Anaesthesia doc May 03

32 Pages·2003·1.36 MB·English

by  Caroline Arbery

Volume 7 Number 1 May 2003 ISSN 1472-8820
World Anaesthesia
n e w s
In this issue
The Copenhagen polio epidemic
and the birth of intensive care
Creating a medical school in Malawi
Primary Trauma Care
in South America
PTC Care Course in Vietnam
News from
around the world
A report from Mvumi Hospital,
Tanzania
Letter from Latvia
W elcome
Contents
to World Anaesthesia News
To practice safe anaesthesia, we must have knowledge, skill and facilities. Not only must we Reporsts/Investigations
have a wide knowledge of medicine, a good understanding of the pathological processes that
Anaestheic practices in a
have brought our patient to the operating room and some insight into what our surgical developing country: The view from
colleague is seeking to achieve and the difficulties he is likely to face, but we must also have Lomé in Togo 3
detailed knowledge of the relevant basic sciences especially physiology and pharmacology that are
Organising a refresher course in
the bedrock of our art. Nigeria - a joy or a nightmare? 5
Skills are learned from our teachers and improve with experience. The more facilities Preoperative starvation and blood
we have, the easier the practice of anaesthesia becomes. These facilities range from the glucose concentration: A case for
basics such as water and electricity to a comprehensive range of drugs, equipment and caution in a developing
monitors. Western anaesthetists could not practice anaesthesia remotely approaching their environment 7
usual standard if they suddenly found themselves working in a third world environment.
Inhalation anaesthesia in developing
At first reading, the paper by Dr Ouro-Bang’na Mamam and his colleagues from Togo countries: the problems and a
and Benin may appear to reflect poor anaesthetic practice with an immediate peri-operative proposed solution 9
mortality of 2.5%, twenty or more times that in Europe. On reflection, however, I believe
they are to be congratulated on several grounds. They work in difficult circumstances and
Feature Stories
most of the anaesthetics they reviewed were administered by nurses with a basic initial
medical education and negligible post-qualification training. Drugs and equipment were The Copenhagen polio epidemic
limited and monitoring facilities were practically non-existent. Nevertheless, the authors and the birth of intensive care 10
took the time to undertake this audit, to review the relevant literature and had the courage
Creating a medical school in
to publish their results.
Malawi: problems and
Likewise, I commend Dr Mato from Nigeria for organising a meeting that targeted achievements 13
those in most need of post-qualification education, the nurse anaesthetists and anaesthetic
Anaesthesia in Blantrye, Malawi 15
officers who give most of the anaesthetics in developing countries and whose educational
needs tend to be ignored and for trying to find out what they really want to improve the
Profiles 17
standard of care that they provide.
Professor Anneke Meursing and
In this issue, there is also an appeal from Prof Michael Rosen, on behalf of the WFSA
Thomas Cecil Gray
Foundation, to anaesthetists in the developed world, asking them to donate a tiny
proportion of their income to the Foundation to enable it to continue to support the
educational activities of the WFSA. In the Chair of the Educational Committee, Dr Angela News from around the World
Enright’s report you can read how such money is being spent. There are few areas of the
A report from Mvumi Hospital,
world that do not obtain some benefit from the work of the WFSA. Tanzania 18
If you work in a developed country and have not already made a donation to the
Letter from Lativa 19
WFSA Foundation, I urge you to do so as soon as possible.
William F Casey
News and Information
Useful information 20-22
The editor of World Anaesthesia Dr Rob McDougal (Australia)
Anaesthetic websites to try 23
News is: Email:
Dr W F Casey [email protected]
Popes Cottage, Cheltenham Rd, Prmary Trauma Care
Dr Tom Ruttmann (S.Africa)
Gloucester, GL6 6TS, UK
Email: [email protected] PTC in South America 24
Tel: [phone]
Fax: [phone] Dr Iain Wilson (UK) PTC Care Course in Vietnam 25
Email: [email protected] Email: [email protected]
Editorial Board Dr Jeanne Frossard (UK) WFSA Committee Report 26
Dr Dixon Tembo (Zambia) Email: [email protected]
WFSA Appeal 27
Email: [email protected]
Editor Emeritus
Prof. Rebecca Jacob (India) Dr Roger Eltringham (UK)
Email: [email protected] Email: [email protected]
Submissions to World Anaesthesia News may be sent to any of the above.
Anaesthetic practice in a developing
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country: the view from Lomé in Togo i
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A.F.Ouro-Bang’na Maman1, K. Tomta1, MS. central block with six operating rooms, an occurred in obstetric patients (56%) with 30% n
Chaïbou2, B. Songné3, M. Chobli2, obstetric block with two operating rooms and a occurring after abdominal surgery, mostly due I
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S.Ahouangbevi1. block for eye and ENT surgery also with two to peritonitis and 8% following trauma surgery. h
1 Service d’anesthésie réanimation, CHU de operating rooms. It does not have any post- On review some 60% of these deaths c
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Lomé (Togo); anaesthetic recovery rooms. were related to the patients underlying a
2 Département d’anesthésie réanimation, CNHU Over a six month period (January – June disease. Inadequate peri-operative e
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de Cotonou (Bénin), 2002), a prospective and descriptive review management contributed to 9 deaths from e
was carried out of all anaesthetics admin- pulmonary oedema in patients with eclampsia, R
3 Service de chirurgie, Pavillon militaire, CHU
istered by physician and nurse anaesthetists at 3 deaths associated with coagulation
de Lomé (Togo).
