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INTRODUCTION: Chest infections are a frequently encountered problem in patients admitted to the intensive care unit (ICU), more so in tracheostomised patients. This study aimed to audit the tracheostomy care practices in patients with neurosurgical pathologies in the ICU of Wellington Clinics Abuja, a tertiary neurosurgical hospital in Nigeria. METHODS: We conducted a closed-loop audit with mixed methods involving analysis of 24 patients who had tracheostomy within the first two weeks of neurosurgical pathology at a tertiary neurosurgical hospital and semi-structured interviews to determine tracheostomy care practices among the primary caregivers - nurses, intensivists, and doctors. RESULTS: Of the 161 ICU admissions in the first cycle, 22 patients received tracheostomy, 16 met the eligibility criteria. At re-audit (second cycle), eight of 40 patients met the criteria. All the patients received open suctioning through a dual cannula-cuffed tracheostomy tube and had independent portable suction units. In the baseline audit (first cycle), suction catheters were reused for 12-24 hours in each patient and were stored in varying combinations of normal saline and Savlon antiseptic (5 mg of cetrimide (0.5% w/w) and 1 mg of chlorhexidine digluconate (0.1% w/w)). The frequency, technique, and assessment of the need for airway suctioning were inconsistent among caregivers interviewed. All 16 patients had at least one episode of pneumonia, 10 patients had a second episode, and two patients had > two episodes. One mortality was recorded directly attributable to the complications of pneumonia. While in the re-audit, with adherence to recommendations, three patients suffered one episode of pneumonia and only one had a second episode. No mortality was recorded. CONCLUSION: A standard practice guideline was necessary for tracheostomy care in our ICU. In low-resource settings, stated recommendations such as single-use suction catheters and improved hygienic practices can reduce rates of pneumonia in tracheostomised patients.
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INTRODUCTION AND IMPORTANCE: The commonest method of elective CSF diversion remains ventriculo-peritoneal shunt (VP shunt). But in some circumstances, VP shunts fail repeatedly or becomes unattractive to the neurosurgeon and this calls for exploration of alternatives. For the index case, Ventriculo-atrial (VA) shunt was favoured and the objective in this report is to share experience gathered there from. Learning points serve to highlight the use of VA shunts as a resort in the drainage of cerebrospinal fluid in the case of repeated failures of peritoneal diversion of CSF and to explain our explain our experience with this index case. CASE PRESENTATION: A 54 years old obese woman with previous history of total abdominal hysterectomy was reported. She underwent repeated (three times) revisions of failed peritoneal end of her VP shunt on a background of obstructive hydrocephalus secondary to a posterior fossa tumour (previously excised). Following repeated failure of peritoneal catheter function, she underwent VA shunt and did well. CLINICAL DISCUSSION: The decision to place a VA shunt was made after careful deliberations. We discuss the peculiarities in placing a VA shunt. Following placement of a VA shunt, improvement was noted in her clinical condition at one week post op and has been sustained at multiple follow up clinic visits. CONCLUSION: VA shunts become an option for cerebrospinal fluid drainage when it becomes unequivocally clear in a multidisciplinary setting that the peritoneal catheter is unlikely to work in view of the unfavourable circumstances of the peritoneal cavity.
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Distinguishing the aneurysmal from nonaneurysmal subarachnoid hemorrhage (SAH) may be difficult as acute bleeding in the subarachnoid space is a common denominator. It is believed that toxic effects of breakdown products of acute bleed, including hemoglobin, contribute to the morbidity and mortality of this condition; and that early drainage will potentially reduce them. This series focuses on our local experience with the application of external cerebrospinal fluid (CSF) drainage in the management of a series of cases confirmed to be nonaneurysmal SAH and its effects on the outcome. The objective of this report is to observe the usefulness of external CSF drainage in the management of nonaneurysmal SAH. Five consecutive cases over four years were reviewed and reported as a case series. The main points we focused on were presentation, diagnostic findings on imaging, CSF drainage, and outcome up to six months. All the patients presented with headaches described as sudden, and only one had significant impairment of consciousness Glasgow Coma Scale (GCS) 10/15. Three out of the five patients had a premorbid hypertensive condition of unclear control status. We also observed that three out of the five had a low-pressure pretruncal/perimesencephalic pattern of bleed, whereas two had the typical high-pressure SAH pattern. CT angiography (CTA) was negative in all. Four had lumbar drainage, while one had external ventricular drainage. All were discharged within three weeks and functioned optimally at six months. CSF drainage in managing nonaneurysmal SAH is achievable with minimal access procedures, including lumbar drain (LD) and external ventricular drainage (EVD), which may have further reduced the low morbidity normally associated with this condition.
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An encephalocele is a congenital tube defect in which there is an extension of intracranial structures outside the normal confines of the skull. Its presentation at birth provokes a lot of anxiety amongst parents, guardians and care providers with regards to compatibility with life, surgical treatments and effects on developmental milestones and higher mental functions. This report is on our initial experience in the first six months following surgical treatment of four consecutive cases presenting in infancy. The aim of this case series is to report our initial experience of the management of encephaloceles using four consecutive cases that presented in infancy. A review of four infants who presented to our neurosurgery service was conducted including patterns of presentation, neuroimaging findings, scope of surgical intervention and neurological outcome at the six-month review. The results are presented in short case reports and summarized in a table. Two five-month-old females, one six-month-old female and one two-month-old female infants presented to our neurosurgery clinic with progressively increasing encephaloceles at different locations. Brain MRI revealed meningo-encephalocele in all, but with associated hydrocephalus in two cases only. They all had excision and repair of encephalocele under the same general anaesthesia while only two had a ventriculoperitoneal (VP) shunt. Developmental milestones were on course at 6 months follow-up following discharge. Although the presentation of encephaloceles can be frightening to parents and care providers, careful clinical and radiological evaluation is a recipe for sound surgical planning and improved outcome.
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Background Acute traumatic subdural hematoma is life-threatening and is associated with high unfavorable outcomes in developing countries. Objective We aim to identify factors contributing to outcomes after severe traumatic brain injury (TBI) due to acute subdural hematoma (SDH) in patients admitted to National Hospital Abuja, Nigeria. Methods This was a retrospective review of 34 patients who consecutively underwent neurosurgery for acute SDH over five years (from January 2015 to December 2019). Demographic data, clinical characteristics, and the time intervals from injury to surgery were investigated to determine the interactions between all these factors and outcome. Outcome was graded according to the Glasgow outcome scale at the three-month follow-up. Results Out of 34 patients who had surgical evacuation for traumatic acute subdural hematoma, 15 patients died (44.1%). A significant correlation was identified between outcome and the Glasgow coma scale score at admission. No significant correlation was seen between the outcome and the age, gender and the time from injury to surgery (chi2 test, p>0.05). Conclusion The rate of unfavorable outcomes in acute subdural hematoma is high. The Glasgow coma score at admission is an important predictor for outcome in traumatic acute subdural hematoma.