Spinal Anesthesia Using Ultra-Low-Dose Isobaric Bupivacaine with Intrathecal Morphine-Fentanyl for Bilateral Low Extremity Procedures in a Geriatric Patient with Recent Myocardial Infarction and Percutaneous Coronary Intervention.

A recent inferior ST-elevation myocardial infarction and percutaneous coronary intervention in an elderly female patient scheduled for bilateral lower extremity operations simultaneously represent significant risks for re-infarction and mortality. Our index patient required an above-knee amputation of the left leg to prevent infection/progressing gangrene as well as application of a back-slab for the conservative management of a fractured right femur. We employed spinal injection of ultra-low-dose 0.5% isobaric bupivacaine 4 mg with morphine 75 mcg plus fentanyl 10 mcg which provided adequate anesthesia for radical amputation, effective postoperative analgesia and good hemodynamic stability.

Specialty preferences among medical students in Botswana.

BACKGROUND: With the establishment of a new medical college in Botswana to train generalist-doctors and specialists, we set out to explore the career preferences of medical students, factors that influence their choices and attitude to local postgraduate training. METHODS: A descriptive cross-sectional questionnaire-based study was conducted among medical students in their third to fifth year, at the Faculty of Medicine, University of Botswana. The structured, self-administered questionnaires which were hand-delivered covered demographic characteristics of responders, career choices, preferred location of specialisation and factors that influenced the choices. RESULTS: Of the 143 medical students approached, 116 (81.0%) returned completed questionnaires. Of the responders, 102 (87.9%) intend to pursue postgraduate specialisation against 2 (1.7%) who declined; 12 (10.3%) were undecided. The four most preferred specialties which constituted 68.1% were surgery (28.4%), paediatrics (19.0%), internal medicine (12.9%), obstetrics and gynaecology (7.2%). There was male preference for surgery (p = 0.04), while women were drawn more towards paediatrics and psychiatry (p = 0.04 and p = 0.01, respectively). Personal interest and aptitude was considered the most important factor among most responders (46.2%), followed by enjoyment of the posting (19.8%). A high proportion of responders 80 (69.0%) preferred to specialise abroad for better exposure/opportunities (48.3%), while for 15.5%, their preferred courses are not currently available locally. CONCLUSION: Our findings indicated that while four major specialties are preferred, significant gender differences exist with female students leaning towards non-surgical disciplines. Students prefer specialising abroad on the pretext that foreign centres offer better training opportunities, and many specialist programmes are unavailable locally.

Polypharmacy among children and adolescents with psychiatric disorders in a mental referral hospital in Botswana.

BACKGROUND: There is a dearth of data on polypharmacy in child and adolescent mental health in Africa, especially Botswana where children and adults are treated in the same facility by general adult psychiatrists. This study was therefore designed to assess the prevalence and the risk factors of psychiatric polypharmacy among children and adolescents treated at Sbrana Psychiatric Hospital, Lobatse, Botswana. METHODS: Data involving socio-demographics, diagnosis (using ICD-10 classification) and pharmacological treatment were retrieved from the records of 120 children and adolescents aged below 18 years, between 1 January 2012 and 31 July 2016, who presented with psychiatric disorders. They were analysed with univariate and multivariate models. RESULTS: The prevalence of psychiatric polypharmacy was 29.2%. Psychiatric co-morbidity (OR = 3.374, 95% CI: 1.177-9.9673) and psychotropic side effects (OR = 5.782, 95% CI: 1.636-20.430) were significantly associated with polypharmacy after regression analysis. CONCLUSION: Psychiatric co-morbidity and psychotropic side effects were significant risk factors for polypharmacy in Botswana.

Single-shot lamina thoracic paravertebral block with ketofol for modified radical mastectomy.

We describe the use of single-shot lamina thoracic paravertebral block (TPVB) with sedation for a 56-year-old female patient who had modified radical mastectomy with axillary clearance. Two years ago, she suffered vocal cord palsy post thyroidectomy, which was managed with tracheostomy. The tracheostomy tube was removed 8 months later, leaving the patient with persistent hoarseness of voice and left vocal cord palsy. She declined general anesthesia and consented for TPVB. The surgery lasted 95 minutes and was successfully completed with TPVB. Her vital signs were stable during the operation. She had low pain scores, minimal opioid use, early alimentation, and no postoperative nausea and vomiting and was discharged early. We present the anesthetic management of this case in our setting, where TPVB under ultrasound guidance and modern drug-delivery systems for sedation are unavailable.