CHU, Lomé. Demographic data (age, gender), disorders, 3 cases of ante-partum haemorrhage
medical data (ASA score, type of operation) and 3 cases of peritonitis with multiple organ
Correspondance to
and anaesthetic technique were recorded. failure. Anaesthesia contributed to 20% of the
Dr AF. Ouro-Bang’na Maman,
peri-operative deaths and was solely
Ancien Interne des Hôpitaux Results responsible for 10%. The main anaesthetic
Service d’anesthésie-réanimation, CHU de 1464 anaesthetics were reviewed; the majority causes were Mendelson’s syndrome (3 cases),
Lomé Tokoin lasting between 30 minutes and two hours mismanagement of severe haemorrhage and
14148 Lomé Togo (Table 1). 52% of the patients were female and inadequately managed post-operative hypoxia.
Tel: [phone]% male. 12% were aged less than 15 years,
Fax : [phone]% between 16 – 60 years and 12% aged Discussion
over 60 years. 95% of the patients were Our study was carried out on a younger
Email : [email protected]
considered to be ASA I or II but a proper pre- population then that in comparable studies
operative evaluation was only recorded for from Morocco and France (5, 6): only 12% of our
Summary 38% of the patients. patients were aged over 60 years compared
A prospective review of anaesthetic morbidity 90% of patients received a general with 18% in the Moroccan and 33% in the
and mortality was carried out over a six month anaesthetic. The drugs used are shown in French study. However, in a study from
period (January-June 2002) in Lomé, Togo. Table II. Thiopentone was the most commonly Yaoundé (Cameroon) (7), only 0.5% of patients
1464 anaesthetics were reviewed; 60% were used induction agent followed by propofol and were aged over 60 years.
for emergency surgery. 90% of patients ketamine. Meperidine (pethidine) was the only We also differed from the Moroccan
received general anaesthesia and 8% a spinal narcotic used. Only 8% of patients received study in having 53% female patients
anaesthetic. Thirty nine patients, all from the spinal anaesthesia. Isobaric bupivacaine (0.5%) compared to their 18% probably reflecting
gynaecological and obstetric service, received and lidocaine (2%) were used. 24% of patients the large number of obstetric patients we
blood transfusion. Early post-operative were treated as out-patients. Intra-operative saw. 95% of our patients were ASA 1 or II
mortality was 2.5% with most of the deaths monitoring was very limited with only 10% of compared to 31% in Cameroon and 97% in
occurring in obstetric patients. patients being monitored with a stethoscope. Morocco. Seventy percent of patients in a
The types of surgery performed is shown French study were ASA 1 or II in 1980 but
Introduction in Table III. The majority of procedures were this had fallen to 59% in 1996. This is
The distribution of anaesthetists in French- obstetric (28%), orthopaedic (28%) or gastro- probably related to improved standards of
speaking sub-Saharan Africa is disastrously intestinal (19%). The commonest operations monitoring and a willingness to accept more
uneven (1, 2). Currently in Togo, there are 74 were caesarean section, the reduction of seriously ill patients for surgery in France.
nurse anaesthetists who have had three years fractures and dislocations and appendectomies An adequate pre-operative assessment
of training and only one physician anaesthetist and laparotomies for peritonitis. 60% of the was only carried out on 38% of our patients
in the government service. Consequently, as procedures were done as emergencies. Only compared with 58% in Morocco (5) and 71%
elsewhere in sub-Saharan Africa, the nurse thirty nine patients (9.4%) received a blood in Cameroon (7). This seems to be related to
anaesthetist is a key provider of anaesthetic transfusion: most of these were receiving the shortage of physicians and nurse
services(3, 4). surgery for obstetrics (40%) or trauma (33%) anaesthetists in Togo (1, 2, 3, 4, and 9)
This does not reflect clinical need but rather, a The anaesthetic induction agents
Method shortage of blood for transfusion. (thiopentone and ketamine) used in our
This review was carried out in the Anaesthesia Thirty patients died in the immediate review were essentially the same as those
and Resuscitation Service of CHU, Lomé, the post-operative period giving an early mortality used in Senegal and Cameroon (7, 8)although
main referral centre for Togo. It consists of a rate of 2.5%. The majority of these deaths we used propofol as frequently as we used
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Continued on page 4
ketamine. This was due to a team of plastic Table I: Distribution of the patients according 4. Adnet P, Diallo A, Chobli M. Pratique de
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surgeons visiting our facility during the study to the duration of anaesthesia l’anesthésie par les infirmiers en Afrique
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period. Chobli(12)was previously commented in Duration Number % francophone sub-sahara. Ann Fr Anesth
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e 1994 on the temporary presence of ≤30 min 190 13 Réanim, 1999,8 : 636-44.
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sophisticated drugs and equipment in African 30min – 2 hours 1018 70 5. Belkrezia P, Kabbay S, Ismaili H, Maazouzi
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c hospitals when basic drugs and material are ‡ 2 hours 256 17 W. Enquête sur la pratique de l’anesthésie
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not permanently present. Total 1464 100 au Maroc. Ann Ff Anesth Réanim 2002, 21
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I General anaesthesia was used for 89% (1) : 20-6.
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of our patients compared to 73% in Morocco Table II: Percentage of the patients receiving 6. SFAR. La pratique de l’anesthésie en
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e (5)and 77% in France(6). Only 8% of our intravenous and inhaled anaesthetics France en 1996. Ann Fr Anesth Réanim
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patients received a spinal anaesthetic, mostly Inhaled anaesthetic 53 1998, 17 : 1299-391.
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g for trauma and abdominal surgery, compared Meperidine 63 7. Binam F, Lemardeley P, Blatt A, Arvis T.
a to 32% in Senegal. There are considerable Muscle relaxants 48 Pratique anesthésique à Yaoundé
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i economic benefits in using regional anaes- Benzodiazepines 93 (Cameroun). Ann Fr Anesth Réanim 1999,
o thetic techniques in developing countries (10, (tranquilizer drugs) 18 : 617-56.
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11)and this would be equally true in our Thiopental 40 8. Ka Sall B, Diatta B. Bilan des activités
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hospital in a capital city. Unlike in Senegal, Propofol 18 anesthésiques à l’hôpital régional de St- Louis
epidurals and nerve blocks were not used in Ketamine 17 de juillet à décembre 2000. Rév Aanesth
our hospital due to ignorance of the techniques. Méd Urg Réanim 2001, 6 (2) : 63-70.
