Faculty of Anaesthesia

A COMPARATIVE STUDY OF GLYCOPYRROLATE AND DEXAMETHASONE IN THE CONTROL OF PONV AFTER INTRATHECAL FENTANYL AND BUPIVACAINE FOR CAESAREAN SECTION.

DR. PATRICK IKEMEFUNA OKONKWO — 2019-04-01

SUMMARY

BACKGROUND

Postoperative nausea and vomiting (PONV) is an undesirable outcome that parturients who undergo caesarean section experience. Complications of PONV range from discomfort, dehydration, electrolyte imbalance to pulmonary aspiration of gastric contents. Different drugs have been employed as prophylaxis against PONV with varying degrees of success and outcome.

AIM

The aim of this study was to compare the efficacies of IV glycopyrrolate and IV dexamethasone as effective prophyaxis against PONV in women undergoing caesarean section after intrathecal fentanyl and bupivacaine.

PATIENTS AND METHODS

This is a prospective, randomized, double blind placebo controlled study of seventy six (76) ASA II patients aged 18-40 years who underwent elective caesarean section under spinal anaesthesia. Patients were randomly allocated to three groups, group G (glycopyrrolate): n=26, group D (dexamethasone): n=25 and group C (control; normal saline): n=25. Data collection was with the aid of a proforma which included the biophysical profile, ASA physical status, Mallampati scores, patient’s haemodynamics, Belville scoring scale for PONV, Likert scale was used for patient satisfaction and side effects were also documented.

The data were analyzed using the Statistical Package for Social Sciences (SPSS) version 17 and presented in tables and figures.

RESULTS

The demographic characteristics and mallampati scores of patients in all 3 groups were similar. Patients in group G had higher mean heart rates compared to groups D and C and this was statistically significant (P=0.046). However, patients in group D recorded the highest mean arterial blood pressure (P=0.028). The results showed that the incidence of PONV in group D was 13.3%, in group G 33.3% and in group C 53.4%. The results showed that the use of 8mg dexamethasone was significantly associated with a lower incidence of PONV (P= 0.048, OR= 0.185, 95% C.I for OR= 0.035 – 0.983). Patients who received IV 8mg dexamethasone were less likely associated with an incidence of PONV. However, the use of IV 0.2mg glycopyrrolate showed a relatively higher incidence of PONV.

All patients expressed satisfaction in the care they received as assessed using the likert scale and only patients who received IV glycopyrrolate experienced side effects in the form of dryness of the mouth. There were no side effects reported in patients who received IV dexamethasone.

CONCLUSION

The study demonstrated the efficacy of 8mg intravenous dexamethasone over 0.2mg intravenous glycopyrrolate in controlling PONV after intrathecal fentanyl and bupivacaine for caesarean section.

EVALUATION OF THE INCIDENCE OF CENTRAL VENOUS CATHETER LINE INFECTION IN PATIENTS ADMITTED IN THE INTENSIVE CARE UNITS OF UNTH ENUGU: RISK FACTORS AND MICROBIOLOGY PROFILE

DR. OKAFOR VITUS ONYEKACHI — 2019-04-01

Background: University of Nigeria teaching hospital has two functional intensive care units(ICU), each is a 5 bedded ICU. Patients admitted in the intensive care unit often require the insertion of various invasive devices such as Central venous catheter, and arterial line for monitoring and therapeutic interventions. These devices though indispensable in the management of these patients in ICU but often puts them at risk of various iatrogenic complications and central venous catheter blood stream infection resulting in prolonged hospital stay, increase morbidity, mortality and cost.

Objective: This prospective observational study was aimed at evaluating the incidence of central venous line infection with its risk factors and microbiology profile among patients in UNTH ICUs. The study was conducted over twelve monthsperiod in the two ICUs of UNTH.

Methodology: Patients admitted into these ICUs, who routinely had CVC inserted in them and met the inclusion criteria were recruited for the study. The first blood sample was collected from each patient and sent for full blood count to ascertain blood sterility. The patients whose blood samples had evidence of infection were excluded as the study was aimed at CVC infection acquired in the ICU. A total of 68 patients were recruited but 65patients completed the study. Blood samples were collected aseptically from a peripheral vein 72 hours after insertion of CVC and at removal of CVC for blood culture. The distal 5cm of the CVC was also collected aseptically when disconnected from patient for catheter tip MCS.

