A comparative study between caudal bupivacaine and bupivacaine co-administered with neostigmine for postoperative analgesia in children.

AIMS AND OBJECTIVES: The aim of this study was to compare the duration of postoperative analgesia and possible adverse effects produced by caudal bupivacaine 0.25% at 1 ml/kg with or without 1.5 ug/kg of neostigmine in children undergoing unilateral herniotomy. PATIENTS AND METHODS: Sixty-six children aged 1-6 years, of ASA physical status classes I or II for elective unilateral herniotomy under general anaesthesia without premedication were studied. The patients were randomly allocated into two groups of 33 each. Group B received caudal analgesia with plain bupivacaine 0.25% at 1 ml/kg alone, while group BN received caudal analgesia using a mixture of plain bupivacaine 0.25% at 1 ml/kg and neostigmine 1.5 ug/ kg. Postoperatively, monitoring of pain scores and time to first analgesic request and, total dose of analgesics administered in the first 24 hours were recorded. RESULTS: All the patients participated throughout the study. There were no differences in the demographic characteristics (age, weight, ASA status)between the two groups. The mean duration of effective analgesia was significantly longer in group BN, 460 ± 60.2 min. compared to group B, 286.4 ± 47.8 mins, (p < 0.001). The analgesic requirement within the first 24 hours postoperatively was also significantly reduced in group BN, p < 0.001. CONCLUSION: The study shows that the addition of low dose neostigmine to caudal isobaric bupivacaine significantly prolonged the time to first analgesic request and hence significantly reduced postoperative analgesic requirement.

Continuous spinal anaesthesia for caesarean section in a parturient with peripartum cardiomyopathy.

Peripartum cardiomyopathy is a potentially fatal form of heart failure associated with pregnancy. A 27-year-old Nigerian woman, gravida 1, para 0, presented at 31 weeks' gestation with no previous history of hypertension heart disease, but morbidly obese (body mass index of 42 kg/m2), with uncontrolled and hypertension, severe pulmonary oedema who required an urgent Caesarean section is presented. The patient was admitted into the hospital's ICU for stabilisation. She was placed on oxygen by non-rebreathing face mask while receiving intravenous labetalol and frusemide. Following a worsening clinical state, an urgent Caesarean section was conducted under continuous spinal anaesthesia using 7.5 mg intrathecal 0.5% isobaric bupivacaine and was delivered of a 1.8 Kg live female baby with good Apgar scores. At the end of the surgery, mother and baby were transferred to the ICU and SCBU respectively. After a 7-day intensive treatment she was discharged. Since then she remained symptom-free and her baby was doing well during the period of admission and discharge. This case report illustrated the recognition of peripartum cardiomyopathy and the use of a more haemodynamic stable anaesthetic technique. It also described the need for collaboration of multiple medical specialists before, during delivery and after delivery to provide the best possible outcome for both mother and infant.

Comparative effects of single shot low dose spinal bupivacaine only and bupivacaine with fentanyl on labour outcome.

BACKGROUND: Childbirth has been recognised as the most painful experience known to women. This study aimed at studying the efficacy and safety of the single shot spinal analgesia for pain relief in labour. MATERIALS AND METHODS: One hundred and twelve parturients in labour were randomized into two groups of 55 paturients each. Group B received 2.5 mg of spinal plain bupivacaine only while Group BF had 2.5 mg plain bupivacaine with 25 gg of fentanyl. Onset of sensory block, time to achieve maximum sensory block, duration of sensory and motor block and the level of block were recorded. The need for oxytocin augmentation, instrumental delivery, neonatal Apgar scores and umbilical artery blood pH were recorded. RESULTS: The numeric rating pain scores for groups B and BF were significantly reduced from a mean prespinal score of 8.17 +/- 0.96 cm and 8.30 +/- 0.23 cm respectively to a mean post-spinal pain score of 0.23 +/- 0.45 cm and 0.09 +/- 0.47 cm respectively, p = 0.000. The mean duration of analgesia in Group B was 61.60 +/- 6.47 mins while it was 128.98 +/- 21.61 mins in Group BF, p = 0.000. CONCLUSION: The study showed that low dose spinal bupivacaine either alone or in combination with fentanyl is safe for labour analgesia, but the combination f bupivacaine with fentanyl provided much more prolonged pain relief

A comparison of the haemodynamic effects of lateral and sitting positions during induction of spinal anaesthesia for caesarean section.

