graduates are working in Ghana, filling an important void. Quality improvement and continuing education must be emphasized in an effort to reduce surgical morbidity and mortality in Ghana.

Teaching neuraxial anesthesia techniques for obstetric care in a Ghanaian referral hospital: achievements and obstacles.

Anesthesia providers in low-income countries may infrequently provide regional anesthesia techniques for obstetrics due to insufficient training and supplies, limited manpower, and a lack of perceived need. In 2007, Kybele, Inc. began a 5-year collaboration in Ghana to improve obstetric anesthesia services. A program was designed to teach spinal anesthesia for cesarean delivery and spinal labor analgesia at Ridge Regional Hospital, Accra, the second largest obstetric unit in Ghana. The use of spinal anesthesia for cesarean delivery increased significantly from 6% in 2006 to 89% in 2009. By 2012, >90% of cesarean deliveries were conducted with spinal anesthesia, despite a doubling of the number performed. A trial of spinal labor analgesia was assessed in a small cohort of parturients with minimal complications; however, protocol deviations were observed. Although subsequent efforts to provide spinal analgesia in the labor ward were hampered by anesthesia provider shortages, spinal anesthesia for cesarean delivery proved to be practical and sustainable.

A prospective evaluation of the incidence of adverse events in nurse-administered moderate sedation guided by sedation scores or Bispectral Index.

BACKGROUND: Moderate sedation is routinely performed in patients undergoing minor therapeutic and diagnostic procedures outside the operating room. The level of sedation is often monitored by sedation nurses using clinical criteria, such as sedation scores. The Bispectral Index (BIS) is derived from changes in the electroencephalograph profile that may provide an objective measure of the level of sedation. In this prospective observational study, we investigated whether using BIS values to guide sedative drug administration influences the level of sedation and the incidence of adverse events compared with using Ramsay sedation scale (RSS) only in nurse-administered moderate sedation. We hypothesized that both depth of sedation and the incidence of adverse events related to oversedation would decrease when sedation nurses used BIS values to help guide sedative drug administration. METHODS: Sedation care was provided by trained sedation nurses under the supervision of a physician performing the procedure. The sedation regimen was initiated with IV midazolam 1 to 2 mg and fentanyl 50 mcg or hydromorphone 0.2 mg. Additional small boluses of midazolam, fentanyl, or hydromorphone were administered to maintain an RSS of 2 to 3 (cooperative, oriented, and responding to verbal command). Propofol was not used. Information including patient demographics, type of procedure, medication administered, RSS, and rates of adverse events was recorded by the sedation nurses for each patient on a computer-readable form. The study was divided into 3 phases. In phase 1 (baseline, 6 months' duration), baseline data on sedation practice were prospectively collected. There was no change from standard of care for all patients except that each patient had a BIS sensor attached, but the monitor was covered and nurses were blinded to the BIS values. In phase 2 (training, 3 months), the sedation nurses received comprehensive education on the use of BIS to guide sedative drug administration, pharmacology of commonly used drugs, and methods for rescue from oversedation. The recommended BIS range for moderate sedation was 75 to 90. Adequate training of all sedation nurses on the use of BIS was documented. In phase 3 (implementation, 6 months), the BIS values were used to guide drug administration. RESULTS: Data were available on 1766 patients (999 and 767 patients in phases 1 and 3, respectively). Most of the procedures were colonoscopies, upper gastrointestinal endoscopies, examinations under anesthesia, endoscopic retrograde cholangiopancreatography, and central venous access catheter placements. No differences in the demographics between the 2 groups were observed. The RSS was inversely associated with the BIS value, r = -0.16 (95% confidence interval, -0.19 to -0.12; P < 0.00001). An RSS of 2 to 3 was maintained in 94% of patients in phase 1 and 96% of patients in phase 3 The mean (±SD) BIS values were 80.9 ± 6.8 in phase 1 and 80.4 ± 6.5 in phase 3. The number of sedation-related adverse events was lower in our sample when BIS was used, with an odds ratio of 0.41 (95% confidence interval, 0.28-0.62; P < 0.0001), and patients with restlessness had a lower BIS value than those without this symptom (P < 0.0001). No serious adverse events or deaths were reported. CONCLUSIONS: Nurse-administered moderate sedation using midazolam and fentanyl was usually associated with appropriate levels of sedation as assessed by both the RSS and BIS with an overall low incidence of adverse events. The use of BIS did not change the mean level of sedation significantly, although the number of sedation-related adverse events appears to be lower when BIS was used.

