Anaesthetic Challenges Associated with Achondroplasia: A Case Report

We report the anaesthetic management of two achondroplastic patients who presented for emergency cesarean section. Regional anaesthesia could not be done in both cases as a result of technical difficulties and general anaesthesia was performed. Airway management was done with two different techniques following airway assessment. The perioperative periods were uneventful. We discuss the anaesthetic implications and problems associated with regional and general anaesthesia in achondroplastic parturients. The controversies in the anesthetic management of these patients are also highlighted (Afr. J. Reprod. Health 2010; 14[2]: 149-155).KEYWORDS: Emergency cesarean section, achondroplasia, difficult airway, subarachnoid block, General anesthesia

Intrathecal tramadol versus intrathecal fentanyl for visceral pain control during bupivacaine subarachnoid block for open appendicectomy

Context: Profound side.effects following intrathecal use of local anesthetics as the sole drugs of choice make spinal anesthesia for open  appendicectomy uncommon.Aim: The aim of this study was to evaluate the effectiveness of  intra-operative analgesia produced by intrathecal tramadol and fentanyl during bupivacaine spinal anesthesia for open appendicectomy.Settings and Design: A prospective randomized study was performed.Materials and Methods: A total of 186 American Society of  Anesthesiologists 1 or 11 patients scheduled for emergency open  appendicectomy were analyzed. Group FB (n = 62) received intrathecal fentanyl 25 µg plus 3 ml of 0.5% hyperbaric bupivacaine, Group SB (n = 62) received 0.5 ml normal saline plus 3 ml of 0.5% hyperbaric  bupivacaine and Group TB (n = 62) received intrathecal tramadol 25 mg plus 3 ml of 0.5% hyperbaric bupivacaine. Visual analog scale scores and frequency of subjective symptoms among patients in the three groups formed the primary outcome measure of this study.Results: Effective intraoperative sensory block was achieved in 100% of patients in group FB and TB while 29 (46.8%)patients in group SB had ineffective sensory block (P = 0.0001). The pain free period was significantly longer in patients inGroup FB than Group SB and TB. Mean time for Group FB with regard to first analgesic request was 304.73 ± 67.91 min,Group SB was 146.59 ± 36.62 and Group TB was 238.39 ± 61.28 min. Incidence of complications were comparableamong the three groups.Conclusion: This study showed that intrathecal tramadol (25 mg) can safely replace intrathecal fentanyl (25 ƒÊg) in themanagement of visceral pain and discomfort during subarachnoid block for appendicectomy.Key words: Analgesia, appendicectomy, intrathecal opioid, spinal anaesthesi

Evaluation of the gravimetric method of propofol infusion with intermittent ketamine injections for total intravenous anaesthesia (TIVA)

Forty four patients scheduled for elective surgery of short to moderate duration (< 90 minutes) were recruited into this study. Anaesthesia was induced with intravenous propofol 2.5mg/kg and maintained with continuous intravenous infusion of pre-mixed propofol and normal saline containing 2mg/ml of propofol. Suxamethonium 1mg/kg was used to facilitate endotracheal intubation. No long-acting muscle relaxant was used. Intravenous ketamine 0.5mg/kg stat dose was given for analgesic supplement, and 0.25mg/kg subsequent intermittent doses on signs of inadequate anaesthesia. The propofol infusion was stopped at the end of the surgery. Mean duration of anaesthesia was 56.5 \ub1 2.6 minutes while mean recovery time was 10.6 \ub1 4.6 minutes. The mean post-anaesthetic recovery scores (PARS) were 4.35/6, 5.17/6, 5.80/6 and 5.85/6 at admission to the recovery room and after 15 minutes, 30 minutes and discharge to the ward respectively. There were no incidents of extreme haemodynamic fluctuations or emergence phenomena noticed in any of the patients

Caudal analgesia for herniotomy: Comparative evaluation of two dose schemes of bupivacaine

