Oral ketamine for wound care procedures in adult patients with burns

Background: This prospective study was carried out to evaluate the usefulness of oral ketamine for burn wound dressing in adult patients. The aim was to achieve a state-of-conscious sedation in which the patient would be communicative and cooperative, with minimal, or no pain during burn wound care procedures. Method: Two hundred and forty wound care procedures were randomly assigned to six treatment groups of patients (groups A-F). The quantities of oral ketamine that they received were as follows: Group A, 0.5 mg/kg; B, 2 mg/kg; C, 4 mg/kg; D, 6 mg/kg; E, 8 mg/kg and F, 10 mg/kg. A five-point verbal rating scale was used to assess pain intensity: the AVPU (alert, voice, pain, unresponsive) scale for level of consciousness. The Likert scale was used for patient satisfaction. Blood pressure, pulse rate and oxygen saturation were monitored. Adverse effects were noted. Comparisons of the efficacy and safety of the different dosages of oral ketamine were made using the SPSS package. The efficacy criterion was verbal rating scale (VRS) ≤ 2, i.e no pain, mild pain or discomfort. Results: Patients in groups A and B reported higher levels of pain, and in groups C, D, E and F, there were varying degrees of efficacy. Groups E and F had the best analgesic profiles, but at the higher doses, some patients became anaesthetised. The most common adverse effects reported were hallucination (37%) and hypersalivation (29.9%), which occurred more frequently in groups E and F. The patients’ assessments of pain were best in Group D, and worst in Group A. Conclusion: The minimum effective subanaesthetic dose of oral ketamine for analgesia during wound care procedures in adult patients with burns was 6 mg/kg.Keywords: burns, wound dressing, oral ketamin

The efficacy of chewing gum on postoperative ileus following cesarean section in Enugu, South East Nigeria: A randomized controlled clinical trial

Background: Postoperative ileus (POI) is a common complication following caesarean section. It impairs patients comfort; delays wound healing and prolong duration of hospital stay. Several methods have been used in the management of this condition with varying efficacy. Chewing gum postoperatively is a recent concept in the western world being advocated as a cost effective and comfortable management of POI.Aim: The aim was to evaluate the efficacy of gum‑chewing in reducing POI following caesarean section in Enugu.Materials and Methods: One hundred and eighty women booked for elective caesarean section were randomized into gum‑chewing group (n = 90) or control group (n = 90) The subjects chewed sugarless gum three times daily from 6 h postoperatively until the first passage of flatus. Each chewing session lasted 30 min. Elective cesarean section was carried out with a Pfannenstiel incision. Groups were compared primarily for time to first bowel sound, and first flatus. Secondary endpoints of comparison were time of operation to first defecation, and patient satisfaction concerning postoperative gum chewing. The Student’s t‑test and Pearson Chi‑square test and multiple linear regression were used for statistical analysis.Results: The groups were comparable in age, body mass index (BMI) and duration of surgery. The mean time to first bowel sounds (21.9 ± 8.0 vs. 26.1 ± 10.0), mean time to first flatus (24.8 ± 6.4 vs. 30.0 ± 10.0) and mean time to defecation (30.7 ± 5.9 vs. 40.0 ± 9.0) were significantly reduced in patients that chewed gum compared with controls. P =0.02, 0.01, and 0.01, respectively. Patients were satisfied with gum chewing and no side‑effect was recorded. Previous surgery and duration of surgery were predictors on duration of POI, while age, BMI and parity had no effect.Conclusion: Gum‑chewing has a beneficial effect on early return of bowel function following cesarean section and should be included in the postoperative management protocol.Key words: Caesarean section, chewing gum, ileu

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Anaesthesia for Oesophageal Replacement with Colonconduit– A Review of Forty Six Cases

