Faculty of Anaesthesia

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SELECTED ADMISSION SERUM ELECTROLYTE LEVELS AND ASSOCIATED CLINICAL OUTCOMES IN CRITICALLY ILL PATIENTS ADMITTED TO THE KORLE-BU TEACHING HOSPITAL, ACCRA
(Ghana College of Physicians and Surgeons, 2023-07-15) BAFFOUR-AWUAH, LORRAINE
INTRODUCTION Electrolytes are minerals that carry an electric charge when dissolved in body fluids (serum) such as blood. Disturbances in serum electrolyte levels are associated with multiple organ system dysfunction; cardiac, respiratory, neuromuscular, immunologic and haematologic function. It is therefore important for clinicians to understand the electrolyte pathophysiology in critical illness. This study therefore seeks to determine some selected serum electrolyte (Phosphate, Magnesium, Calcium, Sodium, Potassium and Chloride) levels and their effect on critically ill patients. AIM To determine the admission levels of selected serum electrolytes (Phosphate, Magnesium, Calcium, Sodium, Potassium and Chloride) and their association with clinical outcomes in critically ill patients at the Korle-Bu Teaching Hospital (KBTH), Accra. METHODOLOGY This was a longitudinal study involving 26 critically ill patients admitted to the Surgical Ground Floor Intensive Care Unit (ICU) and High Dependency Units (HDUs) of KBTH. Laboratory determination of serum electrolytes (Phosphate, Magnesium, Calcium, Sodium, Potassium and Chloride) of the critically ill patients was done at admission and their SOFA scores calculated. Clinical outcomes such as Length of ICU stay (LOS), duration of mechanical ventilation, duration of inotropic support and mortality were measured upon follow up of the patients. The relationship between the measured electrolytes and their association with clinical outcomes was determined using the Pearson correlation co-efficient. Fisher’s Exact test was used to determine the effect of the measured serum electrolytes on mortality. RESULTS The mean admission serum electrolyte levels were: Phosphate (1.35(± 0.84) mmol/l), Magnesium (0.83 (± 0.25) mmol/L), Calcium (1.12 (±0.12) mmol/l), Sodium (139 (± 5.3) mmol/L), Potassium (4.32 (±1.06) mmol/L) and Chloride (104 (±6) mmol/L). There was a positive significant association between serum phosphate and serum magnesium (p-value=0.011) and a non-significant positive association with serum calcium levels (p-value=0.748). There was however a non-significant negative association between serum calcium and serum magnesium levels at admission (p-value=0.175). There was a significant positive correlation between serum phosphate and SOFA scores (p-value=0.041) and mortality (p-value=0.110). A non-significant negative correlation was found between serum phosphate and duration of ventilatory support (p-value=0.638), inotropic support (p-value=0.718) and LOS (p-value=0.683). There was a non-significant positive correlation between serum magnesium and SOFA scores (p-value=0.912) and mortality (p-value=0.199). A non-significant negative correlation was noted between serum magnesium levels and duration of inotropic support (p-value=0.655) and LOS (p-value=0.772). There was a non-significant positive correlation between serum calcium levels and SOFA scores (p-value=0.912), LOS (p-value=0.439), and duration of inotropic support (p-value=0.333). A non-significant negative correlation was found between serum calcium levels and mortality (p-value=0.240). Hypernatraemia and hypophosphataemia were associated with high mortality, though not statistically significant. CONCLUSION Derangements in admission serum electrolyte levels had an effect on SOFA scores, LOS, duration of inotropic support, duration of ventilatory support and mortality in critically ill patients. Hypernatraemia and hypophosphataemia were associated with hundred percent mortality.
