[Anesthesia for upper limb surgery in a developing country: experience of infraclavicular and axillary blocks under neurostimulation]. / Anesthésie pour chirurgie du membre supérieur dans un pays en développement : expérience des blocs infraclaviculaire et axillaire sous neurostimulation.

ABSTRACT: Despite advances in regional anesthesia under ultrasound guidance, neurostimulation remains the primary technique in underequipped locations. MATERIAL AND METHODS: We conducted a prospective descriptive study from January to December 2010 and June 2011 to May 2012 with as our main objective the assessment of the practices of infraclavicular and axillary nerve blocks (ICB and AXB, respectively) at Sylvanus Olympio University Hospital. RESULTS: 105 patients (11.8%) received ICB) and 75 patients (8.5%) axillary blocks (AXB). The average minimum intensity of neurostimulation was 0.4 mA (range: 0.25-0.45 mA. The mean volume of 0.5% bupivacaine used was 30 ± 10 mL. The mean onset time of the block was 15 ± 10 min, and the mean duration of action 6 ± 4 hours. Postoperative pain was significantly worse in patients who received ICB compared to AXB [χ(2) = 19.034, p = 0.00001<0.05]. The cost of either type of locoregional anesthesia under neurostimulation compared with general anesthesia was 44 euros versus 105 euros. CONCLUSION: Peripheral nerve block by ICB and AXB under neurostimulation showed significant difference in terms of postoperative analgesia efficiency. Locoregional anesthesia remains too rarely practiced in underequipped countries despite its benefits and although it is particularly appropriate for these countries.

[Severe differed respiratory depression after intrathecal administration of morphine and clonidine on a 70-year-old patient]. / Dépression respiratoire sévère tardive après administration intrathécale de morphine et de clonidine chez un patient de 70 ans.

We report a case of severe and differed respiratory depression to a 70-year-old patient after spinal anaesthesia for prostatic adenomectomy. Ten milligram of bupivacaine, 30 microg of clonidine and 100 microg of morphine has been administrated intrathecally. The anaesthesia has lasted 4h and, 16h after the induction, the patient had a respiratory depression with bradypnea (5c/min), hypoxia (SpO(2) 80%) and sedation (scale 3 of Wilson). The evolution was favourable after intravenous injection of naloxone and oxygenotherapy. The use of low dose intrathecal morphine can involve a respiratory depression. Intrathecal association of morphine and clonidine must be careful used among old patients and require a monitoring during the first 24h.

[Perioperative morbidity and mortality in a developing country: experience of Lomé teaching hospital]. / Morbidité-mortalité périopératoire dans un pays en développement: expérience du CHU de Lomé (Togo).

OBJECTIVE: New evaluation of early perioperative morbidity and mortality four years after the first study in 2002, at Lomé teaching hospital (Togo). PATIENTS AND METHODS: It was a prospective and descriptive survey during the first semester of 2006. After approval of hospital ethic committee, medical and demographic data, complications and early perioperative deaths have been analyzed. RESULTS: One thousand nine hundred and two anaesthesia was delivered: 58% were women, the average age was 26 years, 94% of patient ASA<3, general anaesthesia (GA) 53% versus regional anaesthesia (LRA): 47%. Spinal anaesthesia (SA) represented 42% of anaesthetic procedures, and emergencies, 56%. 5.49% of complications including 16.16% of deaths were recorded. Death occurred in 69% after GA, and in 60% in the operating room. Seventy percent of patients had cardiovascular complications (five deaths), 30% respiratory failure (six deaths), 11% kidney failures (two deaths). Three deaths were linked to surgery (inadequate management of perioperative haemorrhage). Early perioperative mortality rate was 0.89%. Four cases occurred in the operating room and 12 in intensive care. Deaths were observed often in gynecology and obstetrics (9/16), especially in emergency situations (12/16) and in 75% of cases, patients were ASA>2. Deaths occurred in 13 cases after GA and in three cases after SA. CONCLUSION: This mortality rate was smaller than in 2002. This may be explained by a better prenanaesthetic risk evaluation performed by anaesthetists, the creation of postoperative recovery room, the promotion of regional anaesthesia and the availability of succinylcholine in obstetrics. Significant improvement is still necessary and only be obtained by a national health policy.

