Background: Drug utilization reviews (DURs) can be used to promote rational prescribing and ensure compliance with standard treatment guidelines. In recent years, the use of tramadol hydrochloride (HCl) for pain has increased significantly across countries. We sought to determine prescribing patterns and use of tramadol in a Regional Hospital in South Africa to provide future guidance in view of increasing concerns with the prescribing of tramadol. Method: A prospective, quantitative and descriptive study was conducted over two months. Outpatient and inpatient prescriptions and ward requisitions where tramadol HCl was prescribed or ordered were identified, which included outpatients collecting antiretroviral (ARV) treatment. These were reviewed and evaluated to determine the level of compliance to the Standard Treatment Guidelines and Essential Medicines List (STGs/EML) for South Africa as a measure of the quality of prescribing. Quantities issued to the inpatient wards and expenditure incurred by the pharmacy departments were assessed to determine overall usage and total costs. Results: In total, 415 tramadol HCl prescriptions were collected over a 2-month period. Compliance was 70.1% to the STGs/EML. The outpatient pharmacy department had the highest compliance at 76.4% while the ARV pharmacy compliance was 29.1%. Most prescriptions dispensed at the outpatient pharmacy were from the Surgical Outpatient Department (140; 33.7%) and the Orthopaedic Outpatient Department (108; 26.0%). The outpatient pharmacy had the highest tramadol HCl consumption and expenditure at $4,874.13 (R72,054.28), while the inpatient pharmacy's expenditure was $2,526.63 (R37,351.20), and the ARV pharmacy $590.13 (R8,722.75). The hospital's tramadol HCl expenditure increased when compared to previous financial years, from $10,576.04 (R156,326.00) in 2014-2015 to $39,584.00 (R585,088.80) in 2016-2017. Conclusion: This study highlights the need for the implementation of monitoring and evaluation tools to enhance rational prescribing and use of tramadol HCl. These are being implemented and will be evaluated in future projects.
Tracheal tears can be difficult to manage in the acute postoperative setting. Previous case reports describe immediate extubation and spontaneous respiration 1 , unilateral endobronchial intubation and the use of a Foley catheter to provide CPAP 2 , use of a Robertshaw double-lumen tube 3 , or intraoperative repair of the defect using stomach 4 . We describe management by prolonged bilateral endobronchial intubation and elective ventilation before changing to a tracheostomy tube. CASE HISTORYA 58-year-old man was scheduled for an urgent pharyngolaryngoesophagectomy for extensive oesophageal carcinoma. He was a former heavy cigarette smoker (two packs per day for 40 years) and regular ethanol user. A preoperative CT scan showed tumour extending from the level of the upper border of the thyroid cartilage to level with the aortic arch, involving the posterior tracheal wall. Preoperative arterial blood gas analysis whilst breathing room air showed a PO 2 of 69 mmHg and PCO 2 of 28 mmHg. Anaesthesia was induced with thiopentone and maintained with nitrous oxide (60%) in oxygen and isoflurane. Intraoperative analgesia was provided with fentanyl. Pancuronium was used to facilitate intubation with an 8.0 mm cuffed oral endotracheal tube and to provide ongoing neuromuscular blockade throughout the procedure. At operation, the resectability of the lesion was initially confirmed via an apron flap cervical incision and a tracheostomy was performed.The pharynx and larynx were mobilized as a unit and then separated from the tongue base superiorly and from the trachea inferiorly. The stomach was mobilized via a midline abdominal incision. Trans-hiatal and trans-cervical mobilization of the oesophagus was performed and the specimen was removed. A linear tear of the posterior wall of the trachea from 2 cm below the tracheostomy to within 1 cm of the carina was noted and managed initially by positioning the tracheostomy tube at the carina. Bilateral pneumothoraces were managed by insertion of intercostal drains. The alimentary tract was reconstructed by means of gastric pull-up. The anterior gastric wall appeared to fill the tracheal defect. The remainder of the intraoperative course was uneventful.Postoperatively, residual neuromuscular blockade was antagonized with neostigmine and glycopyrrolate and he was transferred to ICU with the armoured tracheostomy tube in situ and with ventilatory support from a transport Ambubag. On arrival in ICU the SpO 2 had fallen to 85% and it was noted that the cuff of the tracheostomy tube had migrated up the trachea away from the carina, exposing the defect to positive pressure ventilation.The tube was removed and the patient breathed spontaneously on 100% oxygen. A flexible endoscopy was performed using an intubating bronchoscope and a 6.0 mm endotracheal tube with a high-volume, lowpressure cuff was placed down the left main bronchus, with the top of the cuff lying immediately distal to the carina.The oxygen saturation at this point was 85%. This procedure was repeated on the right and the fin...
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