STROKE: CRITICAL APPRAISSAL OF INTENSIVE CARE MANAGEMENT.

BACKGROUND: Stroke is a common medical condition in the medical units. Stroke patients are usually managed on the medical wards while some that needs organ support are admitted into the intensive care unit. However there is conflicting data on the benefits or otherwise of admitting stroke patients into the intensive care unit. This necessitated this study to know how much benefit is derived from admitting stroke patients into the intensive care unit. AIM AND OBJECTIVE: The study aims at the benefits of admitting stroke patients into the intensive care unit. The objective included studying the prognostic factors that determines the outcome of stroke patients admitted into the intensive care unit. METHODOLOGY: The case files of all patients admitted and managed in the intensive care unit of LAUTECH teaching hospital between 2002 and 2014 were retrieved and were analysed. The factors used in analyzing included the type of stroke, the age of the patients, the Glasgow Coma scale at admission, the need for intubation and mechanical ventilation as well as the percentage mortality in each subsets. RESULTS: A total of 48 patients were admitted over the study period of which 19 were males and 29 were females. The percentage mortality in females was 78.95 while mortality in males was 62.5%. The higher the age the worse the prognosis, the higher the GCS the better the prognosis. Patients that were intubated and ventilated had percentage mortality of 68.8% and better than non ventilated patients. The hemorrhagic strokes also carries worse prognosis. CONCLUSION: The admission of stroke patients to the intensive care unit should be individualized considering the above mentioned prognostic factors. However patients that are likely to benefit from intensive care unit should be admitted early for them to derive the maximum benefits.

Trauma admissions into the intensive care unit and outcome of care in a tertiary health facility.

BACKGROUND: Trauma remains a leading cause of morbidity and mortality in resource challenged economies I. In Nigeria, the number of deaths due to trauma-induced injuries is on the rise. Major trauma victims are usually from road traffic accidents and are managed at the accident and emergency unit while the severe ones are admitted into the intensive care unit. METHODOLOGY: All trauma admissions to the intensive care unit (ICU) of LAUTECHTeaching Hospital Osogbo over a 5 year period (2008-2012) after ethical approval from the ethical unit of the hospital were reviewed. RESULTS: During the study period, 112 trauma patients were admitted to the ICU, representing 68% of total ICU admissions. The male:female ratio of ICU trauma cases was 3:1. Out of the trauma admissions 83 (74.1%) of the cases came as emergency from the accident and emergency unit while 2.4% and 1.6% respectively came from operating theatre-- and the general ward respectively. 83 (74.1%) of trauma cases admitted were road traffic accidents, while 20 (17.9%) were burns not related to RTA and the remaining 8(9%) were due to falls, fight/ssault. Most of the road traffic accidents related trauma patients admitted to the intensive care unit had head injuries (66.3%) while 7% and 12% had multiple fractures and chest injuries respectively. The mean patient age 35 years and the mean duration of ICU stay was 6.3 ± 8.4 days. Survivors had a longer ICU stay CONCLUSION: Trauma is a major cause of hospitalization and intensive care utilization. It also consumes a significant amount of the health care budget.In most instances it is preventtable.Trauma prevention, the most effective management strategy should include increased public education, improved security, better implementation of legislative measures to ensure safety for all road users, control of firearms, and minimizing domestic and intentional violence. Appropriate, aggressive intensive care in combination with efficient communications,rapid medical evacuation, and an organized emergency multidisciplinary trauma care team will further improve outcome in trauma patients.

Spinal anaesthesia for caesarean section in pregnant women with fetal distress: time for reappraisal.

Residents' competency-based training and multidisciplinary cooperation are needed for rapid sequence spinal anaesthesia for fetal distress. Multiple standard but 'crash' spinal anaesthesia for non-obstetric procedures is imperative for acquisition of experienced hands. The purpose of this review is to share our modest experiences in the use of rapid spinal anaesthesia for emergency Caesarean delivery in pregnant women complicated with fetal distress. Fetal distress diagnosis is made promtly, intravenous line put in place in labour ward. Pre-loading or not, one-touch, non-touch spinal technique prevents unnecessary delay and further fetal hypoxic injury. Spinal pack is on stand by in the operating room at all time. Preloading is possible during the waiting period for other care providers otherwise coloading is used. A single wipe of the back with chlorhexidine lotion is frequently used for scrubbing. Lidocaine infiltration or spay is essential and does not waste time but opioid as adjuvant to bupivacaine wastes a lot of time to constitute and measure. So, opioid should be avoided. Average of 2.5 ml of 0.5% hyperbaric bupivacaine is frequently used in our centres. Surgery starts almost immediately after cleaning and drapping of the patient by the obstetrician. Ephedrine is made handy and constituted in case there is hypotension which fluid alone cannot treat.

Intrathecal tramadol versus intrathecal fentanyl for visceral pain control during bupivacaine subarachnoid block for open appendicectomy.