This paper reviews the anaesthetic management of 46 adults with severe oesophageal burns replaced with colon conduit at the University ofNigeria TeachingHospital, EnuguNigeria over a 14 year period (Jan.1987 –Dec. 2000).Aim: To highlight the common anaesthetic challenges in the management of oesophageal burns.Methods: A retrospective review of all adult patients with corrosive burns of the oesophagus was made and the preoperative, intra-operative and postoperative anaesthetic care records were extracted and analyzed.Result: Nine (19.5%) patients presented as emergency. Twelve (26%) patients required preoperative tracheostomy and the patients received feeding gastrostomy. Bradycardia occurred in all the patients during intestinalmobilization for the colon graft while tachycardia occurred during retrosternal tunneling of the colon conduit. Elective post-operative ventilationwas necessary in eleven (24%) patients whose pleura were breached during the procedure.Conclusion: Care and protection of the airway and nutritional support are the main pre-operative challenges faced by the anaesthetist in the management of oesophageal burns. During the colon transplant surgery, adequate ventilation, volume replacement and control of arrhythmias are necessary for the success of the procedure.Niger Med J. Vol. 49, No.3, July– Sept, 2008: 70 – 73.Keywords: Oesophagus, Corrosive burns, colon graft, anaesthesia

Anaesthetic Challenges in the Surgical Management of Diabetic Foot Disease at Enugu

A review of the anaesthetic management of lower limb amputations consequent upon diabetes foot disease, carried out at the University of Nigeria teaching Hospital Enugu over a five year period, (April 1998 toMarch 2003) wasmade.Aim: was to identify those anaesthetic problems frequently encountered during the operative procedure, relate them to the outcome of the entire management and to proffer possible solutions to these problems.Method: Clinical notes of all cases of lower limb amputation were assembled and those due to diabetic gangrene were selected. Relevant data were extracted frompre-operative notes, the anaesthetic charts and the post-operative records.Result: Thirty two (32) case notes belonging to twenty three (23)males and nine (9) females, aged 27-73 yearswere reviewed. Anaemia, septicaemia, fever and uncontrolled blood sugar levels were recorded in all the cases. Operationwas delayed for periods between 16 hours and 8 days in the series. Regional anaesthesia (sub-arachnoid block) was used in 81% of the cases while the rest hadGeneral anaesthesia. Blood pressure, electrocardiogram, oxygen saturation, blood sugar and urine output weremonitored intraoperatively. All the patients received blood transfusion as well as slowintravenous infusion of glucose / potassium/ insulin(GKI). Therewere six (6) deaths in the series, allwhich occurred in the first 24 hours of the operation. Themortality in this study was seen only in males, and all related to delay in accepting the operation, the degree of sepsis and fasting blood sugar level.Conclusion: Diabetics for gangrenous lower limb amputation are high risk patients. Surgery should be carried out soon after the decision to amputate and anaesthesia should only wait for those clinical investigations necessary to control and stabilize the patients.Adequate preoperative fluid therapy, intra-operative glucose / potassium / insulin therapy and monitoring of blood sugar and cardiovascular status are necessary for the success of the procedure. Morbidity and mortality are related to bloodglucose levels, degrees of infection and delay in accepting the surgery.Niger Med J. Vol. 49, No.3, July– Sept, 2008: 59 – 62.Keywords: Diabetes, gangrene,Anaesthesia,Amputatio

Airway Complications following ingestion of corrosive

A retrospective study of patients admitted in severe respiratory distress following ingestion of corrosives over a ten year period, (Jan. 1989-Dec. 1998) was made. The Aim was to highlight the peculiar airway problems associated with ingestion of corrosives in our locality. Method and Materials: Clinical notes of all patients who presented with history of ingestion of corrosives were examined and those patients admitted in respiratory distress were selected for the study. Personal data of the patients, the substances ingested, reason for the ingestion, period between ingestion and presentation, the resulting airway complications and clinical management were extracted from the notes. Results: Eleven patients admitted in severe respiratory distress were studied. They were aged 17-42 years, all males. Ingestion was deliberate in 66% of the patients. Symptoms included severe dyspnoea, hoarseness and stridor. Documented clinical signs included oedema of the oral mucosa; eschar formation; ulcers of the oral tissues, cheek and lips; and drooling of saliva. Scaring of oral mucosa, distortion of pharyngeal and laryngeal structures, tracheo-oesophageal and oro-cutanous fistulae were later developments during the course of management. Chest infection was evident in all the patients who presented after seven days. Conclusions: Corrosive ingestion is a major health problem in our environment. The proximal third of the oesophagus and the upper airway are mostly affected. These frequently result in life threatening airway complications demanding urgent tracheostomy. Key words: Corrosives, Burns, Airway, Respiratory distress. Nigerian Journal of Otorhinolaryngology Vol.2(1) 2005: 33-3