Result:A total of 6(9.2%) of the 65 patients had CVC-BSI while 31(48%) had CVC colonization. 1(2.3%) patients whose duration of catheterization was within 5 days had CVC-BSI while 5(22.7%) whose duration of catheterization was beyond 5days had CVC-BSI. Duration of catheterization was the only risk factors and was statistically significant. A total of 37 organisms where isolated and the commonest bacterial isolate was staphylococcus aureus. The bacterial isolates were mostly susceptible to Gentamycin. The organisms showed a high resistance to the antibiotics tested. All the patients were on prophylactic antibiotic.

Conclusion: It was evident in this study that the incidence of central venous catheter blood stream infection and CVC colonization in ICU of UNTH Enugu was 9% and 31% respectively

A COMPARISON OF THE ANALGESIC EFFICACY AND SAFETY OF EPIDURAL PLAIN BUPIVACAINE ALONE WITH PLAIN BUPIVACAINE AND TRAMADOL IN LOWER LIMB ORTHOPAEDIC SURGERIES.

System Systems — 2018-09-06

Background: Tramadol, a centrally acting opioid-like drug with analgesic effect and fewer side-effects than the typical opioids, has been administered through various routes including epidural route. Pain management is necessary based on humanitarian ground as well as for therapeutic reasons. Failure to relieve pain may lead to tachycardia, hypertension, hypoxia, restlessness, nausea and vomiting, increase in metabolism and sleep disturbances in the patient. Pain control remains the key to post-operative recovery of orthopaedic surgical patients and therefore, optimizing post-operative analgesia improves the patient’s ability to fully participate in rehabilitative sessions.

There are various adjuvant drugs that have been added to bupivacaine to modify its action and these include among others tramadol, morphine and fentanyl. The sensory blockade effect of epidural anaesthesia has been used for intra-operative and post-operative pain management in surgeries involving the lower limbs and pelvis. This study therefore, was aimed at comparing the analgesic efficacy and safety of epidural 0.5 % plain bupivacaine alone and epidural 0.5 % plain bupivacaine and tramadol as an additive in lower limb orthopaedic surgeries.

Methods: This is a prospective randomized double blind controlled study involving seventy four (74) ASA I and II patients scheduled for elective lower limb orthopaedic surgeries. The patients were allocated into two groups. Group A (n=37) received 19mls of 0.5% plain bupivacaine with 1 ml of water for injection epidurally at L3-L4 inter-space, while group B received 19mls of 0.5% plain bupivacaine with 1ml (50mg) of tramadol at L3-L4 epidurally. No premedication was given to all the patients that were recruited for this study.

Standard monitoring of the vital signs was done. The researcher was involved in the recording of the pain assessment with Visual Analogue Scale (VAS), blood pressure, heart rate, respiratory rate, and oxygen saturation at intervals.

The quality of block, duration of analgesia and side effects of epidural anaesthesia was also noted. The duration of analgesia was defined as time from administration of local analgesic to first analgesic request or when the VAS scores ≥ 4.

Results: Results showed that the mean onset time of sensory block was 37.03± 3.43 min and 24.32±3.76 min in group A and B respectively, with statistically significant difference (P < 0.01).The mean duration of analgesia was 189.05±21.92 min and 254.19±32.78 min in groups A and B respectively, which was also statistical significant difference (P <0.01).

The variation of intra-operative VAS scores in the two groups did not show any statistical significant difference between groups A and B (P > 0.05). There was no statistical significant difference over time in heart rate, blood pressure, respiratory rate and oxygen saturation.

The grades of motor block and maximum sensory block height was no statistical significant difference (P=0.26) in the study groups.

The common side effects observed were bradycardia, hypotension, nausea and vomiting. However, the incidence was no statistical significant difference between the two groups (P<0.05). Hypotension was observed in 6 (16.2%) patients and 9 (24.3%) patients in group A and B respectively, (p=0.47). While, bradycardia was observed in 5 (13.5%) patients and 7 (18.9%) patients in group A and B respectively (p= 0.68), nausea and vomiting was observed in 5 (13.5%) patients and 7 (18.9%) patients in groups A and B respectively, (P= 0.68).

