Conformity to the surviving sepsis campaign international guidelines among physicians in a general intensive care unit in Nairobi

Background: There are emerging therapies for managing septic critically-ill patients. There is little data from the developing world on their usage. Objectives: To determine the conformity rate for resuscitation and management bundles for septic patients amongst physicians in a general intensive care unit. Design: Cross sectional observational study. Setting: The general intensive care unit, Aga Khan University Hospital, Nairobi. Subjects: Admitting physicians from all specialties in the general intensive care unit. Results: The physicians had high conformity rates of 92% and 96% for the fluid resuscitation and use of va so pressors respectively for the initial resuscitation bundle. They had moderate conformity rates for blood cultures prior to administering antibiotics (57%) and administration of antibiotics within first hour of recognition of septic shock (54%). There was high conformity rate to the glucose control policy (81%), use of protective lung strategy in acute lung injury/Acute respiratory distress syndrome, venous thromboembolism prophylaxis (100%) and stress ulcer prophylaxis (100%) in the management bundle. Conformity was moderate for use of sedation, analgesia and muscle relaxant policy (69%), continuous renal replacement therapies (54%) and low for steroid policy (35%), administration ofdrotrecogin alfa (0%) and selective digestive decontamination (15%). Conclusion: There is varying conformity to the international sepsis guidelines among physicians caring for patients in our general ICU. Since increased conformity would improve survival and reduce morbidity, there is need for sustained education and guideline based performance improvement

The effect of a preanaesthesia clinic consultation on adult patient anxiety at a tertiary hospital in Kenya: a cohort study

Background: Preoperative anxiety is a common perioperative complication seen in approximately 11-80% of adults undergoing surgery. One of the goals of the preanaesthesia clinic is to allay anxiety. A preanaesthesia clinic evaluation has been shown to reduce anxiety however current studies on anxiety and the preanaesthesia clinic have not quantified this reduction. Objective: To determine the reduction in anxiety in patients evaluated in the clinic versus those evaluated in the ward. Methods: Fifty one adult patients with 28 patients in anaesthesia clinic (AC) group and 23 in the ward (W) group were sequentially recruited from both the surgical, gynaecology and antenatal outpatient clinics and the wards. The patient’s State Trait Anxiety Index (STAI) was taken once the patient was booked for theatre. The patients then had a preanaesthesia evaluation either in the preanaesthesia outpatient clinic (PAC) or in the wards. Another STAI score was taken in the preoperative area in theatre on the day of surgery. The difference in the change of STAI scores in both groups was then analysed. Results: Fifty one adult patients were recruited with 28 in the AC group and 23 in the W group. The majority of patients were female (n=38). Statistically significant difference was seen in the reduction of the anxiety scores between the clinic group 2.143 (C.I=1.384-2.902) and ward group 0.74(C.I=0.17-1.31) with a p value=0.0051.There was also significant difference in reduction in anxiety scores within ward group in the patients with no prior anaesthetic experience having a greater reduction than those with prior anaesthetic experience. There were no other significant differences between the two groups. Conclusion: Patients evaluated in the anaesthesia clinic had a greater reduction in their anxiety but it was not as much as hypothesised which may be due to the multi-factorial nature of preoperative anxiety. A larger multicenter study is recommended to increase generalizability to the population

A randomised controlled trial comparing the effect of adjuvant intrathecal 2 mg midazolam to 20 micrograms fentanyl on postoperative pain for patients undergoing lower limb orthopaedic surgery under spinal anaesthesia