BACKGROUND: Hypotension during spinal anaesthesia occurs commonly in parturients. By influencing spread of local anaesthetic, maternal position may affect the speed of onset of sensory block and thus the haemodynamic effects. The aim of this study was to determine whether inducing spinal anaesthesia for caesarean section using plain bupivacaine in the lateral position would result in less hypotension compared with the sitting position. METHODS: One hundred American Society of Anesthesiologists physical status I and II patients undergoing elective caesarean section were randomised to receive spinal anaesthesia in the lateral position (Group L) or the sitting position (Group S). Using the L3-4 interspace, patients received intrathecal plain bupivacaine, 10mg or 12 mg according to their height, after which they were placed immediately in the supine position with left uterine displacement. Maternal blood pressure was measured every minute for 10 min, every three min for 20 min and 5-minutely thereafter. Hypotension was defined as a fall in systolic blood pressure >20% or a value <90 mmHg. RESULTS: There was no difference in the lowest recorded systolic blood pressure in Group L (99.2±8.9 mmHg) compared with Group S (95.4±12.3 mmHg, P=0.081). However, the lowest recorded mean arterial pressure was greater in Group L (72.9±11.2 mmHg) than in Group S (68.2±9.6 mmHg; P=0.025). The incidence of hypotension was lower in Group L (17/50, 34%) than in Group S (28/50, 56%; P=0.027). Onset of hypotension was similar between groups. CONCLUSION: Hypotension occurred less frequently when spinal anaesthesia for caesarean using plain bupivacaine was induced with patients in the lateral compared with the sitting position. Values for the lowest recorded mean arterial pressure were greater but values for the lowest recorded systolic blood pressure were similar for patients in the lateral position group.

ANAESTHETIC CHALLENGES IN A HIGH RISK PARTURIENT WITH MYASTHENIA GRAVIS UNDERGOING CAESAREAN SECTION UNDER SPINAL ANAESTHESIA.

The prevalence of myasthenia gravis is low. The management implications of this disease in pregnant women are very challenging for anaesthetists. The objective is to highlight some of the challenges, the management and the lessons learnt during the management of this patient. This is a case report of a 31-year old parturient with diagnosed myasthenia gravis co-existing with hepatitis B infection that presented for caesarean section. Surgery was carried out under a single-shot spinal anaesthesia with bupivacaine. Intraoperative myasthenia crisis was managed with neostigmine infusion. She was managed in the Intensive Care Unit for a few days and discharged. Under spinal anaesthesia, she became very breathless and developed wide-spread musculo-skeletal weakness while having a stable haemodynamics intra-operatively. Surgery was carried out successfully. Both mother and child were discharged on the 71th day post-operative after baby was confirmed sero-negative of hepatitis B surface antigen. A better understanding of the pathophysiology and complications that accompany myasthenia gravis is needed to manage these patients under anaesthesia.

Anaesthetic management of a super morbidly obese patient for total abdominal hysterectomy: a few more lessons to learn.

BACKGROUND: The prevalence of obesity is on the upward trend world-wide. This epidemic has challenging implications for anaesthetists, following the anthropometric changes associated with the disease. OBJECTIVE: To highlight some of the challenges, the management and the lessons learnt during the management of this patient. METHODS: This is a case report of a 52-year old super morbidly obese, diabetic, and hypertensive patient that presented for total abdominal hysterectomy. Surgery was carried out under a single-shot spinal anaesthesia with bupivacaine/fentanyl. RESULTS: Under bupivacaine/fentanyl anaesthesia, she became very drowsy and had moderate to severe respiratory depression. She was arousable but had an obstructive sleep apnoea. Surgery was carried out successfully CONCLUSION: A better understanding of the pathophysiology and complications that accompany obesity is needed to manage an obese patient under anaesthesia.

The differential impact of two anesthetic techniques on cortisol levels in Nigerian surgical patients.