More of our patients were treated as Table III: Distribution of patients according to 9. Ouro B. Formation des praticiens
out-patients than in the Moroccan study. the type of surgery d’anesthésie dans les pays en développement:
Out-patient anaesthesia offers the potential Type of surgery Number % expérience de l’Afrique francophone au
to reduce the costs of surgery but providing Gastro-intestinal surgery 282 19 sud du Sahara. Thèse de doctorat d’état en
such a service without compromising patient Obstetric surgery 414 28 médecine 2002, FMMP Lomé.
safety provides a major challenge for Orthopaedic surgery 414 28 10. Faisy G, Guegnen G, Lanteri-Minet M, Blatt
anaesthetists (14). Ear, nose and throat surgery 93 6 A, Houmbou I. Intérêt économique des ALR
The French Society of Anaesthesia and Eyes surgery 123 8 en zone déshéritée. Med Trop 1996, 56:
Resuscitation (SFAR) recommend minimal Genitourinary surgery 60 4 367-72.
standards of monitoring (6). These were not Plastic surgery 30 2 11. Kondet A, Chobli M, Bissang K,
implemented due to a lack of suitable Other 48 3 Ahouangbévi S. Utilisation du masque
monitors and ignorance of their maintenance Total 1464 100 laryngé en pratique anesthésique
and appropriate use. This reflects the quotidienne : expérience du CHU de Lomé.
absence of suitably qualified physician Table IV: Peri-operative mortality Rév Anesth Méd Urg Réanim 1997 , 2 : 1-5.
anaesthetists. Centre Mortality (%)Days after Period 12. Chobli M, Mignosin D, Manbana C, Hage
Emergency surgery, mostly for trauma, surgery S, Ahouangbévi S. Niveau d’équipement
constituted 60% of our workload compared to Lomé 2.5 #24 hours 2002 des services d’anesthésie-réanimation en
29% in Cameroon although the amount of (Togo) Afrique noire francophone. Rév Anesth
obstetric anaesthesia was similar to that Dakar 4.2 1-9 days 2000 Méd Urg Réanim 1994, 1 :27-30.
performed in Senegal (40%) and Cameroon (Senegal) 13. Blatt A. Place de l’ALR à l’hôpital de
(33%) (7, 8). Caesarean section was the most Abidjan 2.2 #24 hours 1999 Ziguinchor. Méd Afr Noire 1990, 37 :1-7.
frequently performed operation in our study (Ivory Coast) 14. Maazouzi W. Anesthésie ambulatoire au
compared to appendicectomy in Morocco. Yaoundé 2.2 #24 hours 1999 Maroc. In conférences, XIVème congrès
The early post-operative mortality (Cameroon) national d’anesthésie-réanimation. SMAR
observed in our study (2.5%) was very high (7, Paris 0.3 #24 hours 1992- 2001.
8, and 16). A greater use of regional (France) 1995 15. Otteni JC, Desmonts JM, Haberer JP.
anaesthesia, especially for obstetric surgery, Recommandations françaises et étrangères
should reduce the incidence of Mendelson’s References sur la pratique de l’anesthésie-réanimation.
syndrome. Training in spinal anaesthesia 1. Chobli M, Adnet P. Pratique anesthésique Ann Fr Anesth Réanim 2000 , 20 : 537-48.
should be encouraged for all anaesthetists in en Afrique sub-saharienne. Ann Fr Anesth 16. Dupont H, Mezzaroba P, Degremont AC,
developing countries to assist in reducing this Réanim, 1997, 16 (6) : 234 Niderkorn S, Lebrault M, Fishler M.
unacceptably high mortality (17). 2. Sanou J, Vilasco B, Chobli M. Evolution de Mortalité périopératoire précoce dans un
The practice of anaesthesia in Togo la démographie des praticiens d’anesthésie hôpital pluridisciplinaire. Ann Fr Anesth
falls well below internationally accepted en Afrique francophone au sud Sahara. Ann Réanim 1998, 17 (7) : 755-63.
standards (Table 1V). This is due to a lack of Fr Anesth Réanim, 1999, 8 : 642-6 17. Carpentier JP, Banos JP, Brau R, Malgras G,
equipment but more especially to the lack of 3. Ouro B, Assouto P, Koudet A, Chobli M. Form- Boye P, Dubicq J, Angel G, Roth C. Pratique
suitable trained personnel. More ation des praticiens d’anesthésie en Afrique et complication de la racianesthésie en
anaesthetists need to be trained and to a francophone : expérience du Bénin et du Togo. milieu tropical africain. Ann Fr Anesth
higher standard. Rév Afr Méd Urg Réanim 2001, 6 (2) : 78-81 Réanim 2001, 20 (1) : 16-22.
4
Organising a Refresher Course in Nigeria: A joy or a nightmare?
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C. N. Mato The Budget now confident that the course would be ti
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Department of Anaesthesia, We calculated that that we needed held. So we carried on with a spring in
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University of Port-Harcourt Teaching Hospital, N650,000 (£3000, $5000, e5000) for the our steps although sometimes frustrated i
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1. Venue – big enough to accommodate at exhausted but, nevertheless, determined.
Nigeria. v
least 100 participants, with room for News of the innovative regional n
exhibitions and practical demonstration. course had spread through the hospital I
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Introduction 2. Transport, accommodation and and beyond and several nurses wanted to h
The 1st Nigerian Society of Anaesthetists honorarium for at least 5 Resource attend. The thirst for knowledge especially c
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(NSA) Eastern Regional Refresher / Update persons among this cadre of health workers was a
Course in Anaesthesia and Intensive Care 3. Hiring of public address system, audio- palpable and was an added incentive for us e
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was held on January 31 – February 2, 2002 visual aids, and manikins for practical to ensure that the course would be a success. e
at the Delta Hotels, Port-Harcourt, Rivers sessions R
State. This course was the brain child of the 4. Course bags and writing materials The Course Programme
present NSA President, Dr Sam 5. Snacks and lunch for 100 participants The programme selected by the NSA
Ukponmwan. His vision was to decentralize 6. Reprints, receipts, and identity cards consisted of 30 lecture topics and 12
educational activities, to enable both 7. Printing of programmes and lecture notes problem-based learning discussions. Five
physician anaesthetists, but especially non- 8. Certificates lecturers from out of state were chosen and
physician practitioners of anaesthesia and 9. Secretarial assistance their lecture topics agreed. The visiting
intensive care to update their knowledge lecturers were Professors B. U. Umeh
without having to travel long distances. The Nightmare begins……. (Nnewi), O. A. Soyannwo (Ibadan), Drs
Most courses in anaesthesia and The Venue we chose cost N50,000 £250, Sam Ukponmwan (Benin), S. A. Amanor-
intensive care take place either in Lagos or $400, e400) per day, so we needed to pay Boadu (Ibadan), and Colonel O. A.