Preoperative fasting times in elective surgical patients at a referral Hospital in Botswana.

INTRODUCTION: Adults and children are required to fast before anaesthesia to reduce the risk of regurgitation and aspiration of gastric contents. However, prolonged periods of fasting are unnecessary and may cause complications. This study was conducted to evaluate preoperative fasting period in our centre and compare it with the ASA recommendations and factors that influence fasting periods. METHODS: This is a cross-sectional study of preoperative fasting times among elective surgical patients. A total numbers of 260 patients were interviewed as they arrived at the reception area of operating theatre using questionnaire. RESULTS: Majority of patients (98.1%) were instructed to fast from midnight. Fifteen patients (5.8%) reported that they were told the importance of preoperative fasting. The mean fasting period were 15.9±2.5 h (range 12.0-25.3 h) for solids and 15.3±2.3 h (range 12.0-22.0 h) for liquids. The mean duration of fasting was significantly longer for patients operated after midday compared to those operated before midday, p<0.001. CONCLUSION: The mean fasting periods were 7.65 times longer for clear liquid and 2.5 times for solids than the ASA guidelines. It is imperative that the Hospital should establish Preoperative fasting policies and teach the staff who should ensure compliance with guidelines.

Epidemiology of road traffic crashes among long distance drivers in Ibadan, Nigeria.

BACKGROUND: Road Traffic Crashes (RTCs) are major causes of morbidity and mortality in Nigeria. Few studies in Ibadan have focused on the distribution and determinants of RTC among long distance drivers. OBJECTIVE: To describe the distribution of crashes by place, times of occurrence, characteristics of persons involved and identify associated factors. METHODS: A cross-sectional study was carried out among consenting long distance drivers within selected parks in Ibadan. RESULTS: Respondents (592) were males, with median age of 42.0 years (range 22.0-73.0 years). Secondary education was the highest level of education attained by 38.0%. About 34.0% reported current use of alcohol. The life-time prevalence of crashes was 35.3% (95% CI= 31.5-39.2%) and 15.9% (95% CI=13.1-19.0%) reported having had at least one episode of crash in the last one year preceding the study. The crash occurred mainly on narrow roads [32/94 (34.0%,)] and bad portions of tarred roads [35/94 (37.2%,)] with peak of occurrence on Saturdays 18/94 (19.1%,). Significantly higher proportions of drivers aged ≤39years (23.4%) versus >39years (11.7%), those with no education (29.9%) versus the educated (13.8%) and those who reported alcohol use (21.9%) versus non users (12.8%) were involved in crashes in the year preceding the study. Significant predictor of the last episode of crashes in the last one year were age (OR=2.2, 95% CI=1.4-3.5), education (OR=2.7, 95% CI=1.5-4.6) and alcohol use (OR=1.8, 95% CI=1.2-3.0). CONCLUSION: Road traffic crashes occurred commonly on bad roads, in the afternoon and during weekends, among young and uneducated long-distance drivers studied. Reconstruction of bad roads and implementation of road safety education programmes aimed at discouraging the use of alcohol and targeting the identified groups at risk are recommended.

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

BACKGROUND: In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. METHODS: This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). RESULTS: Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). CONCLUSIONS: The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.

Combined spinal-epidural analgesia for laboring parturients in a Nigerian Hospital.

BACKGROUND: Awareness and demand for neuraxial pain relief for labor are on the increase, but epidural technique appears to be the preferred option among anesthetists in Nigeria. We describe our experience with combined spinal-epidural (CSE) analgesia to fill the gap in knowledge in order to boost its utilization. MATERIALS AND METHODS: In this retrospective observational study, data were collected from the obstetric analgesia proforma completed for all CSE analgesia performed for labor pain relief between January 1, 2011 and June 30, 2014. RESULTS: Thirty parturients (21 nulliparous: 9 parous) with a singleton gestation in labor with a mean age of 31.0 ± 4.1 years were studied. In all, 56.7% of parturients requested for analgesia following oxytocin augmentation. The overall mean onset of analgesia and cervical os dilatation at initiation of analgesia were 2.23 ± 0.43 min and 3.4 ± 1.3 cm respectively, with no significant difference between groups. Overall analgesia was adequate in 90% of cases, and 76.7% had spontaneous vaginal delivery; although only nulliparous parturients (23.3%) had cesarean delivery, it was not significant (P = 0.07). There was a significant difference in Apgar score at 1-min between nulliparous and parous groups (7.7 vs. 8.9; P = 0.03), but no difference at 5-min. The side effects observed were vomiting and shivering. CONCLUSION: CSE technique can be safely used in every laboring parturient irrespective of parity either in early or late labor situations.

