Role of tolterodine in the management of postoperative catheter-related bladder discomfort: Findings in a Nigerian teaching hospital.

BACKGROUND: Patient discomfort secondary to an indwelling urethral catheter in the post operative period can be very distressing. These symptoms resemble the overactive bladder (OAB) syndrome. Muscarinic receptor blockers have been successful in the management of OAB. However, information on the use of these drugs in the management of the postoperative catheter-related bladder discomfort (CRBD) in sub-Saharan Africa is still relatively sparse. OBJECTIVE: To assess the efficacy of preoperative oral tolterodine in the management of CRBD in surgical patients in the immediate postoperative period. METHODS: This was a double-blind placebo-controlled study consisting of 56 patients in each arm who underwent general anesthesia. Each patient was given oral tolterodine or placebo 1 hour before the induction of anesthesia. The patient was later assessed at the recovery room at intervals after recovery from anesthesia. The presence of CRBD was noted and graded. RESULTS: The overall incidence of CRBD in both the tolterodine group and the control were 85.7% and 91.1%, respectively. Overall, tolterodine prophylaxis (TP) was associated with an absolute risk reduction (ARR) of 5.4%, relative risk reduction (RRR) of 5.8%, and a number needed to treat (NNT) of 19. The incidence of moderate-to-severe CRBD in the tolterodine and control groups were 10.7% and 78%, respectively, with an ARR of 74.5% with TP. CONCLUSION: TP does not significantly reduce the incidence of CRBD in the immediate postoperative period but appears to be efficient in the reduction of the severity of postoperative CRBD.

EFFICACY OF INTRAVENOUS ESMOLOL VERSUS LIDOCAINE FOR ATTENUATION OF THE PRESSOR RESPONSE IN NIGERIANS.

BACKGROUND: Laryngoscopy and tracheal intubation are an integral component of airway management and general anaesthesia. Direct stimulation of the pharynx and larynx by the laryngoscope blade and the insertion of an endotracheal tube elicit a sympathetic nervous system response with a reflex consisting of a transient increase in blood pressure, heart rate, and the occurrence of cardiac dysrhythmias referred to as the 'pressor' response. This may be of major clinical significance in patients with pre-existing systemic hypertension, hypertensive heart disease, coronary artery disease, eclampsia, aneurysmal vascular disease and head injury in whom such a change may culminate in perioperative myocardial ischaemia or infarction, cardiac failure, dysrhythmias, cerebrovascular accidents or secondary brain injury. AIM: To evaluate and compare the effects of intravenous lidocaine and esmolol on the pressor response as well as determine the occurrence of complications with the use of either agent in a Nigerian population. METHODOLOGY: Ninety adult ASA I and II patients undergoing elective non-cardiac surgery under general anaesthesia were randomly allocated to one of 3 groups; group E: 2mg.kg -1 esmolol, group L: 1.5mg.kg -1 lidocaine and group C: 20mls normal saline 3 minutes before laryngoscopy. Induction of anaesthesia was standardized for all patients. Heart Rate, Systolic Blood Pressure, Diastolic Blood Pressure, Mean Arterial Pressure and Rate Pressure Product were recorded at baseline, immediate post, 1, 3, 5 and 10 minutes after intubation. RESULTS: Mean heart rate increased by 19.1%, 25.7%, and 41.4%, SBP increased 13.3%, 21.6% and 26.9%, MAP by 12.2%, 19.1% and 30.2%, RPP by 28.1%, 45.8% and 78.7% in groups E, L and C respectively post intubation. There were no complications attributable to the use of either agent. CONCLUSION: Intravenous esmolol 2mg.kg-1 given prior to laryngoscopy is more effective than intravenous lidocaine 1.5mg.kg-1 in significantly attenuating the haemodynamic changes associated with pressure response to laryngoscopy and endotracheal intubation in normotensive patients from a Nigerian population.

HEPATITIS B VACCINATION STATUS AND NEEDLE STICK INJURY EXPOSURE AMONG OPERATING ROOM STAFF IN LAGOS, NIGERIA.

