Is Near-Patient Monitoring with Haemoglobinometer as accurate as Spectrophotometry in determining Intra-Operative Haemoglobin Estimation and the need for Blood Transfusion during Surgery?

Background: Accurate intra-operative estimation of blood loss and haemoglobin (Hb) is crucial in determining if and when to transfuse patients during surgery. In the surgical patient, intravascular volume and haemoglobin may change rapidly and frequent rapid assessment of patient status is indicated. We investigated whether near-patient monitoring using a haemoglobinometer was as accurate as a laboratory spectrophotometry in determining haemoglobin concentration. Patients and Methods: All patients in which the decision to transfuse had been made by the attending anaesthetist were studied. Haemoglobin concentration was measured immediately before transfusion using the haemoglobinometer HumanMeter Hb Plus (HUMAN GmbH, Wiesbaden, Germany). A sample was collected in an EDTA bottle and analysed in the laboratory by spectrophotometry using yanomethaemoglobin method. Demographic data, volume and type of fluids administered before transfusion were documented. Results: Fifty patients were studied with a mean age of 37.28± 19.04 years (range 4 – 90 years). Mean pre-operative PCV was 30.21 ± 4.30% (range 20 – 44%). The mean pre-transfusion Hb level by haemoglobinometer was 7.88 ± 1.84 g/dl (range 3.11 to 11.15 g/dl) which was similar to that estimated by laboratory spectrophotometry of 7.94 ± 1.84 g/dl (range 2.90 to 11.0 g/dl) (p=0.387, t = -0.873, df = 49, correlation = 0.965). The mean difference between the results was 0.05 ± 0.48g/dl (range -0.7 to 1.0). The limit of agreement between the two methods was -0.91 to +1.01. Twenty-one patients (42%) were inappropriately transfused. Conclusion: Near-patient monitoring with the haemoglobinometer provided a sufficiently accurate and reliable estimation of haemoglobin comparable with laboratory spectrophotometry. The routine use of near-patient monitoring could minimise unnecessary intra-operative blood transfusion. Key words: intraoperative haemoglobin; laboratory spectrophotometry, haemoglobinomete

Pattern of Presentation of Multiple Organ Dysfunction Syndrome in Critically ill Patients in a sub-Saharan Tertiary Centre.

Background: Multiple organ dysfunction syndrome is the sequential failure of several organ systems after a trigger event, like sepsis, massive transfusions, burns, trauma and cardiogenic shock.Aim and Objectives- The pattern of presentation of multiple organ dysfunction and the risk factors associated with multiple organ dysfunction in critically ill patients were evaluated.Patients and Methods: Seventy-five patients admitted for more than 24 hours into the intensive care unit were prospectively studied. The occurrence of multiple organ dysfunction (MODs) was evaluated daily using individual organ system failure score (OSF). MODs was diagnosed when at least three organ systems were involved. Factors associated with the development of MODs were identified using a stepwise, multivariate, logistic regression analysis. A p value of <0.05 was considered significant for all tests.Results: MODs occurred in 41 patients (54.67%). Mortality increased with the number of organ dysfunction. The observed incidence of dysfunction of 1, 2, 3, and > 4 organ systems were 20%, 26.7%, 33.3%, and 14.7% respectively with corresponding mortality rates of 53.3%, 70%, 92%, and 100%.Mortality was 56% in patients with MODs compared with 7.1% in the non-MODs group, (p <0.0001). MODs occurring within 72 hours exhibited a mortality rate of 56% compared with 18% in those manifesting MODs later (p = 0.026). The major determinants of the MODs in critically ill patients were haemodynamic instability, (OR = 5.57, 95% CI =1.16-26.84), Glasgow Coma scale < 8, (OR = 5.57, 95% CI = 1.25-24.92), SIRS, (OR = 1.74, 95% CI = 1.14-2.64), and increased creatinine level >308 μmol/L (OR = 1.41, 95% CI = 1.73- 11.39).Conclusion: MODs is common in critically ill patients in our ICU and the mortality increased with increased number of organ dysfunction. The risk factors associated with MODs included haemodynamic instability, GCS d”8, SIRS and increased creatinine level >308 μmol/L.Key Words: MODs, OSF, critically ill, mortalit