MANAGEMENT OF SPINAL ANAESTHESIA-INDUCED HYPOTENSION DURING CAESAREAN SECTION; A COMPARISON OF EPHEDRINE AND NOREPINEPHRINE
(ADJEPONG, PATIENCE, 2024-05-09) ADJEPONG, PATIENCE
Introduction For the majority of caesarean sections, spinal anaesthesia is the preferred anaesthetic technique due to its better safety profile. Hypotension has been the most common adverse effect of spinal anaesthesia for decades. Spinal anaesthesia-induced hypotension if not managed promptly and appropriately could lead to poor maternal and neonatal outcomes. Common vasopressors used in the management of hypotension during spinal anaesthesia include phenylephrine and ephedrine. Currently, norepinephrine is being studied as an alternative to phenylephrine and ephedrine for the management of spinal anaesthesia-induced hypotension. This study sought to compare the effectiveness of intravenous ephedrine and norepinephrine in the aversion of spinal anaesthesia-induced hypotension. Methods This was a prospective, randomised, double-blind controlled study. After ethical clearance and informed consent, parturients were randomised into A (Ephedrine group) and B (Norepinephrine group). The Ephedrine group received prophylactic ephedrine 5mg, augmented with rescue boluses of ephedrine 5mg intravenously. The Norepinephrine group received prophylactic norepinephrine 5μg, augmented with rescue boluses of norepinephrine 5μg intravenously. The primary outcome was the incidence of spinal anaesthesia-induced- hypotension in the two groups. Secondary outcomes included, the incidence of maternal reactive hypertension, bradycardia, nausea and vomiting, and first and fifth-minute Apgar scores of the neonate. A systematic sampling method was used to select all participants. The chi-squared test was used to analyse categorical data, which were presented as numbers and percentages. Shapiro's rank test was used to determine whether continuous data were normally distributed. STATA version 17 (College Station, Texas) statistical software was used for all computations. A p-value of less than 0.050 with a 95% confidence interval was used as the threshold for statistical significance in all tests. Results The study involved 138 participants, 69 in each group. The mean demographics of the participants were age (31.99±5.04) years, parity (2.82±1.49), gestational age (38.56±0.75) weeks, and body mass index (BMI) (26.58±3.52) kg/m². The incidence of spinal anaesthesia-induced hypotension was 62.32% in the ephedrine group and 42.03% in the norepinephrine group (p= 0.017). The incidence of reactive hypertension was 13.04% in the ephedrine and 8.82% in the norepinephrine group (p= 0.429). The incidence of bradycardia was 4.35% in the ephedrine group and 4.35% in the norepinephrine group (p= 0.612). The incidence of nausea and vomiting was 8.70% in the ephedrine and 10.14% in the norepinephrine group (p= 0.710). The Apgar scores of neonates in the first and the fifth minutes were not statistically different between the two groups (p= 0.878 and p= 0.827 for the first and the fifth minutes respectively). Conclusion Norepinephrine maintained maternal systolic arterial pressure better than ephedrine during spinal anaesthesia for caesarean section. However, the outcomes for nausea and vomiting, reactive hypertension, and bradycardia, as well as neonatal outcomes obtained for parturients who received either norepinephrine or ephedrine were similar.
PREVALENCE AND OUTCOMES OF INTRA-ABDOMINAL HYPERTENSION IN CRITICALLY ILL PATIENTS IN A MIXED INTENSIVE CARE POPULATION
(BANDOH IRENE, 2023-09-30) BANDOH, IRENE
Intra-abdominal hypertension (IAH) is a condition with significant morbidity and mortality risks in ICU patients, particularly when it escalates to Abdominal Compartment Syndrome (ACS). IAH and ACS can have detrimental effects like, reduced cardiac output, decreased splanchnic blood flow, and renal impairment. Notably, the prevalence of IAH can be as high as 50.5% among ICU patients. Nevertheless, this condition still demands attention in numerous healthcare facilities, including Ghana. The main objective of this study was to investigate the prevalence and prognostic implications of IAH in a mixed surgical and medical ICU environment MATERIALS AND METHODS The study participants were adult patients admitted to the Main ICU of Komfo Anokye Teaching Hospital. Intra-abdominal pressure was measured on admission and every six hours during the initial 48 hours of admission or until the patient's discharge or demise. The modified Krohn's method was employed to carry out these measurements. The Sequential Organ Failure Assessment (SOFA) scores of the participants were calculated daily to evaluate the extent of organ dysfunction. The baseline SOFA score on admission served as the reference point for comparisons. This allowed for a comparison between the group with IAH and the group with normal intra-abdominal pressure, aiming to ascertain whether IAH significantly impacted SOFA scores as a metric for organ dysfunction. The impact of intra-abdominal pressure on critical outcome measures such as ventilator-free days and length of stay in ICU were also measured. RESULTS AND ANALYSIS Ninety participants