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ORIGINAL ARTICLE
Year : 2010  |  Volume : 4  |  Issue : 1  |  Page : 5-9

Anesthesia for surgery for typhoid perforation in a rural African hospital


1 Department of Anaesthesia, Jos University Teaching Hospital, Jos, Nigeria
2 Department of Surgery, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria

Date of Web Publication17-Dec-2010

Correspondence Address:
H Y Embu
Department of Anaesthesia, Jos University Teaching Hospital, P.M.B. 2076, Jos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-3131.73864

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   Abstract 

Background : Typhoid perforation is a condition commonly seen in developing countries including those of sub-Saharan Africa. Anesthetic management for surgery in typhoid perforation poses great challenges to the anesthetist practicing in Africa, especially in the face of limited resources.
Materials and Methods : The anesthetic management of patients who underwent surgery for typhoid perforation at the SIM Hospital in Galmi, Niger Republic, between December 2004 and December 2005, was retrospectively reviewed.
Results : There were 56 patients who had surgery for typhoid perforation during the period. Forty-one were males while 15 were females with a male:female ratio of 2.7:1. Their age ranged between 3 and 62 years with a mean of 23 years. Of these, 19 (33.9%) were children aged 15 years and below. Twenty-eight of the patients (i.e. 50%) were assessed as American Society of Anesthesiologists (ASA) physical status class IV, while 22 (39%) were ASA III and 6 (11%) were ASA V. Thirty surgeries (i.e. 53.6%) were done under spinal anesthesia, 9 (16%) under general inhalational anesthesia using halothane, 11 (19.6%) under ketamine anesthesia and 6 (10.7%) had drainage of intra-abdominal abscesses under local anesthesia. The overall mortality rate was 26.8%. The mortality rates following the different techniques of anesthesia were: spinal anesthesia 20%, general inhalational anesthesia 22%, ketamine anesthesia 18% and local anesthesia 83.3%. ASA III patients had a mortality rate of 9%, while the mortality rate was 28.6% in ASA IV patients and 83.3% in ASA V patients. Mortality was significantly related to the ASA status of the patient, while there was no correlation between mortality and anesthetic technique used.
Conclusion: Proper preoperative resuscitation and a well-conducted anesthesia, using a technique that the anesthetist is well conversant with, appear to be the key to successful anesthesia in patients with typhoid perforation. Anesthetists practicing in rural Africa should be encouraged to acquire skill in the art of spinal anesthesia since it is cheap, easy to administer and can be safely utilized in these patients.

Keywords: Anesthetic management, rural Africa, spinal anesthesia, typhoid perforation


How to cite this article:
Embu H Y, Nuhu S I, Yilkudi M G. Anesthesia for surgery for typhoid perforation in a rural African hospital. Ann Nigerian Med 2010;4:5-9

How to cite this URL:
Embu H Y, Nuhu S I, Yilkudi M G. Anesthesia for surgery for typhoid perforation in a rural African hospital. Ann Nigerian Med [serial online] 2010 [cited 2021 May 6];4:5-9. Available from: https://www.anmjournal.com/text.asp?2010/4/1/5/73864


   Introduction Top


Typhoid perforation is a common cause of acute abdomen in the developing world. Morbidity and mortality rates could be high from the peritonitis and fluid and electrolyte imbalance which occur in patients who are already very ill from typhoid fever. [1],[2] Surgery is considered the treatment of choice in order to improve the chances of survival of patients with this condition, who most often present late. [3],[4] The management of these patients provides a number of unique challenges to the attending anesthetist.

Many of these patients present at and are managed in rural hospitals where resources are often very limited. Anesthetic techniques employed in the management of these patients usually include the use of ketamine as the sole agent with endotracheal intubation or the use of general inhalational endotracheal anesthesia. [5],[6],[7] None of these methods have been shown to be superior to the other.

The Sudan Interior Mission (SIM) hospital in Galmi, a rural community located in the southern part of Niger Republic, frequently operated on patients with typhoid perforation, and like in most parts of rural sub-Saharan Africa, the hospital staff had to work with very limited resources. The anesthetic unit of the hospital was manned by five nurse anesthetists, with occasional visits by missionary anesthesiologists from America and Europe. The theater was equipped with an Oxford Miniature Vaporiser (OMV) in a draw-over machine, two oxygen concentrators, non-invasive blood pressure, pulse oximeter and facilities for spinal anesthesia. The hospital had a laboratory where investigations such as hematocrit, full blood count, urinalysis and urea and electrolyte could be carried out. There was no intensive care unit or facilities for mechanical ventilation in the hospital.

Apart from ketamine and general inhalational anesthesia, anesthetists at SIM hospital Galmi, also employed spinal anesthesia in the management of patients with typhoid perforation. We report the experience of the anesthesia staff of the hospital in the management of typhoid perforation over a 1-year period.