Ibadan, and are organized by the N150,000 for the 3 day course. The facility Ogunbiyi (Lagos).
Postgraduate Medical Colleges. Their did not accept cheques, bank drafts, The local lecturers included Drs
target course participants are medical payment in instalments or promissory notes! K.L.N. Izuora (Bonny), C. N. Mato, L.N.
doctors, especially anaesthesia residents This was the beginning of our nightmare, Ebirim, and B. Onajin-Obembe. Mr
preparing for fellowship examinations. which was to last for the next six weeks. Anyanwu, a Training and Management
There has been no provision before now We embarked on very many Consultant with the Nigerian Ports plc
for anaesthetists not in residency training discouraging trips to companies, para- was invited to give a lecture on Total
and other non-physician anaesthetists and statals and private hospitals, explaining the Quality Management.
intensive care practitioners to update their importance of the course, inviting them to The LOC decided that the Course
knowledge. This update course was send participants and soliciting financial fee was to be N7,500 (£35, $50, e50) for
therefore innovative and highly welcomed assistance. We were received very cordially Non-physician anaesthetists, and N10,000
by this neglected group. wherever we went, but the story was (£60, $75, e75) for physician anaesthetists.
always the same: we will send our doctors The LOC however reduced these fees for
The Mandate and nurses, but we have No Money. We some participants, especially the self-
Port-Harcourt was chosen to host this 1st spent many agonizing and sleepless nights, sponsored ones, to enable them to attend.
Eastern Regional NSA Refresher Course at wondering if we were going to be able to Shell Petroleum Development
the 9th Annual Scientific Conference of the host our meeting but by the 13th of Company (East) provided the audio-visual
NSA that was held in Calabar on November January, we still had no money to pay for equipment and the manikins for practical
19 – 21, 2001. The dates chosen were the venue. But then came the sessions. To further reduce costs, all the
January 31 – February 2, 2002, giving us breakthrough….. letters of invitation to participate sent to
less than 2 months to organize the course companies, state and private hospitals in
and that at a very difficult time of the year. Hope Port-Harcourt and the other 8 states in
The Local Organizing Committee On behalf of our Teaching Hospital the East were typed and printed by me. I
was made up of: Dr Christie Mato, Dr Management, the Chief Medical Director also printed the invitation cards for the
Longinus Ebirim, Dr Sotonye Fyneface- accepted our invitation to chair the Opening Opening Ceremony. As a consequence,
Ogan and Dr Margaret Osakwe who Ceremony and declare the course open. The my computer skills improved considerably!
quickly realised that, although the NSA hospital also offered to pay for the venue and
had given us the singular honour of provide transport for our Resource persons The Opening Ceremony and Day 1
organizing the 1st Eastern Regional NSA for the duration of the Course. The first Course participant surprisingly
Refresher / Update course in anaesthesia We still had to pay deposits for hotel arrived at 7.30am, and was duly registered.
and intensive care, we had no money, and accommodation, snacks and lunch, This was an indication of how much
no experience! purchase course materials etc., but we were interest and excitement the course had
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generated. Other participants soon arrived, practical demonstrations of Cardio-pulmo- Recommendations
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and by 9.00am, a second Registration desk nary and Cerebral Resuscitation using 1. We salute the NSA for starting this
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s had to be quickly arranged. manikins generated a lot of discussion. laudable program and suggest that these
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The short Opening Ceremony was Group photographs were taken, and courses should continue as an integral
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r chaired by the Chief Medical Director of then a course evaluation has held. The part of NSA activities. They should be
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the University of Port Harcourt Teaching ceremonies were followed by the awarding well advertised so participants can attend
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Hospital and attended by friends of of certificates to participants. the regional centre nearest them.
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I Anaesthesia from other specialties – 2. We suggest that the courses be held in
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surgery, radiology, pharmacy, paediatrics, Audit January / February as was done here. The
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e O&G and the nursing services. Some There were a total of 85 participants, 63 majority of the participants (44.26%)
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t members of the public, as well as registered, 22 unregistered. The participants want the course to be held twice a year
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g representatives from the State Ministry of were drawn from 8 of the 9 states in the but we consider this unrealistic because of
a Education and the Medical Women’s eastern part of Nigeria namely – Abia, the amount of work involved. We suggest
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i Association of Nigeria (Rivers Zone) also Akwa-Ibom, Anambra, Cross River, Ebonyi, that it should hold biennially to enable
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attended. Enugu, Imo and Rivers. There was no participants’ sufficient opportunity to
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s Lectures immediately followed a short break participant from Bayelsa State. identify funds for them to attend. The
after the Opening Ceremony, and consisted 61 participants responded to the audit organizers and Resource persons will also
of the following: and their specialties are shown in Table 1. have enough time to plan.
1. Pre-anaesthetic evaluation of the surgical Table 1 – Participants by specialty 3. Port-Harcourt would be happy to host
patient - Professor Umeh Speciality Number (%) further course for the east of the country.
2. Health & Safety in anaesthetic practice- Physician anaesthetists 12 20 We have the facilities and the manpower:
Professor Umeh Other medical officers 3 5 we are the treasure-base of the nation,
3. Pre-operative hypertension Nurse anaesthetists 12 20 cosmopolitan and there is easy access
Professor Umeh ICU nurses 11 18 from all parts of the country.
