The delivery and challenges of Pediatric Anesthesia within the humanitarian sector: Médecins Sans Frontières and Mercy Ships.

Access to healthcare is inequitable. Poverty, natural disasters and war disproportionally effect those most vulnerable, including children. Non-governmental organizations (NGO) hold a vital role in providing pediatric care in these contexts. Here we describe the delivery and challenges of Pediatric Anesthesia with two such non-governmental organizations; Médecins Sans Frontières (MSF) and Mercy Ships. Descriptions of both are followed by case studies.

Analgesic efficacy of bupivacaine with or without magnesium adjunct in bilateral ilioinguinal and iliohypogastric nerve blocks following cesarean section under subarachnoid block: A randomized controlled trial.

Background: Pain relief is a basic aspect of anesthesia care. Optimal post-cesarean section analgesia should minimize postoperative complications, facilitate infant care, and prevent postoperative morbidity. Bilateral ilioinguinal-iliohypogastric (IIIH) nerve block has been considered as a part of the multimodal approach. This study was designed to explore the efficacy of adding magnesium sulfate as an adjunct to bupivacaine to provide analgesia following cesarean delivery, using bilateral IIIH nerve block. Materials And Methods: Seventy-two parturients who were scheduled for elective cesarean section were randomized into two groups of 36 patients each. Group MB patients were given bilateral IIIH nerve block with 250 mg of magnesium sulfate and 95 mg of 0.25% plain bupivacaine. Group B patients were given bilateral IIIH nerve block with 0.9% normal saline and 95 mg of 0.25% plain bupivacaine. Postoperative visual analog scale (VAS) pain scores at post-anesthesia care unit (PACU), 2, 4, 6, 12, and 24 h, both at rest and with activity were measured. Rescue doses of opioid (intravenous [IV] tramadol 50 mg) at each time point of assessment, total tramadol consumption, time to patients' first request for rescue analgesic agent, and patients' satisfaction score were recorded. Results: The demographic and social parameters of patients in both the groups were comparable. The mean postoperative VAS pain score in group MB was significantly lesser both at rest and with movement than in group B at 12 and 24 h after surgery (P < 0.05). Total postoperative tramadol consumed over 24 h was significantly lesser in the magnesium group than in the control group (125.55 ± 20.76 vs. 160.24 ± 25.82 mg), with a P value of 0.026. The time to patient's first analgesic request was significantly prolonged in group MB compared to group B (505.2 ± 41.4 vs. 372.6 ± 88.8 min, respectively), with a P value of 0.040. However, patients in both groups expressed good satisfaction scores. Conclusion: Magnesium sulfate as an adjunct to bupivacaine in bilateral IIIH nerve block reduced VAS pain scores, total tramadol consumption, and prolonged post-cesarean section analgesia.

Toward Optimization of Cancer Care in Sub-Saharan Africa: Development of National Comprehensive Cancer Network Harmonized Guidelines for Sub-Saharan Africa.

PURPOSE: Standard treatment guidelines improve patient outcomes, including disease-specific survival, in cancer care. The African Cancer Coalition was formed in 2016 to harmonize cancer treatment guidelines for sub-Saharan Africa. METHODS: The African Cancer Coalition collaborated with the National Comprehensive Cancer Network (NCCN) and the American Cancer Society to harmonize 46 cancer treatment guidelines for use in sub-Saharan Africa. Harmonization for each guideline was completed by a group of approximately 6-10 African cancer experts from a range of specialties and with representation across resource levels. Each working group was chaired by an African oncologist and included a member of the appropriate NCCN guidelines panel. Treatment recommendations from the parent guidelines were distinguished as options that are generally available and should be considered standard care in most of the region or as highly advanced options for which cost or other resources may limit widespread availability. Additional recommendations specific to sub-Saharan Africa were added. RESULTS: The NCCN Harmonized Guidelines for sub-Saharan Africa, available for download on the NCCN website and mobile application, provide flexible recommendations appropriate for the range of resources seen in African cancer programs, from private comprehensive cancer centers to resource-constrained public hospitals. IBM (Armonk, NY) has developed a digital interface-the Cancer Guidelines Navigator-that allows oncologists to access the treatment recommendations for the first five guidelines through an interactive web-based application. CONCLUSION: Harmonized guidelines that reflect the diversity of resource levels that characterize the current state of clinical care for cancer in Africa have the potential to fill a crucial gap in efforts to standardize and improve cancer care in Africa.

