Paediatric Cardiac Anaesthesia at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria: The Hurdles, Struggles, and Successes.

BACKGROUND: Open-heart surgery started at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) Ile-Ife, Nigeria, 5 years ago through partnership with foreign partners. This paper reviewed the difficulties facing the development of paediatric cardiac anaesthesia, the pattern, and the outcome of cases managed. METHODS: A review of the infrastructure, equipment, manpower and operational setup for open-heart surgery at OAUTHC was done. A retrospective study of all patients that were operated on from April 2016 to March 2021 was performed. Extracted data were analysed with Statistical Packages for the Social Scientists using descriptive statistics. RESULTS: A total of 102 patients had open-heart surgeries during the period under review by the various teams in a shared facility of the hospital's main theatre. Challenges with manpower, infrastructure, and supplies were major limitations to service delivery. Most of the patients (75.5%) were aged < 5 years. The commonest procedures performed were ventricular septal defect closure (31.4%), total correction of tetralogy of Fallot (26.5%), and atrial septal defect closure (9.8%). Fast-tracked anaesthesia was used always except where it was contraindicated. Most (76.7%) of the cases were extubated within 24 hours after surgery; the mean (SD) duration of ventilation in the ICU was 0.99 (1.2) days and the average length of ICU stay was 3 days. The overall mortality rate was 20.6%. CONCLUSION: Numerous challenges confront the provision of sustainable paediatric cardiac anaesthesia services in resource-constrained settings like ours. Much can be achieved with appropriate investment in material and manpower, and partnership with experienced teams.

CONTEXTE: La chirurgie à cœur ouvert a commencé au complexe hospitalier universitaire Obafemi Awolowo (OAUTHC) Ile-Ife, au Nigeria, il y a 5 ans grâce à un partenariat avec des partenaires étrangers. Cet article a passé en revue les difficultés rencontrées dans le développement de l'anesthésie cardiaque pédiatrique, le schéma et l'issue des cas pris en charge. MÉTHODES: Un examen de l'infrastructure, de l'équipement, de la main-d'œuvre et de la configuration opérationnelle pour la chirurgie à cœur ouvert à l'OAUTHC a été effectué. Une étude rétrospective de tous les patients opérés d'avril 2016 à mars 2021 a été réalisée. Les données extraites ont été analysées avec des progiciels statistiques pour les spécialistes des sciences sociales à l'aide de statistiques descriptives. RÉSULTATS: Au total, 102 patients ont été opérés à cœur ouvert au cours de la période étudiée par les différentes équipes dans une salle commune du bloc opératoire principal de l'hôpital. Les défis liés à la main-d'œuvre, à l'infrastructure et aux fournitures constituaient des obstacles majeurs à la prestation de services. La plupart des patients (75.5%) étaient âgés de < 5 ans. Les gestes les plus fréquemment pratiqués étaient la fermeture de la communication interventriculaire (31.4%), la correction totale de la tétralogie de Fallot (26.5 %) et la fermeture de la communication interauriculaire (9.8%). L'anesthésie accélérée a toujours été utilisée sauf en cas de contre-indication. La plupart (76.7%) des cas ont été extubés dans les 24 heures suivant la chirurgie ; la durée moyenne (ET) de la ventilation en USI était de 0.99 (1.2) jours et la durée moyenne de séjour en USI était de 3 jours. Le taux de mortalité global était de 20.6%. CONCLUSION: De nombreux défis font face à la prestation de services durables d'anesthésie cardiaque pédiatrique dans des contextes aux ressources limitées comme le nôtre. Beaucoup peut être réalisé avec un investissement approprié en matériel et en main-d'œuvre, et un partenariat avec des équipes expérimentées. MOTS-CLÉS: Pédiatrie, Anesthésie, Chirurgie Cardiaque, Nigéria, Pays en Développement.