Conclusion: The addition of 50mg (1ml) of tramadol to plain bupivacaine for epidural analgesia prolonged the duration of analgesia and improved the quality of analgesia when compared to the use of bupivacaine alone. However, there were no statistically significant differences in the side effects/complications among the two groups.

COMPARISON OF INTRAVENOUS EPHEDRINE WITH PHENYLEPHRINE FOR THE MAINTENANCE OF ARTERIAL BLOOD PRESSURE DURING ELECTIVE CAESAREAN SECTION UNDER SPINAL ANAESTHESIA

Tinuola Abiodun Adigun — 2018-09-15

The aim of this prospective study was to compare the effects
of intravenous bolus of Ephedrine with Phenylephrine for the
maintenance of maternal arterial blood pressure during elective
Caesarean section under spinal anaesthesia. The study population
included sixty two healthy parturients ASA I or ASA II at term with
singleton pregnancy scheduled for elective Caesarean section who
consented to spinal anaesthesia.
Parturients were preloaded with 10ml/kg of crystalloid (Normal
Saline or Ringers lactate) before the induction of spinal anaesthesia
and 2.5 ml of 0.5% hyperbaric Bupivacaine was used for the spinal
anaesthesia. Group A received intravenous bolus Ephedrine 5mg
and Group B, Phenylephrine 100ug for the maintenance of maternal
blood pressure
Hypotension was defined as a decrease in systolic blood pressure
of more than 30% below baseline or below 100mmHg. Bradycardia
was defined as heart rate <60 beats/min.
Patients’ characteristics, spinal block height and baseline
haemodynamic values were similar in the two groups studied.
Seven patients (22.5%) in the Ephedrine group and eight patients
(25.8%) in the Phenylephrine group developed hypotension.
2

Both vasopressors effectively restored the systolic blood pressures
but phenylephrine values were greater than ephedrine values and
was statistically significant in the 15th minute of the procedure, with
p value 0.04. Also, the intra operative diastolic blood pressures
were higher in the phenylephrine group compared to the ephedrine
group, and were significant in the 15th and the 20th minutes of the
procedure with p value of 0.03 and 0.04 respectively.
There was significant difference in heart rate between the two
groups, analysis showed a higher heart rate values in ephedrine
group compared to phenylephrine group which showed a downward
trend with p value ranging from 0.01 to 0.04.
The mean oxygen saturation trends in the two groups were
similar, because all patients had oxygen therapy routinely in this
study, the effect of the vasopressor or spinal anaesthesia could not
be ascertained. Changes in the respiratory parameters showed no
statistical difference between the two groups.
Three patients (9.6%) developed nausea in the Ephedrine
group and 4 (12.8 %) patients in the Phenyephrine group and these
occurred in the hypotensive patients, no patient vomited during the
procedure.
3
There was no need to repeat ephedrine or phenylephrine because
no patient developed refractory hypotension.
The mean APGAR Scores were similar for the two groups; no baby
had Apgar score of < 8 in either group.
In conclusion, Phenylephrine is safe and can be used as
effectively as Ephedrine. It’s administration results in higher blood
pressure values than Ephedrine in parturients undergoing
Caesarean section under spinal anaesthesia.

COMPARISON OF INTERVENTIONAL USE OF TRAMADOL AND PETHIDINE FOR THE MANAGEMENT OF SHIVERING DURING SPINAL ANAESTHESIA

DR UKPABIO ESIEN ITA UKPABIO — 2018-09-06

Back ground:

Shivering occurring under spinal anaesthesia is uncomfortable for patients and places the body under physiologic stress. It can increase oxygen consumption, metabolic rate and cause artifacts on the monitor. The incidence of shivering has been found to be quite high, approximating 40-60% in different studies. In lower limb orthopaedic surgery, regional anaesthesia provides useful benefits such as reduced incidence of peri-operative deep vein thrombosis and better postoperative pain relief compared with general anaesthesia. The deleterious effect of shivering warrant a prompt and rapid control on occurrence.

