The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications.

BACKGROUND: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. METHODS: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. RESULTS: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. CONCLUSIONS: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. CLINICAL TRIAL REGISTRATION: NCT03044899.

Pediatric brain tumors in Nigeria: clinical profile, management strategies, and outcome.

INTRODUCTION: Although modern neuroimaging has facilitated early care of brain tumors in children worldwide, there are, however, few published reports on clinical profile, treatment, and outcome of brain tumors in children from our subregion. PURPOSE: We aimed to retrospectively study the clinical profile and outcome of pediatric brain tumors in a tertiary referral center from a developing country. METHODS: Forty pediatric patients with histologically verified brain tumors managed by the authors over a 13-year period (May 1994-April 2006) were studied. Patients' data from clinical, radiological, and pathology records were analyzed using the statistical package for social sciences version 16. RESULTS: The mean age was 9.75 years (range 1-15 years). Twenty-two males, 18 females. Common presenting symptoms were headaches (23 patients, 57.5%) and seizures (15 patients, 37.5%). Hyperreflexia (72.5%) and focal motor deficits (62.5%) were the most common neurologic signs. The mean interval from onset of symptoms to neurosurgical diagnosis was 13.4 months (95% CI). All patients had tumor resection, while 11 (27.5%) patients received adjuvant radiotherapy. Hydrocephalus occurred in 19 (47.5%) patients and was associated with early presentation (X2 = 10.65, p < 0.01). Low-grade astrocytoma (25%) and medulloblastoma (25%) were the most common tumors. Survival at 1 and 5 years were 56 and 47%, respectively. CONCLUSION: Focal motor signs and elevated intracranial pressure are the salient presenting features of brain tumors in children seen in Nigeria. Those of them with hydrocephalus are likely to present early. The outcome for pediatric brain tumors remains poor.

Morphine-sparing effect of intravenous paracetamol for post operative pain management following gynaecological surgery.

OBJECTIVE: The study evaluated the morphine sparing effect of intravenous Paracetamol and the incidence of side effects in the recovery room following lower abdominal gynaecological surgery. METHOD: Fifty six, ASA I and II patients undergoing lower abdominal gynaecological surgery were randomized into two groups, which were either given (A) intravenous (I.V) Paracetamol 1g diluted to 20 mls with normal saline or (B) I.V normal saline 20 mls at the beginning of the skin closure. In the re covery room pain intensity was evaluated and the time of first request for analgesic was noted. Intravenous morphine 2mg bolus was titrated to . Pain relief was evaluated at rest and on movement until pain score at rest Numerical rating score (NRS) < or = was achieved. Total dose of morphine was noted, morphine side effects, adequacy of analgesia and patient's satisfaction were assessed. RESULTS: The mean time of first analgesic request was prolonged significantly in Group A 40.9 +/-18.9 minutes vs. 11.4 +/- 5.5 minutes in Group B ( P = 0.00), with significant difference in morphine consumption 7.1 +/- 1.6 vs. 12.2 +/- 2.1 (P = 0.01) respectively. Morphine related side effects were higher in placebo group (33.3%) compared with (11.1%) in paracetamol group. More patients in the paracetamol group compared with the placebo group felt pain relief was adequate (66.7% vs 44.4%) and also more patients were satisfied with the regimen in paracetamol group compared with placebo group (96% vs 29.6%). CONCLUSION: Intravenous Paracetamol improved analgesia and reduced the amount of morphine consumption in the immediate postoperative period with reduced opioid side effects and better patient satisfaction.

Comparison of intravenous ephedrine with phenylephrine for the maintenance of arterial blood pressure during elective caesarean section under spinal anaesthesia.

