Review of adult head injury admissions into the intensive care unit of a tertiary hospital in Nigeria

Background: Head injury is frequently associated with death and disability and imposes considerable demands on health services. Outcome after head injury is closely related to prompt management, including prevention of secondary brain injury and intensive care unit (ICU) management. This study aimed at determining the aetiological spectrum, injury characteristics, ICU admission patterns, and treatment outcomes of adult head-injured patients at a sub-Saharan tertiary hospital.Methods: A retrospective study on adult head-injured patients admitted to the ICU of a sub-Saharan tertiary hospital between July 2000 and June 2010.Results: A total of 198 head-injured adult patients were managed in the ICU during the study period. This included 128 males and 70 females with a male-to-female ratio of 1.8:1. The most common mode of injury was road traffic accident. All the patients admitted to ICU had either moderate or severe head injury, with 73.7% having severe head injury. About 26.3% of the patients had associated cervical spine injuries and 50% had various musculoskeletal and soft tissue injuries. Cranial computed tomography findings included brain contusions and intracranial haematomas. Mean duration of ICU stay was 18 days (range 24 hours-42 days), with 89.9% discharged out of ICU care. The overall mortality was 10.1%, although only 36.9% had satisfactory outcomes, as determined by the Glasgow Outcome Scale. Outcome had statistically significant (P < 0.05) relationship with severity of head injury and surgical intervention.Conclusions: Head injury management in the ICU requires an approach to ensure prevention of secondary brain injury; appropriate and early neuroimaging to diagnose lesions that would benefit from timely surgical intervention; as well as management of fluid, electrolyte and haematological derangements.Keywords: head injury; admissions; IC

Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices

BACKGROUND. The burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis. METHODS. A pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects. RESULTS. Workers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries. CONCLUSIONS. This pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries

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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Pre-operative haematological investigations in paediatric orofacial cleft repair: Any relevance to management outcome?

Aim and Objectives: To determine the value of routine pre-operative haematologic investigations in children undergoing orofacial cleft repair. Background: Although routine pre-operative laboratory screening tests are carried out traditionally, some studies suggest that they are not absolutely necessary in the management of elective surgical patients. Materials and Methods: This is a prospective cohort study carried out at a tertiary health facility located in Nigeria. A review of the laboratory investigations in 116 paediatric orofacial cleft patients undergoing surgery during a 6-year period was undertaken. Pre-operative laboratory investigations and peri-operative transfusion records were analysed for the frequency and impact of abnormal results on treatment plan and outcome using the Statistical Packages for the Social Scientists 16.0. Results: All the children had pre-operative packed cell volume (PCV) check on admission for surgery. The PCV ranged from 23% to 43%, mean was 32.9 (±3.7%). Twenty-two children (18.6%) had sub-optimal PCV (<30%). Patients with the lowest PCV values (23% and 26%) were transfused pre-operatively. The lowest post-operative PCV was 23%, mean 30.8 (±3.3%). There was no occasion of post-operative blood transfusion. Eighty-six patients (72.9%) had full or partial serum electrolyte and urea analysis. Screening for sickle-cell disease was rarely done. Fourteen intra- and post-operative complications were recorded. None of these were predictable by the results of pre-operative screening tests carried out. All the children were discharged home in satisfactory condition. Conclusions: Routine laboratory testing has minimal impact on management and outcome of orofacial cleft surgeries. However, haematocrit screening may be appropriate, particularly in clinically pale patients

Caesarean section: Intra-operative blood loss and its restitution

No Abstract. The East African Medical Journal Vol. 84 (1) 2007: pp. 31-3

SUPPLEMENTAL OXYGEN FOR CAESAREAN SECTION UNDER SPINAL ANAESTHESIA

Background: Routine administration of supplemental oxygen to parturients undergoingCaesarean section under spinal anaesthesia has been criticised in recent times.Objectives: To assess the need for routine supplementary oxygen in healthy womenundergoing Caesarean section under spinal anaesthesia in resource challenged settingand 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 hospitalsituated in Ile-Ife in South-western Nigeria.Subjects: Seventy parturients with ASA physical status I or Il 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 weresimilar. There was a statistically significant difference in the mean SaO2 at one minutebetween 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 inthe control group (95.9% ± 1.5% versus 94.9% ± 2.0%, p-value = 0.015). The Apgar scoreof the babies at one and five minutes for the study and control group were similar.Conclusion: Healthy parturients undergoing Caesarean section under spinal anaesthesiado well without supplemental oxygen; administration of supplemental oxygen fromthe common gas outlet of anaesthetic machine with the breathing circuit and standardanaesthetic facemask at 4L/min causes relative desaturation

PRACTICE AND ACCEPTANCE OF DAY-CARE SURGERY IN A SEMI-URBAN NIGERIAN HOSPITAL

Objective: To determine the acceptability and practicability of day-care surgery in a semiurbanarea of Nigeria.Design: A twelve- month prospective study.Setting: Wesley Guild Hospital, Ilesa, Nigeria.Patients: Sixty seven consecutive patients with ASA I - I1 status and aged three months to 97years were studied.Intervention: Patients were operated as day-cases using general or local anaesthesia.Main outcome measures: Practicability, post-operative problems and acceptability.Results: The mean age of patients studied was 27.26 years (SD 23.89), with males accountingfor 61% of the 67 cases. Fifty eight per cent and 42% had general and local anaesthesiarespectively. While all patients had post-operative support from family members, less thanseven per cent had access to telephone or family doctor services. About 80% of the patientslived within l0km from the hospital. Intermediate operations accounted for 60% of the cases,while minor ones accounted for 40%. The mean operating time was 30 minutes. Postoperativepain was the only significant problem encountered. This, however, decreased in thepatients with time. Complication rate was 10.5%.Conclusion: A significant number of patients accepted and approved of the day stay surgery.Medical and surgical practitioners in semi-urban regions are encouraged and charged toaccept the practice of short \tay surgery

Practice and acceptance of day-care surgery in a semi-urban Nigerian Hospital

(East African Medical Journal: 2001 78(4): 170-173