BACKGROUND: Surgical procedures are associated with a complexity of stress response characterized by neurohumoral, immunologic, and metabolic alterations. AIM: The aim was to compare the effects on the stress response by isoflurane-based intratracheal general anesthesia (ITGA) and bupivacaine-based epidural anesthesia (EA), using cortisol as a biochemical marker. MATERIALS AND METHODS: Following the approval of the Hospital Ethical Board, informed written consent from patients recruited into this study was obtained. One group received general anesthesia with relaxant technique (group A) while the other group had bupicaine epidural anesthesia with catheter placement for top-ups (group B) for their surgeries. Both groups were assessed for plasma cortisol levels - baseline, 30 minutes after skin the start of surgery and at skin closure. RESULTS: There was no statistically significant difference in the baseline mean heart rate, mean arterial pressure (mean MAP) and the mean duration of surgery between the two groups; the baseline mean plasma cortisol level was 88.70 ± 3.85 ng/ml for group A and 85.55 ± 2.29 ng/ml for group B, P=0.148. At 30 minutes after the start of surgery the plasma cortisol level in the GA group was 361.60 ± 31.27 ng/ml while it was 147.45 ± 22.36 ng/ml in the EA group, showing a significant difference, P=0.001. At skin closure the mean plasma cortisol value of 384.65 ± 48.04 ng/ml recorded in the GA group was found to be significantly higher than the value of 140.20 ± 10.74 ng/ml in the GA group, P<0.002. CONCLUSION: Using plasma cortisol as a measure, bupivacaine-based epidural anesthesia significantly reduces the stress response to surgical stimuli when compared with isoflurane-based tracheal general anesthesia.

Mental distances and relationship to body mass index in young healthy Nigerian adults: a population based study.

AIM: This study was conducted to determine normal ranges of sterno-mental distance (SMD) and thyromental distance (TMD) and to examine the relationship of these measurements to each other and the body mass index (BMI). METHODS: The SMD, TMD and BMI were assessed in a total of 409 apparently healthy adult subjects comprising 218 male and 190 female participants who volunteered for the study. The parameters were measured by standard methods and the obtained data analysed for the degree of association using Pearson Correlation Statistics. RESULTS: Mean values of SMD and TMD were significantly higher in males than in females. The BMI was statistically same in both sexes. Sterno-mental distance correlated positively with TMD in both sexes (r = 0.86, p = 0.005) while BMI correlated negatively with SMD (r = -0.166, p = 0.108) as well as to the TMD (r = -0.147, p = 0.04) in both sexes. CONCLUSION: In young healthy adult populations the SMD and TMD are strongly related to each other but are unrelated to the BMI. Males tend to have on average longer SMD and TMD as compared to females. Our findings could be a useful tool during pre-anaesthetic airway assessment of patients.

Epidural anesthesia: views and outcomes of women in labor in a Nigerian hospital.

BACKGROUND: Pain during childbirth is a well known cause of dissatisfaction amongst women in labor. The use of epidural analgesia in labor is becoming widespread due to its benefit in terms of pain relief. METHOD: After approval of the local Ethics Committee on Research and obtaining informed written consent, 50 American Society of Anesthesiologists (ASA) class I-II consecutive multiparous women in labor requesting pain relief were enrolled in this prospective study. After providing description of the two options of pain relief available to them, they were allocated into two groups according to their request-to receive either parenteral opioid/sedative or epidural labor analgesia. Both groups received analgesia of choice at 4-cm cervical os dilatation. The epidural group received 0.125% plain bupivacaine, while the other group received pentazocine/promethazine intravenously. The time taken to locate the epidural space, catheter-related complications encountered and the amount of intravenous fluid used were documented. RESULT: The two groups were comparable in terms of socio-demographic data. The mean duration of the first and second stages of labor, respectively, were significantly shorter in the epidural group when compared with those in the non-epidural group ([P < 0.01] and [P < 0.02]). There was no difference in the rate of cesarean delivery between them - epidural analgesia (32% [8/25]) versus parenteral opioid/sedative (44% [11/25]), (OR, 0.60; 95% CI, 0.19-1.90). The maternal blood loss from delivery was minimal, with no statistical difference between the two groups (P = 0.27). The neonatal outcome was the same in both groups. Closed questionnaire showed that the overall experience of labor was much better (it was also better than expected) in the epidural group when compared with that in the non-epidural group (80% versus 4%). Eighteen (72%) women had inadequate pain relief in the non-epidural group as compared to 2 (8%) women in the epidural group. CONCLUSION: The study shows that epidural labor analgesia is acceptable to women in our setting. More women in the epidural analgesia group were satisfied with the experience of labor than those who did not receive this form of analgesia than among those who received parenteral opioid/sedative.

A clinical experience with epidural balloon in the localisation of the epidural space in labouring parturients.