Hypotension is a major concern of the anaesthetists whenever subarachnoid block is performed especially in obstetric patients. Vasopressors have been shown to be more effective at limiting spinal hypotension than other treatment of hypotension like preloading and left uterine displacement. The aim of the study is to compare the effect of bolus intravenous Ephedrine with Phenylephrine for the maintenance of arterial blood pressure during elective caesarean section under spinal anaesthesia. This was a randomized, double blind, controlled study of sixty two healthy parturients American Society of Anesthesiologists' (ASA) status 1 and 2 at term with singleton pregnancy who consented to subarachnoid block at University College Hospital, Ibadan, Nigeria. The parturients were preloaded with 10 ml per kg of crystalloid before the induction of spinal anaesthesia with injection of 2.5 ml of 0.5% hyperbaric Bupivacaine at L3/L4 levels. Ephedrine 5 mg (group A; n = 31) or phenylephrine 100 ug (group B; n = 31) was given for the maintenance of arterial blood pressure. Results showed that the incidence of hypotension in the 62 patients was 24.2%. Both vasopressors effectively restored both the systolic and the diastolic blood pressure. There was significant difference in heart rate between the two groups. Nausea occurred in both groups and was found in hypotensive patients, no patient vomited during the procedure. The mean APGAR Scores were similar for the two groups; no baby had Apgar score of < 8 in either group. We concluded that phenylephrine is safe and can be used as effectively as Ephedrine. Its administration results in higher blood pressure than Ephedrine in parturients undergoing Caesarean Section under spinal anaesthesia.

NEBULIZED MAGNESIUM VERSUS KETAMINE FOR PREVENTION OF POST-OPERATIVE SORE THROAT IN PATIENTS FOR GENERAL ANAESTHESIA.

BACKGROUND: Sore throat is a common post-operative complaint which can cause significant distress and morbidity. We tested and compared the efficacy of nebulized Magnesium and Ketamine on the incidence and severity of sore throat within the first 24 hours after general anaesthesia. OBJECTIVE: To compare the incidence and severity of post-operative sore throat at 2, 4, 8, 12 and 24 hours after extubation following pre-induction administration of nebulized Magnesium and Ketamine. METHODOS: In this randomized controlled trial, 99 adult ASA I and II patients between the ages of 16 - 65 years were administered nebulized Ketamine 50 mg, Magnesium Sulphate 250 mg or saline for ten minutes prior to induction of general anaesthesia and orotracheal intubation. Incidence and severity of post-operative sore throat were assessed at 2, 4, 8, 12 and 24 hours post extubation. RESULTS: The incidence of sore throat at 4, 8, 12 and 24 hours post tracheal extubation were significantly lower in the Magnesium (18.2%, 12.1%, 0, 0; p = 0.009, 0.006, ≤0.0001, 0.003) and Ketamine group (24.2%, 12.1%, 6.1%, 0; p = 0.041, 0.006, 0.001, 0.003) compared with the saline group (48.5%, 42.4%, 39.4%, 24.2%). Patients also had significantly less severe sore throat at 4 and 8 hours post extubation in both Magnesium and Ketamine groups (p = 0.0 11, 0.041). CONCLUSION: Pre-induction nebulization of Ketamine or Magnesium can decrease the incidence and severity of sore throat in the first 24 hours after anaesthesia.

Clinical comparison of cardiorespiratory effects during unilateral and conventional spinal anaesthesia.

BACKGROUND: Spinal anaesthesia is widely employed in clinical practice but has the main drawback of post-spinal block hypotension. Efforts must therefore continue to be made to obviate this setback OBJECTIVE: To evaluate the cardiovascular and respiratory changes during unilateral and conventional spinal anaesthesia. METHODS: With ethical approval, we studied 74 American Society of Anesthesiologists (ASA), physical status class 1 and 2 patients scheduled for elective unilateral lower limb surgery. Patients were randomly allocated into one of two groups: lateral and conventional spinal anaesthesia groups. In the lateral position with operative side down, patients recived 10 mg (2mls) of 0.5% hyperbaric bupivacaine through a 25-gauge spinal needle. Patients in the unilateral group were maintained in the lateral position for 15 minutes following spinal injection while those in the conventional group were turned supine immediately after injection. Blood pressure, heart rate, respiratory rate and oxygen saturation were monitored over 1 hour. RESULTS: Three patients (8.1%) in the unilateral group and 5 (13.5%) in the conventional group developed hypotension, P= 0.71. Four (10.8%) patients in the conventional group and 1 (2.7%) in the unilateral group, P= 0.17 required epinephrine infusion to treat hypotension. Patients in the conventional group had statistically significant greater fall in the systolic blood pressures at 15, 30 and 45 minutes when compared to the baseline (P= 0.003, 0.001 and 0.004). The mean respiratory rate and oxygen saturations in the two groups were similar. CONCLUSION: Compared to conventional spinal anaesthesia, unilateral spinal anaesthesia was associated with fewer cardiovascular perturbations. Also, the type of spinal block instituted affected neither the respiratory rate nor the arterial oxygen saturation.

