La pandemia COVID-19 en África: relato de médicos anestesiólogos africanos

Se presenta la experiencia médica recopilada principalmente de países del África Sud-Saharina en relación a la pandemia del COVID-19, donde la mayoría de los contenidos descritos provienen de publicaciones científicas aparecidas durante el transcurso de la epidemia (algunos antes de la revisión por pares), incluyendo artículos de medios de comunicación independientes, junto a frecuentes intercambios de información entre los autores, así como, testimonios personales que ellos mismos han recibido. No se hará referencia a las consecuencias socio-económicas posibles de esta crisis, aunque se podrá suponer que estas serán importantes, aunque diferentes a aquellas consecuencias que afectarán a los países técnicamente avanzados. Las conclusiones expuestas pertenecen exclusivamente a los autores y no comprometen, de ninguna forma, a las instituciones en las cuales ellos forman parte.

[Cardiac surgery in Cameroon. Results at one year of the pilot phase]

In the framework of implementation of his national program for control and prevention of cardiovascular diseases, Cameroonian government has set up a cardiac surgery project. We report in this manuscript results of one year follow up of the patients operated during the pilot phase. From September 22 till 26, 2008, 11 patients have been operated in Cameroun. Surgical procedures were 5 mitral mechanic valve replacement, 2 aortic mechanic valve replacement, 1 atrial septal defect closure, 2 pace maker implantation. No intrahospital death was observed. One patient died at 11th month after the operation due to mitral valve thrombosis and attributed to lack of compliance. One patient presented low cardiac output, pneumonia and a pleural effusion. 2 patients presented 2 minor complications consisting of pericarditis and superficial wound infection. The results of the pilot phase of cardiac surgery in Cameroon are effective. However, the sustainability of the program require human, material capacity building, and funding mechanism as well.

[Results of the first three years of operation of the emergency medical assistance service (SAMU) in Yaounde, Cameroon]

PURPOSE

The purpose of this article is to present the results of a descriptive and retrospective study of the operations of the emergency medical assistance service (SAMU) in Yaounde, Cameroon.

METHODS

Medical regulation and intervention records and monthly statistics forms were analysed for the period going from the creation of the SAMU in 2004 to March 2007. Study was limited to call reception, medical regulation, and extra-hospital and training activities. Study focused on operations and services.

RESULTS

The SAMU in Cameroon is managed by a pilot committee presided by the Minister of Public Health and headed by a technical executive secretary. The single phone number to contact SAMU Yaoundé is 19 (119). When a call comes, the personnel on duty in the regulation room identifies the caller and either gives a non-medical response or transfers the call to an on-call emergency doctor who decides whether or not on-site intervention is required. In the 3-year study period, the SAMU received 50,822 calls per year (mean, 1694 +/- 2195). There were 1 596 prank calls (3.14%), 31 044 (61.08%) calls requesting non-medical information, and 2054 (4.04%) calls requiring on-site intervention. The number of calls decreased by 23% from the first to third year of operation. The number of on site-interventions carried out by Yaoundé SAMU was 578 in the first year, 651 in the second and 825 in the third year. A total of 1555 interventions were carried out including 142 that ended in no action and 107 that ended in late arrival. Road traffic accidents were the main reason for intervention. Only one training session was organised for the personnel during the first year of operations.

CONCLUSION

The SAMU Yaoundé is based on the French model (on-site care). The number of calls has dropped from the first to third year but the number of prank calls has also decreased. Road traffic accidents accounted for most of the on-site interventions. Further work is needed to increase public awareness of the importance of the SAMU and to provide training for SAMU personnel.

Morphine versus morphine-ketamine association in the management of post operative pain in thoracic surgery

The aim of this study was to assess the quality of postoperative analgesia obtained with morphine-ketamine association administered in self-pain controlled analgesia, as well as the amount of morphine that has been spared. Patients who had to undergo thoracic surgery were selected. They were divided into two groups: G1 was made up of patients receiving 0.5 mg/ml of morphine associated with a placebo, with boluses of 2 ml and refractory periods of 5 minutes ; and G2 made up of patients receiving 0.5 mg/ml of ketamine associated with 0.5 mg/ml of morphine with same boluses and refractory periods. The assessment of pain at rest and on stimulation was carried out with the visual analogue scale. The response to pain and the amount of morphine spared were evaluated. Fifty patients with an average age of 34 years were selected. The assessment showed that the response to pain at rest was the same in the two groups as from the twelfth hour. On stimulation, the analgesic response was better in G2 as well as the amount of morphine spared. This study shows that the administration of ketamine in association with morphine in the post operative period procures a favourable efficiency-tolerance relationship and provides a good means of sparing morphine.

