A review of anaesthesia for emergency laparotomy in paediatric intestinal obstruction in Enugu, Nigeria

Background: To review the anaesthetic management and outcome for emergency laparotomy for paediatric intestinal obstruction in the University of Nigeria Teaching Hospital, Enugu, Nigeria. Methods: The anaesthetic charts and folders of pediatric patients that had emergency laparotomy for intestinal obstruction in the general operating theatre of the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria, from October 2007 - September 2008 were reviewed. The records were examined for anaesthetic technique, patient primary diagnosis, intra-operative events, blood and fluid therapy and patient outcome. Patients above thirteen years were excluded. Results: Forty-four out of 285 (15.7%) paediatric patients underwent emergency laparotomy for intestinal obstruction in the general operating theatre. There were 29 males and 15 females. The average age of the patients was 3.75 years. There were a total of 1674 anesthetics in the general operating theatre during the study. The leading causes of intestinal obstruction in this study were typhoid peritonitis (14 or 31.8%), intussusceptions (14 or 31.8%) and congenital anomalies (11 or 25%). Six patients (13%) had a preoperative packed cell volume of less than 30%, while ten patients received intra-operative blood transfusion (21.7%). There was one anesthetic death to give a case mortality rate of 2.2%. Conclusion: The mortality rate in this study shows the importance and relevance of trained providers of anaesthesia managing paediatric patients in the developing world. Early presentation of patients allowed time for resuscitation and fewer complications before surgery

Anaesthetic challenges in emergency peripartum hysterectomy in West Africa: a Nigerian perspective

Background: To determine the foeto-maternal outcome and the anaesthetic challenges in emergency peripartum hysterectomy at the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria. Method: A retrospective study was carried out on parturients that had had emergency peripartum hysterectomy at UNTH in Nigeria, from July 1998 to June 2006. Data collected included demographics, anaesthetic and obstetric records, foeto-maternal outcomes and the need for critical care management. Results: There were a total of 6 798 deliveries and 6 485 live births, with 16 emergency peripartum hysterectomies. The incidence of emergency peripartum hysterectomy was 0.23% of all deliveries (2.3/1 000 deliveries). The causes of emergency hysterectomies were ruptured uterus (11 patients or 69%), placenta accreta/morbidly adherent placenta (4 patients or 25%) and uncontrollable postpartum haemorrhage following vaginal delivery (1 patient or 6%). Eight patients had subtotal hysterectomy, while eight had total abdominal hysterectomy (TAH). All the patients received general anaesthesia and blood transfusion. There were two postoperative admissions to the intensive care unit (ICU) and two procedure-related deaths due to hypovolaemic shock. There were nine stillbirths but no documented neonatal deaths. Conclusion: Emergency peripartum hysterectomies challenge the anaesthetist and the obstetrician who have to maintain haemodynamic stability in patients who may have lost volumes of blood, in a setting where blood and colloid availability is often limited. The maternal mortality was higher than that of most of the studies reviewed.Keywords: anaesthesia; peripartum hysterectomy; West Africa; Nigeri

Eclampsia and seasonal variation in the tropics - a study in Nigeria

Background: A retrospective observational study on the seasonal variation in the admission of eclampsia patients to the multi-disciplinary intensive care unit (ICU) of National Hospital, Abuja, Nigeria over a five-year span (March 2000 – March 2005) was carried out. Method: The patient’s case files and ICU records were used to extract the needed data. The diagnosis of eclampsia was based on clinical and laboratory findings by the obstetricians. Results: There were a total of 5,987 deliveries during the study period. Forty-six eclamptics were admitted to the ICU during the study period giving an ICU admission rate of 7.6/1000 deliveries. The average age of the patients was 28.6 years. Six patients (13%) were booked for antenatal care in the hospital, while forty patients (87%) were referred. Average duration of stay in the ICU was 4.6 days (range 1-42 days).Thirty-one eclamptics (67.4%) were admitted to the ICU during the rainy season (April to October) and fifteen (32.6%) during the dry season (November to April). The rainy season is associated with a lower average high temperature and a higher humidity than the dry season. There is a view that holds that increasing humidity and a lower temperature is associated with increased incidence of eclampsia.There were thirteen deaths giving a case fatality rate of 28.2%. The causes of death were HELLP (haemolysis, elevated liver enzymes, low platelet count) syndrome in six patients, disseminated intravascular coagulation in two patients, and acute renal failure (ARF) in two patients. Septicemia, lobar pneumonia/heart failure and cerebrovascular accident accounted for one death each. Conclusion: In this study, we found an association between the rainy season and the incidence of eclampsia to our intensive care unit. This association should be further explored

