Objective: To present a 40 year old Nigerian woman who presented with a 10 year history of progre... more Objective: To present a 40 year old Nigerian woman who presented with a 10 year history of progressive abdominal swelling and recurrent pain caused by massive enlargement of the gall bladder. Findings: The swelling progressed to the size of a full term gravid uterus. At operation the mass was found to be gall bladder which contained turbid bile and no stone. Comments: The only pointer to the aetiology of this massive gall bladder was the shrivelled gall bladder neck which suggest achalasia of the gall bladder neck, a previously unrecognized clinical entity.
Blood conservation is based on the principle of avoiding allogeneic blood transfusion with the ai... more Blood conservation is based on the principle of avoiding allogeneic blood transfusion with the aim of improving outcome and protecting patients' rights. Surgical patients receive a significant proportion of the allogeneic blood transfused in the hospital. Blood conservation in surgery greatly reduces overall allogeneic blood use, thereby reducing costs, hazards, and adverse outcomes. Blood conservation techniques aim to lower the “transfusion trigger,” optimize the hematocrit, minimize blood loss, and optimize tissue oxygenation. Successful blood conservation involves a combination of techniques tailored to the individual patient. It requires planning and a multidisciplinary team approach but usually little technology. Bloodless medicine and surgery programs represent the gold standard in blood conservation. Blood conservation is evidence based, and it results in faster recovery, lower morbidity, lower mortality, shorter hospital stay, lower cost, and better patient (and physici...
Objectives: Pre-operative anemia is common in Sub-Saharan Africa including Nigeria. Anemia is a k... more Objectives: Pre-operative anemia is common in Sub-Saharan Africa including Nigeria. Anemia is a known risk factor for blood transfusion. In our hospital, like many others, patients are usually admitted a day before elective surgeries and the default treatment for anemia by most surgeons and anesthetists is allogenic blood transfusion. Anemia and blood transfusion are independently and synergistically associated with complications and undesirable outcomes. Patient blood management (PBM) is gaining popularity and has been advocated by the World Health Organization (WHO) for member countries to adopt as a means of improving patient outcomes. There is currently no research from the University of Calabar Teaching Hospital highlighting the prevalence of pre-operative anemia. This research was aimed at filling this gap and also presenting a baseline for comparison as the hospital strives to implement the three pillars of PBM strategies: Manage anemia, minimize blood loss and harness tolera...
Introduction Education is fundamental to bloodless medicine, which is the provision of quality me... more Introduction Education is fundamental to bloodless medicine, which is the provision of quality medical care without the use of allogeneic blood employing various techniques in a multidisciplinary manner A multidisciplinary Bloodless Medicine and Surgery Group (BMSG) in University of Calabar Teaching Hospital (UCTH) has been organizing an annual Week of professional CMEs and public education in bloodless medicine since 2016 In 2020, due to Covid-19 pandemic, the physical meetings were substituted with Webinars This study examines the effectiveness and practicality of this on-line education in bloodless medicine occasioned by the pandemic Methodology Bloodless Medicine & Surgery Webinars were scheduled May 11-16, 2020 on Zoom, for 2 hours each day Pre-registration was required, but attendance was free The webinars were advertised on Twitter, Facebook, LinkedIn, professional WhatsApp groups, and by email Zoom reports on the webinars were downloaded and analysed for the number of resour...