A very interesting and graphic discourse on A & E nurses 1 2 4. Course topics should be relevant to the
Management of the Difficult Airway was Theatre nurses 12 20 host region. In the east, there are a lot of
given by Dr Izuora. Lunch was followed by Emergency medical service staff 2 3 oil exploration activities, frequent
2 lectures: Respiratory concerns during Other nurses 8 13 communal clashes, regular marine
anaesthesia by Dr Ukponmwan, and Post- Total 61 transportation, and erosion problems.
operative pain management by Dr Mato. A 26 out of 61 respondents (42.62%) were There should also be more hands-on
lively problem-based learning session on self-sponsored and all of them agreed that demonstrations with interactive and
Management of the Parturient with Severe the topics would help improve their problem-based learning sessions.
Pre-eclampsia ended the day at about practice. 19 participants (31.14%) felt that 5. We have collected all the lectures given
5.30pm. the time allocated for each lecture (30 during the course into a booklet. We
minutes) was inadequate. There was suggest that lecturers send a copy of their
Days 2 and 3 considerable enthusiasm for holding further lectures to the organizers 6 months before
These followed the same pattern, but were course and suggestions for their frequency the course date and copies be made and
more intensive than Day 1. Professor are shown in Table 2: given to participants with their course
Soyannwo, Dr Amanor Boadu and Colonel Table 2 – Suggestions for Frequency of Update materials on registration.
Ogunbiyi were especially tasked on these 2 Frequency Number Percentage (%)
days and performed brilliantly. The lecture Three times yearly 6 10 Conclusion
topics included the following: Guidelines Quarterly 13 21 A very encouraging statement came from
for pre-operative fasting, current trends in Twice a year 27 44 one participant, and I quote “The update
post-operative pain management, regional Yearly 12 20 course should be extended to one week or 5
analgesia in children, regional anaesthesia in Biennial 3 5 days so it will be less stressful. There should
the district hospital, total intravenous All the respondents wanted to attend be group discussions, but on the whole, it
anaesthesia, head injury and management of another refresher course like this but was rewarding. Thanks to the organizers.”
the unconscious patient, evaluation and suggested that wider publicity, involvement Those comments made it all worthwhile. A
anaesthetic management of the parturient of other health personnel especially those nightmare? Yes, but one I would want to
with major co-existing illness, ICU from the private sector, more brain storming have again. A joy? Most certainly!
management of the critically injured and an sessions and practical demonstrations would We thank the NSA for the opportunity to
update on mechanical ventilation. be an improvement. serve!
The high point of Day 3 was the Four participants suggested some Since the Port-Harcourt, the NSA has
lecture on Total Quality Management by examination before awarding of certificates organized one course in Lagos and one in Ile-
Mr Anyanwu, a senior manager with and an interesting comment made by two Ife in February, 2003.
Nigerian Ports plc. participants was that the food was too much The course proceedings including all the lecture
The interactive session on the manage- and suggested that meals be reduced to notes that were prepared by the LOC sold out
ment of the head-injured patient, and snacks only! at the last NSA conference in Warri.
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Preoperative Starvation and Blood Glucose
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Concentration – A case for caution in a
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I U Ilori,* Sylvia G Akpan,* A B Asemota# blood glucose level of 2.8 mmol/L there is Results h
* Dept. of Anaesthesiology, evidence of significant cognitive There were 25 children in each group. The c
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# Dept. of Chemical Pathology, dysfunction,4,5 while at a level of 2.2mmol/L, female to male ratio was 1:3 in both groups. a
children often exhibit major Thirty-Seven (74%) children fasted in excess e
University of Calabar Teaching Hospital, s
neurophysiological symptoms. of 12 hours (Table I). A total of thirty (60%) e
Calabar, Nigeria
This study was undertaken to assess children had a weight below the 50th R
Summary the preoperative blood glucose concentration percentile, eighteen (72%) in group I and 12
The preoperative blood glucose concentration in Nigerian children aged under 6 years and (48%) in group II. The incidence of
of 50 children (aged 6 months to 6 years, to identify any risk factor predisposing to hypoglycaemia was 44% in group I and 12%
ASA I or II) was estimated. The study preoperative hypoglycaemia. Hypoglycaemia in group II . However, the overall incidence
showed that thirty-seven (74%) of the in this study was taken as a blood glucose of hypoglycaemia in all the fifty patients was
children fasted in excess of 12 hours. concentration below 3.0mmol/L. This is 28% (Table II). The study shows that hypo-
Hypoglycaemia (glucose level <3mmol/l) was because at this level, there is central nervous glycaemia frequently occurred in children
evident in 14 (28%) of the children. When system impairment, even though, the with a weight below the 50th percentile. No
related to the percentile weight, it was accepted definition of hypoglycaemia in child with a weight above the 50th percentile
shown that of the thirty children with a infants and children, is a blood glucose became hypoglycaemic (Table III).
