Distribution of cesarean delivery by Robson classification and predictors of postspinal anesthesia hypotension in Windhoek referral hospitals: A cross-sectional study.

BACKGROUND: There are concerns that high cesarean section (CS) rates are driven by nonmedical indications and unmitigated maternal hypotension following spinal anesthesia (SA) has materno fetal effects. AIMS: Our objective was to investigate CS rates using Robson classification, identify patient groups for focused intervention as well as assess the incidence and predictors of maternal hypotension following SA for cesarean delivery. SUBJECTS AND METHODS: A cross sectional design was employed over 3 months (February-April, 2019). Data about total deliveries (vaginal and operative) were obtained from the hospital medical records. For parturients who had CS, variables which covered maternal characteristics, conduct of anesthesia, and the index pregnancy according to Robson classification system were entered into a proforma designed for the study. RESULTS: The total deliveries were 3031, of which 556 were CSs, giving a CS rate of 18.3%. Twenty one nonconsenting parturients were excluded, so 535 responded. Robson groups 5, 10, and 1 combined contributed 75% [401/535] to the overall CS. Two or more previous CS, 29.7% [159/535], was the main indication for performing CS, followed by maternal request 12.9% [69/535]. The incidence of maternal hypotension was 62.6% (293/468); the independent predictors were elective CS and having comorbidities. CONCLUSION: We found a low CS rate and Robson groups 5, 10, and 1 were the major contributors - previous CS (≥2) and maternal request were the predominant indications for performing CS. The independent predictors of SA induced hypotension were presence of comorbidities and elective CS.

Emergency Department Deaths in a Nigerian University Hospital: Deaths Too Many.

OBJECTIVES: We reviewed the demographic pattern and distribution of deaths in the emergency department (ED) of the University College Hospital (UCH) in order to identify gaps in the standard of care, thereby providing evidence for intervention and enhanced research in acute care. METHODS: After obtaining institutional ethics approval, we retrospectively studied all deaths in the ED of UCH from January 1 to December 31, 2011. Data were retrieved from the ED's electronic register. RESULTS: During the 12-month period, a total of 10 728 patients attended the emergency centre and 647 deaths occurred, giving a mortality rate of 6.0%. Male deaths constituted 62% of all deaths. The mean age at death was 44.5 ± 19.1 (range 5 months-92) years. The age group with the highest proportional mortality was 60-69 years (11.4%). Out of all deaths, 295 (45.6%) had alterations of consciousness. Medicine was the specialty with the most deaths (56%), followed by surgery (40%) and lastly, obstetrics and gynaecology (4%). Of the 190 patients that died from trauma, 153 (80.5%) had injury severity score ≥ 15. Most deaths (75.4%) occurred within 24 hours of arrival and the 12-hour night shift had 322 (50%) of the mortalities. Autopsies were carried out in 36 (5.6%) of the 647 deaths. Of the 36 autopsies, 24 (66.7%) were deaths due to medical causes. CONCLUSION: Mortalities within 24 hours of presentation at the ED of UCH remain high. This calls for an efficient pre-hospital care, well-organized emergency transport system, new guidelines, establishment of protocols and regular audit.

Single-shot lamina technique of paravertebral block as an adjunct to general anesthesia for modified radical mastectomy.

Thoracic paravertebral block can be employed as an alternative or an adjunct to general anesthesia (GA) for breast cancer surgery. There is no report of this new lamina technique for catheter placement in our environment. In low-resource settings, potent opioids are lacking and the extended postoperative analgesia it provides makes this regional block an invaluable addition to an anesthetist's armamentarium. We describe this single-shot, but titratable technique used as an adjunct to GA for modified radical mastectomy with axillary dissection for breast cancer. The total intraoperative opioid analgesic 50 mg pethidine was received at induction. The patient's vital signs remained stable throughout surgery that lasted 115 min. Pain score charted every 10 min in the postanesthesia care unit using the verbal rating scale was 0. The time to the first request for rescue analgesic was 18 h after surgery for which paracetamol 1 g was adequate.

CLINICAL CHARACTERISTICS AND OUTCOME OF PATIENTS WITH UPPER GASTROINTESTINAL BLEEDING AT THE EMERGENCY DEPARTMENT OF A TERTIARY HOSPITAL IN NIGERIA.