Objective: There is currently a wide range of volume schemes for bupivacaine caudal anesthesia. This study evaluated the quality of caudal analgesia achieved with a dosing scheme of 0.75 ml/kg compared with 0.5 ml/kg of 0.25% plain bupivacaine for herniotomy.Methods: After the institutional approval, American Society of Anesthesiologists I–II patients aged between 1 and 6 years scheduled for unilateral inguinal herniotomy with consenting parents/guardian were recruited. The subjects were randomized to receive 0.5 ml/kg (Group 1) or 0.75 ml/kg of 0.25% bupivacaine. Anesthesia was maintained solely with halothane 0.5–1% in 100% oxygen. Postoperatively, pain was assessed using the objective pain scale (OPS). A favorable pain score was defined as <4 (8 point scale) or <5 (10 point scale). The primary outcome was the proportion of subjects with favorable pain scores.Results: Fifty‑six patients were enrolled and there was no difference in sociodemographic parameters, preoperative hemodynamic variables, or duration of surgery. Proportions of subjects with favorable OPS scores showed marked differences from 45 min and peaking at 180 min (11 [39%] favorable scores in Group 1 compared to all [100%] favorable scores in Group 2, P < 0.0001). Mean time to first analgesic requirement was 126 ± 34.2 min in Group 1 compared to 249 ± 23.7 min in Group 2 (P < 0.0001). There was no difference in the incidence of adverse events between groups.Conclusion: This study shows that 0.75 ml/kg of 0.25% plain bupivacaine is superior to the use of 0.5 ml/kg of the same concentration for postherniotomy caudal analgesia with low side effect profile.Key words: Bupivacaine, caudal anesthesia, herniotomy, postoperative analgesi

Understanding the Haemodynamic response to Laryngoscopy and Intubation –Review article.

This review is designed to present a concise description of the state of knowledge of the haemodynamic response to laryngoscopy and endotracheal intubation, with the aim of improving understanding of the phenomenon. Laryngoscopy and endotracheal intubation cause reflex increases in heart rate and blood pressure, as well as abnormalities of cardiac rhythm. While this is of little clinical consequence in healthy patients, it could be dangerous in patients with neurovascular and cardiac diseases. The physiological/ pathophysiological basis of the phenomenon, as well as the best methods of controlling it are not fully elucidated. It is however believed to be a reflex sympathetic and sympatho-adrenal response to airway stimulation or irritation. While the afferent limb of the reflex arc is via the cranial nerves of the upper airway, the efferent limb is via the sympathetic nerves. However, the central integrating station is not satisfactorily described in the literature. This is appraised, and we proffer opinion on the grey areas, based on present state of scientific/medical knowledge. We highlight the historical identification of the phenomenon as well as the development of knowledge about it over the years. We have assembled and appraised the various methods reported over the years to attenuate the pressor response to laryngoscopy and endotracheal intubation. We believe that a good understanding of the phenomenon is a sine qua non to managing it in individual patients

A follow-up programme for preventing post-operative anaesthetic complications in obstetric care

No Abstract

Incidence of obesity in parturients scheduled for caesarean section, intra-operative complications, management and outcome

Objectives: To determine the incidence of obesity in parturients scheduled for Caesarean section, identify intra-operative complications, management and outcome.Design: A prospective observational study.Setting: University of Benin Teaching Hospital, a university-affiliated tertiary centre. Subjects: Parturients scheduled for Caesarean section excluding patients in American Society of Anaesthesiologists (ASA) health status 4 and 5. Results: Three hundred patients were recruited in the study. One hundred and forty eight (49.3%) were non – obese (BMI 30kgm –2). The incidence of obesity was extremely significant

Vasovagal Bradycardia During Subarachnoid Anaesthesia for Myomectomy.