Goldenhar syndrome: a case report and literature review.

The case of a 24-year-old female Nigerian with features of Goldenhar syndrome is presented and the challenges of management especially with reference to reconstructive facial surgery and general anaesthesia are discussed.

Surgical management of tuberculum sellae meningioma in a patient with a twin pregnancy: case report.

BACKGROUND: Meningioma in twin pregnancy is rare. The tumor has an accelerated growth during the pregnancy and may enlarge or become symptomatic during this period. This relationship makes management of patients with this tumor quite challenging. CASE DESCRIPTION: We describe a case of a rapidly deteriorating 35-year-old woman harboring an extensive tuberculum sellae meningioma who underwent craniotomy during the 24th week of pregnancy because of rapid deterioration. The surgical procedure and postoperative period were relatively uneventful. CONCLUSION: To the best of our knowledge, this is the first reported case of surgical management of a meningioma in a patient carrying a twin pregnancy (one missed abortus). When indicated, craniotomy is a safe and effective treatment option for huge frontobasal tumors during the second trimester of pregnancy.

Post operative nausea and vomiting in Nigerians.

A retrospective survey of postoperative nausea and vomiting (PONV) in the recovery room over a five year period was conducted, followed by a prospective study of 200 adult patients to estimate the incidence and predisposing factors to nausea and vomiting during the first 24 hours after anaesthesia and surgery in Nigerians. In the retrospective study only records of 61 patients (0.79%) out of the 7714 post anaesthetic recovery room charts reviewed revealed documentation of vomiting. These were 20 males (32.8%) and 41 females (67.2%). In the prospective study, the incidence of post operative nausea and vomiting within twenty four hours of surgery was 41.6% and 19.6%, respectively. But only two out of 39 patients (one per cent) vomited within the first three hours in postoperative period. The frequency of vomiting varied from one to 15 times and women had significantly more emetic symptoms than men (p < 0.05). Preoperative administration of pethidine and morphine was associated with postoperative nausea and vomiting. It is suggested that Nigerian women should be considered for prophylactic anti-emetic therapy, especially when narcotic analgesic are to be employed in their anaesthetic management.

Anaesthesia and surgical aspects of thyroid swelling: the Ibadan experience.

Seventy-five cases of thyroid swelling operated on at the University College Hospital, Ibadan over a period of two years and three months (March 1990 - May 1993) were reviewed. The male-female ratio was 1:8.6, and the highest incidence was in the fourth decade (34.7%). Benign nodular and multinodular goitre constituted 80%, solitary adenoma constituted 6.7%, papillary carcinoma constituted 4% and toxic goitre 9.3%. Approximately 20% presented with a duration of over 5 years, and 22.7% of the glands removed weighed over 100 gms. Eighteen of the cases (24%) showed tracheal deviation, but this did not cause preoperative respiratory problems although there were difficulties in endotracheal incubation during anaesthesia. The non-toxic benign goitres were totally asymptomatic regardless of their size, and the indication for surgery was for cosmetic reasons. We did not routinely search for the recurrent laryngeal nerve and we did not routinely dissect out the inferior thyroid artery for ligation at its main trunk.