Impact of Pain Management Workshop on the Knowledge and Attitude of Healthcare Workers and Opioid Utilization in a Nigerian Teaching Hospital.

BACKGROUND: Pain is a public health problem requiring serious attention. One major barrier to the provision of quality pain treatment in many countries is lack of training for healthcare workers. The aim of this study was to evaluate the impact of pain education on the knowledge and attitude of healthcare workers, and opioid utilization in a university teaching hospital. METHODS: Pain management workshops were conducted for healthcare workers over a 12-month period. The modified "Knowledge and Attitudes Survey Regarding Pain" questionnaire was administered to participants pre- and post- training for each of the workshops. The total mark by each participant was entered into the Statistical Package for Social Sciences (SPSS) software version 16 software for windows (SPSS Inc., Chicago, Illinois, USA) for comparison of means for pre- and post-test. Changes in opioid utilization were evaluated. RESULTS: The pre-test and post-test questionnaires were filled by 715 and 700 participants respectively. The mean post-test score was significantly higher than the pre-test score (68% versus 49% respectively, p = 0.00001). The doctors scored significantly higher than the other groups (p < 0.0001) in the pre-test. The mean post-test scores were significantly higher than the corresponding mean pre-test scores for the various groups (p < 0.0001). Sustained increase (up to 60.4%) in total morphine utilization was observed during the training. CONCLUSION: There is a wide knowledge gap requiring regular training and re-training to achieve improved pain management and opioid utilization among healthcare workers. Inclusion of robust pain curricula in medical training programs will significantly improve pain management.

Impact of basic life support training on the knowledge of basic life support in a group of Nigerian Dental Students.

UNLABELLED: Aim and Objetive: The burden of cardiac arrest remains enormous globally. Early recognition and prompt and effective cardiopulmonary resuscitation are crucial to successful outcome following a cardiac arrest. This study assessed the impact of basic life support (BLS) training on the knowledge of a group of dental students. MATERIALS AND METHODS: Sixty-eight dental students participated in this interventional study. Using convenience sampling, pre- and post-BLS training assessment were conducted with a questionnaire. RESULTS: The mean score (standard deviation) for pretest was 4.7 (±1.47) with a range of 2-8 out a total of 10, while the mean posttest score was 8.04 ± 1.47 with a range of 3-10. The differences were statistically significant (P < 0.01). There was a marked improvement in the knowledge of the respondents with 88.2% of them having a posttest score of ≥7. CONCLUSION: The results of this study suggest that the group of dental students' knowledge of BLS was very poor prior to the BLS training. The study also showed that the BLS training had a positive influence on the BLS knowledge of the participants.

Cleft care in Nigeria: past, present, and future.

OBJECTIVE: To review the progress of orofacial cleft care in Nigeria and propose a viewpoint for the future. DESIGN: Review of the available literature on cleft care in Nigeria and survey of the status of ongoing cleft care in Nigerian centers. We employed a pretested self-administered questionnaire sent and returned through electronic mail. PARTICIPANTS: Coordinators of cleft care centers in Nigeria. MAIN OUTCOME MEASURES: Findings of literature search and responses to mailed questionnaires. RESULTS: Available literature suggests that the fate of orofacial cleft patients during the precolonial era in Nigeria remains unclear. However, there is evidence of surgical care delivery just before the end of the colonial era. We identified and contacted 39 existing cleft care delivery centers, of which 30 (76.9%) responded. The majority (69.2%) of the responding centers began cleft care delivery between 2006 and 2010; 73.3% have designated cleft clinic locations and 66.7% offer interdisciplinary care. All responding centers offer cheiloplasty, while 86.7% offer palatoplasty. Other aspects of cleft care are provided sparingly in most centers due to paucity of manpower. Challenges with hospital administration, securing bed and theater spaces, drug availability, and performing laboratory investigations were the common limitations reported. CONCLUSIONS: We advocate for improved cleft care delivery through removing administrative bottlenecks, fortifying existing centers, and mentoring younger colleagues for entry into underserved specialties. Concerted effort and international collaborations aimed at transforming some of the existing cleft centers to standard pediatric craniofacial centers are desirable.