CONTEXT: Profound side-effects following intrathecal use of local anesthetics as the sole drugs of choice make spinal anesthesia for open appendicectomy uncommon. AIM: The aim of this study was to evaluate the effectiveness of intra-operative analgesia produced by intrathecal tramadol and fentanyl during bupivacaine spinal anesthesia for open appendicectomy. SETTINGS AND DESIGN: A prospective randomized study was performed. MATERIALS AND METHODS: A total of 186 American Society of Anesthesiologists 1 or 11 patients scheduled for emergency open appendicectomy were analyzed. Group FB ( n = 62) received intrathecal fentanyl 25 µg plus 3 ml of 0.5% hyperbaric bupivacaine, Group SB ( n = 62) received 0.5 ml normal saline plus 3 ml of 0.5% hyperbaric bupivacaine and Group TB ( n = 62) received intrathecal tramadol 25 mg plus 3 ml of 0.5% hyperbaric bupivacaine. Visual analog scale scores and frequency of subjective symptoms among patients in the three groups formed the primary outcome measure of this study. RESULTS: Effective intraoperative sensory block was achieved in 100% of patients in group FB and TB while 29 (46.8%) patients in group SB had ineffective sensory block ( P = 0.0001). The pain free period was significantly longer in patients in Group FB than Group SB and TB. Mean time for Group FB with regard to first analgesic request was 304.73 ± 67.91 min, Group SB was 146.59 ± 36.62 and Group TB was 238.39 ± 61.28 min. Incidence of complications were comparable among the three groups. CONCLUSION: This study showed that intrathecal tramadol (25 mg) can safely replace intrathecal fentanyl (25 µg) in the management of visceral pain and discomfort during subarachnoid block for appendicectomy.

Single dose of dexamethasone for prevention of nausea and vomiting after major gynaecological surgery.

BACKGROUND: Post-operative nausea and vomiting (PONV) is a common complications following general anaesthesia and is a leading cause of morbidity following surgery. The mainstay of management them is by the use of antiemetic. METHOD: It was a randomized double blind placebo controlled study. The sample size was calculated as 90 from previous study with 10% attrition to make the 100. They were randomly divided into two groups; group B received dexamethasone prophylactically at induction while group A received placebo also at induction. All patients had balanced general anaesthesia and were taken to the recovery room postoperatively where incidences of postoperative nausea and vomiting were recorded. Patients with incidences of nausea and vomiting were treated with 10 mg metoclopramide intravenously while postoperative complications that may be associated with dexametnasone prophylaxis were also noted. RESULTS: The groups were comparable with respect to demographic characteristics. More patients in group A (placebo group)) had incidence of nausea than group B (dexamethasone group) with p value of 0.01 and also more patients in group A had vomiting than group B with p value of 0.02; which was significant. The duration of stay in the recovery room for both groups A and B were however comparable with no statistical difference. CONCLUSION: Dexamethasone when given prophylactically at induction reduces incidence of postoperative nausea and vomiting after gynaecological surgeries.

CARDIOPULMONARY RESUSCITATION - KNOWLEDGE, ATTITUDE & PRACTICES IN OSUN STATE, NIGERIA.

BACKGROUND: Cardiopulmonary arrest is not an uncommon event in the medical practice with the causes ranging from reversible to irreversible causes. Therefore the skill in the performance of effective cardiopulmonary resuscitation is an essential part of successful medical practice. In some developed countries the CPR Training programmes were mandatory for all health care givers and even for non medical workers. However in the setting of ours, the situation is not so as most heath workers go for CPR Training programmes by wish except in some few centres were it is mandatory. AIM & OBJECTIVES: To assess the knowledge, attitudes and practices of medical practitioners in relation to cardiopulmonary resuscitation and defibrillation. SETTING: The study was carried out among medical practitioners in Osun State, Southwest Nigeria. METHODS: The study was conducted through a survey of medical practitioners in Osun state during an annual general meeting using a self administered questionnaire. RESULTS: The response rate was 65% with 65 out of 100 physicians returning the completed questionnaire. Only 40% of respondents had attended a basic and an advanced life support training programme while 30% knew how to operate an automated external defribellator (AED), seventy percent knew the meaning of AED. Most of the respondents that had attended a basic and an advanced life support programme were residents (80%) while 16% were consultants and the remaining 4% were general practitioners. More males (67%) among the respondents that knew how to operate an AED and majority (56%) were in the age range of 30-40years. Eighty two percent of the respondents would prefer to do a chest compression only resuscitation of which 44% were. CONCLUSION: Most of the medical practitioners in Osun State were not knowledgeable about cardiopulmonary resuscitation and defibrillation . The few with the knowledge were from the tertiary institutions. There is therefore the need for the creation of more awareness among medical practitioners, especially among those outside tertiary health facilities.

Cardiorespiratory changes during upper gastrointestinal endoscopy.

OBJECTIVES: To determine the changes in oxygen saturation, blood pressure and heart rate during various endoscopic procedures and to find out the risk factors for these changes. METHODS: Forty patients without cardiorespiratory disorders were recruited. Oxygen saturation, blood pressure and pulse rate were monitored during endoscopy using pulse oximeter and automated blood pressure monitor. These were recorded from baseline until 5 minutes after the procedure. The important variables, which were evaluated in relation to these changes, included age, gender, duration of the procedure and drug/dosages. RESULTS: Baseline mean oxygen saturation was 96.8 +/- 1.55%. It decreased significantly to 94.53 +/- 3.30%(p= 0.002) during insertion of probe. Mild to moderate hypoxia was found in 19 (47.5%) patients. Severe hypoxia was found in 5 (12.5%) patients. The variables that reached statistical significance for desaturation were age greater than 50 years and duration longer than 27 minutes. Changes in pulse rate were significant post-sedation, during probe insertion, during scoping, at removal of probe and immediately post-procedure (p < 0.02). The mean change in systolic blood pressure was not significant throughout the procedure when compared to baseline, however 14 (35%) patients developed transient hypertension. CONCLUSIONS: Mild to moderate hypoxia is common during endoscopic procedures and of no serious consequence. However severe hypoxia is less common. We recommend a non-invasive monitoring in patients with age greater than 50 years and procedure longer than 27 minutes.