[Venous thromboembolism in Cameroon (report of 18 cases)]

The purpose of this report was to describe clinical and ultrasound findings associated with venous thromboembolism of the lower extremities and pulmonary embolism observed in our department with special emphasis on the utility of venous ultrasound in the diagnosis of venous thromboembolism. Between January 1, 1998 and December 31, 1999, a total of 47 venous ultrasound procedures were carried out according to the standard technique using a Logic 400 MD system (General Electric). Deep venous thrombosis was diagnosed in 18 cases (38.3%). There were 10 men and 8 women with a mean age of 46 years (range, 24 to 71 years). Thrombosis involved the internal saphenous, popliteal, or sural vein in 12 cases, the common or deep femoral vein in 4, and the external iliac vein in 2. The most common risk factors observed in our series were surgery, predisposing conditions, history of venous thrombosis and morbid obesity (66.8% of case). Prolonged periods of bed confinement and neoplasm (lower extremity Kaposi's disease) were more uncommon (22.2%). Pulmonary embolism occurred during the observation period in six cases (33.3%) including 3 (50%) that were fatal. Based on these findings it can be concluded that although its incidence is relatively low in black African patients at risk, thromboembolic disease is often fatal and requires routine preventive treatment using heparin.

[Are health care facilities in Cameroon compatible with rational management of emergency patients?]

The aim of this month-long cross sectional study was to evaluate the preparedness of health care institutions in Cameroon to provide rational management of emergency patients. During January 2002 a survey was carried out to list all health care institutions offering emergency care services and to determine their other departments and available equipment and staff. A total of 144 institutions with emergency care facilities were found including 12 central reference hospitals and 123 district hospitals equipped to provide primary emergency care. In relation to a population of 15 million inhabitants, the ratio was one reference hospital for 104180 inhabitants and one district hospital for 100,000 inhabitants. None of the services involved in emergency management had facilities for emergency treatment on an outpatient basis. Regarding hospital-based services, an emergency ward was available at the 12 central reference hospitals for a ratio of one ward for 1,250,000 inhabitants. This ratio was 10 times higher than in France in 1994. Almost all major equipment and trained personnel for emergency care medicine were concentrated at the central reference hospitals but these resources were insufficient to organize round-the-clock services except at a single site. The findings of this survey indicate that the distribution of health care facilities in Cameroon was relatively adequate in relation to population density but that equipment and human resources were still insufficient to provide rational management of emergency patients.

[Emergency medical training: the future of emergency care in Africa?]

The main goal of emergency medicine training is to teach the wide range of sciences and skills necessary to recognize and stabilize emergency situations. Emergency medicine training has proven highly effective in developed countries especially with regard to organization of survival medicine. This type of training is especially important in sub-Saharan Africa where there is a severe shortage of intensive care specialists and an almost total lack of other personnel qualified to manage life-threatening trauma and disease. Starting with the 1998 Nsam fire disaster in Yaounde, a number of situations have confirmed the seriously deficient state of resources for handling emergencies in Cameroon. In view of this situation a two-year study program in emergency medicine was proposed and introduced at the School of Medicine and Biomedical Sciences of the University of Yaounde I during the 2000/2001 academic year. The curriculum includes eight 40-hour didactic course modules and 800 hours of hands-on work in local hospitals and in France. Students undergo regular assessment of their scientific knowledge and practical competencies after each module. As additional prerequisites for the diploma, they must be certified in first aid and rescue and present a research paper. Despite the lack of faculty and teaching materials, this program is expected to increase the number of emergency medical care providers and improve access to high-quality emergency care services.

Transfusion outcome in a resource-limited setting of Cameroon: a five-year evaluation

OBJECTIVE

With a goal to establish strategies for improving blood safety in resource-limited conditions, the outcome of blood transfusion in a hospital setting of Cameroon was examined.

METHODS

A 5-year descriptive and prospective study was conducted in which information on donor blood and recipients was obtained by direct patient observation and by examining patient notes in the various services of the hospital and records from the blood bank.

RESULTS

Of 40,134 donations, 35,318 (88%) were from relatives or friends of recipients. Only 80% of all donated blood was considered safe for distribution. An average of about 20% of donated blood was rejected each year for positive human immunodeficiency virus (HIV) or hepatitis B antigen results. Other infections were not screened for. More than 50% of transfusions within the hospital were associated with an unfavorable outcome, predominantly febrile reactions and urticaria (40.1% and 19.4%, respectively). Acute intravascular hemolysis, circulatory overload, and deaths occurred in 0.01%, 0.04%, and 0.14% of cases, respectively. A case of post-transfusion HIV infection was also detected.

CONCLUSIONS

Blood transfusion is still unsafe in many resource-limited communities of developing countries. However, it is possible to reduce some of these complications without sophisticated technology. Efforts to recruit more benevolent and autologous donors in the communities are essential.

[Evolution of the demography of anesthesia practitioners in French speaking Sub-Saharan Africa]

OBJECTIVE

To assess the course of the demography of anaesthesia providers in French-speaking subsaharian countries.

TYPE OF STUDY

Retrospective survey.

PERSONS

Doctors trained in anaesthesia and nurse anaesthetists registered in West African medical societies.