A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia.

Respiratory depression can occur after neuraxial morphine administration. In the obstetric population, there are little data on respiratory depression after neuraxial morphine administration in women undergoing cesarean delivery. In this single-center, retrospective study in 5036 obstetric patients (mean body mass index = 34 kg/m) who underwent cesarean delivery and received neuraxial morphine, we did not identify any instances of respiratory depression requiring naloxone administration or rapid response team involvement. Therefore, the upper 95% confidence limit for respiratory depression in our study is 0.07% (1 event per 1429 cases).

A double-blind, placebo-controlled trial of four fixed rate infusion regimens of phenylephrine for hemodynamic support during spinal anesthesia for cesarean delivery.

BACKGROUND: The administration of prophylactic phenylephrine infusions in combination with fluid cohydration significantly reduces the incidence of hypotension in women having cesarean delivery under spinal anesthesia. The ideal dosing regimen for this purpose is not known. In this study, we investigated the dose of phenylephrine that, when administered as a prophylactic fixed rate infusion, is associated with the least interventions needed to maintain maternal systolic blood pressure (SBP) within 20% of baseline. METHODS: Women undergoing elective cesarean delivery were randomly allocated to receive placebo or prophylactic phenylephrine infusion at 25, 50, 75, or 100 µg/min immediately after spinal anesthesia in combination with a 2-L fluid coload. Maternal SBP was maintained within the target range using a predetermined algorithm. The number of physician interventions, hemodynamic performance, intraoperative nausea and vomiting, and umbilical cord blood gases were compared among the groups. RESULTS: One hundred one patients were included in the analysis. There were no differences between the placebo and phenylephrine groups in the number of interventions needed to maintain maternal SBP within the target range. Doses of phenylephrine of 25 and 50 µg/min were associated with significantly fewer interventions when compared with 100 µg/min (P = 0.004 vs 50 µg/min, P = 0.02 vs 25 µg/min). Predelivery hypotension was more frequent in the control group compared with all phenylephrine groups. Phenylephrine 75 and 100 µg/min groups were associated with a significantly higher incidence of predelivery hypertension compared with control (P < 0.001 vs 75 µg/min and 100 µg/min). There was a trend toward an increase in median magnitude of deviations of SBP above or below baseline (P = 0.006), and the bias of SBP to be above baseline (P < 0.001) with increasing rates of phenylephrine infusion. There were no differences in the incidence and severity of intraoperative nausea and vomiting and umbilical cord blood gases among the groups. CONCLUSIONS: The use of prophylactic fixed rate phenylephrine infusions did not significantly reduce the number of physician interventions needed to maintain maternal predelivery SBP within 20% of baseline compared with placebo. However, prophylactic phenylephrine infusions reduced the incidence and severity of maternal predelivery hypotension. Phenylephrine 25 and 50 µg/min administered as a prophylactic fixed rate infusion provided greater maternal hemodynamic stability than phenylephrine 75 and 100 µg/min. Prophylactic fixed rate infusions may have limited application in clinical practice, and future studies assessing the accuracy of hemodynamic control with variable rate phenylephrine infusions are needed.

Brief report: a randomized controlled trial of Synera versus lidocaine for epidural needle insertion in labouring parturients.

