條信息

文章類型:研究文章

引用:Barboza D, Ntab SO, Diaw M, Traoré MM, Leye PA，等。幾內亞比紹二級軍事醫院的麻醉實踐。中華臨床雜誌3(1):dx.doi。org/10.16966/2470 - 9956.136

版權:©2018 Barboza D等人。這是一篇開放獲取的文章，根據創作共用署名許可協議(Creative Commons Attribution License)發布，該協議允許在任何媒體上不受限製地使用、分發和複製，前提是注明原作者和來源。

出版的曆史:

收到日期:2018年3月28日

接受日期:13 2018年6月,

發表日期:20 2018年6月,

摘要

麻醉在發展中國家的風險很高。幾內亞比紹是衛生麵臨許多困難的國家之一。20多年來，在政治方麵，它一直是一個不穩定的國家，影響了包括衛生在內的幾個領域。尼日利亞、布基納法索和塞內加爾這三個國家的軍隊被部署到維和行動中。塞內加爾部隊的主要任務是部署二級軍事醫院。本研究的主要目的是分析比紹二級軍事醫院的麻醉實踐。這是一項描述性、橫向和分析性研究，時間跨度為2016年1月至2016年12月。對常數、麻醉師人數及其資格、外科醫生資格、現有的監測手段、事故和事故以及住院時間進行評估。我們收集了941名接受麻醉的患者。大多數是年輕人，87.8%在40歲以下，85.54%主要是女性。 In our study urgent surgery was the most representative with 796 patients or 84.6%. The main surgical activity was gynecology and obstetrics, which accounted for 81.7% of cases. Anesthesia consultation was performed in 15.6% of cases. Anesthesia was performed by paramedical staff in 67.48% of cases. Among the 213 patients under general anesthesia, 182 patients underwent anesthesia with orotracheal intubation. Intraoperative hemodynamic complications are most common with arterial hypotension which was predominant in 70.76%. Three deaths were recorded, representing a mortality rate of 0.32%. The practice of anesthesia in Guinea-Bissau is a real public health problem. Support from ECOWAS countries would be useful to raise the health level.

關鍵字

麻醉實踐;幾內亞;比紹;西非國家經濟共同體;軍事

簡介

麻醉在發展中國家存在風險，特別是在撒哈拉以南非洲地區，仍然無法取得麻醉複蘇所取得的進展。圍手術期死亡率很高，這與許多短缺有關，包括缺乏合格工人和設備陳舊。在衛生發展和缺乏醫療資料的情況下，我們似乎有必要分析幾內亞比紹的麻醉做法。這項工作的主要目的是評價幾內亞比紹軍事醫院的麻醉做法，並提出改進建議。

材料和方法

我們的研究是在比紹主要軍事醫院進行的，這是一個二級公共衛生機構，於2012年5月27日開始提供護理服務。與塞內加爾接壤的幾內亞比紹是撒哈拉以南非洲國家之一，衛生麵臨許多困難。這是一個政治不穩定的國家，這導致了金融影響。該國發生了幾次政變，這極大地影響了其經濟。此外，1998年的戰爭導致醫療設施被毀，合格的保健人員移徙到其他政治較穩定的國家。因此，在2012年état政變後，一支由尼日利亞、布基納法索和塞內加爾組成的西非國家經濟共同體軍事部隊被部署執行維和任務。塞內加爾部隊的主要任務是與二級軍事醫院的工作人員，特別是外科小組合作部署二級軍事醫院。它是中國通過中比合作建設的。得益於中國和古巴醫療隊在比紹的存在，工作人員正在接受培訓。它是全國第二大手術醫院。 This was a descriptive, cross-sectional and analytical study conducted from January 1 to December 31, 2016. All patients who had surgery in the operating room under anesthesia during the study period were included. Patients whose records are unusable were excluded from the study. The data were collected using anesthesia registers. The studied parameters were: epidemiological, surgical interventions and perioperative management. We used the Epi Data 3.1 software.