   Materials and Methods Top


Patients who underwent surgery for typhoid perforation at the SIM Hospital in Galmi, Niger Republic, between December 2004 and December 2005, formed the basis for this study. The anesthetic management of these patients was retrospectively reviewed. Information obtained from the anesthetic records and case notes included demographic data, clinical features, preoperative management, techniques of anesthesia and perioperative complications. The study population was described in rates and proportion. Statistical analysis was done using Epiinfo 3:4:1 version with the level of significance set at P < 0.05.


   Results Top


Fifty-six patients had surgery for typhoid perforation during this period. Forty-one were males while 15 were females, giving a male:female ratio of 2.7:1. Their age ranged between 3 and 62 years with a mean of 23 years. Of these, 19 (33.9%) were children aged 15 years and below.

The commonest clinical and laboratory findings at presentation were fever, dehydration electrolyte imbalance and anemia [Table 1]. Twenty-eight of the patients (i.e. 50%) were assessed as American Society of Anesthesiologists (ASA) physical status class IV, while 22 (39%) were ASA III and 6 (11%) were ASA V [Figure 1].
Table 1 :Clinical and laboratory findings at presentation

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Figure 1 :Preoperative American Society of Anesthesiologists (ASA) status of the patients

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The patients at presentation were resuscitated with intravenous (i.v.) fluids, usually 0.9% saline. Electrolyte abnormalities, most often hypokalemia, were corrected before surgery. They were commenced on broad-spectrum antibiotics, and severely anemic patients were transfused blood. Naso-gastric tubes were passed and fluid therapy was monitored using clinical parameters like hydration status, blood pressure and urine output. The time between presentation and surgery was 5-48 hours.

[Figure 2] shows the different techniques of anesthesia utilized in the management of the patients. Spinal anesthesia was the technique of choice for patients aged 15 years and above. Spinal anesthesia was instituted using 5% hyperbaric lignocaine, with the patient in the lateral position after adequate preload with 0.9% saline. A sensory level of T6 was considered adequate for surgery. Hypotensive episodes were managed with i.v. fluids and i.v. ephedrine. Episodes of inadequate block were managed by giving sedative doses of ketamine. Eleven patients (i.e. 30.6%) who had spinal anesthesia had to be given additional doses of ketamine due to inadequate block. In 4 (13.3%) of these patients, the spinal anesthesia was considered to have failed and surgery was done under ketamine anesthesia.
Figure 2 :Techniques of anesthesia utilized in the management of the patients

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General inhalational anesthesia was maintained with halothane in oxygen using an OMV machine, after induction with ketamine. The patients were usually intubated using cuffed endotracheal tubes with the aid of suxamethonium. Ketamine anesthesia was initiated with an i.v. induction dose of 1-2 mg/kg of ketamine and maintained with repeated bolus doses of 0.5-1 mg/kg of ketamine. Oxygen was administered to the patients via nasal catheter or face mask. As for the six patients who were ASA V, drainage of intra-abdominal abscess was done under local anesthesia with the hope that the patients would improve enough to be able to withstand anesthesia later.

Postoperative complications included wound infections, wound breakdown, anastomotic leakages, fecal fistula and pneumonia. Eight patients (14.3%) had pneumonia postoperatively. The rate of postoperative chest infection in patients who had spinal anesthesia was 3.3%, while it was 44% in patients who had general anesthesia. Postoperative chest infection was significantly related with the anesthetic technique used.

The overall mortality rate was 26.8%. The mortality rates following the different techniques of anesthesia were spinal anesthesia 20%, general inhalational anesthesia 22%, ketamine anesthesia 18% and local anesthesia 83.3% [Table 2]. Mortality rate according to ASA status of the patients is given in [Table 3], which shows that ASA V patients had a mortality rate of 83.3%. When we compared spinal anesthesia, general inhalational anesthesia and ketamine anesthesia, we found that mortality was not related to anesthetic technique but was related to the ASA status of the patients (P < 0.05).
Table 2 :Mortalities associated with different techniques of anesthesia

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Table 3 :Mortality associated with ASA status of patients

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   Discussion Top


During the period of study, 56 patients were operated for typhoid perforation. This figure is much higher than that obtained in some studies within similar periods. [5],[8],[9] The high number of cases of typhoid perforation seen in the hospital may be attributable to the severe shortage of clean drinking water in the semi-arid region and also to the fact that SIM hospital in Galmi is one of the few hospitals in the region which is able to offer surgery for such patients. These patients come from most parts of southern Niger and sometimes from northern Nigeria.

Since surgery is considered the treatment of choice for patients with typhoid perforation, [3],[4],[10],[11] anesthetists are often confronted with the perioperative management of these patients. Often, the anesthetists involved have limited training and the resources at their disposal are also limited since the bulk of these conditions usually present at and are managed in rural hospitals where anesthesia is usually conducted by nurse anesthetists.