weight below the 50th percentile, twelve concentration below 2.2mmol/L.6
(40%) of them were hypoglycaemic in the TABLE I
pre-induction phase. None of the patient Mterials and method Duration of
with a weight above the 50th percentile was Approval for the study was received from the fast (hours) 0-4 4 – 8 8 –12 12 –16 16 –20
hypoglycaemic irrespective of the duration of University of Calabar Teaching Hospital Number of
fast. Ethical Committee. Informed verbal and patients 1 5 7 27 10
Children with a weight below the 50th written consent were obtained from each
percentile seem to be more prone to patient’s parent. Fifty children (aged 6 TABLE II
hypoglycaemia during routine preoperative months to 6 years, ASA I or II) were included GROUP I GROUP II OVERALL
fasting. It is recommended that glucose in the study. The children were categorized Percentile weight <50 18 (72%) 12(48%) 30 (60%)
containing fluids are administered either into two groups as follows: Duration of fast (hours) 12.78+/-4.09 14.58+/-3.42 I3.68+/-3.84
orally or parenterally to children especially Group I: 6 months to 2 years Incidence of hypoglycaemia11(44%) 3(12%) 14(28%)
those at increased risk of preoperative Group II: 2 to 6 years
hypoglycaemia. Both in-patient and outpatients were studied. TABLE III
Each patient’s age, sex, weight (in kilograms) Percentile Weight <50 50 >50
Introduction and the time of their last food intake were Number of patients 30 16 4
Due to erratic supplies of electricity, water recorded. The percentile weight was % hypoglycaemic 40 12.5 0
and medical gases, scheduled surgical obtained from height and weight percentile
procedures are often delayed or cancelled in charts for each sex. Two millimeters of Discussion
many developing countries including Nigeria. venous blood was taken as an intravenous Elective surgical patients are fasted for
Preoperative fasting unwittingly becomes line was inserted prior to induction of variable lengths of time before general
starvation especially in the paediatric age anaesthesia. The blood sample was analyzed anaesthesia to prevent regurgitation and
group. This may have serious consequences. immediately in the hospital laboratory. The aspiration. The duration of the fast was
Hypoglycaemia is one of the reported duration of fast (in hours) was taken to be initially the same length for all patients
complications of prolonged preoperative the period from the last food intake to when including children. It was later observed that
starvation in children.1 It has been the blood sample was taken. The data was prolonged preoperative fast predisposed to
classified into mild, moderate and severe analyzed using the Statistical Packages for hypoglycaemia and hypovolaemia especially
corresponding to blood glucose levels below the Social Scientists. The Student t-test was in children. Fasting guidelines were modified
3.3, 2.8 and 2.2mmol/L respectively. It has used to compare the variation between the and now are generally six hours for solids
been observed that there is central nervous groups. The correlation and test of and two hours for clear fluids.1,7
system impairment when the blood glucose significance were determined using Stepwise Despite this recommendations, in
level falls from 3.8 to 3.0 mmol/L3 At a Multiple Regression Analysis. developing countries, erratic supply of water,
7
Continued on page 8
electricity and medical gases result in during periods of preoperative fasting, as Journal Anaesthesia 1990; 37: 493 –495.
R
prolonged preoperative fasting that might confirmed in this study. 8. Soyanwo OA, Sanusi AA. Audit of
e
s better be termed “starvation” as was evident This study also shows that no patient preoperative fasting. African Journal of
e in this study. Thirty-seven (74%) of the with a weight above the 50th percentile had a Anaesthesia and Intensive Care 1996; 2:47
a
r children studied fasted in excess of 12 hours. blood glucose level in the hypoglycaemic –50.
c This study agrees with that of Soyanwo et al, range, irrespective of the duration of their fast. 9. Maclean AR, Reinwick. Audit of
h
who in an audit of preoperative fasting in In some other studies, the authors were unable preoperative starvation. Anaesthesia 1993;
/
I Ibadan, Nigeria, found that 62.5% of the to establish any incidence of hypoglycaemia in 48: 164 –166.
n
children for elective surgical procedures fasted children despite a preoperative fast in excess 10. Laditan AAO, Johnson AOK. Nutritional
v
e in excess of 12 hours.8 A much lower of 8 hours.15-19 These studies did not record disorders in childhood. In: Azubuike JC,
s
t incidence of 35% of children fasting in excess the percentile weight of the children studied. Nkanginieme KEO, eds. Paediatrics and
i
g of 12 hours prior to elective surgical We concluded that in a developing world Child Health in a tropical region. Owerri:
a procedures was recorded in a developed environment, children with a weight below the African Educational Services, 1999:
t
i environment in a study by Maclean from the 50th percentile are at increased risk of 11. Barnes LA. Nutrition and Nutritional
o
United Kingdom.9 becoming hypoglycaemic during routine disorders. In: Behrman RE, Vaughan VC eds.
n
s Thirty (60%) of the children studied had preoperative fasting. Enteral or parenteral Nelson Textbook of Pediatrics. 13th ed.
a weight below the 50th percentile. Eighteen administration of glucose containing fluid may Philadelphia: WB Saunders, 1987; 116.
(72%) of these children were below 2 years of be beneficial in this at risk group in the 12. Alleyne GAO, Hay RW, Picou DI. Protein
age. In Nigeria, children are usually weaned preoperative period. energy malnutrition. Edward Arnold, 1979;
from breast milk between the ages 12 – 24 61 –62.
months. Their food after weaning basically References 13. Thomas DKM. Hypoglycaemia in children
consists of maize and, if not fortified, usually 1. Philip S., Daborn, A. K. , Hatch , D. J., before operation: Its incidence and
lead to malnutrition as nutritional requirements Preoperative fasting for paediatric prevention. British Journal of Anaesthesia
outstrips intake at this age.10 anaesthesia. British Journal of 1974; 46: 66-68.
The overall incidence of hypoglycaemia Anaesthesia 1994; 72: 529 – 536. 14. Payne K, Ireland P. Plasma glucose levels in
was 28% in the studied group. A higher 2. Allison C W, Cater JI, Gray IG, Staziker AC, the preoperative period in children.
incidence of 44% was observed in the younger, Preoperative Starvation In Children – The Anaesthesia 1984; 37: 868.
group I children (below 2 years) and among the role of alanine in blood glucose homeostasis. 15. Graham IFM. Preoperative starvation and
low percentile weight children (40%). This Anaesthesia 1982; 37: 274 –277. plasma glucose concentration in children
could be the result of glycogen stores being 3. Faster WD, Rubenstein AH, Hypoglycaemia undergoing outpatient anaesthesia. British
closely related to body weight.11 Alleyne et al. In: Fauci AS, Braunwald D et al 14th ed Journal of Anaesthesia 1979; 5: 161 – 164.
reported that glycogen metabolism was Harrison’s Principles of Internal Medicine. 16. Padfield A. Blood glucose concentration in
completed earlier in malnourished children New-York: McGraw- Hill 1998; 2081-2087. children undergoing outpatient dental
who also had a more rapid fall in blood 4. Pagliara AS, Karl IE, Haymold M, Kipnis anaesthesia. British Journal of Anaesthesia
glucose levels than well nourished children DM., Hypoglycemia in infancy and 1984; 56: 1225 – 1227.
