Comparison of maternal satisfaction following epidulral and general anaesthesia for repeat caesarean section

Objective: To assess maternal satisfaction following two anaesthetic techniques (general and epidural anaesthesia) for repeat Caesarean section.Design: Prospective study.Setting: University of Port Harcourt Teaching Hospital, Nigeria.Subjects: One hundred and twenty parturients scheduled for elective Caesarean section.Results: The demographic data and mean satisfaction scores obtained from questionnaire and visual analogue scale (VAS) were subjected to analysis using the Student’s t-test with the computerised statistical calculator SPSS Windows 10.0. The mean satisfaction score of the parturients in the epidural anaesthesia population using the questionnaire was 149.0±10.65 while that in the general anaesthesia population was 105.3±12.42. The mean satisfaction score from the VAS was 9.0±1.50 for those who had epidural anaesthesia while it was 2.6±0.70 in the general anaesthesia population. The differences in the mean satisfaction scores from both instruments of measurement were statistically significant at

Anaesthetic Challenges In An Untreated Grave's Disease Parturient Undergoing Emergency Caesarean Section

Background: The evaluation and management of hyperthyroidism in pregnancy is challenging to perioperative care givers. The objective of this report was to demonstrate the role of single shot spinal anaesthesia in managing the haemodynamic challenges associated with untreated Graves ' disease in pregnancy.Method: Following a 500mls preload with normal saline, patient received 10mg of plain bupivacaine in the lateral position. Continuous monitoring of blood pressure, pulse rate, ECG, temperature, oxygen saturation was carried out throughout the procedure and into the post-operative  period.Hypno-sedation was applied as required.Results: At the end of surgery, there was a decrease in the pulse pressure from 94mmHg to 81mmHg. Also the pulse rate decreased from 156beats/min to 121beats. Patient was transferred to the Intensive Care Unit for a few days and subsequently discharged and followed up in the Medical out-patient clinic.Conclusions: Uncontrolled Hyperthyroidism coexisting with pregnancy is very challenging to perioperative care givers. However surgery can be safely performed using a single-shot spinal anaesthesia with bupivacaine and hypno-sedation in addition to the application of background disease pathophysiology and complications in managing the associated haemodynamic challenges.Keywords: Hypno-sedation, hyperthyroidism, spinal anaesthesia, caesarean sectio

The efficacy of Diclofenac for post caesarean section analgesia: comparison of rectal and intramuscular routes

Background: Despite advances in postoperative pain therapy, pain relief may still be inadequate for a substantial number of women.Aim: The aim was to compare the analgesic efficacy of rectal and intramuscular diclofenac for post Caesarean section analgesia.Materials and Methods: Following approval from the Hospital Ethics Committee 94 ASA I and II parturients aged 18 years and above scheduled for elective Caesarean section under spinal anaesthesia were recruited into the study. While one group of parturients received 100 mg Diclofenac suppository rectally (group R) those in the other group received 75 mg Diclofenac intramuscularly (group IM) immediately after surgery. The patients were instructed to request analgesic when they felt pain post-operatively. Pain scores were recorded using the VAS (0 to 10), (0 = no pain, 10 = the most severe pain), initially every 30 minutes for the first 2 hours, then every 2 hours from the 2nd hour to the 8th hour and every 4 hours after the 8th hour till the 24th hour.Results: The demographic data, BMI, PCV and ASA classification between the two groups of patients were comparable; the two groups were also comparable in the haemodynamic variables (mean systolic BP, mean diastolic BP, mean MAP and mean heart rate) and in the mean SpO2 recorded in the recovery room, p > 0.05 for all the variables. The time to first analgesic request in group IM was 313.2 ± 218.8 mins  and in group R 314.1 ± 121.6 mins, p=0.98. There was no significant difference between the IM/R groups in the mean VAS scores of patients, the number of patients who received pentazocine at each time interval in the two groups, and the total pentazocine consumption in the two groups in 24 hours, p>0.05 in all the variables. There was no significant difference between the two groups in the mean satisfaction score in pain relief, p = 0.73, the mean satisfaction score with staff's response to patient's pain management needs, p = 0.85, and the mean acceptability score, p = 0.62.Conclusion: Suppository diclofenac administered through the rectal route is as efficacious as intramuscular diclofenac injection for post Caesarean section analgesia with equal levels of patient satisfaction and acceptability.Keywords: Post Caesarean section analgesia, diclofenac, rectal, intramuscular, spinal anaesthesia