Background: Intrathecal adjuvants are added to local anaesthetics to improve the quality of neuraxial blockade and prolong the duration of analgesia during spinal anaesthesia. Used intrathecally, fentanyl improves the quality of spinal blockade as compared to plain bupivacaine and confers a short duration of post-operative analgesia. Intrathecal midazolam as an adjuvant has been used and shown to improve the quality of spinal anaesthesia and prolong the duration of post-operative analgesia. No studies have been done comparing intrathecal fentanyl with bupivacaine and intrathecal 2 mg midazolam with bupivacaine. Objective: To compare the effect of intrathecal 2mg midazolam to intrathecal 20 micrograms fentanyl when added to 2.6 ml of 0.5% hyperbaric bupivacaine, on post-operative pain, in patients undergoing lower limb orthopaedic surgery under spinal anaesthesia. Methods: A total of 40 patients undergoing lower limb orthopaedic surgery under spinal anaesthesia were randomized to two groups. Group 1: 2.6mls 0.5% hyperbaric bupivacaine with 0.4mls (20micrograms) fentanyl Group 2: 2.6mls of 0.5% hyperbaric bupivacaine with 0.4mls (2mg) midazolam Results: The duration of effective analgesia was longer in the midazolam group (384.05 minutes) as compared to the fentanyl group (342.6 minutes). There was no significant difference (P 0.4047). The time to onset was significantly longer in midazolam group 17.1 minutes as compared to the fentanyl group 13.2 minutes (P 0.023). The visual analogue score at rescue was significantly lower in the midazolam group (5.55) as compared to the fentanyl group 6.35 (P - 0.043). Conclusion: On the basis of the results of this study, there was no significant difference in the duration of effective analgesia between adjuvant intrathecal 2 mg midazolam as compared to intrathecal 20 micrograms fentanyl for patients undergoing lower limb orthopaedic surgery

Knowledge, attitude and use of labour pain relief methods among women attending antenatal clinic in Nairobi

Background: Labour analgesia has rapidly gained popularity in obstetric practice. Low usage in the developing world has raised concern. Objectives: To assess the knowledge, attitude and use of labour pain relief methods in women attending antenatal clinic in Nairobi. Design: A prospective study. Setting: Aga Khan University Hospital, a teaching and referral hospital in Nairobi, Kenya. Subjects: Two hundred and two consecutive expectant mothers attending antenatal clinic at the Aga Khan University Hospital, Nairobi. Results: Fifty-six per cent of the participants had knowledge about labour pain relief methods. Friends, the antenatal clinic and books/leaflets were the major source on information. Ninety per cent indicated they would intend to have some form of labour pain relief at their next delivery. Eighteen percent had been offered some form of pain relief at their last delivery with 82% of those offered having effective pain relief (P \u3c 0.001). Conclusions: While most of our participants were well educated, level of knowledge of labour analgesia is still low. Use of labour analgesia is also still quite low in comparison to the western World. It is recommended that obstetricians and anaesthetists participate in knowledge dissemination and setup of dedicated labour analgesia services in this regio

A randomised controlled trial comparing the effect of adjuvant intrathecal 2 mg midazolam to 20 micrograms fentanyl on postoperative pain for patients undergoing lower limb orthopaedic surgery under spinal anaesthesia

Background: Intrathecal adjuvants are added to local anaesthetics to improve the quality of neuraxial blockade and prolong the duration of analgesia during spinal anaesthesia. Used intrathecally, fentanyl improves the quality of spinal blockade as compared to plain bupivacaine and confers a short duration of post operative analgesia. Intrathecal midazolam as an adjuvant has been used and shown to improve the quality of spinal anaesthesia and prolong the duration of post-operative analgesia. No studies have been done comparing intrathecal fentanyl with bupivacaine and intrathecal 2 mg midazolam with bupivacaine.Objective: To compare the effect of intrathecal 2mg midazolam to intrathecal 20 micrograms fentanyl when added to 2.6 ml of 0.5% hyperbaric bupivacaine, on post-operative pain, in patients undergoing lower limb orthopaedic surgery under spinal anaesthesia.Methods: A total of 40 patients undergoing lower limb orthopaedic surgery under spinal anaesthesia were randomized to two groups. Group 1: 2.6mls 0.5% hyperbaric bupivacaine with 0.4mls (20micrograms) fentanyl Group 2: 2.6mls of 0.5% hyperbaric bupivacaine with 0.4mls (2mg) midazolamResults: The duration of effective analgesia was longer in the midazolam group (384.05 minutes) as compared to the fentanyl group (342.6 minutes). There was no significant difference (P 0.4047). The time to onset was significantly longer in midazolam group 17.1 minutes as compared to the fentanyl group 13.2 minutes (P 0.023). The visual analogue score at rescue was significantly lower in the midazolam group (5.55) as compared to the fentanyl group 6.35 (P - 0.043).Conclusion: On the basis of the results of this study, there was no significant difference in the duration of effective analgesia between adjuvant intrathecal 2 mg midazolam as compared to intrathecal 20 micrograms fentanyl for patients undergoing lower limb orthopaedic surgery.Keywords: Midazolam fentanyl, lower limb, orthopaedic surgery, spinal anaesthesi

