Incidence and factors associated with postoperative nausea and vomiting among elective adult surgical patients at University of Gondar comprehensive specialized hospital, Northwest Ethiopia, 2019: A cross-sectional study

Postoperative nausea and vomiting is a common complication of anaesthesia and surgery. It is considered the most common cause of morbidity following anaesthesia and has significant effects on patient satisfaction and cost. Despite modern anaesthetic and surgical techniques, the incidence of PONV remains high.

The objective of this study was to determine the incidence of postoperative nausea and vomiting and associated factors.

A cross-sectional study was conducted from January 1 to May 30, 2019. A total of 355 adult elective patients who were operated on this period were included in the study.

The incidence of postoperative nausea and vomiting was 17.2% within 24 h after operation. Factors that were associated with postoperative nausea and vomiting were history of motion sickness (AOR = 6.0, CI = 2.51–14.49), previous history of postoperative nausea and vomiting (AOR = 13.55, CI = 6.37–28.81) and long duration of surgery (AOR = 10.1, CI = 3.97–25.92).

and recommendations: The incidence of postoperative nausea and vomiting was still high compared with most studies conducted in the world. However, when it compared to the previous study done in the study area, it showed significant reduction in the incidence of PONV by 19%.We suggest that the use of anti-emetic prophylaxis and the introduction of postoperative nausea and vomiting treatment protocols

Management and outcomes following emergency surgery for traumatic brain injury – A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.

Availability, procurement, training, usage, maintenance and complications of electrosurgical units and laparoscopic equipment in 12 African countries

Background: Strategies are needed to increase the availability of surgical equipment in low- and middle-income countries (LMICs). This study was undertaken to explore the current availability, procurement, training, usage, maintenance and complications encountered during use of electrosurgical units (ESUs) and laparoscopic equipment.

Methods: A survey was conducted among surgeons attending the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 and the annual meeting of the Surgical Society of Kenya (SSK) in March 2018. Biomedical equipment technicians (BMETs) were surveyed and maintenance records collected in Kenya between February and March 2018.

Results: Among 80 participants, there were 59 surgeons from 12 African countries and 21 BMETs from Kenya. Thirty-six maintenance records were collected. ESUs were available for all COSECSA and SSK surgeons, but only 49 per cent (29 of 59) had access to working laparoscopic equipment. Reuse of disposable ESU accessories and difficulties obtaining carbon dioxide were identified. More than three-quarters of surgeons (79 per cent) indicated that maintenance of ESUs was available, but only 59 per cent (16 of 27) confirmed maintenance of laparoscopic equipment at their centre.

Conclusion: Despite the availability of surgical equipment, significant gaps in access to maintenance were apparent in these LMICs, limiting implementation of open and laparoscopic surgery.

Severe maternal outcomes in eastern Ethiopia: Application of the adapted maternal near miss tool.

With the reduction of maternal mortality, maternal near miss (MNM) has been used as a complementary indicator of maternal health. The objective of this study was to assess the frequency of MNM in eastern Ethiopia using an adapted sub-Saharan Africa MNM tool and compare its applicability with the original WHO MNM tool.

We applied the sub-Saharan Africa and WHO MNM criteria to 1054 women admitted with potentially life-threatening conditions (including 28 deaths) in Hiwot Fana Specialized University Hospital and Jugel Hospital between January 2016 and April 2017. Discharge records were examined to identify deaths or women who developed MNM according to the sub-Saharan or WHO criteria. We calculated and compared MNM and severe maternal outcome ratios. Mortality index (ratio of maternal deaths to SMO) was calculated as indicator of quality of care.

The sub-Saharan Africa criteria identified 594 cases of MNM and all the 28 deaths while the WHO criteria identified 128 cases of MNM and 26 deaths. There were 7404 livebirths during the same period. This gives MNM ratios of 80 versus 17 per 1000 live births for the adapted and original WHO criteria. Mortality index was 4.5% and 16.9% in the adapted and WHO criteria respectively. The major difference between the two criteria can be attributed to eclampsia, sepsis and differences in the threshold for transfusion of blood.

The sub-Saharan Africa criteria identified all the MNM cases identified by the WHO criteria and all the maternal deaths. Applying the WHO criteria alone will cause under reporting of MNM cases (including maternal deaths) in this low-resource setting. The mortality index of 4.5% among women who fulfilled the adapted MNM criteria justifies labeling these women as having ‘life-threatening conditions’.

The lucky ones get cured: Health care seeking among women with pelvic organ prolapse in Amhara Region, Ethiopia.

The majority of women suffering from maternal morbidities live in resource-constrained settings with diverse barriers preventing access to quality biomedical health care services. This study aims to highlight the dynamics between the public health system and alternative healing through an exploration of the experiences of health care seeking among women living with severe symptomatic pelvic organ prolapse in an impoverished setting.

The data were collected through ethnographic fieldwork at the hospital and community levels in the Amhara region of Ethiopia. The fieldwork included participant observation, 42 semi-structured interviews and two focus group discussions over a period of one year. A group of 24 women with severe symptomatic pelvic organ prolapse served as the study’s main informants. Other central groups of informants included health care providers, local healers and actors from the health authorities and non-governmental organisations.