The differential impact of two anesthetic techniques on cortisol levels in Nigerian surgical patients

Background: Surgical procedures are associated with a complexity of stress response characterized by neurohumoral, immulogic, and metabolic alterations. Aim: The aim was to compare the effects on the stress response by isoflurane‑based intratracheal general anesthesia (ITGA) and bupivacaine‑based epidural anesthesia (EA), using cortisol as a biochemical marker. Materials and Methods: Following the approval of the Hospital Ethical Board, informed written consent from patients recruited into this study was obtained. One group received general anesthesia with relaxant technique (group A) while the other group had bupicaine epidural anesthesia with catheter placement for top‑ups (group B) for their surgeries. Both groups were assessed for plasma cortisol levels – baseline, 30 minutes after skin the start of surgery and at skin closure. Results: There was no statistically significant difference in the baseline mean heart rate, mean arterial pressure (mean MAP) and the mean duration of surgery between the two groups; the baseline mean plasma cortisol level was 88.70 ± 3.85 ng/ml for group A and 85.55 ± 2.29 ng/ml for group B, P=0.148. At 30 minutes after the start of surgery the plasma cortisol level in the GA group was 361.60 ± 31.27 ng/ml while it was 147.45 ± 22.36 ng/ml in the EA group, showing a significant difference, P=0.001. At skin closure the mean plasma cortisol value of 384.65 ± 48.04 ng/ml recorded in the GA group was found to be significantly higher than the value of 140.20 ± 10.74 ng/ml in the GA group, P<0.002. Conclusion: Using plasma cortisol as a measure, bupivacaine‑based epidural anesthesia significantly reduces the stress response to surgical stimuli when compared with isoflurane‑based tracheal general anesthesia.Keywords: Cortisol levels, epidural anesthesia, general anesthesia, surgeryNigerian Journal of Clinical Practice •Jan-Mar 2012 • Vol 15 • Issue

Epidural anesthesia: Views and outcomes of women in labor in a Nigerian hospital

Background: Pain during childbirth is a well known cause of dissatisfaction amongst women in labor. The use of epidural analgesia in labor is becoming widespread due to its benefit in terms of pain relief. Method: After approval of the local Ethics Committee on Research and obtaining informed written consent, 50 American Society of Anesthesiologists (ASA) class I-II consecutive multiparous women in labor requesting pain relief were enrolled in this prospective study. After providing description of the two options of pain relief available to them, they were allocated into two groups according to their request-to receive either parenteral opioid/sedative or epidural labor analgesia. Both groups received analgesia of choice at 4-cm cervical os dilatation. The epidural group received 0.125% plain bupivacaine, while the other group received pentazocine/promethazine intravenously. The time taken to locate the epidural space, catheter-related complications encountered and the amount of intravenous fluid used were documented. Result: The two groups were comparable in terms of socio-demographic data. The mean duration of the first and second stages of labor, respectively, were significantly shorter in the epidural group when compared with those in the non-epidural group ([ P < 0.01] and [ P < 0.02]). There was no difference in the rate of cesarean delivery between them - epidural analgesia (32% [8/25]) versus parenteral opioid/sedative (44% [11/25]), (OR, 0.60; 95% CI, 0.19-1.90). The maternal blood loss from delivery was minimal, with no statistical difference between the two groups ( P = 0.27). The neonatal outcome was the same in both groups. Closed questionnaire showed that the overall experience of labor was much better (it was also better than expected) in the epidural group when compared with that in the non-epidural group (80% versus 4%). Eighteen (72%) women had inadequate pain relief in the non-epidural group as compared to 2 (8%) women in the epidural group. Conclusion: The study shows that epidural labor analgesia is acceptable to women in our setting. More women in the epidural analgesia group were satisfied with the experience of labor than those who did not receive this form of analgesia than among those who received parenteral opioid/sedative