[Use of ilio-inguinal iliohypogastric nerve block for herniorraphy: a prospective study in a 35-case series at the Lome University Hospital Center in Togo]. / Pratique du bloc ilio-inguinal ilio-hypogastrique pour cure herniaire: étude prospective à propos de 35 cas colligés au CHU de Lomé, Togo.

The purpose of this prospective-descriptive study was to evaluate the quality of anaesthesia and analgesic effect achieved by ilio-inguinal iliohypogastric nerve block (IINB) in patients undergoing herniorraphy. Study was carried out over a 6-month period in the Anaesthesia Intensive Care Department of the Lomé University Hospital Centre in Togo. All patients indicated for unilateral herniorraphy were enrolled. A total of 35 patients underwent herniorraphy with IINB. Mean patient age was 32 years. Farmers accounted for 57% of the population. Men accounted for 86.7%. The anaesthesia classification was ASA I or II in 88.6% of cases. Complete sensory block was obtained within 15 minutes after induction in 71.43% of cases. Additional sedation using ketamine and/or fentanyl was used in 51.43% of cases. Conversion from IINB to general anaesthesia was necessary in three cases including 2 due to extension of the surgical incision and one for the surgeon's convenience. The mean duration of the procedure was 70 minutes. Intraoperative complications included nausea in one case, dizziness in 2 cases, and bitterness in mouth in 3 cases. Postoperatively, extension to the femoral nerve was observed in 2 cases. Five patients presented a visual analogue pain scale (VAS) > or = 4 within 18 hours after the procedure. This study shows that IINB is a useful alternative to general anaesthesia for herniorraphy. Specific training is necessary to allow more widespread use.

Pratique du bloc ilio-inguinal ilio-hypogastrique pour cure herniaire : etude prospective a propos de 35 cas colliges au CHU de Lome; Togo

Evaluer la qualite anesthesique et le benefice analgesique du bloc ilio-inguinal ilio-hypogastrique (BII) dans les cures herniaires. Le service d'anesthesie reanimation du CHU de Lome a servi pour cadre d'etude. Il s'agit d'une etude prospective et descriptive sur une periode de 6 mois. Tous les patients dans le cadre d'un programme pour cure herniaire unilaterale ont ete inclus dans l'etude.Au total; 35 patients ont subi la cure herniaire sous BII. L'age moyen des patients etait de 32 ans. Les cultivateurs representaient 57. Le sexe masculin representait 85;70. Dans 88;6des cas; les patients etaient de classe ASA I et II. Dans 71;43des cas; le bloc sensitif etait complet 15 minutes apres l'induction. Dans 51;43des cas; les patients avaient beneficie d'une sedation complementaire avec de la ketamine et / ou du fentanyl. Trois cas de BII ont ete convertis en anesthesie generale : 2 en raison de l'extension de l'incision chirurgicale; et 1 en raison de l'inconfort pour le chirurgien. La duree moyenne de l'intervention etait de 70 minutes. Les nausees (1 cas); les vertiges (2 cas); la sensation de bouche amere (3 cas) ont ete les complications peroperatoires observees. En postoperatoire; 2 cas d'extension au nerf femoral ont ete observes. 5 patients ont eu une EVA = 4 dans les 18 heures postoperatoires. Dans 68;57des cas; les patients sortaient au 3e jour postoperatoire. Le BII est une alternative interessante a l'anesthesie generale dans les cures herniaires. Sa vulgarisation necessite neanmoins un apprentissage a sa bonne pratique

[Knowledge and acceptance of obstetric peridural analgesia: survey of pregnant women in Togo]. / Niveau de connaissance et acceptabilité e l'analgésie péridurale: enquête auprès des femmes enceintes au Togo.

The purpose of this study was to evaluate knowledge and acceptance of obstetric peridural analgesia among pregnant women in Togo. A prospective, descriptive survey was carried out over a period of one month. A standardized survey form was used to collect data. A total of 303 pregnant women with a mean age of 27 +/- 6 years were interviewed. A proportion of primiparous and multiparous was the same, i.e., 50%. Among multiparous women, 83.5% described labor pain during previous deliveries as severe. Twelve percent of the pregnant women interviewed claimed knowledge of techniques to control labor pain. Three pregnant women reported a detailed understanding of peridural analgesia obtained from the Internet. A total of 253 women (83.5%) replied affirmatively when asked if they would opt for peridural analgesia if it was offered free of charge for delivery at the end of the current pregnancy. Acceptance was motivated by better delivery conditions for the newborn (112 women) and comfort achieved by pain relief (130 women). Refusal was motivated by a religious belief that painful delivery was in the natural order (31 women). Among the six Moslem women that refused painless delivery, two from the Djerma ethnic group stated that pain was the best expression of their femininity. The acceptance rate fell from 83.5% to 70% if peridural analgesia was offered at extra charge. Most pregnant women in Togo expressed interest in trying peridural analgesia. It is compulsory in medical indications.

