Spirometric abnormalities in Jamaica children with SS and SC disease

Pulmonary complications are common in sickle cell disease. The cohort study in Jamaica is unique in seeing children with haemoglobin AA, SC and SS (control, SC disease and SS disease) regularly independent of acute illness. This allowed the controls to be used as an appropriate reference population for determining any abnormalities in spirometric measurements in children with SC and SS disease. Spirometry was performed on 50 controls, 56 children with SC disease and 77 children with SS disease. Age, height, weight, and gender were recorded for each child. Forced vital capacity (FVC), forced expiratory flow in the first second (FEV1) and forced expiratory flow from 25 percent to 75 percent (FEF 25-75) were measured. The results show that spirometric measures, FVC, FEV, and FEF are abnormal in children with SS and SC disease compared with values based on prediction equations derived from the control populations (AU)

Pulse oximetry in a cohort study of sickle cell disease

Oxygen saturation was determined by pulse oximetry in a representative sample of Jamaican patients with steady state sickle cell disease in a cohort study from birth. There were 220 with homozygous sickle cell (SS) disease and 142 with sickle cell-haemoglobin C (SC) disease aged 9-18 years, and 122 with a normal haemoglobin (AA) genotype aged 15-18 years. Pulse oximetry (SpO2) values were lower in SS disease (mean [95 percent confidence interval]), 92.5 [92.0-93.3]. Inhalation of 100 percent oxygen in SS patients with 02 saturations below 90 percent consistency increased saturation to 99-100 percent. In SS disease, Sp02 correlated positively with haemoglobin and fetal haemoglobin and negatively with reticulocyte counts but not MCHC, MCV or bilirubin level. Mean Sp02 in SS subjects with a normal alpha globin gene complement (mean[SD], 91.7 [3.9]percent) was lower than in heterozygotes (93.4 [4.0] percent) or homozygotes (96.1 [3.0] percent) for alpha+thalassaemia, the effects of alpha-thalassaemia not being explained by differences in haemoglobin or MCHC. In SS disease, Sp02 levels were not associated with age (within this age range), sex, number of sick clinic visits or number of hospital admissions. Higher Sp02 levels were associated with greater heights and weights, more frequent painful crises and less frequent acute chest syndrome, but these associations were not significant after adjustment for haemoglobin level. Desaturation is common in steady-state SS disease and knowledge of the individual's steady-state value may be important in the interpreting low value during acute complications.(AU)

Pulse oximetry in cohort study of sickle cell disease

Oxygen saturation was determined by pulse oximetry in a representative sample of Jamaican patients with steady-state sickle cell disease in a cohort study from birth. There were 220 with homozygous sickle cell (SS) disease and 142 with sickle cell- haemoglobin C (SC) disease aged 9-18 years, and 122 with a normal haemoglobin (AA) genotype aged 15-18 years. Pulse oximetry (SpO2) values were lower in SS disease (mean [95 percent confidence interval], 92.5 [92.0-93.0]) than in SC disease (96.7 [96.9-96.9]) or AA controls (97.1 [96.8-97.3]). Inhalation of 100 percent oxygen in SS patients with O2 saturations below 90 percent consistently increased saturation to 99-100 percent. In SS disease, SpO2 correlated positively with haemoglobin and fetal haemoglobin and negatively with reticulocyte counts but not with MCHC, MCV or bilrubin level. Mean SpO2 in SS subjects with a normal alpha globin gene complement (mean [SD], 91.7 [3.9] percent) was lower than in heterozygotes (93.4 [4.0] percent) or homozygotes (96.1 [3.0] percent) for O+ thalassaemia, the effects of O-thalassaemia not being explained by differences in haemoglobin or MCHC. In SS disease, SpO2 levels were not associated with age (within this age range), sex, number of sick clinic visits or number of hospital admissions. Higher SpO2 levels were associated with greater height and weight, more frequent painful crises and less frequent acute chest syndrome, but these associations were not significant after adjustment for haemoglobin level. Desaturation is common in steady-state SS disease and knowledge of the individual's steady-state value may be important in the interpreting low values during acute complications.(AU)

What is the prevalence and significance of oxygen desaturation in clinically well patients with sickle-cell disease? - abstract