BACKGROUND: Hepatitis B virus (HBV) is an infective blood-borne pathogen that is a constant threat to operating room staff. The prevalence of Hepatitis B has been reported to range from 4.3% - 68% in Nigeria. The inadequate funding of health care in low income countries impacts negatively on the implementation of effective vaccination programs to protect health care workers including surgical theatre personnel. AIM: To determine the Hepatitis B vaccination status and the needle stick injury exposure among operating room staff in Lagos, Nigeria. METHODOLOGY: The multicentre prospective survey was conducted in three public tertiary hospitals and two private hospitals in Lagos utilising a self-administered structured questionnaire that was distributed to operating room staff. RESULTS: We found that 96.7% (265) of respondents agreed that their job had exposed them to the risk of HBV infection. Over half (55.8%) correctly identified three doses of HBV as adequate to confer immunity against infection. It was observed that 58% (159) of the respondents were fully vaccinated, most of whom were doctors (69.8%, p=0.001) while a total of 173 (63.1%) reported exposure to needle-stick injury with blood in the preceding year. CONCLUSION: The operating room personnel were knowledgeable about the risk of HBV as an occupational hazard but a large number were not fully vaccinated against HBV infection. There was therefore the need to improve the vaccination coverage and educate identified high-risk operating room staff on appropriate post exposure prophylaxis practices.

ANAESTHETISTS' ATTITUDES AND PRACTICE OF INFORMED CONSENT IN NIGERIA.

BACKGROUND: Informed consent is an integral part of a surgical and anaesthetic procedure, failure to obtain it may result in grave medico-legal implications. AIM: To determine the attitudes of Nigerian anaesthetists to informed consent. METHODOLOGY: The study population included physician anaesthetists who attended a continuous medical education programme in November 2015. The target was to cover over 50% of anaesthetists by convenience sampling. The responses to the questions were recorded and descriptive statistics were employed to calculate the various qualitative variables under study. RESULTS: Fifty-six respondents were analysed, the majority were in the age group 31-40 years (37.5%), consultants were 51.79%, and males constituted 75%. The respondents agreed that the main purposes of informed consent included a need to improve the doctor/patient relationship in 36(64.29%), inform the patient about the desired benefits of the procedure in 32(57.14%), provide the doctor with greater protection against medical litigation in 32(57.14%), and to respect the patient's right of autonomy in 30(53.57%). The general consensus among the respondents was that the anaesthetist should explain to the patient what the procedure entails 40(71.43%), what the procedure aims to achieve and additional procedures that are likely to be necessary to the patient 41(73.21%). It was also agreed that there should be disclosure of all major risks/complications with incidence >1/20 in 29(51.79%) respondents, incidence >1/100 in 20(35.71%), incidence >1/1000, and incidence >1/10000 were 17(30.36%). The respondents who agreed that it is necessary to take consent before performing surgery or anaesthesia on patients and explained the procedure to patients were 48(85.71%). CONCLUSION: We determined that informed consent was an integral part of a surgical procedure. which helped to improve doctor/patient relationship, respected the patient's right of autonomy and provided the surgeon and anaesthetists with greater protection against medical litigation. It is paramount to disclose all major risk and complications. However, few anaesthetists 19(33.93%) obtain informed consent from their patients before epidural labour analgesia.

Routine haemoglobin electrophoresis screening in day case herniotomy in Nigerian children: Is it evidence-based?

BACKGROUND: To determine the prevalence of haemoglobinopathies in children who require day case herniotomy in our centre and ascertain if routine screening is necessary in all patients who require herniotomy. MATERIALS AND METHODS: A 12-month retrospective analysis of patients requiring herniotomy in our centre. Data including age, sex, diagnosis, haemoglobin electrophoresis status, surgical outcome and hospital stay were analysed. RESULTS: Ninety-five patients had complete records. There were 84 boys and 11 girls. M:F ratio: 7.6:1. The mean age was 3.2 ± 0.6 years. Fifty-five point eight per cent of the patients had right inguinal hernias while 35.8% had left inguinal hernias. Eight patients (8.4%) had bilateral inguinal hernias. Twenty-six patients (27.4%) had haemoglobinopathies while 69 patients (72.6%) had homozygous Haemoglobin A. The Sickle Cell trait (HbAS) was found in 22 patients (23.2%) while the HbAC was found in three patients (3.2%). One patient (1.1%) had Sickle Cell disease (Haemoglobin SS). He had had blood transfusion and previous history of jaundice. All patients survived and all patients were discharged on the day of surgery (mean hospital stay: 4hrs (range: 2.5 hrs-12 hrs)) except the patient with Sickle Cell disease who was admitted a day before surgery and discharged a day after the operation. CONCLUSION: One in four children coming for day case herniotomy in our centre had the Sickle Cell trait while only 1% had the Sickle Cell disease. These findings are in keeping with the prevalence in the Nigerian population. Routine screening may not be necessary for all patients coming for herniotomy in our centre. Clear indication(s) should be outlined for screening.

Accreditation of Training Programmes by the West African College of Surgeons.