[Delayed autologous transfusion: about 70 surgical patients at the Saint-Jean-de-Dieu Hospital in Afagnan, Togo]. / Transfusion autologue différée: apropos de 70 cas a l'hôpital Saint-Jean-de-Dieu d'Afagnan, Togo.

This prospective study was conducted from 2000, September the 1st to October the 31st, at the Saint-Jean-de-Dieu Hospital in Afagnan (Togo). All the 75 patients who received indication of autologous blood transfusion (ABT) accepted the protocol; 70 out of them, among whom 63% were female, benefited an ABT The age of the patients varies between 13 and 80 years old (average 33.2). Initial rate of haemoglobin was on average of 11.7 g/dl; 14% of these patients had a haemoglobin diseases. The most frequent interventions were hysterectomies (21%), bone surgery (16%), prostatectomies (11). Only one blood unit was taken from 63 patients and two units from the 7 others inducing giddiness (5) and headaches (1). During intra and postoperative periods, 41 patients were given 45 units of blood (use rate: 58%). The percentage of patients who received transfusion was 56% in gynaecological surgery 79% in orthopaedics and 88% in urology. Only one patient received an additional homologous unit of blood. The rate of haemoglobin was on average 10.2 g/dl the day after surgery. No incident in connection with the ABT was recorded. The ABT is a feasible, effective and secure method in the context of a small African hospital. It may be a solution to the problems of shortage of blood products and transfusion safety. Training and motivation are necessary for its successful implementation.

[Practice of the thromboembolic disease prophylaxis: a survey among surgeons and anaesthetists in Togo]. / Pratique de la prophylaxie de la maladie thromboembolique veineuse: enquête auprès des chirurgiens et anesthésistes au Togo.

OBJECTIVE: The aim of this study was to analyse the current practice of postoperative venous thromboembolism (VTE) prophylaxis among anaesthetists, nurse anaesthetist and general surgeons in Togo. METHOD: A total of 160 questionnaires were distributed to anaesthetists and surgeons with varying subspeciality interests. RESULTS: One hundred and three (64%) (3 anaesthetists, 51 nurse anaesthetists and 49 surgeons) returned the questionnaire. Of these, 16% thought that VTE was as common in Togo as in the western countries. Selective VTE prophylaxis was used by 78% of the prescriptors. In order of frequency, indications for selective VTE prophylaxis were obesity, increased risk of VTE related to surgery and past medical history of VTE. Orthopaedic surgery, caesarean section and vascular surgery were most frequently considered as high-risk surgery for VTE event. When prophylaxis was indicated, low molecular weight heparin was prescribed by 87% of prescriptors. In most cases, VTE prophylaxis duration was less than a week. In 92% of institutions, there was no written protocol for VTE prophylaxis. VTE-related morbidity was reported by 34% of the prescriptors over the past year, and 30% of these cases were fatal; 60% of the prescriptors observed these complications one week after the surgery. CONCLUSION: The practice of VTE prophylaxis in Togo is not sufficient. It is necessary to promote the training of practitioners, particularly of physicians.

Deaths associated with anaesthesia in Togo, West Africa.

This study attempts to determine the anaesthetic death rate, the causes of deaths and the avoidable mortality rate (AMR) in consecutive cases. The number of anaesthetics given was 1464: 30 cases died within 24 h. The incidence of 24-h perioperative deaths per 100 anaesthetics was 2.57. In all, 50% of deaths were observed in obstetric surgery; 47% of deaths were associated with cardiovascular management, 30% with respiratory management; 93% of deaths were identified as avoidable. The AMR was 1.5% (anaesthetic AMR: 0.75%, administrative AMR: 0.68%, surgical AMR: 0.07%). Insufficient or no blood available is the only factor for administrative AMR.