PURPOSE: Skin infiltration with lidocaine, although brief, can be very stressful, painful, and may perpetuate anxiety. Synerat, a local anesthetic patch, which contains an oxygen-activated heating component to enhance the delivery of a eutectic mixture of lidocaine (70 mg) and tetracaine (70 mg), has provided analgesia for minor, dermatological procedures. We hypothesized that the analgesic effect of Synera, for pain in labouring parturients, would be superior to the traditional infiltration of lidocaine prior to epidural needle insertion. METHODS: With Institutional Review Board approval, we recruited women, who consented to epidural labour analgesia and who met the following criteria: older than 18 yr; body mass index less than 45 kg x m(-2); and with no history of hypersensitivity to any study medications. We randomized the labouring parturients into Synera (SS) or placebo (PL) groups. Group SS received the Synera patch and infiltration with saline prior to epidural needle insertion. Group PL received a placebo patch and infiltration with 2% lidocaine. RESULTS: The groups were similar with respect to age, estimated gestational age, gravidity, parity, and body mass index. The subjects' pain, with epidural placement, was significantly greater in the SS group (P < 0.001). More SS subjects required additional, deep, local anesthetic infiltration compared to PL (P = 0.02). CONCLUSION: The Synera patch provided inferior analgesia, for performing epidural labour analgesia in labouring parturients, compared to traditional infiltration with 2% lidocaine.

The management of Cesarean delivery in a parturient with paroxysmal nocturnal hemoglobinuria complicated by severe preeclampsia.

PURPOSE: To describe the anesthetic and peripartum management of a parturient with paroxysmal nocturnal hemoglobinuria complicated by severe preeclampsia, review the pathophysiology of this condition, rationale for thromboembolic prophylaxis, and its implications on the choice of labour analgesia and anesthesia. CLINICAL FEATURES: A 35-yr-old primigravida was diagnosed with paroxysmal nocturnal hemoglobinuria at 18 weeks gestation following new onset pancytopenia. Venous thromboembolic prophylaxis with low molecular weight heparin (LMWH) was started, and continued despite a persistent thrombocytopenia. At 34 weeks, labour was induced after she developed signs of severe preeclampsia, and intravenous magnesium sulfate therapy was commenced. The use of a twice daily dosing regime of LMWH, along with severe thrombocytopenia contraindicated neuraxial anesthesia. As a result, labour analgesia was provided with an intravenous patient-controlled analgesia system with fentanyl. The patient subsequently had an uneventful Cesarean delivery under general anesthesia. Anticoagulation with LMWH was restarted postoperatively, and continued for six weeks postpartum. She was discharged home on day 20 postpartum, on oral prednisolone under the care of the hematologists. CONCLUSION: Paroxysmal nocturnal hemoglobinuria is associated with an increased risk of venous thromboembolism, and so anticoagulation therapy assumes primary importance. The use of LMWH for prophylaxis in combination with thrombocytopenia may contraindicate neuraxial anesthesia. General anesthesia should be aimed at preventing or exacerbating complement mediated intravascular hemolysis.

Use of a modifier reduces inconsistency in the American Society of Anesthesiologists Physical Status Classification in parturients.

In this study, we sought to determine whether there is a significant discrepancy among a group of practitioners when rating pregnant patients using the ASA Physical Status Classification and whether this discrepancy could be resolved with the addition of a modifier for pregnancy. Our results indicate that significant discrepancy occurs and that it is reduced with the use of the modifier, especially when referring to the healthy parturient.

Perioperative anesthetic management for Cesarean section of a parturient with gestational diabetes insipidus.

PURPOSE: Gestational diabetes insipidus (GDI) is a rare endocrinopathy complicating about 4:100,000 deliveries. We present the case of a preterm parturient with GDI and severe hypernatremia (serum sodium concentration = 174 mmol.L(-1)) presenting for an urgent Cesarean section. CLINICAL FEATURES: Fluid resuscitation and desmopressin supplementation partially corrected the patient's homeostasis, allowing us to carefully titrate epidural anesthesia for an urgent Cesarean section. After delivery, the patient was transferred to the intensive care unit. The serum sodium concentration of the mother and the neonate was normalized over 48 hr and three days respectively. CONCLUSION: The careful perioperative management of GDI led to a favourable outcome of the mother and fetus.

Single-dose, sustained-release epidural morphine in the management of postoperative pain after elective cesarean delivery: results of a multicenter randomized controlled study.