Course and outcome of obstetric patients admitted to a University Hospital Intensive Care Unit

Background: Obstetric Critical Care is an important service in the reduction of maternal morbidity and mortality, but few developing country data are available. Objectives: To review all maternity patients admitted to the ICU over a seven year period to determine the causes and outcomes of these admissions and the frequency and causes of maternal morbidity and mortality. Design: Retrospective patient file and ICU chart review. Subjects: ICU Charts and medical files of obstetric patients admitted to the ICU at The Aga Khan University Hospital between (November 2003 – November 2010) were reviewed. Setting: The ICU at The Aga Khan University Hospital, Nairobi, Kenya. Results: Fourty two obstetric patients were admitted to the intensive care unit for the period of November 2003 to November 2010. This constituted 0.24% of deliveries and 1.25% of ICU admissions. Seventeen patients (52%) were in the age group 30 to 40 years, 13 patients (45%) were on their second pregnancy, and 15 patients (51%) were at term. Twenty-five patients (76%) did not have prior co-morbidities. Indications for ICU admission were haemorrhage 15 (44%), sepsis nine (26%), help syndrome four (12%), thromboembolism two (6%), cardiomyopathy two (6%) and anaemia two (6%). The duration of stay ranged from two to 35 days with a mean of seven and median of two days. The outcome was19 patients (58%) were discharged home, 11 patients (33%) deaths and three patients (9%) were transferred to the National referral hospital- their survival outcome unknown. Case fatality rates were three of four patients (75%) for HELLP syndrome, four of fifteen patients (26.7%) for haemorrhage and three of ten patients (30%) after sepsis. Conclusion: Critical Care Obstetrics is vital to the reduction of maternal morbidity. The main indications for ICU admission may be unpredictable but are largely preventable by improved and timely antenatal and intrapartum care. For the few but very sick patients requiring ICU care, a team based approach, as is achieved using the ‘closed’ care model may be feasible. Support to peripheral obstetric facilities via public private partnership initiatives is necessary. Healthcare planners and financiers should factor in critical care obstetric needs. Provision of a planned level of obstetric intensive care with the associated triage and referral infrastructure is a priority for the Region. As part of the drive towards Millennium Development Goal 5, health care financing models should support this essential component of life saving care, through all available channels including public private partnership

Effect of low-dose ketamine versus fentanyl on attenuating the haemodynamic response to laryngoscopy and endotracheal intubation in patients undergoing general anaesthesia: a prospective, double-blinded, randomised controlled trial

Background: The use of drugs to attenuate the haemodynamic response to laryngoscopy and endotracheal intubation is the standard of care during elective surgery. Current evidence is conflicting concerning the best agent and optimal dose for this purpose. In the majority of cases, fentanyl is widely utilized to attenuate haemodynamic responses. Ketamine, an established available drug, has been scarcely studied in this regard at low doses and against varying doses of other common agents. Objective: To compare the overall occurrence of hypertension and tachycardia immediately pre-intubation (post-induction) until 10 minutes post intubation between the study group receiving fentanyl at 1.0 µg/kg and the other receiving ketamine at 0.5 mg/kg, to compare the occurrence of post-induction hypotension and the occurrence of neuropsychiatric phenomena during emergence between the two groups. Methods: One hundred and eight ASA I and II patients aged 18-65 years scheduled for elective surgery under general anaesthesia were randomized into two groups: Control group: received fentanyl 1.0 µg/kg intravenously. Intervention group: received ketamine 0.5 mg/kg intravenously. General anaesthesia was standardized in both groups. The patients and physicians administering anaesthesia were blinded to the study. Haemodynamic responses were evaluated by determining heart rate and blood pressure immediately before laryngoscopy and at 2.5, 5, 7.5 and 10 minutes. Neuropsychiatric phenomena were assessed upon recovery from anaesthesia. Results: One hundred and eight ASA I and II patients scheduled to undergo elective surgery were included in this study, 54 participants (50%) in the fentanyl arm and 54 (50%) in the ketamine arm. Baseline demographic characteristics were similar between the groups. There were more hypertensive episodes in the ketamine arm (11%) compared to the fentanyl arm (1.85%), but not achieving statistical significance: Fisher’s exact test, p=0.06. There was no significant difference in the number of episodes of tachycardia between the Ketamine group 7/54 (13%) and the fentanyl group, 6/54 (11%); x2=0.05, p=0.82. Hypotensive episodes were more common in those who received Fentanyl, 41/54 (76%), compared to ketamine recipients, 21/54 (39%), X2=16.9, p\u3c0.001. The use of Ketamine was associated with less episodes of hypotension, adjusted odds ratio = 0.18 (95% confidence interval 0.07, 0.45). Conclusion: We conclude, based upon findings in this study group, that there is no difference in the occurrence of hypertension with the use ketamine at 0.5 mg/kg in combination with Propofol at 2.0 mg/kg. In this regard, ketamine provides a viable alternative to fentanyl at 1.0 µg/kg for attenuating the pressor response to laryngoscopy and endotracheal intubation. Additionally, our results suggest that ketamine may protect against post-induction (pre-laryngoscopy) hypotension

