Causes of deaths in the intensives care unit of Sylvanus Olympio Teaching Hospital, Lomé, Togo.

To analyze the causes of deaths in the intensive care unit (ICU) at the CHU Sylvanus Olympio (CHU SO) teaching hospital of Lomé. This retrospective study examined the files of patients who died in the ICU of CHU SO, during the 12-month period from November 2012 to October 2013. Of 732 patients admitted to the ICU, 237 died, for a mortality rate of 32.38%. Men accounted for 163 (68.8%) of the deaths, and women 74 (31.2%), for a M/F ratio of 2.2. The average age of patients who died was 41.7 years; the age group 21-30 years comprised 16% of the deaths, that 31-40 years 19.8%, and 41-50 years 17.7%. Trauma (50.64%) dominated the causes of death, including especially severe traumatic brain injury (34.18%), followed by postoperative intensive care (25.32%), including peritonitis (8%). Medical diseases accounted for 18.14% of ICU admissions. More than half the deaths (55.7%) took place in the 72 hours after ICU entry. Mortality in the ICU at CHU SO of Lomé remains very high. It affects young patients, mainly with traumatic and surgery-related pathologies.

Middle meningeal artery aneurysm: Case report.

BACKGROUND: Aneurysms of meningeal middle artery (MMA) are extremely rare. These aneurysms are of two types: true aneurysm and pseudoaneurysm. The true type is usually seen with pathologic conditions. Pseudoaneurysms, on the other hand, are associated with a skull fracture. Epilepsy caused by MMA aneurysm has never been described to our knowledge. We report a case of true aneurysm isolated from MMA revealed by epilepsy. CASE DESCRIPTION: A 57-year-old patient with a history of high blood pressure developed epilepsy which was treated by valproic acid. Initial scalp electroencephalography (EEG) showed seizure activity arising from the right temporal area. Epilepsy had become drug-resistant. Cerebral angiography revealed an aneurysm of the right middle meningeal artery without any other intraparenchymal anomaly. The interrogation did not reveal any history of family aneurysm. The patient underwent surgery with coagulation of the aneurysm and the MMA. The aneurysm was intradural in contact with the temporal cortex, and the surrounding brain tissues were preserved. The operative follow-up was favorable with amelioration of convulsions with a single antiepileptic. We planned to stop antiepileptic treatment according to electroencephalograms. CONCLUSIONS: Aneurysms of the MMA are rare. Their mode of revelation by seizures is unusual. The factors of rupture are not known. When isolated, their physiopathology is identical to that of the aneurysms of the Willis polygon. Their management uses the same techniques as for other cerebral aneurysms.

Clinical profile of subdural hematomas: dangerousness of subdural subacute hematoma.

Subacute subdural hematomas are a poorly individualized nosological entity, often equated clinically to chronic subdural hematomas. Yet, their neurological deterioration which is usually rapid seems to distinguish them from chronic subdural hematomas. We wanted to show this dangerousness by establishing the clinically evolving profile of the three types of subdural hematomas. This was a prospective and retrospective study of 63 subdural hematoma (18 acute, 13 subacute, and 32 chronic) patients admitted between 2012 and 2014 in the neurosurgery unit of Lomé University Hospital. Hematomas were classified according to the elapsed time after head injury and blood density on CT. The main parameter studied was the evolution of the Glasgow Coma Score (GCS) in the 3 months following the trauma, enabling to establish an evolving profile of each type of hematoma. The average age of patients was 58.1 years for chronic subdural hematomas and 47.6 years for subacute subdural hematomas. Disease duration before admission was 13.1 days for chronic against 36.6 h for subacute hematoma. The clinical profile shows acute worsening within hours during the second week for patients with subacute hematoma, while it is progressive for patients with chronic hematoma. We noted two deaths, all victims of a subacute hematoma (one operated, one patient waiting for surgery). Iso-density hematoma on CT, especially in a young person, must be considered as a predictive factor of rapid neurological aggravation suggesting an urgent care or increased monitoring by paramedics.

[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.

[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.

[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.