Emergency Caesarean section in a patient with known sickle-cell disease and myasthenia gravis

A 33-year-old patient with known sickle-cell disease (SS) booked for antenatal care at the Lagos University Teaching Hospital at six weeks gestational age. She had been diagnosed with myasthenia gravis three years prior to presentation and placed on oral anticholinesterase and steroid therapy, but her compliance was poor. She had had an operative delivery six years previously, under a general anaesthesia relaxant technique. It had been complicated by delayed emergence and residual muscle weakness, necessitating postoperative ICU admission for mechanical ventilation. In the index pregnancy, she had an emergency Caesarean section with bilateral tubal ligation under a combined spinal-epidural technique. A level of sensory block of T6 was achieved with 2.8 mL of 0.5% hyperbaric bupivacaine administered intrathecally. Towards the end of surgery, analgesia was supplemented through the epidural catheter with injection of 25 μg fentanyl in 6 mL of 0.25% plain bupivacaine. Supplemental oxygen was administered via a Hudson mask at 4 L/min. A live male baby with Apgar scores of 9 and 10 at one and five minutes, respectively, was delivered. The intraoperative period was uneventful. Postoperatively, she was managed in the high care unit. Postoperative analgesia was achieved via the epidural catheter with 6 mL of 0.125% bupivacaine and 2 μg/mL fentanyl four hourly for 48 hours. Subsequent recovery was uneventful. She was discharged to the postnatal ward on the fourth day postsurgery, and home with her baby 10 days later.Keywords: Caesarean section, myasthenia gravis, epidural, sickle-cell diseas

Human Immunodeficiency Virus needlestick injury: knowledge and management in a population of Nigerian anaesthetists

Objective: To determine the knowledge of HIV transmission and of post exposure management, following an HIVinfected needlestick injury, in a population of Nigerian anaesthetists. Subjects and Method: A cross-sectional, prospective assessment was conducted voluntarily in anaesthetists at an annual healthcare provider's forum, and at a major general hospital, using a structured questionnaire. Results: 63 Anaesthetists participated in the study. One anaesthetist knew the percentage of infected HIV needlestick injury that would result in HIV infection. ALL the high risk body fluids were correctly identified by 7 (11.1%) respondents. Twelve (19.0%) knew the correct immediate management when injured by a HIV-infected needlestick. Fifty eight (92.1%) were aware of post exposure prophylaxis (PEP), 25 (39.7%) had a PEP policy in their institutions and 57 (90%) knew when to commence PEP.Conclusion: Nigerian anaesthetists, though acutely aware of post exposure prophylaxis, are not aware of the fluids at risk and have not demonstrated adequate knowledge in the management, when injured by a HIV-infected needlestick. Keywords: HIV, needle-stick injury, anaesthetist, knowledge, management South African Psychiatry Review Vol. 11(4) 2005: 131-13

Anaesthetic management of post-burn contractures, a recurrent challenge from oil pipeline vandalization in Nigeria: a case report

A 13 year- old girl presented to the department with sternomental contractures as a result of facial burns from kerosene explosion. Difficult airway was envisaged. Over the period of time she developed sub-mental contracture with keloids; and was scheduled for release of contractures and flap closure

Pattern of post-anaesthetic shivering at the Lagos University Teaching Hospital, Idi-Araba, Lagos

Background: Post-anaesthetic shivering (PAS) is a common complication following anaesthesia and one of the leading causes of discomfort in patients. Aim: To determine the incidence and associated factors relating to post anaesthetic shivering. Methods:  This was a prospective study of patients who received anaesthesia over a period of 8 months at the Lagos University Teaching Hospital. Analysis of data from demographic and anaesthetic record including ambient theatre temperature (ATT), pre and post shivering temperature, shivering characteristics and management offered was made.Results: Four hundred consecutive patients aged 16-79 years, with a male to female ratio of 1:3.3 were studied. Mean ATT and mean body temperature at onset of shivering were 28±1.8°C and 36.26±0.6oC respectively.  Shivering occurred in 79 (19.8%) cases and was significantly associated with female gender [65(82.3%)], obstetric surgery  [46(58.2%)], regional anaesthesia (RA) [55(69.6%)], grade 2 shivering [42(53.2%)]  but not with duration of anaesthesia or degree of blood loss. Perioperative thermal care was not routine; 27(77.1%) received oxygen therapy and 84.8% described it as unbearable (p<0.05). Conclusion: PAS was associated with the female gender, obstetric surgery and RA. Hypothermia recorded in shivering patients was not statistically significant. A high mean ATT contributed to the moderately low incidence and grade of shivering. Shivering was unbearable in most  of the affected patients.Keywords: Post-anaesthetic shivering, Hypothermia, Obstetrics, Regional anaesthesia, Unbearabl

