The Effect of Pre-Incision Field Block versus Post-Incision Inguinal Wound Infiltration on Postoperative Pain after Paediatric Herniotomy

BACKGROUND: The Ilioinguinal/iliohypogastric nerve block has been shown to significantly decrease opioid analgesic requirements and side effects after inguinal herniotomy. We compared the effect of pre-incisional field block with 0.25% bupivacaine and post-incisional wound infiltration with 0.25% bupivacaine for postoperative pain control after inguinal herniotomy.PATIENTS & METHODS: This was a randomized controlled double blind study in 62 ASA I and II children aged 1-7 years scheduled for inguinal herniotomy. They were assigned to receive either pre-incision field block (group I) or post-incision wound infiltration at the time of wound closure (group II). The pain score was assessed in the recovery room using mCHEOPS score and VAS or FLACC score at home by the parents for 24 hours.RESULTS: The mean pain scores during the 2 hour stay in the recovery room, at 12 and 18 hours at home were similar in both groups, p > 0.05. However, the mean pain scores were significantly lower at 6 hours at home in group I (1.22 ± 0.57) than in group II (1.58 ±0.90), p <0.001, but significantly higher at 24 hours at home in group I (3.29 ± 0.46) than in group II (2.32 ± 0.24), p = 0.040.There was no difference in mean paracetamol requirement, and in the number of patients who required paracetamol for pain relief at home in both groups, p > 0.05.CONCLUSION: We have demonstrated that both pre-incisional ilioinguinal/iliohypogastric field block and post incisional wound infiltration provided adequate postoperative analgesia for 24 hours after inguinal herniotomy

Training and Confidence Level of Junior Anaesthetists in CPR- Experience in A Developing Country

Training in resuscitation is done worldwide by a dedicated council who is responsible for training and frequent recertification. Nigeria has no Resuscitation council and training is the responsibility of individual health institutions. There is no mandatory law on resuscitation training or recertification. This study sought to investigate how much training in CPR occurs, how effective this training is and how confident our anaesthetic trainees are in implementing present guidelines. A detailed questionnaire was anonymously filled by trainee anaesthetists who attended a revision course prior to postgraduate examinations. They answered questions on their length of training in anaesthesia, CPR training re-ceived, confidence in implementing existing guidelines and suggestions for improvement. Thirty -six trainees responded. Mean length of anaesthetic training was 3.55 ±2.39 years. 55.6% of trainees had received some CPR training. 75% of this was conducted by their anaesthetic department. Eleven trainees (30.6%) were confident in their ability to perform CPR according to 2005 guidelines, twelve (33.3%) had ever defibrillated a patient and only ten (27.8%) were confident in their ability to interpret ECG There is low confidence among junior anaesthetists in Nigeria in performance of CPR, poor knowledge of ECG interpretation of cardiac arrest rhythm and little practice in defibrillation. The establishment of a Resuscitation council would ensure adequate and frequent training which would improve knowledge, boost confidence and result in better patient care

Cleft deformities in adults and children aged over six years in Nigeria: Reasons for late presentation and management challenges

Wasiu L Adeyemo1, Mobolanle O Ogunlewe1, Ibironke Desalu2, Akinola L Ladeinde1, Bolaji O Mofikoya3, Michael O Adeyemi4, Adegbenga A Adepoju4, Olufemi O Hassan41Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, 2Department of Anaesthesia, 3Department of Surgery, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria; 4Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos, NigeriaAbstract: In developing countries, untreated cleft lips and palates are found with increasing frequency and patients often present to the surgeon far past the optimal time for closure of the cleft deformities. A prospective study was conducted between March 2007 and September 2009, to identify the reasons and treatment challenges of delayed presentation of cleft lip and palate deformities at the Lagos University Teaching Hospital, Nigeria. Out of a total of 150 patients with cleft defects during the period, 43 (28.7%) were adults and children aged over six years. The mean age of these patients at the time of presentation was 17.3 years. The most common reasons for late presentation were lack of money (56.7%), lack of health care services nearby (18.4%), and lack of awareness of treatment availability (13.3%). Common challenges in these patients included surgical, orthodontic, speech, anesthetic, and psychological. Although adult clefts were significantly enlarged in three dimensions the anatomic landmarks were easier to discern than in an infant. However, extensive soft tissue dissection in adult cleft lip repair resulted in significant postoperative edema. Closure of wide palatal cleft often required the use of adjunct intraoral flaps. Despite late presentation, surgical outcome of these patients was satisfactory and comparable to cleft repair in infants.Keywords: cleft deformities, adults, adolescents, late presentation, management, challenge