e19717 Background: Breast cancer patients, like all cancer patients, are prone to anemia arising ... more e19717 Background: Breast cancer patients, like all cancer patients, are prone to anemia arising from the disease, from chemotherapy, and from surgery. Repeated blood transfusion is hazardous, especially in a resource-poor setting, and is associated with a poor prognosis. EPO is effective but expensive in our setting. We aimed to carry out total breast cancer care without blood transfusion using pre-emptive and therapeutic iron therapy, and blood conservation methods during surgery. METHODS Fifteen female breast cancer patients had initial hemogram done and were placed on oral iron therapy with vitamin adjuncts (minus folate) from the first outpatient visit. Patients with HCT <27% also received intravenous iron dextran using the formula: [normal Hb - actual Hb] x 200 + 500 mg. All patients received 250mg of IV iron dextran with each cycle of chemotherapy. Patients on chemotherapy had a hemogram before each cycle and 3 weeks after the last cycle. Patients for surgery were assessed for blood conservation methods tailored to each patient. Postoperative hemograms were done on the third day and after 3 weeks. RESULTS Six patients successfully completed 6 cycles of chemotherapy, and 4 defaulted between the 1st and 5th cycles. Five patients died of non anemia-related complications of late-stage disease. One patient with early breast cancer and 3 patients with late breast cancer had modified radical mastectomy using blood conservation methods. All who had surgery recovered satisfactorily and 3 completed 6 cycles of chemotherapy. One patient reacted to iron dextran with pruritus which was relieved with intravenous hydrocortisone. All patients maintained a hematocrit >30% throughout chemotherapy and none received blood transfusion. CONCLUSIONS Intravenous iron is practical, safe and effective in blood management of breast cancer patients in a resource-poor environment. Avoiding the hazards and cost of blood transfusion is desirable, and enhanced survival may also be achieved.
Significance and Background- Bloodless Medicine is a standard of care at Pennsylvania Hospital Ed... more Significance and Background- Bloodless Medicine is a standard of care at Pennsylvania Hospital Education, patient identification, and care planning is facilitated through the Center for Transfusion-Free Medicine (CTFM) Onset of the COVID 19 pandemic necessitates social distancing, and protective strategies to minimize exposure and transmission (CDC, 2019) However, it is critical that we are providing vigilant, individualized, high quality care A virtual and telephonic workflow offers accessibility Purpose - The purpose of process change was to create a workflow to maximize access to patients and providers, while improving care delivery for patients refusing blood transfusion Interventions - CTFM maintains 250-400 patient encounters monthly The CTFM SOP was adjusted to accommodate a virtual and telephonic platform to meet with patients and providers In addition, patient identifiers physically and electronically in the EMR allow tracking of trends and outcomes Evaluation - Inpatient/f...
Bloodless Medicine and Surgery (BMS) is the provision of quality health care to patients without ... more Bloodless Medicine and Surgery (BMS) is the provision of quality health care to patients without the use of allogeneic blood with the aim of improving outcome and protecting patients’ rights.1, 2 It involves the use of Blood Conservation techniques in combinations that are specific to the individual patient, ideally following a protocol and a multidisciplinary approach, and is synonymous with Transfusion-free Medicine and Surgery.3, 4
This case report describes bloodless management of a 32-year-old Jehovah’s Witness who had severe... more This case report describes bloodless management of a 32-year-old Jehovah’s Witness who had severe obstetric hemorrhage at 23 weeks of gestation, spontaneously delivering twin fetuses. After resuscitation with crystalloids and colloids, the patient was still bleeding and hemoglobin fell to 3.3 g/dL. She had emergency hysterectomy. On postoperative day 1, her hemoglobin was 1.3 g/dL and Glasgow Coma Scale 6 of 15. Electrolyte derangement and fluid overload were detected and treated promptly. She regained consciousness and received intravenous iron and erythropoietin. She recovered fully without complications and without blood transfusion. Hemoglobin at discharge (postoperative day 18) was 6.9 and 12.5 g/dL 4 months later.