Job satisfaction among anesthesiologists at a tertiary hospital in Nigeria.

BACKGROUND: We assessed job satisfaction among anesthesiologists at a tertiary hospital in Nigeria and identified elements of job stress and dissatisfaction. METHODS: A cross-sectional study design was employed; a structured self-administered questionnaire was distributed, which focused on sociodemographic data, rating of job satisfaction, identification of stressors, and work relationships. RESULTS: Out of 55 questionnaires distributed, 46 (83.6%) completed questionnaires were returned. Overall, 27 (58.7%) of the anesthesiologists were satisfied with their job. While 8.7% were very satisfied (grade 5), 6.5% were very dissatisfied (grade 1) with their job. The stressors identified by the respondents were time pressures, long working hours with complaints of insufficient sleep, and employment status. Among the respondents, the medical officers were the most discontented (9 out of 12, 75%), followed by senior registrars (5 out of 9, 56%). A high percentage of participants (54.1%) declared that the one change if implemented that would enhance their job satisfaction was having a definite closing time. CONCLUSION: Our results showed that despite the demanding nature of anesthesiology as a specialty, many anesthesiologists were contented with their job.

Interscalene block for shoulder surgery.

Fracture dislocation of the shoulder is a common musculoskeletal injury following road traffic accident. Peripheral nerve block has become a recognized anesthetic technique due to the rapid onset of prolonged analgesia, sufficient for both pain and surgical management. However, interscalene block for shoulder surgery has not been reported as a primary anesthetic technique in our environment. We report its successful use in open reduction and internal fixation of left humeral surgical neck fracture dislocation. The interscalene brachial plexus were localized by a Polystim II nerve stimulator (te me na, Bondy, France) with sustained biceps motor response at 0.2 mA and 40 ml of local anesthetic, comprising 0.25% bupivacaine and 1.0% of lidocaine with 1 : 200,000 epinephrine in equal parts was administered to establish the block. Surgical anesthesia was achieved 18 minutes after instituting the block and surgery lasted 70 minutes without complications. This technique may obviate the use of general anesthesia with its risks.

Spinal anesthesia in children: no longer an anathema!

BACKGROUND: Spinal anesthesia is underutilized for surgery in children in Nigeria. Until recently, only caudal and general anesthesia are employed in the pediatric age group, and the thought of spinal anesthesia was an anathema. This study evaluated cardiovascular changes, duration of spinal block, the length of surgery, length of spinal needle to establish lumbar puncture, and the incidence of complications associated with this procedure. METHODS: Thirty-two children ASA 1 and 2 between the ages of 2 and 12 had spinal block from August 1, 2008 to February 28, 2010 for orthopedic and plastic surgical procedures. Spinal block was carried out at L5/S1 interspace, and the dose of bupivacaine was 0.5 mg·kg(-1). RESULT: Satisfactory surgical anesthesia was achieved in 31 of 32 children. There was no sensory or motor block within 10 min in one child, despite an easy lumbar puncture necessitating the use of general anesthesia. No patient showed oxygen desaturation, bradycardia, or hypotension. Two (6.5%) children aged 5 and 8 reported mild, position-dependent headaches, 3 (9.7%) had nausea and vomiting, and 5 (16.1%) had postspinal shivering. There was a positive correlation between the size of the child and the needle length to establish spinal anesthesia (r = 0.7, P = 0.0001). CONCLUSION: This study demonstrates that spinal anesthesia in children causes minimal hemodynamic disruption and therefore is a safe technique for lower extremity surgeries. This technique that hitherto has not been popular with children in our environment has been found to be safe and equally effective.

The use of regional anesthesia by anesthesiologists in Nigeria.

There is growing interest in the use of regional anesthesia worldwide. With this survey, we determined the use of regional techniques among anesthesiologists in Nigeria using a cross-sectional study design. A self-administered questionnaire was mailed to a randomly generated list of anesthesiologists in Nigeria. From 196 questionnaires, 140 anesthesiologists (71.4%) responded. Regular use of spinal, epidural, and peripheral nerve blocks was 92.9%, 15%, and 2.9%, respectively. A high percentage of respondents (47.1%) had never performed a nerve block and only 31.4% had used a nerve stimulator technique. Limited exposure to equipment and techniques accounted for their lack of use.