Tapia's syndrome after surgery for recurrent pleomorphic adenoma of the parotid gland

Tapia's syndrome consists of concurrent injury to the recurrent laryngeal and hypoglossal nerves. Trauma as a result of direct pressure from inflated cuff of the tracheal anesthetic tube and/or overextension of the neck during surgery have been reported to be possible causes of this syndrome. Here, we report a case of Tapia's syndrome following surgical excision of a very large recurrent parotid tumor. The aim of this report is to draw the attention of head and neck surgeons and anesthetists to this often unexpected condition. A 30-year-old female presented to the surgical outpatient clinic of the Lagos University Teaching Hospital with a massive, multinodular, right facial swelling. There was no sensory or motor nerve paresis on presentation. The patient underwent surgical excision of the swelling under general anesthesia. Two hours after extubation, the patient had difficulty moving the entire tongue and had difficulty with phonation. A working diagnosis of Tapia's syndrome was made based on clinical presentation and assessment. The patient was reassured and placed on tablets neurobion three times daily and tablets prednisolone 20 mg daily. Fourteen days after surgery, hoarseness of voice had resolved completely and full tongue control returned after 2 months. Tapia's syndrome must be considered, especially by all head and neck surgeons and anesthetists even though it is usually a rare complication of surgery

Critical incidents and near misses during anesthesia: A prospective audit

Background: A critical incident is any preventable mishap associated with the administration of anesthesia and which leads to or could have led to an undesirable patients' outcome. Patients' safety can be improved by learning from reported critical incidents and near misses. Materials and Methods: All perioperative critical incidents (excluding obstetrics) occurring over 5 months were voluntarily documented in a pro forma. Age of patient, urgency of surgery, grade of anesthetist, and patients' outcome was noted. Results: Seventy-three critical incidents were recorded in 42 patients (incidence 6.1% of 1188 procedures) with complete recovery in 88.1% (n = 37) and mortality in 11.9% (n = 5). The highest incidents occurred during elective procedures (71.4%), which were all supervised by consultants, and in patients aged 0–10 years (40.1%). Critical incident categories documented were cardiovascular (41.1%), respiratory (23.25%), vascular access (15.1%), airway/intubation (6.85%), equipment errors (6.85%), difficult/failed regional technique (4.11%), and others (2.74%). The monitors available were: pulse oximetry (100%), precordial stethoscope (90.5%), sphygmomanometer (90.5%), capnography (54.8%), electrocardiogram (31%), and temperature (14.3%). The most probable cause of critical incident was patient factor (38.7%) followed by human error (22.5%). Equipment error, pharmacological factor, and surgical factor accounted for 12.9%. Conclusion: Critical incidents can occur in the hands of the highly skilled and even in the presence of adequate monitoring. Protocols should be put in place to avoid errors. Critical incident reporting must be encouraged to improve patients' safety and reduce morbidity and mortality

Central venous catheter insertion in critical illness: Techniques and complications