Comparison of Caudal Analgesia and Intravenous Diclofenac for Postoperative Pain Relief in Paediatric Patients Undergoing Daycase Herniotomy

Background: Effective postoperative pain management is a vital determinant to when a child can be safely discharged from the hospital after day case surgery. This study compared the effect of caudal bupivacaine block with intravenous diclofenac for postoperative pain relief in children aged 1-7years undergoing herniotomy.Patient and method: Sixty(60) ASA physical status I & II children randomly received caudal block with 0.125% bupivacaine 1ml/kg (Group A) or intravenous infusion of diclofenac 1mg/kg in 4.3% dextrose in 0.18% saline 4ml/kg (Group B) after induction of general anaesthesia. Postoperative pain was assessed in the recovery room with mCHEOPS on arrival, 1, 2, 3, and 4hr intervals. The parents assessed pain for 24 hours postoperatively. Oral paracetamol 20mg/kg was administered if pain was moderate or severe. Total analgesic consumption was compared in both groups at 24hr after surgery.Results: The time to first rescue analgesia was 239.3± 24.6min in group A versus 167.6±43.2min in group B, (p=0.024). Pain scores at 0, 1, 2 and 3hours were significantly different with patients in group A having lower scores at 0-2 hours. The time to micturition was 156.5±28.3min in group A and 182.9±39.5min in group B (p=0.004) while time to ambulation was 186.5± 44.2min in group A, but 218.0± 32.4min in group B (p=0.003). The times to discharge from the recovery room were not different between the groups. Twenty five patients (83.33%) in group A were given oral paracetamol compared with16 patients (53.3%) in group B. No complication was noted in any of the two groups.Conclusion: Caudal bupivacaine provided better post-operativepain relief than i/v diclofenac in the first 3hours after administration but i/v diclofenac decreased pain and analgesic requirement in the latter part of the postoperative period due to its long duration of action

The Incidence of Electrolytes and Acid-Base Abnormalities in Diabetic Emergencies using the I-Stat Portable Analyser.

Diabetic patients with prolonged insulin insufficiency can present in the emergency department with life threatening ketoacidosis,el ectrolyte abnormalities,an d morbid arrhythmias. A quick and accurate determination of the metabolic abnormalities with rapid intervention is paramount in their management. The aim of this study was to determine the incidence of electrolyte and acid-base abnormalities in diabetic emergencies using the I-STAT point of care testing technique. The study involved thirty diabetic patients admitted into the accident and emergency department of the Lagos University Teaching Hospital. Informed consent was obtained from all participants. Blood samples were obtained for estimation of electrolytes and acid-base using point of care testing (I-Stat portable analyser). A Multistix urine strip (Bayer Diagnostics Reagent Strips) was used for urine analysis to detect the presence of ketones. The mean age was 60.37 ±10.45 (40-79) years, made up of 21(70%) females and 9(30%) males, with a mean duration of diabetes mellitus of 6.5 ±3.56 years. Hyperglycaemia was observed in 70%, and hypoglycaemia in 20%.T he commonest electrolyte abnormality was hypokalaemia (56.67%)followed by hyponatremia (50%).Other abnormalities included hyperkalaemia (10%) and hypernatremia (3.3%). Abnormalities of acid base balance included low pH (20%), low TCO2 (16.67%), high TCO2 (16.67%), high PCO2 (46.67%),and low PCO2 (23.33%). The results indicated that in diabetic emergencies the commonest electrolyte abnormality was hypokalaemia followed by hyponatremia, and the least was hypernatremia.Key words: Diabetes mellitus, I-stat portable analysers, electrolyte and acid-base abnormalitie

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. METHODS: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. FINDINGS: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). INTERPRETATION: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. FUNDING: Medical Research Council of South Africa.Medical Research Council of South Africa