Anesthetic techniques that have been used in the management of these patients include ketamine as a sole agent and general anesthesia using halothane with tracheal intubation. [5],[6],[12] At SIM hospital, Galmi, ketamine anesthesia, general inhalational anesthesia and spinal anesthesia were used in managing these patients. For moribund patients (ASA V), drainage of peritoneal abscess which was done under local anesthesia, may be all that could be achieved while trying to buy time. [7],[13] This was also our experience.

Some authors prefer ketamine anesthesia with endotracheal intubation over other techniques of anesthesia because they feel that these patients would not be able to withstand the hypotensive effects of other anesthetic techniques such as inhalational anesthesia and central regional blocks. [5] Despite this, anesthetists have continued to utilize general inhalational anesthesia in the management of these patients with good outcomes. [6],[12],[14] It appears that proper patient resuscitation and preoperative preparation form the basis for successful conduct of anesthesia, irrespective of the technique used. Special attention should be paid to fluid and electrolyte imbalance, especially hypokalemia, often seen in these patients.

At SIM hospital, anesthesia was usually administered by nurse anesthetists, some of whom were not versed in the art of endotracheal intubation but were proficient in the conduct of spinal anesthesia. The fact that spinal anesthesia is cheap and does not require sophisticated equipment is a common knowledge. [15] This makes it suitable for resource-poor areas like sub-Saharan African countries where a great number of patients cannot afford basic medical bills. Most surgeries in the abdomen, groin and lower limbs in adults and adolescents are done under spinal anesthesia at SIM hospital, Galmi. [16] A sensory level of T6 was discovered to be adequate for exploratory laparotomy, though sometimes, as in our case, sedative doses of ketamine may be required to make the procedure more tolerable for the patient. This is usually associated with better operating conditions compared to the use of ketamine alone as obtained in most rural hospitals. This is because spinal anesthesia is also characterized by profound muscle relaxation. [17] Muscle relaxation is a problem when using ketamine as the sole agent in many rural settings since the patients are not intubated and muscle relaxants are not used. Aspiration of gastric content could also occur in these situations.

The most common intraoperative complication of spinal anesthesia in our patients was hypotension. These episodes were successfully managed with rapid infusion of i.v. fluid and administration of a vasopressor like ephedrine. There is also the reduced risk of pulmonary aspiration with spinal anesthesia. In our case where 5% hyperbaric lignocaine was the agent used for anesthesia, speed was a requirement of the surgeon because the block with this agent usually lasted an average of 1 hour. In some cases where the spinal anesthesia wore off before the end of surgery, the procedure was usually concluded with ketamine infusion. The use of 0.5% hyperbaric bupivacaine should enable longer periods of anesthesia but was not available in the hospital during the period of study. However, it is also advisable that patients with this condition spend the briefest time possible under anesthesia, even when using general inhalational anesthesia or ketamine. Epidural anesthesia is an option in these patients since it has been used in upper abdominal surgeries and in high-risk patients. [18],[19] Epidural anesthesia is however more technically demanding and may not be suitable for rural hospitals, especially where a catheter needs to be inserted.

Anesthetic technique was not statistically associated with mortality in our patients. Though mortality in these patients was often multifactorial, only one mortality was directly traceable to anesthesia. This was a patient who aspirated during general anesthesia. Most of the mortalities occurred postoperatively within the first week after surgery. It is possible that the higher rate of chest infection in patients who had general anesthesia as compared to spinal anesthesia was due to aspiration which was not noticed during anesthesia. The patients who had ketamine anesthesia were not intubated while those who had inhalational anesthesia were intubated but rapid sequence induction was usually not performed due to lack of skill.

The overall mortality rate was 26.8%. This was similar to that obtained in other studies in the African subregion. [12],[20],[21] Low mortality rates in the region of 3-9% have been recorded in countries like South Korea and South Africa. [22],[23] These countries have better economic conditions than most African countries, and such low mortality rates were achieved by close electrolyte and blood gas monitoring, intensive care nursing and the use of total parenteral nutrition. [22],[23] These measures are not obtainable in most developing countries, especially in rural settings. We found that the mortality rates correlated with ASA status of the patients rather than the technique of anesthesia used. This makes it imperative that these patients be properly resuscitated before surgery, though in some cases a satisfactory level of resuscitation may be difficult to achieve before surgery.


   Conclusion Top


A large number of patients with typhoid perforation in sub-Saharan Africa are managed in the rural areas where resources, both human and material, are limited. Anesthetic techniques employed in the management of these patients include ketamine as the sole agent, endotracheal anesthesia using halothane and spinal anesthesia. Proper preoperative resuscitation and a well-conducted anesthesia using a technique that the anesthetist is well conversant with, appear to be the key to successful anesthesia in these patients. Anesthetists practicing in rural Africa should be encouraged to acquire skill in the art of spinal anesthesia since it is cheap, easy to administer and can be safely utilized in patients with typhoid perforation.


   Acknowledgment Top


We would like to express our gratitude to the staff of SIM Hospital, Galmi, especially the anesthetic department, for the cooperation rendered to us during this study and for making our stay at Galmi worthwhile.

 
   References Top

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