Background: Werner Forssman, in 1929, first described central venous catheter (CVC) insertion when he canalized his own right atrium through the cephalic vein. It is now a routine procedure in critical care. We investigated the pattern of insertion of CVC in our intensive care unit. Patients and Methods: A prospective observational study conducted in a 5-bed general intensive care unit of a 770-bed university teaching hospital. All prospective patients admitted from January 2013 to June 2014 were recruited. The technique, site and complications following insertion were documented. All had postprocedure chest radiography performed to confirm catheter tip position. Results: The most common site and technique of CVC insertion were the right internal jugular vein (IJV) 71 (79.8%), and the anatomic landmark (AL) 66 (74.2%), respectively. The mean catheter depth was significantly shorter in the AL (15.0 ± 2.4) cm than the Peres' formula (16.5 ± 3) cm, P = 0.046. Catheter tips were correctly placed at the carina in 62 (69.7%) patients. The complication rate was 28 (31.5%), which was significantly higher in males 25 (45.5%) than females 3 (8.9%), P = 0.03, and increased by 57.9% with attempts >2. The most common complications were failure to insert 9 (10.1%), right carotid artery puncture (8.9%), and arrhythmias (5.9%). Pneumothorax was reported in (4.5%), all occurred with the subclavian approach. Conclusion: Central venous catheter insertion is more common through the right internal jugular vein, and with the anatomical landmark technique. The complication increased with attempts >2, male gender, and subclavian approach

Endotracheal intubation in the prone position, in a patient with a high-velocity missile injury to the abdomen and thorax

The airway management in prone position secondary to penetrating posterior thoracic injury is challenging to the anesthetist. We described a successful endotracheal intubation under direct laryngoscopy at first attempt in the prone position in a 25-year-old male with a 6-foot hollow metal impacted in the right posterolateral thorax

Laparoscopy‑assisted Transanal Endorectal Pull‑through for the Management of Hirschsprung’s Disease in Nigeria: Report of Two Cases

Hirschsprung's disease is a relatively common disease in pediatric colorectal surgery. The treatment modalities have evolved from third-stage to single-stage in the past three decades. The single-stage procedure can be performed using the open, transanal or laparoscopy–assisted techniques. We use these cases to illustrate the first laparoscopically assisted procedures for Hirschsprung's disease in our center. The laparoscopic-assisted technique is described, and lessons in collaboration across institutions and within institutions are discussed

Frequency of homologous blood transfusion in patients undergoing cleft lip and palate surgery

Aim: The study aims to determine the frequency of homologous blood transfusion in patientsundergoing cleft lip and palate surgery at the Lagos University Teaching Hospital, Nigeria. Setting and Design: A prospective study of transfusion rate in cleft surgery conducted at the Lagos University Teaching Hospital, Nigeria. Material and Methods: One hundred consecutive patients who required cleft lip and palate surgery were recruited into the study. Data collected included age, sex and weight of patients, type of cleft defects, type of surgery done, preoperative haematocrit, duration of surgery, amount of blood loss during surgery, the number of units of blood cross-matched and those used. Each patient was made to donate a unit of homologous blood prior to surgery. Results: There were 52 females and 48 males with a mean age of 64.4 ± 101.1 months (range, 3-420 months). The most common cleft defect was isolated cleft palate (45%) followed by unilateral cleft lip (28%). Cleft palate repair was the most common procedure (45%) followed by unilateral cleft lip repair (41%). The mean estimated blood loss was 95.8 ± 144.9 ml (range, 2-800ml). Ten (10%) patients (CL=2; CP=5, BCL=1; CLP=2) were transfused but only two of these were deemed appropriate based on percentage blood volume loss. The mean blood transfused was 131.5 ± 135.4ml (range, 35-500ml). Six (60%) of those transfused had a preoperative PCV of < 30%. Only 4.9% of patients who had unilateral cleft lip surgery were transfused as compared with 50% for CLP surgery, 11% for CP surgery, and 10% for bilateral cleft lip surgery. Conclusions: The frequency of blood transfusion in cleft lip and palate surgery was 10% with a cross-match: transfusion ratio of 10 and transfusion index of 0.1. A "type and screen" policy is advocated for cleft lip and palate surgery