Acute Oxygen Therapy on Hospital Wards in Low Middle-Income Country: Experience from a Referral Centre in Ilorin, Nigeria.

BACKGROUND: Oxygen is like any other medication that can cause severe consequences if administered inappropriately. OBJECTIVE: To audit the pattern of acute oxygen therapy on regular hospital wards of a referral centre in Ilorin, Nigeria. METHODS: We reviewed 150 patients that received or had a prescription for acute oxygen therapy in three months and extracted relevant information using a proforma. RESULTS: About one-third of the patients (30%) were >65 years of age and the male to female ratio was 1:1. The commonest indication and medical condition for acute oxygen administration were hypoxemia (70.7%) and pneumonia (26.0%), respectively. Pneumonia accounted for most (41.2 %) of the oxygen therapy in childhood. The majority of patients (88.0%) had written order for oxygen prescription, 40.7% had a prescription to target oxygen saturation and only 31.3% achieved their target saturation. Oxygen prescription was adequate (documentation of delivery device, flow rate of oxygen, and target oxygen saturations) in 40.7% of patients. The assessment, monitoring and titration of oxygen therapy were adequate in 92.7%, 65.3% and 28 % of patients respectively. Overall mortality was 27.3% in patients receiving acute oxygen supplementation. Eleven patients had unstable COPD, and 63.6 %, 54.5 % and 45.6 % of them had adequate oxygen prescription, monitoring and titration respectively. The challenges to oxygen use were faulty delivery devices, emptied oxygen cylinders, inability to routinely do arterial blood gas analysis and lack of hospital oxygen protocol. CONCLUSION: The current practice of acute oxygen therapy is not satisfactory and interventions are advocated to improve the healthcare providers' administration of oxygen.

EFFICACY AND SAFETY OF ORAL KETAMINE PREMEDICATION IN CHILDREN UNDERGOING DAY CASE SURGERY.

BACKGROUND: Oral premedication for paediatric age group is an uncommon practice amongst anaesthetists in Nigeria. Both parents and the child suffer some form of emotional or psychological distress. AIM: To determine the efficacy and safety of oral formulated ketamine for premedication in children scheduled for ambulatory surgeries. METHODS: Seventy three children aged 1 - 6 years with American Society of Anesthesiologists (ASA) physical status I-II were prospectively studied. They were assigned randomly to receive either 5 mg/kg (Group A), 10 mg/kg (Group B), or no ketamine (Group C).The children were observed for acceptance of premedication, sedation and anxiolysis at 10, 20 and 30 minutes after drug administration. Behavior/response of each child at the time of separation from parents, intravenous access, and acceptance of facemask for induction, postanaesthetic arousal state and complications were also recorded. RESULTS: There were 73 children in this study with a mean age of 37.4±18.0 months. The groups were comparable in age. The studied agent was tolerated by both groups that received premedication with no significant difference (P 0.73). Adequate sedation and anxiolysis were observed in groups A and B, (52%, 84%) and (68%, 88%) respectively. However, more children in group B (82.6%) had satisfactory behaviour at separation from parents and a better acceptance of anaesthetic face mask (64%) at induction than those in groups A and C (33.3%, 21.7%, respectively). No side effect was recorded in either of the premedication groups or the control group. CONCLUSION: Oral ketamine is acceptable and safe premedication for children. It provided good sedation, relieved anxiety and had no side effect in the children at the studied doses.

Predictors of maternal mortality among critically ill obstetric patients.

AIM: Evaluation of the predictors of maternal mortality among critically ill obstetric patients managed at the intensive care unit (ICU). METHODS: A case control study to evaluate the predictors of maternal mortality among critically ill obstetric patients managed at the intensive care unit (ICU) of the University of Ilorin Teaching Hospital, Ilorin, Nigeria from 1st January 2010 to 30th June 2013. Participants were critically ill obstetric patients who were admitted and managed at the ICU during the study period. Subjects were those who died while controls were age and parity matched survivors. Statistical analysis was with SPSS-20 to determine chi square, Cox-regression and odds ratio; p value < 0.05 was significant. RESULTS: The mean age of subjects and controls were 28.92 ± 5.09 versus 29.44 ± 5.74 (p = 0.736), the level of education was higher among controls (p = 0.048) while more subjects were of low social class (p = 0.321), did not have antenatal care (p = 0.131) and had partners with lower level of education (p = 0.156) compared to controls. The two leading indications for admission among subjects and controls were massive postpartum haemorrhage and severe preeclampsia or eclampsia. The mean duration of admission was higher among controls (3.32 ± 2.46 versus 3.00 ± 2.58; p = 0.656) while the mean cost of ICU care was higher among the subjects (p = 0.472). The statistical significant predictors of maternal deaths were the patient's level of education, Glasgow Coma Scale (GCS) score, oxygen saturation, multiple organ failure at ICU admission and the need for mechanical ventilation or inotrophic drugs after admission. CONCLUSION: The clinical state at ICU admission of the critically ill obstetric patients is the major outcome determinant. Therefore, early recognition of the need for ICU care, adequate pre-ICU admission supportive care and prompt transfer will improve the outcome.

Coagulation profile in severe pre-eclampsia and eclampsia in Ilorin, Nigeria: implications for anaesthetic management in operative obstetrics.