BackgroundBreast cancer is the commonest malignancy of women in Nigeria. Change in serum levels o... more BackgroundBreast cancer is the commonest malignancy of women in Nigeria. Change in serum levels of some biochemical parameters could assist diagnosis and follow-up of breast cancer.ObjectiveTo determine serum levels of calcium, inorganic phosphates, alkaline phosphatase (ALP) and acid phosphatase (ACP) activities in patients with breast cancer, and change in the serum levels over time.MethodsTotal serum calcium and inorganic phosphates, and serum ALP and ACP activities were determined in 25 women with breast cancer and 25 age-matched controls using colorimetric and enzymatic methods, over 6 months with bimonthly analysis.ResultsThe serum calcium level, ALP and ACP activities were significantly higher (p<0.05) in the study group than in the control group. No significant difference was seen in the inorganic phosphate levels of both groups. There were significant increases in serum calcium levels, ALP and ACP activities in the study group with time (p<0.05), whereas no significant increase was observed in the control group.ConclusionBreast cancer patients have higher calcium levels and higher ALP and ACP activities. The increase in the levelsof these parameters with time shows that they could be of importance in monitoring treatment and disease progress in a resource-poor setting.
11565 Background: Breast cancer is the commonest cancer among women in Nigeria, and the incidence... more 11565 Background: Breast cancer is the commonest cancer among women in Nigeria, and the incidence seems to be increasing. Most cases present late and receive palliative care utilizing traditional chemotherapy regimens, with bone marrow depression as a major side effect. Repeated blood transfusion has been the norm here, but it is hazardous, expensive, and of questionable benefit. We devised a protocol for managing breast cancer patients without allogeneic blood transfusion in a resource-poor setting. Methods: Female breast cancer patients were placed on prophylactic oral iron on diagnosis, along with Vitamin B12, and Vitamin C. Parenteral iron was given to patients with PCV <27%. During surgery, acute normovolemic hemodilution, appropriate positioning, normothermia, and meticulous hemostasis were applied. Parenteral iron was given prophylactically with each course of chemotherapy. Phlebotomies were restricted. Full blood count, liver function test, serum urea, electrolytes and creatinine were assayed befo...
Breast cancer appears to be on the increase in Nigeria, and its management presents peculiar chal... more Breast cancer appears to be on the increase in Nigeria, and its management presents peculiar challenges here. Two cases of breast cancer managed in University of Calabar Teaching Hospital (UCTH), Calabar are reviewed in this paper. Five major challenges in their management are discussed. The need for a multidisciplinary team approach, innovativeness on the part of the management team, further research, and more involvement of national health authorities in breast cancer management are stressed.
This study aimed to identify epidemiological characteristics of HIV seropositive patients in Surg... more This study aimed to identify epidemiological characteristics of HIV seropositive patients in Surgery Department, University of Calabar Teaching Hospital (UCTH), Nigeria, and the challenges in diagnosing and managing these patients. Records of the HIV Laboratory in Hematology Department, UCTH were examined retrospectively and compared with records in the Surgical Wards, Surgical Outpatient Department, and Casualty Department between January 1999 and December 2002. Name of patient, age, sex, Hospital Number, Ward, Serology Kits used, and test results were extracted there from. Total number of HIV seropositive patients recorded for the period was 992, out of which 228 patients (23%) were from Surgery Department. Peak age group was 21-30 years (63 cases). Overall Male to Female (M:F) ratio was 1.1:1 but females predominated in age group 21-30 years (M:F 1:1.2) and in an unspecified group of “Adults” (M:F 1:1.3). Records showed that only Rapid Enzyme Immunoassay and Latex agglutination t...
20 EAST AFRICAN MEDICAL JOURNAL January 2001 Table 1 Age and sex distribution of eighty nine pati... more 20 EAST AFRICAN MEDICAL JOURNAL January 2001 Table 1 Age and sex distribution of eighty nine patients with intussuception Sex Age (in months) M Total 0-3 4-6 7-9 10-12 Above 12 8 35 9 3 2 5 17 7 2 1 13 52 16 5 3 Total (%) 57(64%) 32(36%) 89(100%) Table 2 ...