Aim and Objective:

This study compared the effectiveness of intravenous 0.35 mg kg^-1pethidine and intravenous 0.25 mg kg^-1tramadol in abolishing shivering in patients undergoing spinal anaesthesia for lower limb orthopaedic surgery.

Patients and Methods:

This was a prospective, randomised, double-blinded study conducted in 100 ASA grade I and II eligible patients aged between 15 and 65 years of age who were scheduled for lower limb orthopaedic surgery and shivered during spinal anaesthesia.

All the patients had preloading with warmed normal saline administered at a dose of 10 ml kg^-1. Spinal anaesthesia was induced in the sitting position with 3 mls of 0.5% hyperbaric bupivacaine before being positioned for surgery. When shivering occurred, the patients were given either intravenous 0.35 mg kg^-1pethidine or intravenous 0.25 mg kg^-1tramadol based on the group allocation; taking notice of a change in the intensity or dissappearance of shivering as well as haemodynamic parameters such as non-invasive blood pressure, pulse rate, peripheral oxygen saturation and temperature at intervals. Also noted were time to disappearing and recurrence of shivering as well as outcomes such as level of sedation, nausea and vomiting.

Results:

A total of 100 patients met the inclusion criteria and participated in the study out of 394 consecutive patients. The incidence of shivering was 25.38%. Complete disappearance of shivering occurred in 41(82%) patients in the tramadol group compared to 34(68%) in the pethidine group (p=0.0059). Recurrence of shivering after treatment was seen in 10(20%) patients in tramadol group compared to 6(12%) in the pethidine group (p=0.555). The most common side effect noted was nausea occurring in 16(32%) patients in the tramadol group compared to 26(52%) of the pethidine group (p=0.149). A total of 17(34%) patients in the tramadol group had sedation compared to 6(12%) in the pethidine group (p=0.285).

There were no significant differences in the mean arterial pressures, heart rate and axillary temperature of the two groups.

Conclusion:

The result of this study revealed that intravenous 0.25 mg kg^-1tramadol use for abolishing spinal anaesthesia induced shivering is as effective as intravenous 0.35 mg kg^-1 pethidine in lower limb orthopaedic surgery, however it’s use is associated with more sedation.

COMPARATIVE EFFECTS OF PROPHYLACTIC METOCLOPRAMIDE AND GRANISETRON AS ANTIEMETICS DURING CAESAREAN SECTION UNDER SPINAL ANAESTHESIA.

MATTHEW OMUYA ONIPE — 2018-09-15

Background: Peri-operative nausea and vomiting have been found to increase morbidity and mortality in surgical patients. The use of different antiemetics that act at different receptor sites have proven to reduce these complications. As such, this study was designed to compare the effectiveness and safety of two antiemetics, iv metoclopramide 10mg (antidopaminergic) and iv granisetron 0.04mg/kg (antiserotonergic), in the prevention of nausea and vomiting in parturients who had elective caesarean section under subarachnoid block.

Materials and methods: One hundred and thirty five consenting parturients were randomized into three equal groups of 45 patients each. The patients in the first group (MT) were given iv metoclopramide 10mg, another group (G) had iv granisetron 0.04mg/kg, while iv normal saline 5mls was administered to all the patients in the placebo group (NS). All the study drugs were given slowly over 2 minutes before subarachnoid block was established. With patients in sitting position, the L3- L4 interspace was identified. Using size 26G spinal needle, 2.5mls of 0.5% heavy bupivacaine was injected intrathecally when free flow of cerebrospinal fluid (CSF) was observed. The incidence of nausea and emesis, the drugs side effects on the mother, the effects of the study drugs on parturients’ haemodynamics as well as the drugs effects on the neonatal Apgar scores were assessed and documented intra-operatively and at specific intervals for 24 hours post-operatively.Influence of some risk factors for PONV were also assessed during the study period