The prevalence and significance of oxygen desaturation (SaO2) is unknown in asymptomatic patients with sickle-cell disease (SCD). Because of the invasive nature of measuring SaO2, until recently, insufficient data have been obtained on clinically well subjects with SCD. SaO2, was measured by pulse oximetry, on 913 occasions in 485 asymptomatic children (112 AA, 143 SC and 220 SS) aged 9.1-17.5 years during routine clinic visits. The SpO2 in SS disease (mean ñ SD 92.5 ñ 4.3 percent) was significantly lower than in AA (97.1 ñ 1.3 percent) or SC (96.7 ñ 1.4 percent) genotypes (0<0.001) and within genotype and within patient variance was greater. SpO2 did not correlate with age, sex or growth patterns nor with the frequency or "sick" visits to the clinic or with hospital admissions. Only a weak positive correlation with painful crisis and a negative one with acute chest syndrome were noted but none with the other major clinical manifestations of the disease. Oxygen desaturation < 95 percent was present in 74 percent of asymptomatic patients, and desaturation between 80 and 90 percent in 25 percent. The apparent lack of correlation with clinical severity casts doubt on the significance of these levels of desaturation in SCD, which may be a reflection of compensatory mechanisms (AU)

Adolescent blood pressure in a cohort study of sickle cell disease

BACKGROUND: Previous studies on low blood pressure in patients with homozygous sickle cell (SS) disease have sought new hypothesis on the mechanism of low blood pressure but have not analyzed the role of known determinants such as weight. METHODS: Blood pressure has been measured by an automated oscillometric method in 220 patients with SS disease, 144 with sickle cell-hemoglobin C disease (both groups aged, 9.5 to 18.5 years) and 122 control subjects with a normal hemoglobin genotype (aged 16.0 to 18.5 years) participating in a cohort study from birth. RESULTS: Significant age-related increases in systolic and mean arterial pressure occurred in sickle cell-hemoglobin C disease but not in SS disease. Further analysis were confined to a subgroup of 51 patients with SS, 41 patients with sickle cell-hemoglobin C, and 97 subjects with normal hemoglobin, aged 16.0 to 18.5 years in whom simultaneous measurements of height, weight, arm circumference, and hematologic test results were also available. Crude analysis showed significantly lower systolic, diastolic, and mean arterial pressure in SS disease compared with control subjects with normal hemaglobin, but further analysis showed the systolic difference to be confined to males and all differences disapperared after ajustment for weight. No difference occurred in sickle cell-hemoglobin C disease. CONCLUSIONS: These results suggest that the lower blood pressure in SS disease is attributable to low weight and that no further mechanisms need be postulated (AU)

Experience with abdominal field block for laparotomy in critically III patients: a preliminary report - abstract

Patients undergoing laparotomy are usually anaesthetized using conventional general endotracheal anaesthesia with controlled respiration and/or spinal or epidural block. When critically ill patients (ASAIV - V, Gold-mann's score > 26) present for abdominal surgery of short duration, these methods cannot be considered ideal; the associated cardio-respiratory instability and impaired neuromuscular function sometimes necesitate prolonged intubation and controlled respiration in the Intensive Care Unit (ICU). The complications of these were well-known. From June 1987 to November 1988, 25 patients of the above physical status (age range from 3 days to 81 years) had undergone abdominal surgery of short duration (30 to 110 minutes) under general anaesthesia and required ICU admission. Their stay in ICU was from 1 to 36 days. Thirteen died in the first admission, 3 required re-admission and died. At the end of the study, 9 patients were alive. There was clinical, radiological and autopsy evidence of pulmonary infection and ARDS in all these cases. Concurrently 12 patients, of similar physical status and age range ( 2 days to 82 years), were subjected to short abdominal procedures and Caesarean Sections (45 to 111 minutes) under abdominal-field-block. It was supplemented when necessary with "light" (patient arousable to command). All patients were returned to the ward after a short stay in the recovery room. There were 3 deaths, one on the 5th day and 2 on the 8th day; autopsy showed that these were due to the primary pathology. Abdominal-field-block seems a satisfactory technique in poor-risk patients for abdominal procedures of short duration. The avoidance of prolonged intubation, controlled respiration and their complications offer distinct advantages; it is also cost-effective (AU)

