Prevalence of postdural puncture headache among caesarean section patients in North Central Nigeria

Spinal anaesthesia is now a popular choice for Caesarean sections in Africa but one of the draw-back is the development of post-dural puncture headache (PDPH) and it could be quite distressing to a mother. Identifying risk factors and reducing the prevalence is pertinent. This study sought to determine the prevalence of PDPH among patients who underwent Caesarean sections in a tertiary hospital in Jos, Plateau State, Nigeria and some of its possible associated factors. Method: It was a prospective study of all Caesarean sections done under spinal anaesthesia between November 2016 and June 2017. Spinal anaesthesia was performed on 236 parturients using Quincke-type needles sizes 23-26G. In the postoperative period, all the patients were followed-up to determine the incidence, onset, and severity of post-dural puncture headache. Epi-info version 7 was used for data analysis. Results: The prevalence of PDPH was 22.03%. Most of the parturients who developed PDPH in our study were of mild to moderate intensity using the numeric rating scale. Twenty six (11%) had mild, while 11 (4.7%) had moderate intensity of headache and which was resolved with treatment. Conclusion: The prevalence of PDPH is high in the obstetric population especially with the use of traumatic Quincke-type needles. Deliberate efforts must be made to reduce its occurrence by acquiring of small calibre pencil-point needles and training staff on how to use it

Obstetric admissions in a general intensive care unit in north-central Nigeria

Context: Maternal mortality remains unacceptably high in many developing countries and many pregnant women in these countries will require critical care during pregnancy and will be managed in general intensive care units.Objective: To determine the indications for admission of obstetric patients into the general intensive care unit of Jos University Teaching Hospital over a 14 years period and the outcome of their management.Study Design: The study is a retrospective descriptive study. All obstetric admissions into the intensive care unit of Jos University Teaching Hospital from January 1994 to December 2007 were reviewed.Results: There were 231 obstetric admissions which was 17.29% of total ICU admissions and 2.05% of all deliveries in the hospital during the period of review. The mean age of the patients was 25±7.1 years. Pregnancy induced hypertension made up 80.52% of the admissions, while haemorrhage was 12.56% and non-obstetric admission was 6.93%. The most common non-obstetric admission was sepsis (43.70%). Of all admissions 90.91% were in the postpartum period and 9.09% during the antepartum period. The medium length of was two days. The mortality rate was 15.15% with significantly higher ratio of deaths in patients with non-obstetric indications for admission and in patients older than 35 years.Conclusion: There is a high rate of ICU admission of obstetric patients in our hospital. This increases the burden of care in the ICU and contributes to poor outcome. Establishment of obstetric high dependency units will reduce the burden on general ICUs

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

Anaesthesia workforce and infrastructure in a north central state of Nigeria: a survey

Background: Anaesthesia has evolved over the decades to have become a specialty in medicine. The dearth of personnel and unavailability of required equipment world over has made safe delivery of anaesthesia difficult. This study evaluated workforce situation and availability of anaesthetic drugs/equipment in public secondary health facilities.Methods: A multi-centre study using an interviewer administered questionnaire was carried out in September 2013. Information about the anaesthesia personnel situation, surgical work force, as well as infrastructure, equipment and drugs was obtained.Results: Nine (64.3%) out of the 14 public hospitals surveyed had general physicians (medical officers who performed surgeries) and nurse anaesthetists. Ten (71.4%) of the hospitals had at least one back-up generator as a source of electricity. All the hospitals had laryngoscopes but there were no functional anaesthetic machines and none had oxygen or pulse oximeters. None of the hospitals had pipe-borne water though 11 (78.6%) had wells as a source of their water supply. However, 12 (85.7%) of the hospitals had laboratories where blood could be grouped and cross matched.Conclusion: There is a dearth of anesthetic and surgical workforce and basic infrastructure in public hospitals. Capacity building, revamping of existing infrastructure and workforce expansion in anaesthesia is needed as an integral part of tackling the burden of surgical diseases.Keywords: Anaesthetic workforce, infrastructure, equipment, drugs, Plateau State, Nigeri

Effect of paracetamol pre-treatment on Propofol injection pain among surgical patients

Background: Propofol injection pain is often a cause of distress for patients. This study was conducted to find the incidence of Propofol induced pain and the efficacy of Paracetamol (Acetaminophen) in the prevention of Propofol injection pain among surgical patients at a tertiary hospital.Methods: The study was a prospective, double blind randomized clinical trial carried out at the Jos University Teaching Hospital main theatre. Consenting American Society of Anesthesiologists (ASA) physical status I or II patients scheduled to undergo general anaesthesia for elective surgery were allocated into one of two study groups of 35 each. Group I  was the Paracetamol (drugamol® ) group, who received 2mg/kg of intravenous Paracetamol while the control group (group II) received 5ml of 0.9% saline with venous occlusion. The venous occlusion was released 2 minutes after injecting the study drug and one-fourth of the total calculated dose (2.5mg/kg) of  Propofol (Pofol 1% ®Dongkook Pharmaceutical) was delivered through the iv line over a period of five seconds and the patients assessed for pain on a 4-point scale. Results: The two groups were comparable in demographic characteristics and ASA classification. Twenty-one (60.0%) patients in the control group and 1 (2.9%) patient in the Paracetamol group experienced pain on injection of Propofol, p = 0.000. There were no significant haemodynamic variations between the two groups during the study period.Conclusion: Paracetamol when applied with tourniquet significantly attenuated Propofol injection pain in our adult patients with no significant haemodynamic variations.Key words: Paracetamol, Propofol, Injection pai

Theatre start and turnover times in a developing country

Background: Enormous amounts of resources are spent to keep the operating suites running and approximately one-third of total hospital budget is devoted to it. Delays in start or turnover times (TOT) lead to needless cancellations of procedures. Our study seeks to evaluate the causes of delay and to proffer some solutions to these identified reasons.Methods: A prospective observational study carried out to collect data of elective procedures using a proforma. The causes of delay in starting surgical procedures and turnover times were assessed and documented.Results: Three hundred and ninety seven elective procedures were evaluated between 2nd January and 31st July, 2018. All scheduled first procedures were delayed and a third (36%) of subsequent procedures was delayed for between 45-60 minutes. One hundred and forty six (27.2%) of procedures delayed were due to prolongation of time for washing of instruments by perioperative nurses after a procedure and cleaning of the theatre suite by attendants before a subsequent case was brought in. Delays due to challenges with central sterile supply department (CSSD) had 16.0% (86). Other causes of delay included delay in porters transporting patients from ward to theatre (15.6%), and collection of anaesthetic drugs from pharmacy/non-availability which accounted for 10.4%Conclusion: Multiple factors are responsible for delays in turnover times in the operating room. The commonest cause was washing of instruments and cleaning of theatre suites; others were challenges with the central sterile supply department (CSSD and delay in obtaining drugs from the theatre pharmacy. A multidisciplinary approach where all parties involved in surgery target these specific areas would help improve efficiency and reduce turnover times. Keywords: Theatre, delays, turnover time, developing countr

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research