A 52-year-old woman was scheduled for modified radical mastectomy on account of advanced carcinoma of the right breast. The patient was a known hypertensive and diabetic, diagnosed 3 years prior to presentation and also a known asthmatic, diagnosed at childhood. She was being managed with lisinopril, amlodipine, and Mixtard insulin injection. However, she was not compliant on her medications. Three days before the scheduled surgery, her blood pressure (BP) was 170/110 mmHg, and fasting blood sugar was 10.8 mmol/L. Additionally, she suffered an asthmatic attack 2 days prior to surgery. Her regular doses of antihypertensive drugs and insulin(42 IU/day) were increased, while salbutamol inhaler at 2 puffs as required, along with aminophylline and prednisolone tablets were used to manage the mild asthmatic attack. On the evening prior to surgery her vital signs were as follows: pulse rate (PR) 88/minute, BP 130/70 mmHg, respiratory rate (RR) 20/minute and temperature 36.8°C. Her chest was clinically clear and other examination findings were normal. Her packed cell volume (PCV) was 36%. Electrocardiogram (ECG) and chest x-ray findings were suggestive of left ventricular hypertrophy. Other investigation results, including electrolyte, urea, and creatinine were within normal limits. Based on the comorbid conditions, she was assigned class to III of the American Society of Anesthesiologists (ASA) classification scheme. She was counselled for thoracic epidural anaesthesia, as general anaesthesia was considered a more risky alternative, and consent for the procedure was obtained. On the morning of surgery her fasting blood sugar was 8.9 mmol/L and 500 mL of 5% dextrose water infusion, into which 5 mmol of potassium and 5 IU of soluble insulin were added, was set up to run at 100 mL/hour. Additionally, the morning doses of her regular antihypertensive medications were given. In theatre, a multiparameter monitor was attached to the patient, measuring peripheral capillary oxygen saturation and noninvasive BP. Baseline values were as follows: PR 84/ minute, BP 110/70 mmHg, and SpO 2 96%. In the sitting position, a midline thoracic epidural was performed at the T4/T5 interspinous space using a size 18G Tuohy epidural needle and loss of resistance to air technique. The skin epidural depth was 5 cm, and 4 cm of the epidural catheter was left in situ in the epidural space in the cephalad direction, and the catheter adhered to the back with adhesive tape. After a test dose of 3 mL of 1% lidocaine with adrenaline, a loading dose of 7 mL of 2% lidocaine with adrenaline 1:200,000 was given in 4 mL and 3 mL aliquots at 5-minute intervals. The epidural catheter was connected to a syringe pump for continuous infusion of 2% lidocaine-adrenaline at 4 mL/hour. Five minutes later, a sensory block height of T1 to T10 was achieved bilaterally, and the surgery commenced. The breast tissues and tumour were excised en bloc, including fibrofatty tissues of the medial aspect of the right axilla. Oxygen was given via face mask at 4 L/minute througho...
Background: Thoracic epidural anaesthesia (TEA) has many benefits over general anaesthesia in major abdominal surgeries including avoidance of endotracheal intubation. Aims: To evaluate the feasibility of TEA for major abdominal surgeries in the private hospital setting. Patients and methods: This was a retrospective study of all major abdominal surgeries performed under TEA in two private hospitals in Uyo, Akwa Ibom State, Nigeria over a two-year period. All thoracic epidural anaesthesia was performed under aseptic conditions at the T 8/9 , T 9/10 , or T 10/11 interspinous space using a size 18G Tuohy epidural needle and catheter inserted as appropriate. A test dose of 3 ml of 1% lidocaine with adrenaline was used in all patients, after which a loading dose of 10-15 ml of 2% lidocaine with adrenaline was injected at 5 ml every 5 minutes till a block height of approximately T 4-L 1 was obtained. Anaesthesia was maintained with 5 ml of 2% lidocaine with adrenaline every 45 minutes till the end of surgery. The operative condition was assessed on the basis of sedation and analgesic requirement, as well as response to mesenteric traction. The pulse rate, blood pressure and oxygen saturation were monitored throughout the procedure and recorded. Data were obtained from the patients' folders and operation register. Information obtained included: age, gender, ASA status, diagnosis and type of surgery performed. Data analysis was performed using SPSS®, version 16. Results: Twelve patients underwent major abdominal surgeries under TEA. The mean age (range) was 49.58 (20-78) years, with a male to female ratio of 1:1.4. TEA was adequate in 10 (83.3%) patients, while two (16.7%) patients developed total spinal anaesthesia and were successfully resuscitated and their surgeries completed under general endotracheal anaesthesia. Conclusion: TEA for major abdominal surgeries is feasible. However, careful patient selection, a meticulous approach and preparation for resuscitation is required to prevent and manage complications.