Fetus-in-Fetu Airway Teratoma Management of a Newborn in a Low-Resource Country: A Case Report.

A term baby was delivered by cesarean and found to have an unexpected large teratoma attached to its mouth. Surgical excision was planned within 24 hours. Anesthesia concern of airway control required multidisciplinary team consultation, airway and patient preparation, and anticipation for failure. Challenging airway cases in low-resource countries can be successfully managed with deliberate attention to detail, preparation, and experience.

Fluoroscopic-guided sacroiliac, joint injections for treatment of chronic axial low back pain in a tertiary Hospital in Nigeria: a preliminary study.

BACKGROUND: The injection of mixture of plain bupivacaine and triamcinolone acetonide into the sacroiliac joint (SIJ) to relieve chronic low back pain is uncommon in the West African sub-region. The objective of this study was to demonstrate the efficacy or otherwise of fluoroscopic-guided SI joint injection in the management of chronic axial low back pain in Nigeria. DESIGN: This was a prospective observational interventional study. SETTING: The study was carried out at a tertiary hospital in Nigeria. PARTICIPANTS: Twenty-six patients with SI joint pain, based on IASP diagnostic criteria, who presented to our unit over 36 months from March 2012 to March 2015 and. INTERVENTIONS: Fluoroscopic-guided injections of 5mls mixture of bupivacaine and triamcinolone acetonide into the sacro-iliac (SI) joints of 26 patients with SI joint pain out of 116 patients who were offered different interventions for chronic low back pain. The patients were followed up for year and pain intensity and functional status were assessed at 3-, 6- and 12 months post-intervention. MAIN OUTCOME MEASURES: Pain relief and functional improvement were the main outcome measures. RESULTS: The mean numeric rating score (NRS) and Oswestry Disability index (ODI) score in 14 (53.9%) patients at 12 months post-interventions were significantly lower compared with baseline values; 3.19 ± 1.10 vs 8.54 ±1.14 p=0.000 and 25.35 ± 5.40 vs 37.54 ±8.41, p=0.000 respectively. CONCLUSION: Fluoroscopic-guided steroid injection into the SI joint resulted into reduction in pain intensity and improved physical function in the majority of patients with SI joint pain. FUNDING: Not declared.

Opioid prescribing habits of physicians in Kwara State, Nigeria.

OBJECTIVE: Although opioid analgesics are effective in the treatment of moderate to severe acute, cancer and chronic non-malignant pains, they are under-prescribed in Nigeria. The objective of this study was to assess the prescription pattern of opioids among physicians in a north central State, Nigeria.. DESIGN: This was a descriptive cross sectional study. SETTING: The study was conducted at the International Association for the Study of Pain (IASP)-sponsored workshops on pain and palliative care at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. PARTICIPANTS: These were physicians at the monthly workshops organized by the Pain and Palliative Care Unit of the hospital between August 2011 and July, 2012. INTERVENTIONS: Pre-tested semi-structured questionnaires were used to obtain responses to questions on pain management including opioids utilization in the various hospitals of the 114 participants. MAIN OUTCOME MEASURES: The main outcome measure was opioid prescription by the participants. RESULTS: Out of the 114 questionnaires distributed, 113 were returned with complete information giving a response rate of 99.1%. The mean age of the respondents was 42.0±10.8 years. Although 97.3% of the respondents reported that pain was a frequent complaint in their practice, 69.5% of those who reported seeing patients with moderate to severe pain on a daily basis rarely or never prescribed opioid analgesics. The reasons given for poor opioid prescription were fear of respiratory depression (86.8%), fear of addiction (85.1%) and non-availability (28.9%). CONCLUSION: Opioid prescription rate for patients with moderate-severe pain is low possibly due to myths and misconceptions about their adverse effects. FUNDING: International Association for the Study of Pain (IASP) Initiative for Improving Pain Education Grant awarded to Dr. K.W. Wahab in 2011.