when fasting.12 Allison et al. also observed childhood – Part 1. Journal of Pediatrics 17. Redfern N, Addison M, Meakin G. Blood
that children with a low percentile weight had 1973; 82: 365 - 379. glucose in anaesthesized children.
a lower mean blood glucose concentration 5. Ganong W F. Review of medical physiology, Anaesthesia 1986; 41: 272 – 275.
than their counterpart with a higher percentile 18th ed. Stamford: Appleton and Lange 18. Huang SJ, Lee KC, Lai YY, Su HP, et al.
weight despite similar periods of fasting.2 1997; 576. Prolonged fasting in pediatric outpatient
Similarly, Payne et al. and Thomas in their 6. Sperling MA. Hypoglycaemia. In: Berman does not cause hypoglycaemia. Ma Zui Xue
studies also found a higher incidence of RE, Kliegma RM, Jensen HB,eds. Nelson’s Za Zhi 1993; 31: 249 –53.
hypoglycaemia among low percentile weight Textbook of Pediatrics 16th ed. Philadelphia: 19. Somboonviboon W, Kijmahatrakul W. Blood
children during preoperative fasting.13,14 WB Saunders, 2000: 439 –444. glucose concentration in pediatric
Children with lower percentile weight are 7. Goresky GV, Malty JR. Fasting guidelines outpatient surgery. J. Med. Assoc. Thai
therefore more susceptible to hypoglycaemia for elective surgical patients. Canadian 1996; 74: 236 – 239.
Pain in Europe
4th Congress of EFIC – The European Federation of the International Association for the Study of Pain Chapters
Prague, Czech Republic, September 2-6, 2003
e50,000 have been budgeted for financial aid to applicants from low-resource and currency restricted countries. Applications together
with the Registration form and the abstract for free poster presentations can be downloaded from the website.
Congress Secretariat: Kenes International 17 rue du Cendrier, PO Box 1726 CH-1211 Geneva 1, Switzerland
Tel: [phone] Fax: [phone] Email: [email protected]
8
Inhalation anaesthesia in developing countries:
s
n
o
the problems and a proposed solution. i
t
a
g
i
t
Paul M Fenton DTM&H, FFARCSI. and, being non-recycling, it is wasteful of that meaningless word so beloved of s
e
Email:[email protected] the expensive anaesthetic agent. Strict the aid donors? v
precautions against cross infection would I believe there is such a machine. In n
require either a change in valve with each this article and the next I hope to I
/
The title, from a paper by Ezi-Ashi, patient or the use of a bacterial filter convince the reader of the practical h
Papworth and Nunn, may be between the patient and the valve at the possibilities. c
r
familiar to some readers. It airway – very cumbersome. There is no Oxygen but no compressed gas? a
appeared 20 years ago in Anaesthesia1 built-in ventilator and the hand operated Oxygen concentrators have been around e
s
So, what has happened to ‘the bellows or self inflating bag is generally for 20 years but the technology has not e
problems and proposed solution’ in the regarded as Stone Age technology or only taken off. I have to explain what an R
meantime? The short answer is: not much. good for resuscitation. oxygen concentrator is to just about every
The paper is as relevant today as it was It is human nature to want the best anaesthetist I meet in the UK. Like the
then, in that the same problems exist and and if the West will not use it, EMO, most people have never seen one!
the same solutions are still proposed. But anaesthetists in developing countries will There is no earthly logic in separating
we heard no more from these authors. not be satisfied with draw-over anaesthesia oxygen from liquid air, compressing it to
In 1983, the authors drew attention and will never be persuaded (by people very high pressure or cooling it to very low
to the widening technology gulf between like me) to want it. If you doubt this, pay temperatures - all at vast expense -
the West and developing countries. It is a visit to Medica, the world’s largest transporting it to a hospital and passing it
wider still today. exhibition of medical equipment held each through concrete walls for use on a patient
year in Düsseldorf. There is no draw-over who, like everyone else inside the
Therefore, in our quest
equipment to be found anywhere in its operating room, lives and breathes at
for “Anaesthesia for All” hundreds of acres of exhibition halls, nor atmospheric pressure. Why not make
any delegations of eager Third World oxygen on the spot with a concentrator
we must look for a
buyers looking for it! If you are still not and supply it at atmospheric pressure?
universal system suitable convinced, ask any anaesthetist from Why has this wonderful technology
Nigeria what he or she thinks about draw- flopped? The mainstream manufacturers
for rich and poor.
over anaesthesia. do not want to know about oxygen
Therefore, in our quest for concentrators for anaesthesia. The
Ezi Ashi et al proposed 4 levels of “Anaesthesia for All” we must look for a technology does not fit their machines,
equipment but today’s reader looking for universal system suitable for rich and poor. therefore the developing world will not get
practical solutions would find they are still It must have the following features: the technology.
on the drawing board and we are no l Looks good but is cheap Most new operating theatres being
nearer attaining their proposed goal. l Uses the circle breathing system - for built today have a built-in pipeline gas
Could there be just one inhalation economy and to reduce pollution system. The “experts” say it must be so.
anaesthesia machine which meets the l Provides oxygen but has no need for But there is no medical or physiological
needs of excellence that the West demands compressed gases requirement for compressed gases in
yet could also be used in the poorest, most l Is easy to service with readily available anaesthesia. Not in New York, not in the
under-resourced rural location. replacement components and spares Zambezi Valley.