Three case stories were chosen to illustrate the key findings related to health care seeking among the informants. The women strove to find remedies for their aggravating ailment, and many navigated between and combined various available healing options both within and beyond the health care sector. Their choices were strongly influenced by poverty, by lack of knowledge about the condition, by their religious and spiritual beliefs and by the shame and embarrassment related to the condition. An ongoing health campaign in the study area providing free surgical treatment for pelvic organ prolapse enabled a study of the experiences related to the introduction of free health services targeting maternal morbidity.

This study highlights how structural barriers prevent women living in a resource-constrained setting from receiving health care for a highly prevalent and readily treatable maternal morbidity such as pelvic organ prolapse. Our results illustrate that the provision of free quality services may dramatically alter both health-and illness-related perceptions and conduct in an extremely vulnerable population.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented.This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs.The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%).Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.

Developing Process Maps as a Tool for a Surgical Infection Prevention Quality Improvement Initiative in Resource-Constrained Settings.

Surgical infections cause substantial morbidity and mortality in low-and middle-income countries (LMICs). To improve adherence to critical perioperative infection prevention standards, we developed Clean Cut, a checklist-based quality improvement program to improve compliance with best practices. We hypothesized that process mapping infection prevention activities can help clinicians identify strategies for improving surgical safety.We introduced Clean Cut at a tertiary hospital in Ethiopia. Infection prevention standards included skin antisepsis, ensuring a sterile field, instrument decontamination/sterilization, prophylactic antibiotic administration, routine swab/gauze counting, and use of a surgical safety checklist. Processes were mapped by a visiting surgical fellow and local operating theater staff to facilitate the development of contextually relevant solutions; processes were reassessed for improvements.Process mapping helped identify barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. Compliance with most processes improved significantly following organizational changes to align tasks with specific process goals.Enumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. Simplifying these process maps into an adaptable tool could be a powerful strategy for improving safe surgery delivery in LMICs.

Delayed access to care and unmet burden of pediatric surgical disease in resource-constrained African countries.

The purpose of this study was to estimate the unmet burden of surgically correctable congenital anomalies in African low- and middle-income countries (LMICs).We conducted a chart review of children operated for cryptorchidism, isolated cleft lip, hypospadias, bladder exstrophy and anorectal malformation at an Ethiopian referral hospital between January 2012 and July 2016 and a scoping review of the literature describing the management of congenital anomalies in African LMICs. Procedure numbers and age at surgery were collected to estimate mean surgical delays by country and extrapolate surgical backlog. The unmet surgical need was derived from incidence-based disease estimates, established disability weights, and actual surgical volumes.The chart review yielded 210 procedures in 207 patients from Ethiopia. The scoping review generated 42 data sets, extracted from 36 publications, encompassing: Benin, Egypt, Ghana, Ivory Coast, Kenya, Nigeria, Madagascar, Malawi, Togo, Uganda, Zambia, and Zimbabwe. The largest national surgical backlog was noted in Nigeria for cryptorchidism (209,260 cases) and cleft lip (4154 cases), and Ethiopia for hypospadias (20,188 cases), bladder exstrophy (575 cases) and anorectal malformation (1349 cases).These data support the need for upscaling pediatric surgical capacity in LMICs to address the significant surgical delay, surgical backlog, and unmet prevalent need.Retrospective study and review article LEVEL OF EVIDENCE: III.

International Study of the Epidemiology of Paediatric Trauma: PAPSA Research Study.

Trauma is a significant cause of morbidity and mortality worldwide. The literature on paediatric trauma epidemiology in low- and middle-income countries (LMICs) is limited. This study aims to gather epidemiological data on paediatric trauma.

This is a multicentre prospective cohort study of paediatric trauma admissions, over 1 month, from 15 paediatric surgery centres in 11 countries. Epidemiology, mechanism of injury, injuries sustained, management, morbidity and mortality data were recorded. Statistical analysis compared LMICs and high-income countries (HICs).

There were 1377 paediatric trauma admissions over 31 days; 1295 admissions across ten LMIC centres and 84 admissions across five HIC centres. Median number of admissions per centre was 15 in HICs and 43 in LMICs. Mean age was 7 years, and 62% were boys. Common mechanisms included road traffic accidents (41%), falls (41%) and interpersonal violence (11%). Frequent injuries were lacerations, fractures, head injuries and burns. Intra-abdominal and intra-thoracic injuries accounted for 3 and 2% of injuries. The mechanisms and injuries sustained differed significantly between HICs and LMICs. Median length of stay was 1 day and 19% required an operative intervention; this did not differ significantly between HICs and LMICs. No mortality and morbidity was reported from HICs. In LMICs, in-hospital morbidity was 4.0% and mortality was 0.8%.

The spectrum of paediatric trauma varies significantly, with different injury mechanisms and patterns in LMICs. Healthcare structure, access to paediatric surgery and trauma prevention strategies may account for these differences. Trauma registries are needed in LMICs for future research and to inform local policy.

Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia. A prospective study of 22 children (32 feet) from 2 to 10 years of age.

Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti’s technique in neglected clubfoot in children in a rural setting in Ethiopia.A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2-10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years.A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot.This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.