The establishment of surgical training programmes of the West African College of Surgeons started in six teaching hospitals the early 1970s in Nigeria and Ghana; it was championed by College Fellows, surgeons who had returned to the sub-region after having trained in Europe and America. Surgical programmes accreditation, captured in the College's constitution and mission statement, uses objective guidelines in the identification and encouragement of suitable institutions for surgical training through periodic peer-review audits of installed manpower, facilities, clinical services and academic programmes. This pan-regional model adopted by the five Anglophone countries of West Africa has standardized and nurtured surgical training in the disciplines of surgery, obstetrics and gynaecology, ophthalmology, otorhinolaryngology, dental surgery, radiology and anaesthesia. It has also proven to be a useful template in the current drive for the ongoing harmonization of surgical training programmes with Francophone West African as a prelude to an integrated sub-regional accreditation body. This paper details the evolution of surgical programmes accreditation in West Africa, its progress, challenges, opportunities and future trends.

Post operative nausea and vomiting in adult Nigerians.

BACKGROUND: This is a prospective study to determine the pattern of postoperative nausea and vomiting in a Nigerian adult population. METHOD: 348 consecutive patients were assessed prospectively for the incidence and risk factors of postoperative nausea and vomiting over a 6-month period. The exclusion criteria included inability to give consent, nausea or vomiting during the period 24 hours before surgery, raised intracranial pressure and patients who received an anti-emetic in the period 48 hours before surgery. RESULT: Patient's age ranged between 18 and 90 years. There were 213 females (61.2%) and 135 males (38.8%). The incidence of postoperative nausea was 32.2% and vomiting was 20.1%. The major risk factors identified were female gender, body mass index, general anaesthesia-inhalational technique, Ketamine induction, pancuronium, pain and movement of patients from the recovery room to surgical wards (p < 0.05). CONCLUSION: Nausea and vomiting was identified as a common postoperative complication with multifactoral aetiology. It is recommended that high risk patients should receive prophylactic antiemetics. Regional techniques should also be considered in such patients.

An audit of surgical admissions to the intensive care unit of the Lagos University Teaching Hospital (1997 - 2002).

OBJECTIVE: To review the pattern of adult surgical admissions into the Intensive Care Unit (ICU) of Lagos University Teaching Hospital (LUTH). METHODS: A six-year retrospective review of data of patients above 12 years old admitted to the ICU of LUTH was performed. RESULTS: 290 patients representing 82.6% of the total ICU admissions (351) during the study period were evaluated. 251 (86.6% ) were surgical and 39 (13.4% ) non-surgical. The overall mortality was 40.3% (Surgical - 37.8% , Medical 62.9% ). Emergency admissions accounted for 221 (76.2% ) while electives were 69(33.8% ). The Mean hospital stay (MHS) was 4.8 +/- 0.4 days (Surgical: Medical - 3.9 +/- 0.2:10.1 +/- 2.5). The highest admissions were as a result of trauma (32.1% ) and obstetric complications (9.7% ). Cardiorespiratory monitoring (57.2% ) and respiratory distress (34.1% ) were the main indications for admission. Emergency admission and artificial ventilation contributed significantly to the observed mortality (p < 0.0001) CONCLUSION: At LUTH, trauma and obstetric complications constituted the major causes for ICU adult surgical admissions.

Comparison of suxamethonium and priming with atracurium for rapid sequence orotracheal intubation in a Nigerian adult population.

OBJECTIVE: To compare suxamethonium with atracurium using the priming principle, for rapid sequence orotracheal intubation assessing onset time, time to successful laryngoscopy and intubation and quality of intubating conditions. PATIENTS AND METHODS: A prospective double-blind, randomised study was performed in 90 ASA physical status I and II patients aged between 18 and 64 years undergoing elective surgery requiring endotracheal intubation between October 2002 and June 2003 in a university teaching hospital . All patients were premedicated with 5-10mg oral diazepam and randomly assigned to one of two groups to receive either suxamethonium as a bolus dose (group A) or atracurium (priming with 0.05 mg/kg followed by 0.55 mg/kg after induction of anaesthesia) (group B). In both groups, the trachea was intubated when there was maximal muscle relaxation, determined clinically by jaw muscle relaxation. Muscle paralysis using a PNS, quality of intubating conditions, and occurrence of muscle weakness due to the priming dose of atracurium, time to laryngoscopy and onset time were all noted. RESULTS: Onset time was 87.1 +/- 25.60s and 135.8 +/- 46.23s in groups A and B respectively (P < 0.05). Group A had a laryngoscopy time of 73.6 +/- 25.22s compared to 107.7 +/- 41.32s in group B (P < 0.05). Intubating conditions were significantly better in group A compared to group B (P < 0.05). The frequency of muscle weakness from the priming dose of atracurium was 6.6%. CONCLUSION: Atracurium, using the priming principle, is an option in our environment for modified rapid sequence induction when suxamethonium is contraindicated.