Assessment of minidose intrathecal morphine for analgesia after hemorroidectomy.

The efficacy of 0.5kg intrathecal morphine was tested on 10 patients who had hemorrhoidectomy performed at the University College Hospital (UCH), Ibadan. They were anesthetized with 3 mls of 0.5% intrathecal bupivacine to which 0.5mg of morphine was added. Another 14 patients had intrathecal 3 mls of 0.5% bupivacine with normal saline. Post-operative analgesia was prolonged in the opiate group compared to the saline group up to 8th post-operative hour. Narcotic analgesic requirement was much less in the opiate group. There were no serious complications in either group. In view of the excellent analgesia in the immediate post-operative period and absence of delayed respiratory depression usually associated with higher doses of spinal opiates it is recommended that use of the technique be encouraged in similar surgical patients for pain relief.

The effect of parental presence at induction of anaesthesia on the behaviour of unsedated Nigerian children presenting for day-case anaesthesia.

The effect of parental presence at induction of anaesthesia on one hundred and eighteen children presenting for day-case inguinal operations and the behaviour of the attending parents at induction were studied. Of the 24 children aged 5 years and below whose parents at were present at induction, 25% were distressed, while 80% of 36 children of this age group whose parents were absent showed distress. Better behaviour was observed among the children who were above 5 years of age. When parents were present 7% of 28 children cried while 20% of 30 children cried when parents were absent. In both age groups induction heart rates were significantly higher in the children whose parents were absent. All parents except one who cried and another one who was too anxious, were helpful at induction and they would welcome the same opportunity to be present at the children's induction.

The diagnostic dilemma of intraoperative hyperpyrexia in a malaria endemic area.

Malignant hyperthermia (MH) is a serious and feared complication of general anaesthesia. The diagnosis of MH may pose a diagnostic dilemma, as its two most common signs tachycardia and hyperthermia are also common features of infections, transfusion and drug reactions. We report three cases of hyperthermia occurring during anaesthesia posing diagnostic dilemma in which two of the cases appear to be due to malaria. It is therefore suggested that all patients undergoing anaesthesia in a malaria endemic area should be investigated and treated for malaria if indicated preoperatively even when asymptomatic to prevent such diagnostic confusion.

Complications following day case paediatric surgery.

Several children have day surgery under general anaesthesia and depend on adult relatives for support and postoperative care at home. This prospective review examines the post operative problems encountered by 62 such children from the time of discharge from hospital to the first outpatient visit. The children were in the age range 3 months to 12 years. The commonest complications reported were:- Pain (18.9%), Cough/Sore throat (18.9%), Fever (16.2%), Restlessness (13.5%), Vomiting (12.2%), and Sleeplessness (6.7%). Eight patients reported more than three complications each. Day case surgery should not be regarded as "Minor Surgery" under Minor Anaesthesia", rather, the concerns for safety and comfort of the patients should extend beyond the recovery room to the ward and home.

Pathological fracture complicating epidural local anaesthetic opioid infusion for cancer pain.

Two cases of severe bone pains from metastatic cancer, without clinical or radiological evidence of fractures on admission, are presented. Pain control and mobilization were achieved initially with local anaesthetic-opioid epidural infusion. Subsequent loss of analgesia prompted a re-examination, which revealed pathological fractures of the femur. Internal fixation of the fractures resulted in good control such that strong opioids were no longer required.

Intra-operative cardiac arrests.

This is a review of patients who had cardiac arrest in the operating suites at the University College Hospital (UCH), Ibadan between January 1994 and December 1998. The main objectives of the study were to evaluate the incidence of intraoperative cardiac arrests, identify associated factors and, in particular, those factors that might be essential for better prognosis. The study was retrospective, descriptive and cross-sectional. The figures were retrieved from the theatre records, the intensive care records, case notes and pathology reports. During the study period, 6,356 operations were performed. There were 35 cardiac arrests giving an incidence of 55 per 10,000 operations. Of the 35 cases, 18(51.4%) were males while 17(48.6%) were females. The age range was 4 months to 84 years (mean 32.5 years) with wide distribution through the decades. Of the twenty-four patients (68.6%) that were done as emergency cases, four patients (17.1%) recovered fully. Of the 11(31.4%) elective cases, 5 (41.7%) made full recovery. Ten patients (28.6%) were ASA I & II, while 25 (71.4%) were graded ASA status III to V. The factors associated with cardiac arrest in this study included emergency operation and the ASA status.