A proposed protocol and case report of the anaesthetic management of an HIV-positive patient

This report describes the anaesthetic mangement of an HIV-positive patient and proposes a protocol for the management that is suitable for the present working conditions in Jamaica (AU)

Anaesthetics and intensive care 1948-1988 - abstract

This paper will review the development of the Department of Anaesthetics and Intensive Care at the U.H.W.I. and the growth of the specialty of anaesthesia between 1948 and 1988 (AU)

Continuous supraclavicular brachial plexus block using indwelling cannulae for prolonged analgesia of the upper extremity - abstract

The upper extremity has a specially organized innervation, the brachial plexus, which can be easily blocked by a supraclavicular approach. However, its use for prolonged intra-operative and post-operative analgesia has only been recently explored. The rising costs of general anaesthetic agents and the associated hospital stay, together with the desirability of reducing, or eliminating, the need for systemic narcotic analgesics, prompted us to investigate prolonged brachial plexus analgesia. The method is inexpensive, usually not technically difficult, as safe as conventional local anaesthesia and suitable for both emergency and elective cases. A pilot study on 10 healthy patients was carried out between June and November, 1987. Patients of either sex, from 14 to 47 years old, were included. The three-dimensional approach to the brachial plexus of McIntosh and Mushin, using an intravenous cannula, was employed throughout. After injecting an initial test dose of local anaesthetic, the cannula was left in-situ for further "top up" doses, through a suitable injection port. Xylocaine (1-2 percent) was used for the initial block and bupivacaine, (0.5 percent) for the post-operative maintenance of analgesia. The mean dose of xylocaine for surgical anaesthesia was 5.42 mg/kg body weight, and the mean duration of anaesthesia 137.8 minutes. The mean time lapse to the first "top up" dose was 225.4 minutes and the mean duration of effect to the 2nd "top up" dose 412.5 minutes. No patient required more than two post-operative doses. This pilot study appears to be sufficiently promising to warrant a more extensive trial of prolonged brachial plexus analgesia (AU)

Should air-oxygen nitrous oxide-oxygen in general anaesthesia?

The use of compressed air-oxygen mixtures to replace nitrous oxide-oxygen in general anaesthesia was investigated in 378 patients. There were neither prolongations of recovery time nor instances of awareness under anaesthesia. The cost of general anaesthesia using compressed air-oxygen was about half that for nitrous oxide-oxygen mixtures.(AU)

Modification of the cardiovascular responses to general anaesthesia by transdermal nitroglycerine - abstract

Low dose, transdermal nitroglycerine (TD-NTG) in a "nitropatch" formulation was used in an attempt to ameliorate the hypertensive, tachycardiac response to tracheal intubation. Observations were also made to elucidate whether TD-NTG 5 mg has any effect on the subsequent period of general anaesthesia and recovery. TD-NTG 5 mg patches were applied to ten young, healthy patients with ten similar patients as controls. Premedication, induction and the first four minutes of anaesthesia were standardized. Systolic (SBP), diastolic (DBP) and mean (MAP) arterial pressures along with heart rate (HR) were measured at constant intervals. Rate-pressure product (RPP), as an indicator of myocardial oxygen consumption, was derived for each set of measurements. There was a short-lived, significant (p<0.05) rise in all variables in both groups, during intubation. This rise was significantly lower for all variables (except HR) between the two groups. The increase in HR was similar between the groups. There were no significant differences in the pre-induction or recovery-room measurements between the groups. No gross differences were noted during the course of anaesthesia after intubation. The only side-effect noted was slight headache in TD-NTG patients. TD-NTG patches are a useful addition to the anaesthetic armoury of drugs to control blood pressure during intubation. Their removal before induction from patients using them for the control of angina must be carefully considered in the light of the present study's findings of no adverse effects during general anaesthesia (AU)

Can compressed air/oxygen replace nitrous oxide/oxygen in general anaesthesia? a preliminary survey - abstract

The use of compressed air/oxygen mixtures to replace nitrous oxide/oxygen in general anaesthesia is investigated in 378 patients. There was no prolongation of recovery time nor instances of awareness under anaesthesia. The cost of general anaesthesia, using compressed air/oxygen mixtures was BDS$10.05 per patient while the cost of using nitrous oxide/oxygen mixtures was BD$20.11 per patient (AU)

