Factors Associated with Intensive Care Unit Admission Refusal

Background: The need for intensive care exceeds its availability most times because resources are limited. Our objectives were to determine the incidence of admission refusal and factors associated with such in our Intensive Care Unit (ICU). Methods: The following information was obtained from patients referred to our ICU over a 6-week period: age, gender, date and time of referral, source of referral, reason for referral, whether ICU was full or not full at the time of referral, and modified early warning score (MEWS). Others included; whether admitted or not, and if not admitted, reasons for admission refusal. Binomial logistic regression analysis was used to determine predictors of ICU admission refusal. Results: Patients admitted and those denied admission were 37(50.7%) and 36(49.3%) respectively. Following univariate analysis, there were no statistical differences in the age and MEWS of patients in the admitted and not admitted groups respectively. Refusal was highest for sepsis (80%) and respiratory failure (71.4%) and lowest for severe head injury (18.2%), no difference was found in the MEWS for patients with sepsis and those with severe head injury. Lack of ICU bed was the only independent predictor of ICU admission refusal. Conclusions: The crude ICU admission refusal rate was 49.3% and unavailability of ICU bed independently predicted ICU admission refusal. To ensure reduction in ICU admission refusals, the ratio of ICU beds over the population must be appropriate.Key words: ICU, Admission refusal, Bed availabilit

EPIDEMIOLOGY OF BACTERIA COLONIZATION AND ICU-ACQUIRED INFECTION IN A NIGERIAN TERTIARY HOSPITAL

Background: Health care associated infection (HCAI) or Hospital acquired infection is associated with significant morbidity, mortality and cost. The incidence is about 6% and disproportionately higher in critically ill patients who may have been immune-compromised with many invasive procedures already performed. Prevention of HCAI and appropriate management of patients in the intensive care unit (ICU) requires knowledge on the pattern of microbial colonization and infections. The aim of this preliminary study was to provide current data on the pattern of ICU acquired infections in our hospital. Patients and Methods: It was a cross sectional study of patients admitted into the ICU who were expected to stay longer than 48hrs between July 2011 and September 2012. Urine, blood, and tracheal aspirate were collected on days 1, 3 and 5 for microbiological studies. All patients involved in the study had urethral catheter in-situ and received mechanical ventilation in the ICU. Results: Fifty-nine patients were recruited into the study. The mean age of the patients was 30.08 + 19.9yr; while the reasons for admissions were respiratory failure (59.3%), cardiovascular instability, trauma and neurological diseases. About 30% of the samples taken from the study sites on arrival in the ICU had positive culture yields. Organisms cultured included Klebsiella oxytoca, Staphylococcus aureus, and Pseudomonas aeruginosa. The urinary tract had the highest number of isolated organisms- 9(60%), followed by equal number of isolated organisms-3(20%) in the blood and respiratory tract. Eleven (73.3%) of the organisms isolated were Gram-negative bacteria, and 4 (26.7%) were Gram-positive cocci. The commonest bacteria isolates were Staphylococcus aureus (4/26.7%) and Klebsiella oxytoca (4/ 26.7%). A total of 15 ICU- acquired infections were detected in 9 of 59 patients. Conclusion: The HCIA infection rate was 15%, and urinary tract infections (UTI) was the commonest hospital acquired infection in our ICU. Klebsiella oxytoca and Staphylococcus aureus were the commonest organisms

Challenging Airway Management in a Patient with Retrosternal Goiter Presenting in Respiratory Distress

A number of options exist for patients with anticipated difficult intubation on account of a retrosternal goiter compressing on the trachea. The chosen technique(s) to secure the airway in this delicate situation often depends on the location and degree of airway obstruction, available resources/facilities, and an anesthetist's experience and preferences. We report the case of a 68-year-old woman with severe airway obstruction from a retrosternal goiter coming for total thyroidectomy. Airway management started with an awake fiber-optic intubation, proceeded to a tracheostomy and finally to use of a rigid bronchoscope following failure of the earlier techniques to achieve adequate ventilation

ICU utilization by cardio-thoracic patients in a Nigerian Teaching Hospital: Any role for HDU?

Background: The underlying pathological conditions in cardio-thoracic patients, anesthetic and operative interventions often lead to complex physiological interactions that necessitate ICU care. Our objectives were to determine the intensive care unit (ICU) utilization by cardio-thoracic patients in our centre, highlight the common indications for admission; and evaluate the interventions provided in the ICU and the factors that determined outcome. Materials and Methods: The intensive care unit (ICU) records of University College Hospital, Ibadan for a period of 2 years (October 2007 to September 2009) were reviewed. Data of cardio-thoracic patients were extracted and used for analysis. Information obtained included the patient demographics, indications for admission, interventions offered in the ICU and the outcome. Results: A total of 1, 207 patients were managed in the ICU and 206 cardio-thoracic procedures were carried out during the study period. However, only 96 patients were admitted into the ICU following cardio-thoracic procedures, accounting for 7.9% of ICU admissions and 46.6% of cardio-thoracic procedures done within the review period. The mean length of stay and ventilation were 5.71 ± 5.26 and 1.30 ± 2.62 days. The most significant predictor of outcome was endotracheal intubation (P = 0.001) and overall mortality was 15%. Conclusion: There is a high utilization of the ICU by cardio-thoracic patients in our review and post-operative care was the main indication for admission. Some selected cases may be managed in the HDU to reduce the burden on ICU resources. We opine that when endotracheal intubation is to continue in the ICU, a 1:1 patient ratio should be instituted