were enrolled in the study consecutively. The results of the same were analysed. The mean age of participants was 44.3(S. D 17.9, CI=40.4-48.03). Males represented the majority of participants with 53.3% while females formed 46.6%. Intra-abdominal hypertension was defined as “IAP ≥ 12mmHg” according to the WSACS consensus guidelines while abdominal compartment syndrome was defined as “IAP ≥ 20mmHg with new onset organ failure”. The prevalence of IAH was 47% (95% CI 0.36-0.57) and that of ACS was 1.1% of the general population and 2.38% of the cohort that developed intra-abdominal hypertension. Identified risk factors for IAH included Mechanical Ventilation (p-value 0.004), positive fluid balance (p-value 0.028), obesity (p-value 0.073) and massive fluid resuscitation (p-value 0.012). Other identified risk factors included abdominal surgery, major trauma, Acidosis and sepsis but these were not statistically significant. The mean SOFA score on day one for all participants was 7.3±3.9 which was lower than that of the group that developed IAH and higher than the normal IAP group. Mean SOFA scores worsened significantly in the IAH group over the first 48 hours but reduced in the normal IAP group. IAH did not significantly prolong the ICU length of stay. However, the IAH group had significantly less ventilator-free days than the normal IAP group. CONCLUSION The prevalence of IAH was 47% in the KATH ICU. IAH increased mean SOFA scores and increased ventilator dependence. It is crucial to have protocols for identifying and managing intra-abdominal hypertension to improve ICU outcomes.
EFFECT OF PERINEURAL DEXAMETHASONE ON ULTRASOUND GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK FOR POST CAESAREAN ANALGESIA AT KORLE-BU TEACHING HOSPITAL
(SOTTIE AKWANFO YAW DANIEL, 2022-04-01) SOTTIE, AKWANFO YAW DANIEL
INTRODUCTION Caesarean delivery (CD) is a common surgical procedure with associated significant post-operative pain. Adequate post caesarean analgesia enables the new mother to take care of the new born while preventing the debilitating effects of uncontrolled post-operative pain. The most frequent negative response to caesarean delivery in Ghanaian women is pain. Analgesic options following CD in Korle-Bu Teaching Hospital include the use of intrathecal opioids (fentanyl), parenteral opioids (intramuscular pethidine), intravenous paracetamol and rectal diclofenac. The addition of the bilateral transversus abdominis plane (TAP) block with dexamethasone as an adjunct to the existing pain management modalities will provide adequate post caesarean delivery analgesia and improve patient satisfaction. AIM The aim of this study was to assess the effectiveness and safety of perineural dexamethasone in ultrasound guided bilateral TAP block in providing post-operative analgesia in parturients who underwent caesarean delivery under spinal anaesthesia at Korle-Bu Teaching Hospital. METHODS This was a prospective, randomized, double blind study of 99 electively booked patients for caesarean delivery under spinal anaesthesia. These were divided into three groups of 33 each after meeting inclusion/exclusion criteria and giving informed consent. Ultrasound guided bilateral TAP block was administered immediately after caesarean delivery under spinal anaesthesia (using either bupivacaine + dexamethasone (group A), only bupivacaine (group B) or only saline (group C)). Time to request for first analgesia, systemic opioid consumption, numerical rating scale (NRS) pain scores, incidence of pruritus, nausea and vomiting and participants’ satisfaction were recorded. This was entered into Microsoft Excel spread sheet and Statistical Package for the Social Scientists (SPSS) software version 25 used for data analysis. RESULTS The time to first analgesic request was significantly prolonged in the bupivacaine group (327.5 ± 98.69 minutes) compared to the saline group (256.5 ± 72.33 minutes) (p-value = 0.023); with addition of dexamethasone resulting in further prolongation (485.2 ± 143.03 minutes) (p-value < 0.0001) of the time to first rescue analgesic. There was a significantly lower consumption of systemic opioids in the bupivacaine group (269.1 ± 64.44mg) compared to the saline group (380.6 ± 39.21mg) (p-value < 0.0001); with further significant lowering of opioid analgesic requirements (113.6 ± 81.58mg) on addition of dexamethasone (p-value < 0.0001). NRS pain scores at rest and on coughing were lower in the intervention groups compared to the control group. Lower NRS pain scores were recorded with addition of dexamethasone although they were not always significant. The incidence of adverse events of pruritus, nausea and vomiting and sedation was not significantly different amongst the three groups. Participants who had dexamethasone + bupivacaine had higher satisfaction scores than participants who had bupivacaine; who in turn had higher satisfaction scores than participants who had saline. CONCLUSION Addition of dexamethasone to bupivacaine for a TAP block is safe, has opioid sparing effect and provided better postoperative analgesia after Caesarean delivery compared to control and bupivacaine alone TAP at Korle-Bu Teaching Hospital.