Draw-over equipment must surely be l Is intuitive in use – switch on and ven- Our Mercedes Benz must run
the answer - why can’t we all use it? It is tilate by pushing the first knob you see without nitrous oxide. The gas is
the life-saving mainstay of countless l Is safe when electronic monitoring and expensive, a pollutant and carries the
hospitals in Africa, India and elsewhere. even human vigilance is absent potential for allowing a hypoxic gas
Simple draw-over is safe, robust and easy l Has a one-step mechanical ventilation mixture to be delivered to the patient. It is
to use for the less well trained anaesthetist. facility also unnecessary: the analgesic and sleep
It is wonderful in its simplicity but we l Permits the patient to be ventilated effects of nitrous oxide can be simply
have heard all this before.2 with room air when all else fails obtained by giving intravenous analgesia
Anaesthetists in developed countries, The machine has to be of Mercedes (e.g. 50 mg pethidine) and increasing the
and those that aspire to be developed (ie Benz design and quality to compete at dose of volatile agent (eg an extra 0.5%
almost every gasman in the world), will Medica, but can we all afford our halothane or isoflurane).
never choose to use draw-over: the system Mercedes Benz and keep it in the remotest Therefore I propose a modern
requires a bulky inflating valve to be near bush and keep it running, year after year, anaesthesia machine with a recycling circle
the patient’s airway, scavenging is difficult thereby making it “sustainable”, to use breathing system that is powered by an
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Continued on page 10
oxygen concentrator. Some modifications The Copenhagen polio epidemic
F
are required to make this combination
e
a work and be safe.
t and the birth of Intensive Care
u “Why”, I hear you say “we don’t
r need to read Fenton’s paper on this!” Just
e
go to the hi-tech junk room in your own

S
hospital, find a donated continuous flow Dr John S M Zorab that between 24 July and 3 December, 1952,
t
o machine gathering dust – surely there is 2722 patents with polio were admitted to this
Consultant Anaesthetist Emeritus
r
one – and link it up to an oxygen hospital - 866 with respiratory paralysis and
i Frenchay Hospital Bristol
e
concentrator donated to the paediatric 1856 without1. Even today, it is difficult to
s ([email protected])
department that they have not noticed is imagine how any hospital could cope when
missing. Find the oxygen inlet to the Introduction faced with 866 patients in acute respiratory
rotameter block at the back of the Poliomyelitis, formerly known as Infantile failure in a 4 month period. In Copenhagen,
machine and connect it to the Paralysis, owing to its prevalence in children, is previous experience with treating respiratory
concentrator. If the chassis has space, you an ancient disease and there is evidence from insufficiency with respirators (Cuirass type) had
can even mount the concentrator in the the withered and deformed limbs of Egyptian been bad. Between 1934 and 1944, Cuirass
base. Provided the continuous flow mummies that it first occurred nearly 6000 respirator treatment was used in 76 patients
machine does not have alarms for low years ago. It is both an endemic and an with a mean mortality rate of 80%. In the early
pipeline pressure, “oxygen” (being really a epidemic disease and has occurred in all parts days of the 1952 epidemic, with very few
70-95% pure oxygen/air mix from the of the world. The year 2003 marks the 50th exceptions, all patients with respiratory failure
concentrator) will flow rather sluggishly anniversary of the successful trials of the Salk from bulbar paralysis died. Treating patients
from the rotameter and you are in vaccine against polio, an event which will with tracheostomy in order to manage
business. A flow up to 5 litres per minute hopefully lead, to its eventual total eradication. secretions proved ineffective and most still
into the circle (the maximum the As a result of immunisation programmes, died. Although Bower and his colleagues from
concentrator will usually supply) is Europe, WHO's Region of the Americas and the Los Angeles had described the efficacy of early
usually sufficient and the only Western Pacific Region have now been
disadvantage compared to using piped declared polio-free zones. The WHO reported
oxygen from a cylinder is that pre- that, by the close of 2002, there were only
oxygenation with 10 litres flow of 100% seven countries where polio was still endemic.
oxygen is not possible. These include Afghanistan, Egypt, India,
Setting up the patient breathing Nigeria, Niger, Pakistan and Somalia. Currently,
system with soda lime, etc will be another there is a major immunisation programme in
task. India that aims to vaccinate 165 million
But I do not recommend this children to combat a polio epidemic that swept
machine: when the power goes off or the that country since 2002. As WHO, UNICEF,
concentrator fails, as sooner or later one or Rotary International and other organisations
both must happen, you cannot ventilate strive towards the goal of declaring the world
the patient nor give oxygen. There will a polio-free zone, it is appropriate to recall the
have to be an emergency resuscitation bag terrible epidemic that struck Copenhagen in
always nearby. Then, one day, someone 1952 which led, indirectly, to the birth of
will take that bag for an emergency and intensive care medicine as we know it today.
not put it back. Although there had been previous epidemics,
The idea still has potential: why can’t notably in Toronto, Canada, in 1937 and in the H.C.A. Lassen– Professor of Epidemiology
we have a circle system that does not need UK in 1938, the Copenhagen epidemic was of University of Copenhagen (by kind permission
compressed gases and is as simple to use as astonishing proportions and was probably the of Medicinsk-historisk Museum, Copenhagen)
a draw-over system? worst polio epidemic ever to strike a single
In the next article I will propose how city. Whilst by no means all those contracting treatment of bulbar polio in a tank respirator2,
it can be done. the disease develop respiratory failure, this (Fig 2) this treatment was only effective if
To be continued………………… was a marked feature of the Copenhagen instituted at a very early stage, before the
epidemic and overwhelmed the health care patient had developed respiratory
References: services since no effective treatment was complications. But, at the outbreak of the
1. Ezi-Ashi TI, Papworth DP, Nunn JF available. epidemic, Copenhagen had only one tank
Inhalational anaesthesia in developing The epidemic respirator and 6 cuirass respirators while
countries. Parts I & II. The problems At the time, Copenhagen had a population of nearly 50 new patients with respiratory failure
and a proposed solution. Anaesthesia. 1,200,000 and only a single hospital for were being admitted every day! In the first
1983 Aug; 38(8):729-47. communicable diseases, the Blegdam Hospital. month of the epidemic, 31 patients were
2. Stop The Rot. P.M. Fenton Comment: In his preliminary report, the chief physician, admitted with respiratory paralysis of whom 27
World Anaesthesia, Vol. 1, No 1. 1997 Professor H.C.A. Lassen (before Fig 1) recorded died. Copenhagen was in a state of siege.
10