BACKGROUND: Severe preeclampsia and eclampsia are associated with coagulopathy which may be a contraindication to central neural axial blockade for caesarean section. Many investigations of bleeding tendencies are not done in our environment because of logistic reasons and emergency presentations of these patients.The study was designed to determine the coagulation profile of severe preeclamptic and eclamptic women in labour and possibly arrive at affordable and readily available investigation(s) that can be used in excluding bleeding tendencies in these patients. STUDY DESIGN: In a prospective study, 50 severely preeclamptic/eclamptic patients in labour and, 50 parturients with normal pregnancies, and, in labour were recruited. Full blood count including platelet count, prothrombin time (PT) using the International Normalized Ratio (INR) and partial thromboplastin time with kaolin (PTTK) were done in all the patients. RESULTS: Mean platelet count was significantly lower in study patients than in controls, 158.1 × 10(9)/l versus 216.9 × 10(9)/l, p = 0.0001. Mean INR and PTTK were within the reference values for the reagents used but mean INR was significantly greater in cases than in controls, 1.06 ± 0.01 versus 0.92 ± 0.01 (p = 0.001) while PTTK was also significantly longer in cases than in controls, 38.4 ± 0.21 versus 34.3 ± 0.44 seconds (p = 0.002). CONCLUSION: As platelet count can be readily obtained and it is affordable in our environment, it can be used in assessing bleeding tendencies in these patients for their effective management.

Negative pressure pulmonary oedema following adenoidectomy under general anaesthesia: a case series.

BACKGROUND: Negative pressure pulmonary oedema (NPPE) is a potentially life-threatening complication of laryngospasm that occurs during or after general anaesthesia. It is a complication of poorly treated or unrecognized laryngospasm occurring at extubation or later in the postoperative period. OBJECTIVE: To emphasize prompt recognition of laryngospasm during or after general anaesthesia and to prevent its progression to NPPE in a resource-challenged environment. METHODS: Three children aged two to four years, one of whom was a known sickle cell anaemia patient presented with adenoid hypertrophy. Surgery was postponed on account of upper respiratory tract infection in each of them. RESULTS: Following treatment of upper respiratory tract infection, they had adenoidectomy under general anaesthesia. They all developed severe laryngospasm at extubation. This progressed to NPPE which was diagnosed on clinical parameters. The children were subsequently admitted to the intensive care unit (ICU) for mechanical ventilation with high FiO2 (0.7-1) and PEEP between 12-24hours. While two of the children survived, the child with sickle cell anaemia died in the ICU. CONCLUSION: Negative pressure pulmonary oedema is a self limiting complication of laryngospasm if it is well managed. However, its outcome may not be good in a patient with intercurrent medical illness such as sickle cell anaemia in which hypoxaemia is deleterious.

Methicillin resistant Staphylococcus aureus: awareness, knowledge and disposition to screening among healthcare workers in critical care units of a Nigerian hospital.

BACKGROUND: Awareness level about methicillin resistant Staphylococcus aureus (MRSA) is high in the western world but the status in developing countries is not well defined. OBJECTIVE: To assess MRSA awareness level, knowledge and disposition to screening among critical healthcare givers (HCGs) in Nigeria. METHODS: A self-administered questionnaire was used to assess the level of awareness and knowledge of HCGs in critical care units of the University of Ilorin Teaching Hospital, Ilorin, Nigeria on MRSA and their willingness to submit to screening. RESULTS: Only 103 (52.0%) of the 198 participants were aware of MRSA but all were favourably disposed to screening for the organism. Awareness was through hospital rounds 65(63.1%) and journals/ textbooks 35(34.0%), and Many, 120 (60.6%) considered MRSA as a threat in the hospital, while only 27 (13.6%) thought otherwise and 51(25.8%) were indifferent. Most HCGs, 124 (87.9%) reported that there were no MRSA control measures in their respective duty post. The age, cadre of work, and number of years in the hospital's critical care units correlated positively with awareness level. CONCLUSION: Methicillin resistant Staphylococcus aureus awareness level among the HCGs in our hospital is just a little above 50.0% with substantial proportion of them not realizing the medical implication of the organism. However, majority are well disposed to MRSA screening. Inadequate publicity is a major contributor to poor knowledge and awareness. There is need for educational intervention and sensitization programs on MRSA and other infection control techniques for HCGs in developing nations especially Nigeria.

Anaesthesia management for thyroidectomy in a non-euthyroid patient following cardiac failure.

A 24-year-old male thyrotoxic student of a tertiary institution had thyroidectomy in the presence of a persistently elevated thyroxine (T4) and tri-iodothyronine (T3) levels. He was initially managed for hypertension at a private hospital before he was referred to our hospital for expert management. He had symptoms of thyrotoxicosis three years before presentation at our hospital. Physical examination revealed bilateral anterior neck masses and a diagnosis of toxic goitre was made. The serum T3 and T4 were elevated. Chest X-Ray, electrocardiogram and echocardiography showed abnormal findings. He was commenced on antithyroid drugs. Surgery was postponed several times due to persistently elevated thyroid hormones. However, he developed cardiac failure after six months on medical treatment and was treated with digoxin and frusemide. He had thyroidectomy under general anesthesia after his cardiovascular status was optimized in order to prevent further deterioration of his cardiac function. The anesthetic management is presented and discussed.