Bladder exstrophy is a rare congenital malformation. It presents as leakage of urine in the anterior abdominal wall following defects in midline anterior abdominal wall skin and bladder. We report the use of combined general anaesthesia and caudal epidural analgesia in a 4yr old boy for repeat bladder exstrophy repair. Problems of prolonged surgery and the challenges of pain and sedation management in the post operative period are discussed.
Objectives: Pre-operative anemia is common in Sub-Saharan Africa including Nigeria. Anemia is a known risk factor for blood transfusion. In our hospital, like many others, patients are usually admitted a day before elective surgeries and the default treatment for anemia by most surgeons and anesthetists is allogenic blood transfusion. Anemia and blood transfusion are independently and synergistically associated with complications and undesirable outcomes. Patient blood management (PBM) is gaining popularity and has been advocated by the World Health Organization (WHO) for member countries to adopt as a means of improving patient outcomes. There is currently no research from the University of Calabar Teaching Hospital highlighting the prevalence of pre-operative anemia. This research was aimed at filling this gap and also presenting a baseline for comparison as the hospital strives to implement the three pillars of PBM strategies: Manage anemia, minimize blood loss and harness tolerance to anemia to improve patient outcomes. Material and Methods: All surgical patients who consented to the study were recruited prospectively. Patients who had no pre-operative hemoglobin (Hgb) or packed cell volume (PCV) recorded were excluded from the study. Demographic data, type of surgery, and pre-operative PCV levels were documented. Anemia was defined using the WHO standard as PCV <39% (Hgb 13.0 g/dL) in men and <36% (Hgb 12.0 g/dL) in women. Data were obtained about transfusion at the end of surgery. Surgeries were categorized into general, orthopedic, obstetric, gynecological, urologic, pediatric, ear, nose, throat/maxillofacial, burns and plastic unit (BPU), neurological, and thoracic. The information was entered into SPSS version 20. Data were cleaned and analyzed. The statistical significance was placed at P < 0.05. Results are presented as tables, chats, and histograms. Results: A total of 237 patients were recruited with a mean age of 37.30 ± 19.05. More of them were females (54.0%) and a higher proportion of them (64.6%) had elective surgery. The categories of surgeries were predominantly general surgical (24.9%) and gynecological (21.9%) followed by orthopedic (17.7%), ENT/maxillofacial (9.3%), urologic (8.0%), and obstetric (7.2%) cases. The rest were neurosurgical (3.4%) and pediatric surgical (2.1%) cases. The overall prevalence of anemia was found to be 54.9%. The mean pre-operative PCV was 34.90 ± 7.37%. The highest proportion of pre-operative anemia was found among the pediatric surgical cases (80.0%) followed by the urologic (68.4%) and neurosurgical cases (62.5%). The prevalence of pre-operative anemia among the different surgical patients was gynecological (46.2%), general surgical (45.8%), obstetric (41.2%), ENT/maxillofacial (40.9%), and orthopedic (38.1%) cases. The lowest proportion of pre-operative anemic patients was found among the thoracic (25.0%) and Burns and Plastics (11.1%) cases. Most of the patients (86.5%) were not transfused intraoperatively. Whereas 20% of the anemic patients were transfused; only 5.6% of the non-anemic ones needed a blood transfusion. Conclusion: Pre-operative anemia remains prevalent in our environment and anemia is a risk factor for a blood transfusion which carries both risk and cost implications. PBM has as its first pillar the management of anemia. This pre-emptive approach to allogeneic blood transfusion avoidance is aimed at improving patient outcomes. Prevention and treatment of pre-operative anemia will be beneficial not just to the patients but to all healthcare stakeholders.
Aims: To enlighten both clinicians and Jehovah's Witness patients on closed-circuit acute normovolemic hemodilution (ANH) and deliberate hypotension (DH) as safe and acceptable blood conservation strategies. Case Presentation: A 32 yr old male Jehovah's Witness patient was scheduled for nephrolithotomy on account a right nephrolithiasis (Staghorn calculus). He was fit and young weighing 76 kg with packed cell volume of 34%. The anticipated blood loss during the surgery was 1500 ml or more, hence we decided to use combined closed-circuit ANH and DH. These combined strategies were accepted by the patient; they minimized blood loss to only 400 mls and provided a good operating field visibility. Discussion: Several blood conservation strategies have been developed and accepted by Jehovah's Witness patients provided the blood circulation circuit is not broken. Our resident doctor and patient were not initially aware of the acceptability of ANH by the Jehovah's witness. Blood conservation strategies could be used either singly or in combination, our patient was suitable for both. Conclusion: Combined closed-circuit ANH and DH are safe and acceptable to Jehovah's witness patients.
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