The Incidence of Low Plasma Cholinesterase Level and Prolonged Suxamethonium Apnoea in Sub-Saharan Africa

Background: Plasma cholinesterase is involved in the metabolism of numerous drugs including the short acting muscle relaxants suxamethonium and mivacurium. Patients deficient in BChE will exhibit a prolonged reaction to suxamethonium, and apnoea can persist for a period varying from minutes to hours. Prolonged suxamethonium apnoea may arise from inherited or acquired abnormalities of BChE, this study aimed to determine the incidence of low plasma cholinesterase and prolonged apnoea following suxamethonium. Methods: One hundred healthy patients with the American Society of Anesthesiologists (ASA) physical status I and II scheduled for elective surgery under general anaesthesia requiring endotracheal intubation were studied. Blood samples were obtained before induction of anaesthesia for estimation of baseline cholinesterase using an automated spectrophotometric method employing benzoylthiocholine. Suxamethonium 2mg/kg was administered after induction of anaesthesia and its onset was determined as the time from the administration of suxamethonium to the time of cessation of spontaneous respiration. The duration of apnoea is time from cessation of respiration to the first evidence of return of spontaneous respiration, or using peripheral nerve stimulator the time from the cessation of respiration until the response to TOF stimulation of the ulnar nerve reappears as evidenced by adduction of the thumb. Results: The mean cholinesterase level was 6573.29 ±2128.29 (ranged from 1227-14536) IU/L, the cholinesterase activity was similar in both children and adults (p = 0.97). The mean duration of apnoea was 5.88 ±2.00 minutes. Normal cholinesterase level constituted 81%, high cholinesterase level 3%, and low cholinesterase level 16% of the patient population (11% in adults and 5% in children). Prolonged apnoea with a mean duration of 10.69 ± 0.52 minutes occurred in 7% of patients with cholinesterase levels between 1227-4206 IU/L. Conclusion - Low cholinesterase level is not uncommon among healthy Nigerians. The incidence of prolonged apnoea however is small. Key words: Plasma cholinesterase, suxamethonium, prolonged apnoe

Pre0induction hypokalaemic phenomenon in Nigerian adult population

No Abstract

Propofol versus Halothane in paediatric Daycase surgery: A comparison of the duration of induction and haemodynamic profile

Background: Inhalational induction with Halothane is commonly used for anaesthesia in children. Its drawbacks include bradycardia and  hypotension. Intravenous propofol has recently challenged this position.Objective: This study sought to compare duration of and cardiovascular changes at induction of anaesthesia in children.Methods: Sixty ASA I and II children aged 1- 7 years scheduled for elective daycase surgery were prospectively studied from January to July 2008. They were assigned to receive inhalational induction with halothane 3% orintravenous induction with 3.5mg/kg of propofol. Heart rate, systolic, diastolic and mean blood pressure as well as oxygen saturation were monitored throughout induction. The duration of induction as well as any complications were documented.Results: Demographic data was comparable between the two groups. Duration of induction was significantly longer in the halothane group 8.23 ± 2.34 minutes compared with 2.30 ± 1.26 minutes in the propofol group (p< 0.001). Heart rate rose by 4.7 ±17.73 beats/minute in the propofol groupand fell by 4.19± 18.03 in the halothane group (p=0.05). Systolic, diastolic and mean blood pressures fell in both groups with values being less in the halothane group. These differences were not significantly different  (p=0.189, p=0.059, p=0.058 respectively). Sixteen patients (33%) in the propofol group developed apnoea compared to 2 (6.6%) in the halothane group (p<0.001). The duration of apnoea differed significantly between groups (p=0.003).Conclusion: Halothane and propofol had similar changes to cardiovascular parameters during anaesthetic induction. The shorter duration of induction of propofol may be preferable for daycase surgeries.Key words: Anaesthesia, induction; paediatric; halothane, propofo