結果

941(941)名病人在比紹主要軍事醫院接受了手術，平均每天做2.57次手術。在我們的研究中，147例患者進行了麻醉前會診，占所有幹預措施的15.6%。會診是由醫院畢業的麻醉科醫生進行的。女性最多，為85.54%，性別比為0.17。手術患者平均年齡為29.19±11.709歲(圖1)。

圖1:根據年齡組重新劃分。

急診手術最多，有796例，占84.6%。在幹預措施中，婦科產科手術占81.7%，其次是下段剖宮產幹預占8835%(表1)。

幹預類型	數量	百分比
剖腹產	641	83年,35
肌瘤切除術	43	5, 59歲
Extra-uterinepregnancy	37	4, 81
子宮破裂	12	1, 56
Kystectomie	25	3、25
其他(縫合失敗、產後出血、 子宮穿孔，胎盤殘留)	11	1, 44

表1:根據婦產科手術幹預類型重新分區。

內髒外科(165例)以頂骨外科(44.84%)為主，其次為消化外科(43.03%)。矯形活動占所有幹預的0.8%。在941例麻醉中，有6例是在複蘇麻醉師在場的情況下進行的，31.88%是由醫院醫生進行的。麻醉護士完成67.48%的手術。所有在研究期間手術的患者都接受了心電鏡、脈搏血氧計和自動血壓監測儀的監測。手術室中沒有二氧化碳記錄儀用於測量神經肌肉傳輸。728例(728例)手術僅在LRA下進行(77.36%)，其餘在全身麻醉下(22.64%)。213例全麻患者中，14.08%為單純麵罩全麻，85.45%為經口氣管插管全麻。54.46%的患者使用氯胺酮催眠誘導。98.35%的患者使用了磺胺嘧啶。 Maintenance of anesthesia was done with Ketamine in 41.23% of the interventions followed by propofol in 33.17% (Table 2). Fentanyl was the only opioid analgesic used intraoperatively.

催眠藥產品	數量	百分比（％）
克他命	116	54歲,46
硫噴妥鈉	62	29日11
異丙酚	35	16日,43歲

表2:根據麻醉產品重新劃分。

血流動力學並發症更為常見，在術中有6.9%的患者出現。術中血流動力學並發症中，70.76%的患者以動脈性低血壓為主。全麻手術患者均在手術台上拔管。728例患者行局部-區域麻醉。脊髓麻醉是最常見的。隻有1例患者在全身麻醉時進行了硬膜外麻醉。脊髓麻醉針(25尺)消毒後多次使用。使用的局麻藥為布比卡因、高壓氧和異壓巴與嗎啡芬太尼聯合使用，劑量為25μg或50μg。100%的患者使用撲熱息痛注射液，0.64%的患者使用Nefopam, 7.12%的患者使用NSAID。曲馬多是不可用的。 One patient had received an epidural catheter for postoperative analgesia with 0.125% bupivacaine. Patients were admitted to SSPI in 100% of cases because there is no resuscitation. The mobilization was carried out as quickly as possible after the intervention in all our patients. The drug prevention of thromboembolic disease based on an injection of 4000 IU of enoxaparin sodium per day was not made because the product was unavailable. The evolution was favorable at 99.68%. Three patients died intraoperatively. The deaths occurred during two uterine breaks and one peritonitis.

討論

比紹軍醫院的手術室不符合目前公認的標準。沒有氧氣植物。這種情況給手術室工作人員帶來了不安全的問題，有爆炸的風險，但也給病人帶來了不安全的問題，因為在控製模式通氣過程中，氧氣有崩潰的風險。介入後監控室作為術前檢查室。這裏沒有監控設備。在強製監督某些病人時，在那裏發現的所有設備都來自該街區，因此使該房間不符合國際標準[2]。手術室位於外科和婦科的旁邊，優化了對患者的管理。我們在服務領域遇到了不均勻的人群，但也遇到了其他專業的病態。為了精確起見，根據所治療的年齡組的特殊性和專科來調整服務將更加有利。在陸軍主要醫院，自2012年開業以來沒有麻醉-複蘇專科醫生，但有一名合格的醫院醫生。 He was trained by Cubans. The doctor’s training took place over a period of six months at the end of which he obtains a hospital diploma. Anesthetist nurses, six in number, were also trained at Simao Mendes Hospital for one year. Standards accepted in Western countries were an operating room anesthesiologist operating daily and for 20 surgical beds [2]. In addition, we noticed a lack of information collected on the anesthesia sheets. We noticed a lack of systematization in the search for a difficult intubation history, ASA and Mallampati classifications, airway patency. The difficulties encountered and the measures taken during certain routine procedures such as external laryngeal maneuvers, multiple attempts at intubation, use of a mandrel defining intubation as difficult were not noted by the anesthesia teams.