Results: There was no significant statistical difference in the patients’ demographic distribution and pre-operative basic vital signs among the groups. More patients 24.4% experienced nausea intra-operatively in group NS, compared with 6.67% and 13.3% of the patients in groups G and MT respectively, p=0.046 for Groups NS vs MT; p=0.002 for Groups NS vs G; and p=0.346 for Groups G vs MT. In the early (0-2 hours) post- operative periods, 8.8%, 20% and 15.5% of patients in groups G, NS and MT had nausea respectively, p=0.04 for groups G vs NS, p=0.473 for groups MT vs NS, and p=0.251 for groups G vs MT. In the late postoperative (2-24 hours) period, 2.22% of patients in group G versus 13.3% and 15.5% of patients in groups MT and NS respectively had nausea, p=0.039 for groups G vs MT, p=0.018 for groups G vs NS and p=0.702 for groups MT vs NS. Furthermore, 15.5% of patients in group NS compared with 2.2% of patients in group G and 8.88% of patients in group MT vomitted intra-operatively, p= 0.012 for groups G vs NS, p=0.201 for groups MT and NS, p=0.206 for groups G and MT. Throughout the study period, 6.66%, 17.7% and 33.3% of patients in groups G, MT and NS respectively vomited, p= 0.004. No statistical significant differences were found between the groups with respect to the side effects of study drugs, changes in haemodynamic parameters of the parturient and the neonatal Apgar scores.

Conclusion: Intravenous granisetron 0.04mg/kg was found to be more effective against intra-operative and post- operative nausea and vomiting compared to intravenous metoclopramide 10mg and placebo. There were no statistical signifant differences between the groups with respect to the side effect profiles of the study drugs, APGAR scores of the neonates as well as the maternal haemodynamic variables.There were no recognized influences of the assessed risk factors on the prevalences of intra-operative and post- operative nausea and vomiting.

A COMPARISON OF THE EFFECT OF HIGH DOSE PROPOFOL, STANDARD DOSE PROPOFOL AND SODIUM THIOPENTONE IN THE PREVENTION OF SUXAMETHONIUM INDUCED FASCICULATION AND MYALGIA

ABBEY. ABIODUN OMOSANYA — 2018-09-15

Background: Suxamethonium is the most commonly used depolarizing neuromuscular agent in clinical practice for rapidly providing ideal conditions for endotracheal intubation.

Its use results in fasciculation and myalgia as part of the potential problems of suxamethonium. These problems have negative impact on the overall medical care of the patients.

Aim: This study was a prospective double blind randomized study designed to compare the efficacy of high dose propofol, 3.5mg/kg with standard dose propofol,2mg/kg and thiopentone sodium, 5mg/kg in reducing the suxamethonium induced fasciculation and myalgia.

Methods: One hundred and five, unpremedicated, ASA l or II, aged between 16 –60 years patients who presented for elective general anaesthesia were recruited. The patients were randomized and induced with either propofol, 2mg/kg (Group P), thiopentone, 5mg/kg (Group STP) or high dose propofol,3.5mg/kg (Group HP). After baseline vital signs were taken, about 500ml of intravenous fluid (normal saline) was given.The induction agents were slowly injected over 90seconds to establish an adequate depth of anaesthesia. Tracheal intubation was facilitated with administration of suxamethonium,1mg/kg. The incidence and severity of fasciculation were recorded.

Anaesthesia was maintained with oxygen/air/isoflurane mixture and pancuronium, 0.1mg/kg was given to facilitate mechanical ventilation. At the end of procedure, residual muscle paralysis was reversed and the trachea was extubated. All patients were assessed with respect to the following : incidence and severity of fasciculation immediately after administration of intravenous suxamethonium, complications during induction, haemodynamic variables, serum creatine phosphokinase (CPK) levels – baseline and 24hours postoperatively as well as theincidence and severity of postoperativemyalgia after 24hours

Results:The demographic and clinical variables were comparable in the three groups.

The incidence of fasciculation was significantly lower in GroupHP, 25 (71.4%) followed byGroup STP, 34 (97.1%) andGroup P, 32(91.4%),(p< 0.001). Similarly, the severity of fasciculation was higher in Group STP,39% than inGroup P, 37%orin Group HP, 24.2%,

(p = 0.034). The incidence of myalgia followed a similar trend and was,17(48.6%) inGroup STP,13(37.1%) inGroup Pand3(8.6%) inGroup HP, (p <0.001). However, the severity of myalgia was lessin Group HP, 7.4% thanin Group P, 41%orin Group STP, 52%,

(p = 0.010).