Transfusion Alternatives in Transfusion Medicine, 2010
Bloodless surgery was introduced initially for the care of patients who refused blood transfusion... more Bloodless surgery was introduced initially for the care of patients who refused blood transfusion. Recently however, adverse outcome with blood transfusion has been reported in virtually all subspecialties of surgery and conversely, improved outcome with non-transfusion surgery. Thus blood conservation is the standard of care because it is evidence-based. Thyroid surgery is historically associated with blood loss, and a lower hematocrit would be expected postoperatively. We report a case of subtotal thyroidectomy for a large simple multinodular goiter using planned blood-conservation techniques tailored to the patient that resulted in maintenance of a normal hematocrit throughout the perioperative period. The patient received oral hematinics preoperatively, while acute normovolemic hemodilution and other techniques were used to minimize intraoperative blood loss. The outcome was an optimized hematocrit preoperatively, minimal blood loss intraoperatively, and hematocrit which remained optimal on the third postoperative day and 3 weeks postoperatively. No allogeneic blood was used at any stage. This suggests that maintenance of normal hematocrit can be regarded as an achievable goal in high-risk surgery through blood-conservation techniques. Avoiding allogeneic blood transfusion is possible in a resource-poor setting, where HIV prevalence is high and screening of blood may be suboptimal, and it is the ideal clinical approach as demonstrated in this case report.
Objective: To present a 40 year old Nigerian woman who presented with a 10 year history of progre... more Objective: To present a 40 year old Nigerian woman who presented with a 10 year history of progressive abdominal swelling and recurrent pain caused by massive enlargement of the gall bladder. Findings: The swelling progressed to the size of a full term gravid uterus. At operation the mass was found to be gall bladder which contained turbid bile and no stone. Comments: The only pointer to the aetiology of this massive gall bladder was the shrivelled gall bladder neck which suggest achalasia of the gall bladder neck, a previously unrecognized clinical entity.
Blood conservation is based on the principle of avoiding allogeneic blood transfusion with the ai... more Blood conservation is based on the principle of avoiding allogeneic blood transfusion with the aim of improving outcome and protecting patients' rights. Surgical patients receive a significant proportion of the allogeneic blood transfused in the hospital. Blood conservation in surgery greatly reduces overall allogeneic blood use, thereby reducing costs, hazards, and adverse outcomes. Blood conservation techniques aim to lower the “transfusion trigger,” optimize the hematocrit, minimize blood loss, and optimize tissue oxygenation. Successful blood conservation involves a combination of techniques tailored to the individual patient. It requires planning and a multidisciplinary team approach but usually little technology. Bloodless medicine and surgery programs represent the gold standard in blood conservation. Blood conservation is evidence based, and it results in faster recovery, lower morbidity, lower mortality, shorter hospital stay, lower cost, and better patient (and physici...
Objectives: Pre-operative anemia is common in Sub-Saharan Africa including Nigeria. Anemia is a k... more Objectives: Pre-operative anemia is common in Sub-Saharan Africa including Nigeria. Anemia is a known risk factor for blood transfusion. In our hospital, like many others, patients are usually admitted a day before elective surgeries and the default treatment for anemia by most surgeons and anesthetists is allogenic blood transfusion. Anemia and blood transfusion are independently and synergistically associated with complications and undesirable outcomes. Patient blood management (PBM) is gaining popularity and has been advocated by the World Health Organization (WHO) for member countries to adopt as a means of improving patient outcomes. There is currently no research from the University of Calabar Teaching Hospital highlighting the prevalence of pre-operative anemia. This research was aimed at filling this gap and also presenting a baseline for comparison as the hospital strives to implement the three pillars of PBM strategies: Manage anemia, minimize blood loss and harness tolera...