In this multicenter, randomized, controlled study, we compared the analgesic efficacy and safety profile of a new single-dose extended-release epidural morphine (EREM) formulation (DepoDur) with that of epidural morphine sulfate for the management of postoperative pain for up to 48 h after elective cesarean delivery. ASA physical status I or II parturients (n = 75) were anesthetized with a combined spinal/epidural technique. Parturients received intrathecal bupivacaine 12-15 mg and fentanyl 10 mug for spinal anesthesia and a single epidural injection of either 5 mg of standard (conventional preservative-free) morphine or 5, 10, or 15 mg of extended-release morphine after cord clamping for postoperative pain control. Single-dose EREM 10 and 15 mg groups significantly decreased total supplemental opioid medication use and improved functional ability scores for 48 h after surgery compared with those receiving 5 mg of standard morphine. Visual analog scale pain scores at rest and with activity at 24 to 48 h after dosing were significantly better in the 10- and 15-mg single-dose EREM groups versus the standard morphine group. There were no significant differences between the two 5 mg (single-dose EREM and standard morphine) groups. Single-dose EREM was well tolerated, and most adverse events were mild to moderate in severity. Single-dose EREM is a potentially beneficial epidural analgesic for the management of post-cesarean delivery pain and has particular advantages over standard morphine for the period from 24 to 48 h after surgery.

Intrathecal morphine for analgesia after postpartum bilateral tubal ligation.

Postpartum bilateral tubal ligation (PPBTL) causes postoperative pain. We designed this study to determine the efficacy of 50 microg intrathecal morphine for analgesia after PPBTL. Sixty-five women received spinal anesthesia with 12.75 mg hyperbaric bupivacaine, 20 microg of fentanyl, and either 50 microg of morphine (morphine group) or 0.05 mL of saline (control group). Postoperative analgesia was provided with regular naproxen 500 mg and oxycodone 5 mg/acetaminophen 325 mg mixture as needed. Overall, satisfaction was higher (P=0.003) and pain was less intense at rest (P=0.008) and on movement (P <0.0001) in the morphine group. There was no significant overall difference in nausea, pruritus, or sedation scores, but vomiting occurred more frequently in the morphine group (21.4% versus 3.5%; P=0.052). In post hoc comparisons, pain at rest within the morphine group was significantly less at 4 h (P=0.006), pain on movement was significantly less at 4 h (P=0.002) and 12 h (P=0.0004), and pruritus was significantly more frequent at 12 h (P=0.002) compared with the control group. Oxycodone 5 mg/acetaminophen 325 mg mixture consumption was significantly smaller (P=0.006) and the time to first request of analgesia was significantly longer (P=0.006) in the morphine group. We conclude that the addition of 50 microg of morphine to intrathecal hyperbaric bupivacaine and fentanyl provides improved postoperative analgesia in women undergoing PPBTL.

A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor.

In this multicenter, randomized, controlled trial, we sought to determine whether patient-controlled epidural analgesia (PCEA) for labor affected the incidence of cesarean delivery when compared with patient-controlled IV opioid analgesia (PCIA). Healthy, term nulliparous patients in 4 Canadian institutions were randomly assigned to receive PCIA with fentanyl (n = 118) or PCEA with 0.08% bupivacaine and fentanyl 1.6 microg/mL (n = 124). There was no difference in the incidence of cesarean delivery-10.2% (12 of 118) versus 9.7% (12 of 124)-or instrumental vaginal delivery-21.2% (25 of 118) versus 29% (36 of 124)-between groups. The duration of the second stage of labor was increased in the PCEA group by a median of 23 min (P = 0.02). Fifty-one patients (43%) in the PCIA group received epidural analgesia: 39 (33%) because of inadequate pain relief and 12 (10%) to facilitate operative delivery. Patients in the PCIA group required more antiemetic therapy (17% versus 6.4%; P = 0.01) and had more sedation (39% versus 5%; P < 0.001). Maternal mean pain and satisfaction with analgesia scores were better in the PCEA group (P < 0.001 and P = 0.02, respectively). More neonates in the PCIA group required active resuscitation (52% versus 31%; P = 0.001) and naloxone (17% versus 3%; P < 0.001). These observations support the hypothesis that PCEA does not result in an increased incidence of obstetrical intervention compared with PCIA. PCEA provides superior analgesia and less maternal and neonatal sedation compared with PCIA.