Management of pituitary adenoma with mass effect in pregnancy: a case report

A middle aged primigravida was managed at the University of Nigeria Teaching Hospital, Enugu, Nigeria for a pituitary macroadenoma. She was admitted at 33 weeks gestational age following a history of blurred vision and generalized headache, worse on bending down. After neurological consultation and investigations, a diagnosis of pituitary macroadenoma with mass effect was entertained. A plan for neurosurgery after delivery was made and the patient put on bromocriptine to reduce tumour size. Premature labour at 35 weeks resulted in caesarean delivery of a live baby. She was managed in the intensive care unit for three days where oral bromocriptine was resumed before she was transferred to the postnatal ward. Within ten hours of the transfer, she developed accelerated hypertension with encephalopathy and had a cardiac arrest shortly afterwards. This rare case highlights both the possible role of bromocriptine as a cause of postpartum hypertension and the possible development of a sudden catastrophic intramoural infarction or hemorrhage (pituitary apoplexy) in a patient with a macroadenoma

Maternal death and obstetric care audits in Nigeria: A systematic review of barriers and enabling factors in the provision of emergency care.

Acknowledgements We would like to thank Yutaka Osakabe for co-ordinating the retrieval of full text articles. The John D. and Catherine T. MacArthur Foundation supported this study, grant number 12-100074-000-INPPeer reviewedPublisher PD

Challenges in critical care services in Sub-Saharan Africa: Perspectives from Nigeria

Critical care services in Nigeria and other West African countries had been hampered by economic reversals resulting in low wages, manpower flight overseas, government apathy towards funding of hospitals, and endemic corruption. Since then things have somewhat improved with the government′s willingness to invest more in healthcare, and clampdown on resource diversion in some countries like Nigeria. Due to the health needs of these countries, including funding and preventive medicine, it may take a long time to reach reasonably high standards. Things are better than they were several years ago and that gives cause for optimism, especially with the debt cancellation by Western nations for most countries in the region. Since most of the earlier studies have been done by visiting doctors, mainly outside the West African subregion, this paper seeks to present a view of the challenges faced by providers of critical care services in the region, so that people do not have to rely on anecdotal evidence for future references. DOI: 10.4103/0972-5229.5311

Postoperative vomiting and fever following tonsillectomy in Enugu, Nigeria

OBJECTIVE: To determine the incidence of postoperative vomiting and fever in patients that had tonsillectomy in our centre over a five year period.METHODS: The hospital records (case files) of patients that had tonsillectomy with or without adenoidectomy under general anaesthesia at the University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu, Nigeria from January 2004 to December 2008 were retrieved and analyzed. Patients that had an adenoidectomy only were excluded. The patients were of the American Society of Anesthesiologists (ASA) 1 to III status. RESULTS: There were fifty two (52) patients that had tonsillectomy and adenotonsillectomy under general anaesthesia during the period under review. Forty one (41) patients were between the ages of 1-13 years (78%) and eleven (11) patients between the ages of 18 - 62 years (12%). There were 32 males and 20 females. The average age for all the patients was 9.03 years. There were seven (7) patients with post operative vomiting (13.4%). These included four (4) patients in the paediatric population (9.75%) and three (3) in the adult population (27.2%). Twenty one (21) patients (40.3%) developed postoperative fever. There were no deaths. The other significant morbidity was postoperative pain.CONCLUSION: The number of patients that had tonsillectomy in our center was small compared to other studies. The incidence of postoperative vomiting in this study is lower than that reported from Western World, showing possible racial variations, a trend that has been reported in some earlier studies in Black populations.KEYWORDS: Tonsillectomy, postoperative vomiting and fever, Afric

Risk Factors for Maternal Deaths in Unplanned Obstetric Admissions to the Intensive Care Unit-Lessons for Sub-Saharan Africa

This study was undertaken to determine the risk factors for maternal deaths in unplanned or unbooked obstetric admissions to the intensive care unit of a tertiary health centre. Hospital records of unbooked obstetric admissions to the intensive care unit of the hospital from January 1997 to December 2006 were retrospectively reviewed. Data collected included patients’ demographics, diagnosis, duration of stay in the ICU and patient outcome. The intensive care unit records showed that there were 25 unbooked obstetric admissions. Major diagnoses for unplanned admissions to the ICU were preeclampsia/eclampsia (41.1%), obstetric haemorrhage (37.5%), and respiratory distress (12.5%). There were 12 deaths (48%). Organ dysfunction on admission, massive blood loss and late presentation were the risk factors for mortality. The high maternal mortality was mainly due to limited supply of blood products and inadequate prenatal care resulting in disease severity