Fluoroscopic-guided supra-scapular nerve block in the management of shoulder pain in a Nigerian Teaching Hospital: Report of five cases.

Shoulder pain complaints are common in our environment. The disorder can occur among the young active age group or in the older patients as a result of degenerative changes with its attendant limitations of the function of the affected upper limb, hindrance of the performance of activities of daily living, and reduced quality of life. The traditional oral analgesics, physiotherapy, and intra-articular corticosteroid injections are seldom ineffective at providing the desired pain relief and functional improvement at the shoulder joint. We investigated the role of fluoroscopic-guided supra-scapular nerve blocks (SSNBs) in patients with shoulder pain who failed to respond to the routine conservative management. With the patient lying prone and the C-arm fluoroscope placed in anterior-posterior position, the scapula notch was visualized and a 22G spinal needle was directed toward the nerve. The mixture of local anesthetic agent and steroid was injected as close to the nerve as possible after negative aspiration. Fluoroscopic-guided SSNB can produce substantial pain relief and improved range of movement in patients with painful shoulders. The procedure is safe, well tolerated, and can be done on a day-case basis.

Comparison of caudal ketamine with or without bupivacaine in pediatric subumbilical surgery.

In this prospective, randomized, double-blind study, we evaluated the perioperative analgesic efficacy of caudal ketamine with or without bupivacaine in 62 American Society of Anesthesiologists I-II children undergoing lower abdominal surgery. Patients were randomized into three groups, and all blocks were placed under general anesthesia. Group 1 (n=20) had caudal injection of plain 0.125% bupivacaine 1 mlkg(-1). Group 2 (n=22) received caudal ketamine 0.5 mgkg(-1) diluted with 0.9% saline using the same weight-related volumes. Group 3 (n=20) received a similar dose of ketamine mixed with 0.125% bupivacaine 1 mlkg(-1). No supplementary intraoperative analgesic was required in any of the groups. Patients in group 3 had the longest duration of analgesia compared to the other two groups. There was no significant difference in the incidence of side effects among the three groups. We conclude that ketamine can safely be used as an adjuvant to prolong the duration of caudal analgesia in this group of West African children.

Intercostal nerves block for mastectomy in two patients with advanced breast malignancy.

Regional anesthesia is recognized as an alternative to general anesthesia for modern breast cancer surgery. Various techniques of block have been described. Each has its unique problems. Regional anesthesia was chosen for simple mastectomy in two patients with advanced breast malignancy, due to compromised pulmonary status resulting from widespread malignant infiltration of both lungs. We used intercostal nerves block. The block was supplemented with an infraclavicular infiltration to interrupt the branches of the superficial cervical plexus that provide sensation to the upper chest wall and subcutaneous infiltration in the midline to block the nerve supply from the contralateral side. Anesthesia was generally effective and the operations were uneventful. Both patients and surgeons expressed satisfaction. We conclude that where patients have significant comorbidities that make general anesthesia undesirable, the use of intercostal nerves block remains a safe and reliable anesthetic option that allows the patient access to surgery for simple mastectomy.

Emergency thyroidectomy in a patient with severe upper airway obstruction caused by goiter: case for regional anesthesia.

A case of severe airway obstruction caused by a giant malignant goiter is presented. The patient had emergency thyroidectomy under regional anesthesia (bilateral superficial cervical plexus block). The procedure was well tolerated and the intraoperative course was uneventful. The anesthetic challenges are discussed and a case is made for regional anesthesia as a safe and reliable anesthetic option for thyroidectomy in this situation.