The mean baseline CPK values were,79.80± 37.09 IU/Lin Group P, 77.54± 21.82 IU/L inGroup STP and 73.99± 39.76 IU/L inGroup HP, (p = 1.000). There was an increase in 24 hours postoperative CPK levelsin all the three groups. However, the mean 24hours postoperative CPK value was significantly lower in Group HP,100.85±46.42 IU/Lthanin Group STP, 139.66±35.73 IU/L orin Group P, 138.25±53.06IU/L, (p<0.001).

There was no correlation between incidence of fasciculation and myalgia, {r = -0.076,

(p = 0.56)}, as well as, no correlation was obtainedbetweenincidence of myalgia and increase in CPK levels,{r = 0.081, (p = 0.37)}.

The mean HR, blood pressures (SBP, DBP, MAP) for various time intervals measuredwere comparable in all the groups, with initial drop in the levels of post- induction, then peaked at intubation and subsequent gradual return to pre-induction levels. The mean SpO₂was also comparable in all three groups with no significant difference,however, mean EtCO₂in Group HP was significant at intubation, 2 mins post-intubation and 4 mins post- intubation but the decreasing percentage change in mean EtCO₂ among the groups during these periods showed no significant difference.

Conclusion:The study has demonstrated that high dose propofol is more efficient thanstandard dose propofol and thiopentone in minimizing post suxamethonium fasciculation and myalgia, however, associated with side effects of hypotension and bradycardia.

Antiemetic prophylaxis during elective Caesarean section under spinal anaesthesia: Comparison of Cyclizine, Metocloparide and placebo

DR. FRIDAY OKONNA — 2018-09-15

BACKGROUND: Emetic symptoms are frequent and undesirable perioperative events in patients undergoing caesarean delivery under spinal anaesthesia. Many drugs have been tried, with varying degrees of successes in preventing intraoperative nausea and vomiting. These symptoms are distressing to patients intraoperatively and in the postoperative period, hence prophylaxis is recommended.

PATIENTS AND METHODS: This was a prospective, randomized, double-blinded, placebo-controlled study comparing the effectiveness of single dose intravenous cyclizine, metoclopramide, and placebo in preventing emetic symptoms among parturient undergoing caesarean section under spinal anaesthesia. Each of the 116 parturient of American Society of Anesthesiologist (ASA) I-II undergoing elective caesarean section under spinal anaesthesia was randomly allocated into three groups: 39 patients in group I, 39 patients in group II, and 38 patients in group III. Before establishing spinal anaesthesia, patients in group I were given 2 ml of 0.9% saline intravenously, patients in group II were given 10 mg of metoclopramide in 2 ml intravenously, while those in group III were given 50 mg of cyclizine diluted with water for injection to 2 ml and given intravenously. Patients were monitored and records of emetic symptoms, vital signs and side effects of drugs were documented. Neonatal APGAR scores were also recorded.

RESULTS: Emetic symptoms experienced intraoperatively were nausea, retching and vomiting. Nausea occurred in 14(35.9%) patients in group I, 6(15.4%) patients in group II and 1(2.6%) patient in group III, P = 0.001. Retching occurred in 7(17.9%) patients in group I, 2(5.1%) patients in group II and none in group III, with a P = 0.010. Vomiting occurred in 5(12.8%) patients in group I, 2(5.1%) patients in group II and none in group III, P = 0.059. 4(10.3%) patients had severe nausea in group I, 3(7.7%) patients in group II, and none in group III, P = 0.017. Use of rescue antiemetics was similarly less in group III, P = 0.006. Sedation was associated more with group III, P = 0.001, but no respiratory depression. Also newborn APGAR scores were similar, and no signs of depression recorded among the babies delivered by the patients in any of the groups.

CONCLUSION: Cyclizine is superior to metoclopramide in preventing nausea and vomiting in women undergoing caesarean section under spinal anaesthesia.