Pain on Propofol Injection: The Gender Differences in Pain Perception

Background: Injection pain, which distresses patients, is a major disadvantage of propofol as an induction agent. Lignocaine pretreatment is the most popular method for reducing this pain but this drug alone cannot eliminate the problem. The aim of this study was to investigate the gender differences in pain perception/responses, and the analgesic effect of lignocaine and metoclopramide combination, compared with lignocaine alone, during propofol injection in an adult Nigerian population at the Lagos University Teaching Hospital (LUTH).Methods: A total of seventy patients were studied, comprising twenty-seven men (38.57%) and forty-three women (61.43%). Thirty-five patients in each group; who came in for various elective surgical procedures under intravenous general anesthesia were randomly assigned to two different groups, A or B. The effectiveness of a combination of i.v lignocaine 20mg/ i.v metoclopramide 10mg ( group A, n=35) when mixed with i.v propofol 2.0mg/kg in reducing pain on injection at induction of anesthesia was compared with i.v lignocaine 20mg alone mixed with i.v propofol 2.0mg/kg into a dorsal hand vein (group B, n=35). During a ten-second pause, after the first 25% of the calculated propofol dose (mixed with study drugs), the patients were asked standard questions regarding pain on injection before induction of anaesthesia. The incidence and intensity of pain were assessed using a four point Verbal Rating Scale 0 to 3 during propofol injection. Thereafter, the induction of anesthesia was continued and completed with the remainder of the calculated propofol dose and endotracheal intubation facilitated with 0.1mg/kg pancuronium in the two groups. In all other respects, except for the type of surgery, the patients had the same treatment.Results: With regard to incidence of pain on injection, the difference between the two groups was statistically significant (P<0.05) using the Chi-square test. There was no statistical difference in Verbal Pain Response (intensity) (P>0.05) Female patients had statistically significant greater pain responses/perception than men in both groups (P< 0.05).Conclusion: A lignocaine/metoclopramide combination was more effective than lignocaine alone for reducing pain on injection of propofol, and in addition, women had significant greater pain perception than men.Keyword: propofol injection pain, gender differences, pain perception, lignocaine, metoclopramide

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

Routine hemoglobin electrophoresis for pediatric surgery day case in at‑risk populations: Suggested algorithm for screening using clinical risk factors

Background: Hemoglobin electrophoresis (HBE) is a part of the preoperative routine requested by anesthetists. However, the prevalence of hemoglobinopathy in the population is low. This study aims to determine the clinical risk factors for hemoglobinopathies and propose clinical guidelines for preoperative screening of patients for pediatric day care surgery.Patients and Methods: A prospective study carried out over 12 months. Consecutive patients aged 6 months and older who had day case surgery were recruited to the study. Biodata and relevant clinical data were collated and documented in a proforma and analyzed using a statistical package for social sciences version 17.Results: There were 124 patients106 boys and 18 girls. The median age was 3 years. Scrotal lesions were the most common conditions managed (71.7%). Seventy‑eight percent of patients had HbAA, 15.3% had HbAS, and 4.8% had HbAC while 0.8% each had both HbSC and HbSS. At least one parent of 78.2% knew their Hb phenotype, of which, 79% were HbAA. A history of jaundice (P = 0.0001), hand and foot syndrome (P = 0.0001), frontal bossing (P = 0.0001), and low packed cell volume at surgery (P = 0.001) were found significant in predicting hemoglobinopathies. There was no mortality.Conclusion: Risk factors for hemoglobinopathies from this study included a positive history of jaundice, hand and foot syndrome, frontal bossing, and anemia. Proposed guidelines for HBE screening include the presence of hemoglobinopathy in one parent if one parent has sickle cell trait, and the other parent’s genotype is unknown or if any of the risk factors is present.Keywords: Algorithm, day case surgery, hemoglobin electrophoresis screenin