Epidural Space Localization: A Novel Slingshot Approach

Background: The location of the epidural space for local anaesthetic injection can be a very challenging one. Methods of locating the epidural space depend on the negative pressure exhibited during the introduction of the epidural needle into the space. Aim: This study describes the sling-shot technique to identify pressure changes in the syringe during puncture of the ligamentum flavum in identifying the epidural space. Knowledge of pressure changes might be of help to the anaesthetist who attempts to ascertain the location of the needle tip. Method: Epidural punctures were performed in 30 patients, using an 18 guage Tuohy needle connected to a 10 ml epidural syringe with its grooved plunger mounted on a thin rubber sling. The plunger with the rubber sling was pulled and tip of the syringe mounted on the hub of the Tuohy needle. The epidural space was located by the loss of resistance to air technique. Result: The mean age of the patients was 39.5±2.3 years while the mean height and weight were 163±4.1 cm and 78.9±3.8 kg respectively. With an advancing Tuohy needle the change in pressure was observed in all patients as evidenced by the collapsed grooved plunger on correct epidural space needle placement. The mean time from skin to space localisation was 17.3 seconds. Conclusion: This novel method of epidural space identification is fast, safe and could increase the use of epidural technique in anaesthetic practice.Keywords: epidural space localisation, sling-shot epidural syringe, accidental dural puncture, loss of resistance to ai

Anaesthetic Challenges in a High Risk Parturient with Myasthenia Gravis Undergoing Caesarean Section Under Spinal Anaesthesia

The prevalence of myasthenia gravis is low. The management implications of this disease in pregnant women are very challenging for anaesthetists. The objective is to highlight some of the challenges, the management and the lessons learnt during the management of this patient. This is a case report of a 31-year old parturient with diagnosed myasthenia gravis co-existing with hepatitis B infection that presented for caesarean section. Surgery was carried out under a single-shot spinal anaesthesia with bupivacaine. Intraoperative myasthenia crisis was managed with  neostigmine infusion. She was managed in the Intensive Care Unit for a few days and discharged. Under spinal anaesthesia, she became very breathless and developed wide-spread musculo-skeletal weakness while having a stable haemodynamics intra-operatively. Surgery was carried out successfully. Both mother and child were discharged on the 7th day  post-operative after baby was confirmed sero-negative of hepatitis B surface antigen. A better understanding of the pathophysiology and complications that accompany myasthenia gravis is needed to manage these patients under anaesthesia

Epidural anesthesia: Views and outcomes of women in labor in a Nigerian hospital

Background: Pain during childbirth is a well known cause of dissatisfaction amongst women in labor. The use of epidural analgesia in labor is becoming widespread due to its benefit in terms of pain relief. Method: After approval of the local Ethics Committee on Research and obtaining informed written consent, 50 American Society of Anesthesiologists (ASA) class I-II consecutive multiparous women in labor requesting pain relief were enrolled in this prospective study. After providing description of the two options of pain relief available to them, they were allocated into two groups according to their request-to receive either parenteral opioid/sedative or epidural labor analgesia. Both groups received analgesia of choice at 4-cm cervical os dilatation. The epidural group received 0.125% plain bupivacaine, while the other group received pentazocine/promethazine intravenously. The time taken to locate the epidural space, catheter-related complications encountered and the amount of intravenous fluid used were documented. Result: The two groups were comparable in terms of socio-demographic data. The mean duration of the first and second stages of labor, respectively, were significantly shorter in the epidural group when compared with those in the non-epidural group ([ P < 0.01] and [ P < 0.02]). There was no difference in the rate of cesarean delivery between them - epidural analgesia (32% [8/25]) versus parenteral opioid/sedative (44% [11/25]), (OR, 0.60; 95% CI, 0.19-1.90). The maternal blood loss from delivery was minimal, with no statistical difference between the two groups ( P = 0.27). The neonatal outcome was the same in both groups. Closed questionnaire showed that the overall experience of labor was much better (it was also better than expected) in the epidural group when compared with that in the non-epidural group (80% versus 4%). Eighteen (72%) women had inadequate pain relief in the non-epidural group as compared to 2 (8%) women in the epidural group. Conclusion: The study shows that epidural labor analgesia is acceptable to women in our setting. More women in the epidural analgesia group were satisfied with the experience of labor than those who did not receive this form of analgesia than among those who received parenteral opioid/sedative