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.

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.

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.

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.

An Audit of Anaesthetic Record Charts in the Orthopaedic Theatre of a Nigerian Teaching Hospital

Objective: The anaesthetic record is an essential part of a patient's record; providing useful information for the management of the patient. It is of medico-legal importance and can be used for quality assurance and researchpurposes. An analysis of anaesthetic record charts from a satellite operating theatre of the University of Port-Harcourt Teaching Hospital (UPTH) was undertaken to determine their legibility; correctness and completeness. Method: A retrospective analysis of the anaesthetic record charts from March 2003 to February 2004 of the orthopaedic theatre of the UPTH was undertaken. Results : A total of 232 anaesthetic record charts were analyzed. All entries were manually-written. Of these; 141 (60.9) were filled by anaesthetic registrars; the rest were filled by senior registrars 85 (36.5) and consultants 6 (2.6). One hundred and twenty-one charts (52.2) were legible; completely and correctly filled; but 47.8were incompletely filled; and 47.7had at least an illegible parameter. Conclusion: It is concluded from this analysis that the standard of anaesthetic record-keeping needs to be improved and consideration given to the use of computer-generated records which will eliminate the problems of illegible records

Total Intravenous Anaesthesia in a Developing Environment

Background: Total intravenous anaesthesia (TIVA) is a technique of anaesthesia which has become widely popular in the developed world with the availability of computerized infusion devices and appropriate drugs making its use easy and safe for the practitioner; and acceptable; tolerable and cost-effective for the patient. Such infusion devices and new drugs are not readily available in the developing world; although in Nigeria today; infusion devices may be obtained through medical equipment companies now established in the country; and opioids are available through the National Agency for Food; Drug; Administration and Control (NAFDAC).Aim: This paper aims to discuss TIVA giving insights into its practice in a developing economy without the use of sophisticated equipment and drugs; in order to encourage practitioners to use the technique. Method : At the 1st South-South regional anaesthesia conference in Calabar in July 2004; a symposium on TIVA in a developing economy was held as part of the conference. This review utilized literature from relevant texts and that obtained through Medline search. Results: This paper discusses TIVA highlighting aspects of its use in the developed world; and presenting its rather peculiar practice in our environment without the use of sophisticated equipment and opioid analgesics. Conclusion: TIVA is a unique technique of anaesthesia which is easy to master. It is cost-effective and safe. Hence; it is possible to use what is available in the developing environment to obtain what is necessary

Total intravenous anaesthesia in a developing environment

Background: Total intravenous anaesthesia (TIVA) is a technique of anaesthesia which has become widely popular in the developed world with the availability of computerized infusion devices and appropriate drugs making its use easy and safe for the practitioner; and acceptable; tolerable and cost-effective for the patient. Such infusion devices and new drugs are not readily available in the developing world; although in Nigeria today; infusion devices may be obtained through medical equipment companies now established in the country; and opioids are available through the National Agency for Food; Drug; Administration and Control (NAFDAC).Aim: This paper aims to discuss TIVA giving insights into its practice in a developing economy without the use of sophisticated equipment and drugs; in order to encourage practitioners to use the technique.Method: At the 1st South-South regional anaesthesia conference in Calabar in July 2004; a symposium on TIVA in a developing economy was held as part of the conference. This review utilized literature from relevant texts and that obtained through Medline search.Results: This paper discusses TIVA highlighting aspects of its use in the developed world; and presenting its rather peculiar practice in our environment without the use of sophisticated equipment and opioid analgesics.Conclusion: TIVA is a unique technique of anaesthesia which is easy to master. It is cost-effective and safe. Hence; it is possible to use what is available in the developing environment to obtain what is necessary

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.

Mechanical airway obstruction from the laryngeal mask airway cuff.