UNLABELLED: Localisation of the epidural space is one of the key steps in the provision of epidural analgesia during childbirth. Many ingenious devices have been designed to improve the success of the puncture procedure. A clinical experience with a modified Macintosh epidural balloon in the localisation of the epidural space is described. METHOD: Fifty ASA Class I-II consecutive parturients requesting pain relief in labour were enrolled in this prospectively randomized study. They were allocated to receive either air (LORA) or epidural balloon (EB) to assist in the identification of the epidural space. The end-point for the EB was marked by the collapse of the balloon while this was depended on the loss of resistance felt on the syringe plunger in the LORA. The primary outcome was ease of epidural space identification and adequate pain relief between the two groups. RESULT: There were no statistical differences in age, height, weight, gestational age, gravidity and parity between the two groups. Twenty-two women in the EB group had a successful localisation at first attempt as compared to 14 women in the LORA group (p < 0.0126). The time taken to localise the epidural space was less in the EB than the LORA, (p < 0.0001). There were more Accidental Dural Punctures and failed blocks in the LORA group. The overall quality of block was better in the EB group. CONCLUSION: The epidural space was identified more often at the first attempt, and more swiftly, with the epidural balloon.

Caesarean section outcome in eclamptic patients: a comparison of infiltration and general anaesthesia.

BACKGROUND: Eclamptic patients undergoing caesarean delivery present extreme management problems for both obstetricians and anaesthetists. These problems reflect a poor maternal and perinatal outcome. OBJECTIVE: To determine outcomes following the use of infiltrative anaesthesia (gLA) compared with general anaesthesia (gGA) in eclamptic patients undergoing caesarean section. METHODS: Eclamptic patients scheduled for emergency caesarean section were prospectively studied. They were randomised into two groups to receive either infiltration with local anaesthetic or general anaesthesia for caesarean section. The protocol used for this study included clinical and sociodemographic data, chest examination prior to administration of anaesthesia, maternal and perinatal outcome, duration of maternal hospital stay and intraoperative blood pressure measurement. RESULTS: There were a total of 76 eclamptic patients in the study. There were no significant differences between the infiltration and general anaesthesia groups with regard to clinical and bio-socio-demographic parameters. Fourteen (40.0%) newborns in the gLA had lowerApgar scores in the first minute than 27 (73.0%) in the gGA group. Five (14.3%) newborns were stillbirths in gLA while 2 (5.4%) were found in the gGA. Twenty-one (60.0%) in gLA had Apgar scores e"8 compared to 10 (27.0%) in the gGA. The duration of hospital stay was longer in the gGA (17.1+/-4.1 days) than the gLA (13.0+/-1.6 days) with a statistically significant difference (p<0.0001). There were five (12.5%) maternal deaths in the gGA and two (5.0%) in the gLA. Intraoperatively, the mean arterial pressure and mean systolic pressure at skin incision were consistently and significantly higher in the gGA group than in gLA group. CONCLUSION: Local infiltrative anaesthesia appears to have a better maternal and perinatal outcome than general anaesthesia for eclamptic patients undergoing caesarean section.

Post-dural puncture headache following caesarean section in Nigerian parturients: A comparison of two spinal needles.

OBJECTIVE: The purpose of this study was to evaluate the role of needle diameter of the same tip configuration in the causation of Post Dural Puncture Headache (PDPH). METHODS: This prospective, single blind, randomised study compares the incidence of PDPH from two spinal needles (Becton Dickinson Whitacre sizes 25 G and 26 G needles) in obstetric patients. One hundred women undergoing elective and emergency Caesarean delivery under spinal anaesthesia were recruited. Each of the patients was interviewed using a standard questionnaire and reviewed until the seventh day postoperative. Both intraoperative and postoperative complications that occur were promptly treated. RESULTS: There was no significant difference in the number of attempts at insertion in both groups, although a shorter time was achieved in group25. PDPH occurred in 6.0% of those in group25. CONCLUSION: There was no difference in the insertion characteristics between the two needles.

Postpartum perineal pain in primiparous women: a comparison of two local anaesthetic agents.

BACKGROUND: Episiotomy is the commonest obstetric surgical operation performed to increase the introitus to enhance vaginal delivery. This study was to compare the effect of two local anaesthetic agents on postpartum perineal pain and time for demand for oral analgesics. METHODS: A randomized double-blinded controlled clinical trial was conducted in primiparous women who had spontaneous vaginal delivery, comparing 1% plain lidocaine and 0.25% plain bupivacaine infiltration for the repair of selective episiotomy or perineal injury. RESULTS: The two groups were comparable in sociodemographic characteristics. At 2 and 4 hours, women who had perineorraphy under lidocaine had significantly higher pain scores on the Visual Analogue Scale (VAS) than those who had the repair under bupivacaine, (4.0 v. 2.0)and(6.0 v. 3.0)respectively. At the 6h hour, the mean pain score for the bupivacaine group was 4.0 on the VAS while the lidocaine group had already received a dose of oral analgesic (Ibuprofen 400 mg) following severe pain from the repair. There was however no statistically significant difference in the pain score on the VAS between the two groups at the time of request for oral analgesics. The mean time lapse before demand for oral analgesics for the lidocaine group was 2.25 +/- 0.46 hrs (Mean+Standard deviation) while that for the bupivacaine group was 7.13 1.56 hrs (Mean Standard deviation). The P value was P < 0.0000 (Student's t-test) and statistically significant. CONCLUSION: It is concluded that the patients in the bupivacaine group had a prolonged analgesia and needed fewer doses of oral analgesics in the immediate postpartum perineal repair period.