Some medical and economic implications of oxygen therapy - abstract

Oxygen is widely used in hospital practice. This paper documents critically its use in a 500-bed teaching hospital in Kingston, Jamaica. Three aspects of oxygen therapy were examined, namely, the prescription and administration of oxygen, the condition and maintenance of oxygen equipment and lastly the supplies of oxygen to the hospital. It was apparent that the same thought and precision normally accorded the prescribing of drugs was not exercised in the case of oxygen, which often seemed to be given as a routine measure. It was also noted that both medical and nursing staff were often unfamiliar with the performance of oxygen equipment and not always able to supervise its use. Little awareness of the likely inspired concentrations delivered by oxygen equipment was found. Much of the equipment used for oxygen therapy, including anaesthetic machines, was found to be defective and no regular preventive maintenance was being carried out. As a result, there was an enormous wastage of oxygen as well as deficient therapy. There was an enormous rise in the cost of oxygen. The cost of a 100-cubic foot oxygen was found to have increased from J$3.3 in 1977 to J$14.8 in 1984, and its transportation cost from the manufacturing plant to the hospital from J$1,000 to J$4,000 per month. Since the cost of oxygen is likely to rise even further, serious consideration should be given to the installation of oxygen concentrators or possibly to the use of industrial grade oxygen. In addition, there is clearly a need for further education in the use of oxygen and for improved maintenance and operation of equipment used for oxygen therapy (AU)

Incidence of sickle cell-related sequelae in 60 patients with sickle cell disease following uneventful anaesthesia and surgery: a follow-up study - abstract

The precise relationship between the complications of sickle-cell disease and clinically uneventful anaesthesia and surgery is not clear. Patients with sickle-cell disease are susceptible to certain well-known complications such as infection or sickle-cell crises. The incidence of such sickle-cell-related complications (SCRC's) and their association with procedures requiring anaesthesia was carefully observed in 60 patients during all hospital admissions over the period July, 1978 to October, 1983. Fifty-five (SS) and 5 (SC) patients underwent surgical or major diagnostic procedures under anaesthesia. There were no intraoperative complications or deaths related to anaesthesia. There was on surgically related death due to concealed haemorrhage, and one death on the 8th postoperative day after open-heart surgery due to primary cardiac disease. Of the remaining 58 patients, 3 who underwent 5 procedures under anaesthesia, had no SCR's either before or after operation, or during the period of the study. Fifty-five patients suffered 89 SCRC's unrelated to anaesthesia and surgery. Three had 5 SCRC's related to pregnancy. Thirty-two had 43 SCRC's in the immediate preoperative period, none intraoperatively, and 19 suffered 33 SCRC's in the postoperative period. Twenty-one of 40 patients (53 percent) transfused had postoperative SCRC's and 12 out of 20 (60 per cent) of these were not transfused. The lower incidence of SCRC's in the postoperative period over that in the immediate preoperative period, or in circumstances unrelated to anaesthesia and surgery, suggests that any relationship between SCRC's and uneventful anaesthesia may be one of chance or may reflect individual patient susceptibility to SCRC's (AU)

Transtracheal ventilation using an intravenous canula and ambient air for managing asphyxia - abstract

Some patients may be impossible to intubate due to anatomical or pathological obstruction of the airway, and conventional methods of ventilation cannot be employed. One of us (J.H.) has successfully applied transtracheal ventilation in such an emergency. Under the circumstances it was not possible to measure the adequacy of ventilation by this method using arterial blood gas studies. A laboratory experiment using dogs was therefore devised. Five dogs acting as their own control were alternately ventilated by conventional expired air (mouth to endotracheal tube) (M.E.T.T.) and via a transtracheal cannula and insufflation of room air with a blood pressure cuff inflation bulb. (T.T.V.A.). The result showed an oxygen saturation of more than 80 percent in all cases and no significant difference in pH between the groups. There was a statistically significant differences in PO2 in two dogs (p<0.05) and in PCO2 in three instances )p<0.05). However, the differences in favour of M.E.T.T. did not appear clinically significant, and the quality of T.T.V.A. was certainly sufficient to sustain life for the duration of the experiments (AU)