Life threatening spinal shock and complete neurological recovery following minor spinal cord trauma in a patient with pre-existing cervical canal stenosis: case report

Mild to moderate trauma to the spinal cord that is complicated by existing cervical canal stenosis or spondylosis can be a life threatening event. It is against this background that we present a 41 year old male with cervical spinal stenosis who developed marked quadriparesis and respiratory embarrassment following collision with a colleague. He was admitted to the intensive care unit, electively sedated, paralysed and ventilated for a period of 48 hours. During the initial 24 hours of admission, he received methylprednisolone as per the National Acute Spinal Cord Injury Studies (NASCIS) protocol. Forty five hours later he had regained full neurological and respiratory function, allowing extubation and subsequent discharge from the intensive care unit. While patients with cervical spinal cord trauma in a setting of cervical canal stenosis or spondylosis can deteriorate dramatically, early recognition of this condition and prompt management using methylprednisolone, cervical stabilisation and ventilatory support during the initial window of opportunity will enable them make a full recovery

The prevalence of postoperative pain in the first 48 hours following day surgery at a tertiary hospital in Nairobi

Background: Day case surgery services are increasing all over the world. The prevalence of postoperative pain after day surgery is found to be high. Little is known about the prevalence of postoperative pain, in Kenya, after day case surgeries. Objective: To investigate the prevalence of postoperative pain after day surgery at Aga Khan University Hospital (AKUH), Nairobi, to determine the severity/intensity of postoperative pain following day case surgery Methods: Consecutive sampling was carried out until sample size of one hundred and fifty patients was achieved. The purpose and nature of the study was explained to patients before informed consent was obtained. They were shown how to score their pain using a visual analogue scale prior to the surgical procedure. A questionnaire was used to collect data from the patients. Follow up information was obtained through telephone interviews at 24 and 48 hours, after discharge from the day surgery unit. Results: The prevalence of postoperative pain after day care surgery was found to be 58% within 30minutes postoperatively, 55.3% after 24 hours, and 34.7% after 48 hours following surgery. The prevalence of moderate to severe postoperative pain was 13% after 24 hours, and 11.7% after 48 hours. Conclusion: The overall prevalence of postoperative pain after day surgery at the Aga Khan University Hospital, Nairobi was noted to be different from what has been reported in the literature. The prevalence of moderate and severe pain however, is less than reported in the literature

Incidence of post dural puncture headache following caesarean section under spinal anaesthesia at the Aga Khan University Hospital, Nairobi

Background: Post dural puncture headache can be a debilitating complication of subarachnoid anaesthesia for a new mother. Successful management of post dural puncture headache requires adherence to clear policies and protocols with close follow up of patients by an experienced obstetric anaesthetist. Objectives: To examine the cumulative incidence and severity of post dural puncture headache in obstetric patients who consented for spinal anaesthesia for Caesarean section. Design: Prospective cohort study. Subjects: All women who underwent Caesarean sections under spinal anaesthesia and fulfilled the inclusion criteria. Setting: Aga Khan University Hospital, a teaching and referral hospital in Nairobi, Kenya. Results: The overall cumulative incidence of post dural puncture headache was found to be 20.35 % but was significantly higher in patients in whom the quincke type of needle was used than in those whose spinal anaesthetics were administered using the pencil point needle (24.2% and 4.5% respectively: p=0.042). Conclusions: The incidence of post dural puncture headache can be significantly reduced in the obstetric population at the Aga Khan University Hospital if the pencil point spinal needle was to be routinely used. We recommend that the Quincke needles should not be used in the obstetric population at the Aga Khan University Hospital