Pain assessment in Nigerians--Visual Analogue Scale and Verbal Rating Scale compared.

The usefulness of 2 methods of pain assessment was determined in a cohort of Nigerians who had pain as a symptom and were receiving physiotherapy for various indications. The English and Yoruba versions of two Pain Rating Scales, the Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS) with 1 to 4 or 1 to 5 intensity scales (VRS-4 or VRS-5) were employed for the assessment of pain in 100 patients. The mean pain score on the 4-point VRS scale was 2.49 +/- 0.72, for the 5-point VRS 2.1 +/- 1.18 and for the VAS 4.93 +/- 2.5. Correlation analysis for corresponding groups of patients showed a significant positive relationship between the VAS and VRS-4 (r = 0.68 P < 0.001) VAS and VRS-5 (r = 0.64 P < 0.001) indicating that both VAS and VRS constitute useful tools for pain assessment in Nigerian patients.

Complications following sedation of paediatric oncology patients undergoing radiotherapy.

Sedation is often required to achieve immobilisation of small children during radiotherapy to avoid irradiation of normal tissues during the course of treatment. At the University College Hospital, Ibadan radiotherapists provide sedation for such patients with administration of parenteral and/or oral promethazine, diazepam, chlorpromazine and paraldehyde. This retrospective review of 84 children aged 1 month to 6 years who received sedation for radiotherapy over a period of twenty-one to twenty-eight days showed that 48% had complications. These included injection cellulitis (85.3%), injection abscess (4.87%), paresis of the lower limb (7.3%), aspiration pneumonia (2.4%). Anaesthetists in developing countries should be encouraged to extend their expertise in caring and resuscitation of sedated or unconscious patients to the radiotherapy unit. This will allow for the use of a wider variety of sedative agents and better monitoring as well as minimise or eradicate complications.

Ketamine anaesthesia for young children undergoing radiotherapy.

Young children with radiosensitive malignant tumours often require sedation or anaesthesia to provide immobility for radiotherapy sessions lasting several days. This paper describes the use of repeated intramuscular ketamine anaesthesia for radiotherapy in children age 1.5 to 5 years. Intramuscular ketamine 5-13mg/kg body weight was administered on 280 occasions to 15 children, the highest number of sessions per child being 30 and the least 9. The airway and cardiovascular parameters were well maintained. The time to complete recovery varied from 15 to 90 minutes (mean 52.5+/-31.7 S.D.). Involuntary movements of the tongue, mouth and limbs were observed in 8 patients (52.3%) during 63 sessions (22.5%) but only necessitated interruption of radiotherapy on 6 occasions (2.1%). Ketamine was found to be safe and effective for sedation of young children in the radiotherapy suite and minimal aneasthetic facilities were required.

Case report: difficult spinal anaesthesia for caesarian section in two obese pregnant patients.

Two obese patients presented for Caesarean Section for poor progress in labour. Spinal anaesthesia was chosen because of obesity, gravidity and worry about possible related airway problems in both patients. In both cases the needle seemed to be short. In case 1, no cerebrospinal fluid (CSF) was obtained, and she was subsequently done under General Anaesthesia (GA); in case 2, CSF was obtained when the needle was pressed firmly into the patients back but flow stopped if the pressure was released. These case reports serve to illustrate that although spinal anaesthesia for obese pregnant patients may seem the safer alternative, mechanical difficulty may be considerable and eventually a GA may be considered in spite of possible risk of difficult intubation.