Unrecognised guide wire migration during internal jugular cannulation and its retrieval--a case report.

AIMS AND OBJECTIVES: The objective of this article is to report a case of unrecognised missed guide wire diagnosed two months after right internal jugular cannulation and which was successfully retrieved from the right femoral vein. PATIENT AND METHODS: The case record of a patient that had retained intravenous guide wire was reviewed with relevant literature. RESULT: A 40-yr-old female had an emergency left thoracotomy on account of haemorrhagic pleural effusion. A right internal jugular central venous catheter (CVC) insertion was performed for resuscitation and haemodynamic monitoring before induction of anaesthesia. A follow-up thoraco-abdominal Computed tomography (CT) scan taken after 8 weeks showed a pigtail intravascular metallic foreign body traversing the distal superior vena cava, right atrium, inferior vena cava, and ending at the right femoral vein. The guide wire was successfully removed via a right femoral venotomy under local anaesthesia. CONCLUSION: Intravascular loss of a guide wire is a rare complication of CVC insertion. If basic precautionary measures were taken, the loss of guide wire would have been avoided.

PERCEPTION OF NIGERIAN ANAESTHETISTS ON INTRA-OPERATIVE DEATH.

BACKGROUND: Intra-operative death is an unusual devastating occurrence in anaesthetic practice, and it is of serious concern when it happens. OBJECTIVES: To assess the causes, the effects and the perception of Nigerian anaesthetists to intra-operative death. DESIGN: A cross-sectional and questionnaire-based study. SETTING: Five University Teaching Hospitals in South-Western Nigeria. SUBJECTS: Nurse anaesthetists, resident doctors in anaesthesia and consultant anaesthetists. RESULTS: One hundred and five anaesthetists participated in the study (72.9% response rate). Seventy seven (73.3%) of the respondents had experienced an intra-operative death with most of them having five or more years of experience (p = 0.0001). Majority 53 (68.8%) of the respondents felt that the deaths were avoidable, and most deaths occurred mainly during emergency surgery (96.1%). Forty three (55.8%) of them were psychologically disturbed, fifty six (53.3%) respondents were of the opinion that it is reasonable for the anaesthetists involved not to take partin further surgery for that day. Sixty (57.1%) respondents considered discussion at mortality meeting as appropriate after an intra-operative death. CONCLUSION: This study showed that most anaesthetists would want those involved in the intra-operative death not to take part in further surgery for that day. Adequate preventive measures should be put in place with departmental or institutional policies on what to do after such events.

Oxygen supplementation during awake fibreoptic bronchoscopy in a Nigerian tertiary hospital.

BACKGROUND: Examination of the airway is necessary in a wide variety of conditions. This study was carried out to determine the need for oxygen supplementation during the conduct of flexible fibreoptic bronchoscopy on the awake patient. STUDY DESIGN: A prospective study of consecutive consenting patients requiring awake flexible bronchoscopy between January 2010 and December 2011 using a fibreoptic bronchoscope in the study centre was conducted. With the aid of transcutaneous pulse oximetry, baseline oxygen saturation values were recorded as well as at the various stages of the procedure as well as during brush cytology, washings, biopsy, transbronchial biopsies and transbronchial needle aspirations and 5, 15 and 30 minutes post-procedure. Data was analysed using SPSS 16 and significant values were taken at pd"0.05. RESULTS: Sixty-seven awake fibreoptic bronchoscopies were performed on 61 patients comprising 38 males and 29 females and a mean age of 51.9 ± 18.9 years. The lowest mean SPO2 of 91.2% was attained during brush cytology. Thirty- four patients (50.7%) had the procedure without oxygen supplementation. Supplemental oxygen was required in all seven patients with a baseline SPO2 of d"92% while it was required in 63.2% of patients with baseline SPO2 of 93- 96%. Baseline oxygen saturation was the most important predictor of the need for oxygen supplementation (p= 0.005). CONCLUSION: Routine oxygen supplementation is not mandatory for the safe conduct of flexible bronchoscopy. The baseline oxygen saturation value accurately predicts the need for oxygen administration.