Anesthesia for cesarean section in a patient with spinal muscular atrophy.

We describe the anesthetic management for cesarean section and tubal ligation of a 23-year-old primipara with type II spinal muscular atrophy (benign Werdnig Hoffmann). She was wheelchair-bound, had severe restrictive lung disease, and severe kyphoscoliosis, with Harrington rods extending from the thoracic to the sacral spines. A general anesthetic was given. We used propofol and alfentanil for rapid-sequence induction of anesthesia. We did not use any muscle relaxants intraoperatively. Postoperative care was provided in the intensive care unit. The patient made a good recovery.

Anesthetic management of a ventilator-dependent parturient with the King-Denborough syndrome.

PURPOSE: The King-Denborough syndrome (KDS) is a rare disorder that is associated with myopathy, susceptibility to malignant hyperthermia (MH) as well as congenital skeletal and facial anomalies. We report the anesthetic management of a parturient with KDS. CLINICAL FEATURES: We describe the management of a 24-yr-old primiparous woman with a diagnosis of KDS and a history of previous MH reaction (age two). Her KDS resulted in chronic respiratory failure. She had a permanent tracheostomy and required overnight ventilatory support for the previous two years. She had three admissions during her pregnancy, one for pneumonia and two for preterm labour. Labour was induced at 37 weeks. Her labour was managed in the operating room where a "clean" anesthesia machine was ready. Cooling aids and a MH emergency kit were immediately available. Intravenous access, an arterial line and a lumbar epidural catheter were inserted before induction of labour. Ropivacaine 0.08% + fentanyl 2 microg x mL(-1) were used for patient-controlled epidural analgesia. After 6.5 hr of labour the patient required ventilation. An outlet forceps was performed for delivery. Postpartum, she was ventilated overnight in the intensive care unit. CONCLUSION: The use of epidural analgesia, close monitoring and collaboration between the various disciplines were important in achieving a safe and uneventful labour in this high-risk parturient.

A multicenter, randomized, controlled trial comparing bupivacaine with ropivacaine for labor analgesia.

BACKGROUND: A meta-analysis of studies comparing high doses of bupivacaine with ropivacaine for labor pain found a higher incidence of forceps deliveries, motor block, and poorer neonatal outcome with bupivacaine. The purpose of this study was to determine if there is a difference in these outcomes when a low concentration of patient-controlled epidural bupivacaine combined with fentanyl is compared with ropivacaine combined with fentanyl. METHODS: This was a multicenter, randomized, controlled trial, including term, nulliparous women undergoing induction of labor. For the initiation of analgesia, patients were randomized to receive either 15 ml bupivacaine, 0.1%, or 15 ml ropivacaine, 0.1%, each with 5 microg/ml fentanyl. Analgesia was maintained with patient-controlled analgesia with either local anesthetic, 0.08%, with 2 microg/ml fentanyl. The primary outcome was the incidence of operative delivery. We also examined other obstetric, neonatal, and analgesic outcomes. RESULTS: There was no difference in the incidence of operative delivery between the two groups (148 of 276 bupivacaine recipients vs. 135 of 279 ropivacaine recipients; P = 0.25) or any obstetric or neonatal outcome. The incidence of motor block was significantly increased in the bupivacaine group compared with the ropivacaine group at 6 h (47 of 93 vs. 29 of 93, respectively; P = 0.006) and 10 h (29 of 47 vs. 16 of 41, respectively; P = 0.03) after injection. Satisfaction with mobility was higher with ropivacaine than with bupivacaine (mean +/- SD: 76 +/- 23 vs. 72 +/- 23, respectively; P = 0.013). Satisfaction for analgesia at delivery was higher for bupivacaine than for ropivacaine (mean +/- SD: 71 +/- 25 vs. 66 +/- 26, respectively; P = 0.037). CONCLUSIONS: There was no difference in the incidence of operative delivery or neonatal outcome among nulliparous patients who received low concentrations of bupivacaine or ropivacaine for labor analgesia.