Anaesthetic challenges in surgical excision of phaeochromocytoma

Background: Phaeochromocytoma is a rare tumour; which is benign but metabolically active; with a potential for malignancy. This tumour of adrenal or extra adrenal origin usually presents as hypertension; which can be sustained or paroxysmal and with lethal complications. Aim: To present an anaesthetic experience during the surgical resection of a phaeochromocytoma. Method: A 26-year old woman with phaeochromocytoma of the right adrenal gland is presented. The tumour was excised under general anaesthesia. The anaesthesia involved the use of continuous infusion of esmolol (an ultra short-acting intravenous cardioselective beta-antagonist) and propofol. The resected tumour was sent for histopathological examination. Results: The tumour was completely excised under general anaesthesia. The haemodynamic changes that occurred during tumour handling were controlled with fentany1;propofol/esmolol infusion. Histopathological findings confirmed phaeochromocytoma. Conclusion: Although; the anaesthetic and surgical management of a phaeochromocytoma could be an uphill task; it is possible in an environment with limit laboratory and intensive care facilities

Epidural anaesthesia for caesarean section in a patient with extreme cardiovascular and respiratory disease.

A 24-year old booked primigravida, with rheumatic heart disease in heart failure and lobar pneumonia presented in active labour. She was stabilized and prepared for an emergency Caesarean section that was successfully managed with Epidural Anaesthesia. She was admitted into the intensive care unit where the pneumonia and heart failure were managed by the physicians. The importance of proper follow up and treatment and, the need to perform more epidural techniques to meet the ever increasing challenges to the Anaesthetist are highlighted.

A monoblock resection for malignant phaeochromocytoma.

BACKGROUND: Phaeochromocytoma is a rare surgically treatable cause of hypertension. The aim of this paper is to present a case of phaeochromocytoma treated in Port Harcourt. METHOD: The case record of a patent with phaeochromocytoma and a review of the relevant literature. RESULT: A 40 year-old man presented with episodic malignant hypertension resistant to several anti-hypertensive drugs. A 24-hour urinary Vanillyl Mandelic Acid estimation was high at 68 mmol. An ultrasound scan revealed a huge right suprarenal mass. Preoperative medication was given to reduce the blood pressure and prevent perioperative arrhythmias. Under general anaesthesia with propofol, the tumour was explored. It appeared to invade the kidney and there were multiple hepatic secondaries. It was resected in block with the kidney. Intra- and postoperatively he had episodes of hypertension which were successfully controlled with a combination of intravenous chlorpromazine 50 mg, tramadol 100 mg and lorazepam 4 mg. Histopathology examination showed that the suprarenal mass and hepatic lesions were identical showing malignant phaeochromocytoma. The post-operative period was satisfactory. Cytotoxic drugs were not given because they were not available. On review 8 weeks later, the patient remained well. CONCLUSION: Meticulous anaesthetic and surgical skills are essential in the resection of a phaeochromocytoma.

Drug errors in anaesthetic practice: case reports.

BACKGROUND: Error is inherent in any complex human endeavour. It is therefore not unusual for these to occur in drug administration. We report three cases of such errors. METHOD: The anaesthetic record of 3 patients who had errors in drug administration and discussion of the relevant literature. RESULT: Through the years in anaesthetic practice at the University of Port Harcourt Teaching Hospital (UPTH), our Pharmacy has always supplied standard ketamine hydrochloride in a dark brown bottle containing 10 mls of the 5% solution. Suxamethonium chloride on the other hand was always supplied in a 2 ml clear glass ampoule. A change in this known packaging without prior notification resulted in near misses, all of which had the potential for serious morbidity. CONCLUSION: A strict adherence to standard procedure is necessary to minimize the risk, since there is no substitute for vigilance if morbidity and mortality is to be prevented.