Supplemental oxygen for caesarean section under spinal anaesthesia.

BACKGROUND: Routine administration of supplemental oxygen to parturients undergoing Caesarean section under spinal anaesthesia has been criticised in recent times. OBJECTIVES: To assess the need for routine supplementary oxygen in healthy women undergoing Caesarean section under spinal anaesthesia in resource challenged setting and establish the efficacy of administration of oxygen at 4L/min. DESIGN: Simple randomized trial using sealed envelopes. SETTING: The Obafemi Awolowo University Teaching Hospital; a 580 bed hospital situated in Ile-Ife in South-western Nigeria. SUBJECTS: Seventy parturients with ASA physical status I or II undergoing Caesarean section under spinal anaesthesia. MAIN OUTCOME MEASURES: Outcome measures were arterial oxygen saturation (SaO2) and Apgar scores at one and five minutes. RESULTS: The mean pre-induction arterial oxygen saturation in the two groups were similar. There was a statistically significant difference in the mean SaO2 at one minute between the two groups, with the control group being higher (97.7% +/- 1.5% versus. 96.7% +/- 1.5%; p-value = 0.008). The mean least SaO2 during surgery was also higher in the control group (95.9% +/- 1.5% versus 94.9% +/- 2.0%, p-value = 0.015). The Apgar score of the babies at one and five minutes for the study and control group were similar. CONCLUSION: Healthy parturients undergoing Caesarean section under spinal anaesthesia do well without supplemental oxygen; administration of supplemental oxygen from the common gas outlet of anaesthetic machine with the breathing circuit and standard anaesthetic facemask at 4L/min causes relative desaturation.

Feasibility study for a randomized clinical trial of bupivacaine, lidocaine with adrenaline, or placebo wound infiltration to reduce postoperative pain after laparoscopic cholecystectomy.

Background: Short-term pain relief can be achieved by local anaesthetic infiltration of port sites at the end of laparoscopic surgery. This study aimed to assess feasibility of performing an RCT to evaluate short-term postoperative analgesia after laparoscopic surgery in Nigeria using two local anaesthetics for port-site infiltration versus saline placebo. Methods: This was a placebo-controlled, patient- and outcome assessor-blinded, external feasibility RCT. Patients undergoing elective laparoscopic cholecystectomy for symptomatic ultrasound-proven gallstones were randomized into three groups: lidocaine with adrenaline (epinephrine), bupivacaine or saline control. The feasibility of recruitment, compliance with randomized treatment allocation, and completion of pain and nausea outcome measures were evaluated. Pain was assessed at 2, 6, 12 and 24 h after surgery using a 0-10-point numerical rating scale (NRS) and a four-point verbal rating scale. Nausea was assessed using NRS at the same time points. Clinical outcomes were assessed only in patients who received the correct randomized treatment allocation. Results: Of 79 patients screened for eligibility, 69 were consented and randomized (23 per group). Overall, compliance with randomized treatment allocation was achieved in 64 patients (93 per cent). All pain and nausea assessments were completed in these 64 patients. On the NRS, most patients had moderate to severe pain at 2 h (39 of 64, 61 per cent), which gradually reduced. Only six patients (9 per cent) had moderate to severe pain at 24 h. Conclusion: Recruitment, compliance with the randomized allocation, and completion of pain outcome measures were satisfactory. This study demonstrates the feasibility of conducting a surgical RCT in a resource-limited setting. Registration number: ISRCTN 17667918 (https://www.isrctn.com).