There is an increasing use of central neuraxial blocks for lower abdominal surgeries. Increased vagal tone under subarachnoid block is a well-known phenomenon and can have non-classical presentations. It can manifest with bradycardia, hypotension, bronchospasm, coronary artery spasm and cardiac arrest. In a patient with an additional underlying vagal predominance, disturbing intraoperative events such as peritoneal traction can complicate the situation, precipitating a vasovagal reaction of bradycardia and even cardiac arrest. We report a 30 year old Nigerian woman who had an elective myomectomy under subarachnoid anaesthesia. Intra operatively, she developed sudden bradycardia and cardiac arrest which were successfully managed. We propose that the bradycardia and cardiac arrest was secondary to a combination of the vasovagal effects of peritoneal traction in a patient with an increased vagal tone under spinal anaesthesia. We recommend prompt and effective management to ensure good outcome.Keywords: Vasovagal, bradycardia, subarachnoid anaesthesia, complications, parasympathetic nervous syste

Postoperative Analgesia using Bupivacaine Wound Infiltration with Intravenous Tramadol or Dexamethasone Following Obstetric Spinal Anaesthesia

Context: Effective management of postcesarean section (CS) pain is important for the well‑being of mother and child; even in limited‑resource areas, there are drug options which can be explored to achieve this. Aim: This study aimed to compare the analgesic effects of a combination of bupivacaine wound infiltration with either intravenous (IV) dexamethasone or tramadol after CS. Setting and Design: This study was a randomized, double‑blind, comparative study in a tertiary hospital. Clearance obtained from the Institution’s Ethics and Research Committee. Methods: One hundred and twenty American Society of Anesthesiologists I or II pregnant women scheduled for CS under spinal anesthesia were recruited after giving consent. At the end of skin closure, all the patients received 20 ml of 0.1% plain bupivacaine for wound infiltration and IV dexamethasone 8 mg (Group BD) or tramadol 100 mg (Group BT). Outcome measures were time to first analgesic request, visual analog scale (VAS) scores, side effects, and patients’ satisfaction. Results: Time to first analgesic request was 3.2 ± 1.87 and 3.3 ± 2.01 h for BD and BT groups, respectively (P = 0.778). VAS scores for the first 2 h were lower in the bupivacaine/tramadol group compared to bupivacaine/dexamethasone group; the differences were statistically significant at 30 and 60 min (P = 0.027 and 0.008), respectively. Ninety percent versus 93% of the patients in BD and BT groups, respectively, expressed good to excellent satisfaction with pain relief. Conclusion: Combination of bupivacaine wound infiltration and IV tramadol provided better quality pain relief.Keywords: Bupivacaine wound infiltration, cesarean section, intravenous dexamethasone, intravenous tramadol, postoperative pai

Are Nigerian Parturients afraid of Information Regarding the Complications of Spinal anaesthesia?

Background: Sufficient information regarding various aspects of an anaesthetic technique including possible complications is necessary in order for a patient to make decisions with regards to the choice of anaesthesia and to give fully informed consent. This study evaluated if parturients were informed of possible complications of subarachnoid block preoperatively and the extent of information desired with regards to the complications. They were also asked to assess the information provided by the anaesthetists regarding the complications and if detailed information regarding the complications would have affected their acceptance of subarachnoid anaesthesia.Patients and Methods: One hundred and fifty parturients who had subarachnoid anaesthesia were studied. Postoperatively, patients were asked to fill a questionnaire form concerning the complications associated with SAB. They were asked to indicate if the anaesthetist informed them of the possibility of complications, the complications they were aware of and the extent of information desired regarding the complications. They also indicated if detailed information regarding the possible complications would have affected their choice of anaesthesia.Results: Ninety seven patients (64.7%) stated that they were informed of the possibility of complications from SAB prior to the technique. Three of these informed patients assessed the information as detailed while 80 assessed it as adequate. With regards to the details of information desired before a subarachnoid block, 64% wanted to know all the possible complications. Thirty four of the patients (53.9%) who had complications were aware in advance that they could have those complications. No patient stated that awareness in advance with regards to complications would have altered their choice of anaesthesia.Conclusion: Our results indicate almost all our patients would like to be aware of the possible complications of subarachnoid anaesthesia. Only a few felt the information provided was detailed. The questionnaire form may be a useful tool for patient education, possibly during antenatal care.Keywords: Anaesthetic complications, informed consent, subarachnoid block, regional techniqu