Introduction Education is fundamental to bloodless medicine, which is the provision of quality me... more Introduction Education is fundamental to bloodless medicine, which is the provision of quality medical care without the use of allogeneic blood employing various techniques in a multidisciplinary manner A multidisciplinary Bloodless Medicine and Surgery Group (BMSG) in University of Calabar Teaching Hospital (UCTH) has been organizing an annual Week of professional CMEs and public education in bloodless medicine since 2016 In 2020, due to Covid-19 pandemic, the physical meetings were substituted with Webinars This study examines the effectiveness and practicality of this on-line education in bloodless medicine occasioned by the pandemic Methodology Bloodless Medicine & Surgery Webinars were scheduled May 11-16, 2020 on Zoom, for 2 hours each day Pre-registration was required, but attendance was free The webinars were advertised on Twitter, Facebook, LinkedIn, professional WhatsApp groups, and by email Zoom reports on the webinars were downloaded and analysed for the number of resour...
e19717 Background: Breast cancer patients, like all cancer patients, are prone to anemia arising ... more e19717 Background: Breast cancer patients, like all cancer patients, are prone to anemia arising from the disease, from chemotherapy, and from surgery. Repeated blood transfusion is hazardous, especially in a resource-poor setting, and is associated with a poor prognosis. EPO is effective but expensive in our setting. We aimed to carry out total breast cancer care without blood transfusion using pre-emptive and therapeutic iron therapy, and blood conservation methods during surgery. METHODS Fifteen female breast cancer patients had initial hemogram done and were placed on oral iron therapy with vitamin adjuncts (minus folate) from the first outpatient visit. Patients with HCT <27% also received intravenous iron dextran using the formula: [normal Hb - actual Hb] x 200 + 500 mg. All patients received 250mg of IV iron dextran with each cycle of chemotherapy. Patients on chemotherapy had a hemogram before each cycle and 3 weeks after the last cycle. Patients for surgery were assessed for blood conservation methods tailored to each patient. Postoperative hemograms were done on the third day and after 3 weeks. RESULTS Six patients successfully completed 6 cycles of chemotherapy, and 4 defaulted between the 1st and 5th cycles. Five patients died of non anemia-related complications of late-stage disease. One patient with early breast cancer and 3 patients with late breast cancer had modified radical mastectomy using blood conservation methods. All who had surgery recovered satisfactorily and 3 completed 6 cycles of chemotherapy. One patient reacted to iron dextran with pruritus which was relieved with intravenous hydrocortisone. All patients maintained a hematocrit >30% throughout chemotherapy and none received blood transfusion. CONCLUSIONS Intravenous iron is practical, safe and effective in blood management of breast cancer patients in a resource-poor environment. Avoiding the hazards and cost of blood transfusion is desirable, and enhanced survival may also be achieved.
Significance and Background- Bloodless Medicine is a standard of care at Pennsylvania Hospital Ed... more Significance and Background- Bloodless Medicine is a standard of care at Pennsylvania Hospital Education, patient identification, and care planning is facilitated through the Center for Transfusion-Free Medicine (CTFM) Onset of the COVID 19 pandemic necessitates social distancing, and protective strategies to minimize exposure and transmission (CDC, 2019) However, it is critical that we are providing vigilant, individualized, high quality care A virtual and telephonic workflow offers accessibility Purpose - The purpose of process change was to create a workflow to maximize access to patients and providers, while improving care delivery for patients refusing blood transfusion Interventions - CTFM maintains 250-400 patient encounters monthly The CTFM SOP was adjusted to accommodate a virtual and telephonic platform to meet with patients and providers In addition, patient identifiers physically and electronically in the EMR allow tracking of trends and outcomes Evaluation - Inpatient/f...
Bloodless Medicine and Surgery (BMS) is the provision of quality health care to patients without ... more Bloodless Medicine and Surgery (BMS) is the provision of quality health care to patients without the use of allogeneic blood with the aim of improving outcome and protecting patients’ rights.1, 2 It involves the use of Blood Conservation techniques in combinations that are specific to the individual patient, ideally following a protocol and a multidisciplinary approach, and is synonymous with Transfusion-free Medicine and Surgery.3, 4
This case report describes bloodless management of a 32-year-old Jehovah’s Witness who had severe... more This case report describes bloodless management of a 32-year-old Jehovah’s Witness who had severe obstetric hemorrhage at 23 weeks of gestation, spontaneously delivering twin fetuses. After resuscitation with crystalloids and colloids, the patient was still bleeding and hemoglobin fell to 3.3 g/dL. She had emergency hysterectomy. On postoperative day 1, her hemoglobin was 1.3 g/dL and Glasgow Coma Scale 6 of 15. Electrolyte derangement and fluid overload were detected and treated promptly. She regained consciousness and received intravenous iron and erythropoietin. She recovered fully without complications and without blood transfusion. Hemoglobin at discharge (postoperative day 18) was 6.9 and 12.5 g/dL 4 months later.