BACKGROUND: The laryngeal mask airway (LMA) classic has been found useful in airway management of both routine and emergency unexpected failed intubations. We report a case of mechanical airway obstruction from anterior in folding of the laryngeal mask airway classical cuff. METHOD: The anaesthetic record of a 55-year-old 70 kg female patient fora left sided total hip replacement that had a failed spinal and was augmented with the laryngeal mask airway. RESULT: Near complete airway obstruction developed after the size 4 laryngeal mask airway classic was inserted and the cuff inflated with 30 ml of air. The reduced reservoir volume and the desaturation that ensued as detected by the portable handheld pulse oximeter alerted the anesthesiologist and called for a check which was not corrected by any head and neck manoeuvre. On withdrawal of the laryngeal mask airway, the cuff was noted to have folded unto the fresh gas aperture thereby obstructing ventilation and oxygenation of the patient. CONCLUSION: Monitoring the monitors and quick reassessment of laryngeal cuff placement guaranties the evasion of anaesethetic catastrophes.

Abdominal actinomycosis; an unusual cause of intestinal obstruction

Background: Actinomycosis is a rare inflammatory disease caused by an anaerobic bacterium; Actinomyces israelii. Aim: To report a case of abdominal actinomycosis presenting as intestinal obstruction. Setting: University of Port Harcourt Teaching Hospital; Port Harcourt. Case report: A 54-year-old gentleman was involved in a road traffic accident in which he sustained fractures of the right humerus and pubic rami. A month later; he developed signs and symptoms of intestinal obstruction. At operation; a retroperitoneal mass obstructing the transverse colon and the proximal ileum was found and resected. Histological examination confirmed the mass to be due to actinomycosis infection. The patient was therefore placed on a parenteral therapy of 20 mega units of crystalline penicillin daily for three weeks and then a maintenance therapy of oral Amoxycillin for another six months. He recovered fully from the infection. Conclusion: Abdominal actinomycosis infection is an uncommon disease entity. Careful and expert histopathological analysis is essential in post operative diagnosis

Atlanto-occipital gap in Nigerians: Its relationship to difficult intubation

Background: Half of persons living with HIV/AIDS are below 25 years and majority of the remaining are believed to have been infected in their youth. The impact of HIV on young people has continued to generate increasing global medical; social; economic; political and academic interests. Aim: This paper reviews the pattern of existing documentation on HIV/AIDS regarding young people in Nigeria in presentations on this subject at international meetings and conferences. Methods: The review relied on a bibliography of 364 presentations from 17 books of abstracts and several solicited submissions; spanning 18 years; collated; indexed and published by the Nigerian Institute of Medical Research and the National Action Committee on AIDS. A matrix was constructed to categorize and tally the abstracts by several technical themes against the characteristics of the young people; aged 10 to 24 years that they reported on. Results: Eighty-five (23.5) out of the 364 were articles on adolescent/youths; the 18-year period; giving a rate of 4.7 articles per year. Regarding the context; 67 (78.8) concerned adolescents/ youths of both sexes. About half (47 or 55.3) were conducted among schooling adolescents/youths; and 23 (27.1) involved out-of-school youths. Twenty-three (27.1) titles were socio-medical research exploring knowledge; attitude; behaviour and practice; while three (3.5) were studies of biomedical nature; involving serologic investigations. Reports of interventions accounted for over half (47 or 55.3) of the presentations; most of which were on HIV awareness and prevention programmes. Conclusion: A low rate of reports on HIV/AIDS specific to young people at international conferences was observed; which does not reflect the level of importance and impact of the infection on this group of individuals. Amongst them; socio-medical studies; and interventions featuring awareness and prevention among schooling youths predominate. Interventions involving testing; treatment and care; and bio-medical studies especially involving vulnerable non-schooling youths; remain a challenge that must be faced

Epidural blood patch for post dural puncture headache: a handy ally [corrected].

BACKGROUND: Epidural blood patch is a well-known item in the management protocol of post dural puncture headache though never been practised or reported in our environment. The aim of this report is to document its efficacy and establish a rationale for its use. METHOD: A review of the case record of patients with post dural puncture headache and the relevant literature. RESULT: A case of post dural puncture headache was encountered at a free medical missionary outreach program following spinal anaesthesia for myomectomy. Having exhausted all the available conservative management options, she was offered epidural blood patch. The recovery profile was collected by assessment of her abilities and disabilities before and after the epidural blood patch, with visual analog scale for pain. The clinical condition improved a lot, with remarkable improvement in neck movement and the visual analog scale. CONCLUSION: We conclude that epidural blood patch is a superior therapy for post dural puncture headache and recommend that post-anaesthetic rounds be conducted routinely to identify complications and enable early institution of therapy.

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.

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.