Anaesthetic Requirement in Spinal Cord Injured Patients undergoing Operation below the Level of Cord Injury

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Managing Sacrococcygeal Teratoma in a New Born of a Psychopathic Widow: Case Report

Background: Sacrococcygeal tumors are composite embryonal tumours reflecting any one or more of embryonal/foetal remnants such as germinoma, embryonal carcinoma, teratoma, choriocarcinoma and yolk sac tumors. Teratomas are the commonest variety of these tumours encountered in clinical practice. Sacrococcygeal tumors are most commonly found in females. Male presentations tend to carry high risk of malignancy.Clinical management of sacrococcygeal tumours in males therefore requires more meticulous attention to the details of surgery and follow-ups.Study design: This is a clinical case report of a huge sacrococcygeal tumour highly valued by a mentally deranged mother, which was excised from a three (3) month old baby boy under general anaesthesia in prone position over a three and half hour period. The purpose of the report is to highlight the special challenges in the management of the case not only onaccount of the sheer size of the tumour but also the unusual psychopathic attachment of the mother to her baby's tumour. The accompanying literature review was by both manual and Medline searches.Result: Surgery and postoperative recovery were uneventful. Histology showed tumour variety to be sacrococcygeal teratoma. Patient showed steady progress with each follow-up visit.Conclusion: Sacrococcygeal tumours are rare, but are the commonest tumours of the newborn. Early surgery avoids tendency to malignant transformation and a good follow-up program is necessary for a guarded prognosis.Niger Med J. Vol. 50, No. 3, July – Sept., 2009: 74 – 76.Key words: sacrococcygeal teratoma, germ cell, malignancy, male neonate

Unanticipated Quadraplegia in an Unconscious Mechanically Ventilated Traumatic Head Injured Patient

Objective  A significant number of unconscious patients who present to the emergency department as a result of Road TrafficAccident (RTA) or fall have a major injury to the Cervical Spine. This case highlights the problems of identification of such injuries in the unconscious. CaseReport An unconscious young adult was admitted from the accident and emergency into the intensive care unit with a clinical impression of traumatic head injury. Neck collar was applied and the airway secured with an orotracheal tube. Following positive pressure ventilation for about tenminutes, the patient suddenlywoke up to full consciousness and started shaking his head violently and uncontrollably, necessitating his tracheal extubation. He then complained of his inability to use or feel his limbs. Radiological investigation revealed complete dislocation of first (C1) and second (C2) cervical vertebra; a crack in the left temporal skull and a contused left lung.Hewas re-intubated about 20minutes laterwhen his respiratory efforts began to weaken, and ventilated under propofol sedation. He gradually became ventilator dependent, with collapse of cardiovascular and respiratory systems and died on thirteenth day of admission. Conclusion Cervical Spine injury should be suspected in all unconscious patients following trauma. Key Words: Cervical Spine Injury, Quadriplegia, Mechanical Ventilation

Mordified Submental Endotracheal Intubation Technique in Maxillofacial Injuries

Submental endotracheal intubation was carried out in five patientsover a two-year period. Each patient required maxillomandibular fixation following trauma.Acommon feature in these patients was depressed fracture of the frontonasal bone which could not permit nasal intubation. These patients were reluctant to have tracheostomy if there was an alternative option of securing their airway. Following a normal orotracheal intubation, a submand incision was made and the proximal endotracheal tube (ETT)exteriorized through it. At the end of anaesthesia and surgery, the tube was left insitu for six to forty-eight hours before extubation. The incision was closed following local anaesthetic (LA) infiltration and no airway compromisewas noted. Submental intubation is a simple and useful technique with low morbidity in cases of craniomaxillofacial trauma and the authors’ clinical experience with this technique is described.Niger Med J. Vol. 49, No. 4, Oct – Dec, 2008: 101– 103.Keywords: SubmentalEndotracheal, Intubation,Maxillofacial