BACKGROUND: Upper gastrointestinal bleeding is a potentially life threatening condition with multiple causes. There is scarcity of health data depicting the clinical characteristics of the condition in African countries. This study was designed to describe the demographic, clinical characteristics and outcome of the patients who presented to our Emergency Department. METHOD: The records of cohort of all patients admitted with upper gastrointestinal tract bleeding from 1 January 2011 to 31 December 2012 were retrospectively reviewed from admission to discharge or death. RESULTS: There were 169 patients with median age of 44.0 years (range 13-89); 25 (15.0%) of them were known peptic ulcer disease patients. Most (69.2%) of the patients were males. The most common presenting symptom was haematemesis (34.9%) followed by melaena (16.6%). There was a history of NSAIDs use in 16.8% and alcohol ingestion in 12%. Upper Gastrointestinal Endoscopy was performed in 6.8% cases. Twenty-three (13.6%) patients died. There was association between mortality and diastolic blood pressure; more deaths (1/7; 14.3%) occurred in those with diastolic blood pressure > 90mmHg compared with ≤90mmHg (5/70; 7.1%) (P = 0.002). There were more deaths among patients who did not receive blood transfusion (4/40; 10.0%) compared with those who had blood transfusion (2/37; 5.4%) (P=0.008). CONCLUSION: The common presentations were haematemesis and melaena, mainly in middle aged men with mortality in one out of seven patients. The high mortality may be due to co-morbidities and poor support services.

Anaesthesia for caesarean deliveries and maternal complications in a Nigerian teaching hospital.

BACKGROUND: The aim of this audit was to evaluate the frequency of caesarean delivery, anaesthetic techniques employed, investigate potential trends and the rate of maternal complications associated with general or regional anaesthesia in our institution. METHODS: We reviewed data collected on all deliveries from patients' medical records, anaesthetic charts and relevant surgical notes from 1 January 2008 to 31 December 2010. RESULTS: A total of 10,911 deliveries were conducted during the study period and there were 3389 caesarean sections, giving a rate of 31.1%; which showed an upward trend from 27.8% in the first year to 34% in the third year. Our data showed a predominant use of regional anaesthesia for caesarean section generally (86.2%) and 83.8% for emergency caesarean deliveries in line with global trends. The overall complication rate was 10.5%. However, 34.5% of parturients who had general anaesthesia in contrast with 6.7% who had regional techniques had anaesthesia-related complications, postoperative intensive care unit admission rather than recovery room care, intra-operative cardiac arrest and haemorrhage exceeding 1200 ml (p = 0.001). Haemodynamic fluctuations were the most common anaesthesia-related complication. Our data revealed that general anaesthesia was a significant risk factor for maternal complications. CONCLUSION: Obstetric general anaesthesia is low in our hospital. Our result showed that general anaesthesia was a significant risk factor for maternal complications during caesarean section.

GEOGRAPIC INFORMATION SYSTEMS IN DETERMINING ROAD TRAFFIC CRASH ANALYSIS IN IBADAN, NIGERIA.

BACKGROUND: Road traffic accidents are frequent in this environment, hence the need to determine the place of geographic information systems in the documentation of road traffic accidents. AIM & OBJECTIVES: To investigate and document the variations in crash frequencies by types and across different road types in Ibadan, Nigeria. MATERIALS & METHODS: Road traffic accident data between January and June 2011 were obtained from the University College Hospital Emergency Department's trauma registry. All the traffic accidents were categorized into motor vehicular, motorbike and pedestrian crashes. Georeferencing of accident locations mentioned by patients was done using a combination of Google Earth and ArcGIS software. Nearest neighbor statistic, Moran's-I, Getis-Ord statistics, Student T-test, and ANOVA were used in investigating the spatial dynamics in crashes. RESULTS: Out of 600 locations recorded, 492 (82.0%) locations were correctly georeferenced. Crashes were clustered in space with motorbike crashes showing greatest clustering. There was significant difference in crashes between dual and non-dual carriage roads (P = 0.0001), but none between the inner city and the periphery (p = 0.115). However, significant variations also exist among the three categories analyzed (p = 0.004) and across the eleven Local Government Areas (P = 0.017). CONCLUSION: This study showed that the use of Geographic Information System can help in understanding variations in road traffic accident occurrence, while at the same time identifying locations and neighborhoods with unusually higher accidents frequency.