PERIOPERATIVE ANALGESIC EFFECT OF SERRATUS ANTERIOR PLANE BLOCK ON BREAST SURGERY. A PROSPECTIVE, RANDOMIZED, CONTROLLED DOUBLE BLIND STUDY CONDUCTED AT THE KORLE BU TEACHING HOSPITAL, ACCRA, GHANA.
(MENSAH KOFI DAVID, 2022-04-01) MENSAH, KOFI DAVID
INTRODUCTION Breast cancer is the most common cancer in women both in the developed and less developed world, according to World Health Organisation. The mainstay of treatment for breast cancer is breast surgery. Pain after breast surgery has been described as moderate to severe. Inadequately treated post-operative pain after breast surgery invariably leads to greater postoperative morbidity, higher hospital cost and persistent post-operative pain. Opioids have been the drugs of choice for management of postoperative pain after breast surgery, however, they are associated with many undesirable side effects. Serratus anterior plane (SAP) block is a new interfascial injection technique for analgesia of the chest wall. There is paucity of data with regards to its use for pain relief and possible opioid-sparing in the West Africa subregion. AIM The aim of this study was to determine whether serratus anterior plane block administered for breast surgery has analgesic effect during the perioperative period in patients undergoing elective breast surgery at the Korle-Bu Teaching Hospital. METHODOLOGY This was a prospective, randomized, double-blinded study. Following Ethical Committee approval, patients who fulfilled the inclusion criteria and gave informed consent were consecutively enrolled into the study. A total of fifty-two (52) patients were enrolled into the study and were randomly assigned into one of two groups. The intervention group (n=26) and the placebo group(n=26). Patients demographic characteristics were recorded. Their pre-induction blood pressure, heart rate, respiratory rate and oxygen saturation were also noted. All patients underwent standard general anaesthesia and their airways secured with laryngeal mask airways. After induction of anaesthesia a blinded anaesthetist performed ultrasound guided serratus anterior plane block with 0.25% plain bupivacaine or 0.9% normal saline. Intraoperatively, heart rate and mean arterial blood pressure were maintained within 20% of the preoperative baseline values by giving intravenous bolus doses of morphine. Intraoperatively, patients’ blood pressure, heart rate and respiratory rate were recorded every five minutes. After surgery, a blinded investigator assessed and noted the numerical rating scale (NRS) score of pain at the recovery ward when patients were conscious and alert, at 1, 4, 8 and 24 hours postoperatively. The incidence of PONV was recorded immediate postoperative period and at 1, 4, 8 and 24 hours postoperatively. Patient satisfaction was also assessed using a simple questionnaire. RESULTS Patients receiving SAP block had lower NRS scores at all measured time points but this was only statistically significant at 4 hours postoperative time(p-value=0.002). The mean intraoperative opioid consumed (morphine equivalent) was slightly higher in the control group (11.9±1.5mg) than it was in the intervention group(11.3±1.5mg), however the difference was not statistically significant (p value = 0.131) There was statistically significant difference in the postoperative opioid consumption in the intervention group and the control group (4.6±5.7mg versus 10.5 ± 6mg) respectively (p value=0.001). Most participants in this study did not experience PONV. Those who had PONV, the highest incidence occurred 4 hours postoperatively but this was not statistically significant between the two groups (p-value = 0.098). No participant experienced severe PONV. No adverse effects were noticed in those who had the SAP block. Generally, patients in both groups were very satisfied with their postoperative pain management. CONCLUSION Serratus anterior plane block reduces NRS pain scores postoperatively. It also significantly reduces postoperative opioid consumption but does not significantly reduce intraoperative opioid consumption.

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