METHODS

Countries, hospitals, anaesthesia manpower, seniority and place of training were analysed.

RESULTS

In the 13 French-speaking subsaharian countries including 97.5-M inhabitants, 122 doctors and 868 nurses were registered as anaesthetists in 1998. Mean ratios were one doctor trained in anaesthesia for 799,180 inhabitants and one nurse anaesthetist for 112,327 inhabitants. From 1980 to 1998, these figures increased by a factor 11 for doctors (+1100%) and by a factor two for nurses (+100%). Most doctors were working in the chief town, in both public and private health care institutions.

CONCLUSIONS

In all French-speaking subsaharian countries, a major shortage of doctors trained in anaesthesia is existing.

[Anesthesia practices in Yaounde (Cameroon)]

This descriptive and prospective study, carried out during a 6-month period at Yaounde (Cameroon), assessed work practices relating to anaesthesia in public and private health care institutions, the incidence and causes of complications, and considers possible means for improving security of the anaesthetized patient. This study included 1,103 patients, aged 12 days to 89 years. Main surgical indications were gynaecology-obstetrics (33.3% of cases) and emergency surgery (28.6% of cases). Anaesthetic practices were characterized by an unsuitable and non systematic use of procedures which are essential parts of a safe anaesthetic. Pre-anaesthetic assessment was carried out in 71.4% of cases, premedication in 78.4% of cases and management in recovery room in 24% of cases only. Patients were anaesthetized by nurses in 78.6% of cases (40% of them had been trained on-the-job only). The anaesthesia equipment of operating room was poor in most places, especially with respect to physiological monitors. The rate of complications, 476 in 321 patients (29.1% of cases), was similar to the incidence registered in 1977 (30%). Twenty-four deaths occurred (overall mortality rate of 2.2%). Besides the shortage of equipment, this study underlines the necessity for producing and adhering to guidelines for safe practice of anaesthesia, adapted for developing countries.

[Transfusion practices and quantification of blood loss in a surgical setting in Cameroon]

The purpose of this prospective study was to analyze compliance by surgical teams with new guidelines for blood transfusion. Study was focused on routine, presumably hemorrhagic procedures performed electively in adults at the Central Hospital in Yaounde, Cameroon. Overall blood loss was less than 20% of the total volume in 89% of the 303 patients included. Blood loss was between 20 and 30% in 10.6% and greater than 30% in 0.3%. Administration of replacement blood products was warranted only in the last two groups. Blood transfusion was performed in 104 patients and was unjustified in 81.7%. Seven percent of the remaining 199 patients presented indications for transfusion which was not performed and not compensated for by appropriate alternative precautions. At least one unit of whole blood had been requested and delivered to the operating room in 70% of cases with blood loss less than 20%, but was used in only 45% of cases. This study demonstrates poor compliance with new guidelines for blood transfusion in the surgical setting. Overconsumption of blood products represents the main problem. These findings underline the need for wider teaching of new blood transfusion strategies. Interest in this information is usually great in developing countries where blood banks are faced with limited facilities, qualified personnel, and supplies.

[Ocular manifestations and sequelae of Lyell syndrome caused by sulfadoxine-pyrimethamine in Cameroon]

We report a Lyell syndrome secondary to anti-malarial treatment with sulfadoxine-pyrimethamine. Eye lesions predominated: symblepharon and corneal opacification. Desinsertion of conjunctival synechias was performed by ophthalmologists. There were corneal opacities and fibro-vascular veil on the two eyes. A keratoprosthesis was done on one eye. It is very likely that the incidence of this syndrome will increase mainly because of two factors. The continuous increase of plasmodii resistance to chloroquine hence the more frequent use of sulfonamides for the treatment of malaria; secondly, sulfonamides are used in the treatment and prevention of opportunistic infections in AIDS patients. It is important for ophthalmologists in tropical areas to be aware of Lyell's syndrome so that proper and early management may be undertaken.

[The detection of gas embolisms in neurosurgery caused by joint monitoring with capnography and the Swan-Ganz probe. (Apropos of 7 patients operated on in the sitting position]

The aim of this study was to detect per-operative venous gas embolism in neurosurgery using capnography coupled to the Swan-Ganz catheter method. Using both methods, our study, carried out on seven patients operated in the sitting position, showed an occurrence of air embolism in four cases. The diagnosis of air embolism was made on a rapid and progressive drop of FECO2 with, at the same time, a rise of the pulmonary arterial pressure.

[Filarial meningoencephalitis: discussion of a case]

Loiasis treatment by diethylcarbamazine (DEC) may be complicated by a meningoencephalitis that is often fatal. Following one case, four others have been reviewed in the literature and the therapeutic approach in resuscitation departments discussed. Until the discovery of other less-dangerous microfilaricidal or macrofilaricidal drugs, we raise the question of the opportunity to treat loiasis by DEC, while many authors consider it as a simple nuisance.