Cardiac arrest during anesthesia at a university Hospital in Nigeria.

BACKGROUND: We assessed the incidence and outcomes of cardiac arrest during anesthesia in the operating room at our university hospital. A previous study on intraoperative cardiac arrests covered a period from 1994-1998 and since then; anesthetic personnel, equipment, and workload have increased remarkably. MATERIALS AND METHODS: After obtaining institutional ethics approval, we retrospectively reviewed patients' hospital records such as anesthetic charts and register and ICU admission charts between 1 st July 2005 and 30 th June 2010. The cardiac arrests encountered during anesthesia was identified from anesthetic charts and followed-up in the intensive care unit (ICU) for the first 24 h postoperatively. We consider that cardiac arrest occurred in any patient under anesthesia with asystole or ventricular fibrillation requiring cardiac compression or electrical defibrillation. We define recovery as an alive and non-comatose patient 24-h after the cardiac arrest. RESULTS: During the study period, a total of 12,143 surgeries were done; the median age of all the patients was 30 years (range: 1 day-119 years). A total of 31 cardiac arrests identified (frequency 25.5:10,000; 95% confidence interval (CI) 17.7-35.8) out of which 17 were nonfatal. Mortality related to anesthesia was 11.5:10,000 (95% CI 6.5-18.9). The median age of patients with cardiac arrests was 39 years (range: 2 months-78 years). Overall, 80.7% cardiac arrests occurred in the American Society of Anesthesiologists' (ASA) physical status 3-5. Cardiothoracic and neurosurgical operations accounted for 54.8% of the total cardiac arrests. The known risk factors identified among those who had cardiac arrest were, ASA physical status 3-5 (80.7%), procedures performed out-of-work hours (60%), and manually ventilating patients during general anesthesia (39%). CONCLUSION: Cardiac arrest during anesthesia is higher in poor risk patients (ASA 3-5) who are manually ventilated under general anesthesia and operated during out-of-work hours.

Orthopaedic anaesthesia for upper extremity procedures in a Nigerian hospital.

BACKGROUND: General anaesthesia and regional anaesthesia have been used successfully for upper extremity orthopaedic procedures. Despite the advantages of regional anaesthesia, there is low utilisation in Nigeria. In this study, we assessed the types of anaesthesia employed for upper extremity surgeries in our centre. METHODS: After obtaining approval from the institutional ethics committee, all the patients who had upper extremity surgeries from 1 January 2011 to 31 December 2012 were included in this review. Both prospective and retrospective data were gathered. The choice of anaesthesia was at the discretion of the attending anaesthetist. RESULTS: A total of 226 patients with a male-to-female ratio of 1.6:1 and median age of 35.0 (range 2 - 89) years, had orthopaedic upper extremity procedures during the study period. Sixty-three cases (27.9%) had general anaesthesia, 5 (2.2%) combined regional and general anaesthesia while 158 (69.9%) had regional blocks. The regional blocks comprised 145 (89%) different approaches to the brachial plexus and 18 (11%) local anaesthetic infiltrations. The arm was the site mostly operated upon; while supraclavicular and axillary brachial plexus blocks were performed in equal amounts. In 14 (6.2%) patients, brachial plexus blocks were performed with spinal anaesthesia because of concomitant iliac crest bone grafts. While the duration of surgery did not differ significantly, regional anaesthesia provided a significantly longer duration of anaesthesia than general anaesthesia (251 ± 70.8 min versus 141.3 ± 65.5 min; p = 0.0000001). CONCLUSION: There is a high use of regional anaesthesia for upper extremity orthopaedic surgeries in our centre, which is a positive development in a resource limited setting.

Subclavian perivascular block for open reduction and internal fixation of left midshaft humeral fracture--a case report.

Traumatic injuries affecting bones of the hand and forearm often require peripheral nerve blocks for analgesia and surgical intervention. The successful use of subclavian perivascular block as a sole anaesthetic for orthopaedic surgery has not been reported in our environment. We report the use of this technique for open reduction and internal fixation of a left midshaft humeral fracture. The trunk of the brachial plexus was localized by a Polystim II nerve stimulator. Complete sensorimotor block was achieved within 15 minutes and surgery lasted 55 minutes without complications. This technique obviated the use of general anaesthesia with its risks. The surgeon and the patient were satisfied with the quality of the anaesthesia.