大多數麻醉患者是年輕人，87.80%小於40歲，在大多數非洲研究中，塞內加爾[3]和喀麥隆[4]。這種優勢與非洲人口的年輕結構有關，特別是與政治不穩定的國家有關。不同年齡組的分布顯示，大多數研究人群非常年輕，87.8%的患者年齡在50歲以下。這一結果與Alain Kabey[5]的研究結果相似，其中麻醉患者多數為年輕人(90.9%在50歲以下)，與該次區域的其他國家相似[3,6]。我們的研究人群年齡小於SFAR和SMAAR[7,8]調查:60歲以上的患者占我們係列的3.7%，而SFAR和SMAAR分別為33%和18%。在我們的係列中，女性占主導地位。這一百分比遠遠高於塞內加爾大多數這類國家的百分比[3]。許多研究證實，女性患者的比例高於男性患者。這些觀察結果與麻醉活動在婦產科的重要性有關。還應注意到，國家政治不穩定是金融危機的基本因素。 Gynecoobstetric surgery was the most commonly performed surgery with 81.7%, followed by visceral one 17.5%. These proportions were found in several studies in Senegal [3] and in Cameroon, while the opposite was noted in studies made in Lubumbashi, Morocco [8] and Madagascar by Rasamoelina [9]. This predominance of obstetric activities is related to the accessibility of the hospital because it is at the entrance of the capital but also because the population is sexually active. Among the 941 anesthesia 77.36% of the anesthetic acts were performed under LRA and 22.64% under GA. This high percentage of LRA is found in works in Togo and Senegal, unlike in Morocco and Lubumbashi. Spinal anesthesia (77.36%) was the only technique performed and this is mainly related to interventions indications. The strong predominance of spinal anesthesia was explained by the fact that it is a safe technique during cesarean section, beneficial for postoperative analgesia, and its limited cost is suitable for countries with limited means [10,11]. The only product used as a local anesthetic for LRA is 0.5% bupivacaine associated with fentanyl 25 μg. The same product is used in many studies [12]. In general anesthesia, Ketamine was the most used narcoanalgesic for intravenous induction (54.46%) followed by thiopental (29.11%), similar to the results found in Togo. In addition to its availability and low cost, its adaptation to the conditions of use and specific clinical situations encountered in developing countries makes it the most important molecule, and sometimes the only hypnotic available in hospitals [13]. Isoflurane was the only inhalation agent used because the anesthesia machine only has isoflurane and sevoflurane. All patients anesthetized during the scheduled surgery had benefited from a pre-anesthetic consultation made by the graduate physician in anesthesia, which was not the case for those involved in emergency surgery. We find the same situation in most African studies [1,3,4,14]. This could be explained by a low activity of programmed surgery related to the lack of specialist. Paracetamol was the analgesic prescribed to all patients alone or in combination with other molecules. This molecule has shown efficacy in monotherapy for low to moderate pain intensity surgery or in combination with opioids or nonsteroidal anti-inflammatory drugs. It allows the morphine savings by reducing the EVA scores, whether at rest or mobilization. The incidents identified in our study were dominated by low blood pressure. These data were similar to those found in other African studies, such as in Senegal [3] and in Lubumbashi [5]. Indeed, the sympathetic block is very marked in the pregnant woman and Bupivacaine doses are not codified. This complication was treated in our series by a crystalloid filling and bolus administration of ephedrine. Overall mortality was 0.32% in our series. This percentage is lower than that found in some studies [3,5]. The main factors in question were: delayed care: patients who consult late, sometimes living in remote localities, isolated and facing transport problems for medical evacuation; the financial crisis; early pregnancy and often not followed or poorly followed; the frequency of anemia in the female population; frequent breaks in blood products; the severity of the pathology (uterine rupture, eclampsia, peritonitis) but especially the absence of a resuscitation service.

結論

幾內亞比紹的麻醉技術落後於西方國家。自從西非經共體部隊作出承諾以來，情況有所改善，同時開辦了軍事醫院，並設立了一個二級醫院，由塞內加爾武裝部隊負責。結果表明，麻醉是在困難的條件下進行的。麻醉團隊在完整和專業的麻醉信息收集方麵的意識和培訓應用於提高未來護理的質量。

研究的局限性

• 一些並發症有時是致命的，這與缺乏足夠的設備有關。
• 對員工進行更好的培訓可以減少事故和事故;
• 可憐的記錄。

西非經共體在保健方麵的幫助可能是該國的強項

參考文獻

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