Characteristics and anesthetic management of patients presenting for cleft surgery

Background: Anesthetic management during surgery for cleft repair can be challenging due to abnormal airway anatomy and preoperative medical conditions. We sought to determine the characteristics, type, and incidence of associated medical problems, airway and other intraoperative complications in patients who presented to our facility for cleft lip and palate repair. Methodology: Fifty-six consecutive patients aged 16 years and below who had surgical repair of cleft lip or palate under general anesthesia during the study period were involved in this prospective, observational study. Routine preoperative review and anesthetic management were not altered. Preoperative medical and airway problems, associated congenital anomalies, intubation outcomes, intraoperative anesthetic complications, and postoperative airway problems were recorded by a blinded observer. Results: Forty-eight (72.7%) and 18 (27.3%) of the 56 patients had cleft lip and palate repair, respectively. Baseline packed cell volume was not significantly different. The incidence of upper respiratory tract infections (URTIs) and anemia were 33% and 0%, respectively, in the cleft palate repair group compared to 18.8% and 16.7% in the cleft lip repair group. Difficult laryngoscopy was found in 4.2% and 11.1% of patients that presented for cleft lip and palate repairs, respectively, and the overall incidence of desaturation was 7.5%. The mean blood loss was more in the cleft palate group compared to that of the cleft lip repair group (33.33 ± 37.73 versus 7.92 ± 6.51, P = 0.001). Conclusions: Cleft lip repair was most common in our review, and URTI was the predominant comorbidity in both groups. The risk of a wide range of perioperative airway complications necessitates the presence of skilled manpower during general anesthesia for cleft lip and palate surgery

ATTITUDE OF GENERAL PUBLIC TO RISKS ASSOCIATED WITH ANAESTHESIA

Objective: To identify specific fears being entertained about general anaesthesia. Methods: People who do work in any medical facility were targeted in this prospective questionnaire-based study. All respondents were literate. The questionnaire was divided into two sections; (a) The baseline information, which included age, sex, marital status, occupation, previous exposure to anaesthesia and patient preference for anaesthesia technique. (b) Fear about risks associated with general anaesthesia; respondents were expected to pick one of four options (very concerned, somewhat concerned, not concerned and not sure), to indicate how they feel about each of the eight risks listed in the questionnaire. The data obtained was analyzed using SSPS version 10 for Windows. Results: In a bivariate analysis, marital status, occupation and previous exposure to anaesthesia are not associated with the expressed fear by the respondents. Respondents had the highest concern for the fear of death (82%), followed by fear of postoperative pain (75.4%). Least concern was for awareness during anaesthesia (37.7%). The mean age of those who expressed concern about being aware during operation is 37.0± 8.6years while those not concerned is 31.8± 8.5years(p=0.034). More of those who are concerned with nakedness preferred general anaesthesia (p=0.023). Also, more females (95.7%) than males (70.6%) expressed fear about pain during general anaesthesia (p= 0.019). Conclusion: Fear of death is a great concern for our patients coming for general anaesthesia and it is followed closely by fear of postoperative pain, the later was of greater concern to females. Finally, more of those who were concerned about nakedness preferred general anaesthesia

The Effect of Single‑Dose Bupivacaine on Postoperative Iliac Crest Graft Donor Site Pain

Background: Postoperative donor site pain remains a major source of morbidity following iliac crest bone graft harvesting (ICBGH). Aim: The aim of this study was to investigate the effect of single-dose infiltration of bupivacaine on donor site pain following ICBGH. Subjects and Methods: This study was a double-blind randomized controlled trial of 30 adult individuals that required an ICBG as part of the treatment for mandibular reconstruction. Individuals were divided into two groups, to receive a single-dose subcutaneous infiltration of either 0.25% bupivacaine or 0.9% normal saline at the iliac crest graft incision site following ICBGH. Length of incision at the ICBGH site, dimensions of harvested graft, time taken for the iliac crest harvest surgery, total daily dose of postoperative analgesics, pain from the ICBGH site as well as gait disturbance were recorded. Data were analyzed using SPSS version 17.0, and P < 0.05 was considered statistically significant. Results: There was a progressive decrease in pain score from the 1st to the 4th postoperative day, with no significant difference between the two groups. There was no statistical difference between the two groups in terms of dynamic median pain score at the early postoperative period as well as at the 4th and 12th week postoperative period. The analgesic consumption between the two groups also did not show any significant difference. Conclusion: Local injection of single dose of 0.25% bupivacaine did not offer additional benefit in the management of postoperative iliac crest donor site pain following ICBGH

Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1% (3.3-4.8), 3.9% (2.6-5.1) and 3.6% (2.0-5.2), respectively). Surgery performed >= 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5% (0.9-2.1%)). After a >= 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0%), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms >= 7 weeks from diagnosis may benefit from further delay