BackgroundBreast cancer is the commonest malignancy of women in Nigeria. Change in serum levels o... more BackgroundBreast cancer is the commonest malignancy of women in Nigeria. Change in serum levels of some biochemical parameters could assist diagnosis and follow-up of breast cancer.ObjectiveTo determine serum levels of calcium, inorganic phosphates, alkaline phosphatase (ALP) and acid phosphatase (ACP) activities in patients with breast cancer, and change in the serum levels over time.MethodsTotal serum calcium and inorganic phosphates, and serum ALP and ACP activities were determined in 25 women with breast cancer and 25 age-matched controls using colorimetric and enzymatic methods, over 6 months with bimonthly analysis.ResultsThe serum calcium level, ALP and ACP activities were significantly higher (p<0.05) in the study group than in the control group. No significant difference was seen in the inorganic phosphate levels of both groups. There were significant increases in serum calcium levels, ALP and ACP activities in the study group with time (p<0.05), whereas no significant increase was observed in the control group.ConclusionBreast cancer patients have higher calcium levels and higher ALP and ACP activities. The increase in the levelsof these parameters with time shows that they could be of importance in monitoring treatment and disease progress in a resource-poor setting.
11565 Background: Breast cancer is the commonest cancer among women in Nigeria, and the incidence... more 11565 Background: Breast cancer is the commonest cancer among women in Nigeria, and the incidence seems to be increasing. Most cases present late and receive palliative care utilizing traditional chemotherapy regimens, with bone marrow depression as a major side effect. Repeated blood transfusion has been the norm here, but it is hazardous, expensive, and of questionable benefit. We devised a protocol for managing breast cancer patients without allogeneic blood transfusion in a resource-poor setting. Methods: Female breast cancer patients were placed on prophylactic oral iron on diagnosis, along with Vitamin B12, and Vitamin C. Parenteral iron was given to patients with PCV <27%. During surgery, acute normovolemic hemodilution, appropriate positioning, normothermia, and meticulous hemostasis were applied. Parenteral iron was given prophylactically with each course of chemotherapy. Phlebotomies were restricted. Full blood count, liver function test, serum urea, electrolytes and creatinine were assayed befo...
Breast cancer appears to be on the increase in Nigeria, and its management presents peculiar chal... more Breast cancer appears to be on the increase in Nigeria, and its management presents peculiar challenges here. Two cases of breast cancer managed in University of Calabar Teaching Hospital (UCTH), Calabar are reviewed in this paper. Five major challenges in their management are discussed. The need for a multidisciplinary team approach, innovativeness on the part of the management team, further research, and more involvement of national health authorities in breast cancer management are stressed.
This study aimed to identify epidemiological characteristics of HIV seropositive patients in Surg... more This study aimed to identify epidemiological characteristics of HIV seropositive patients in Surgery Department, University of Calabar Teaching Hospital (UCTH), Nigeria, and the challenges in diagnosing and managing these patients. Records of the HIV Laboratory in Hematology Department, UCTH were examined retrospectively and compared with records in the Surgical Wards, Surgical Outpatient Department, and Casualty Department between January 1999 and December 2002. Name of patient, age, sex, Hospital Number, Ward, Serology Kits used, and test results were extracted there from. Total number of HIV seropositive patients recorded for the period was 992, out of which 228 patients (23%) were from Surgery Department. Peak age group was 21-30 years (63 cases). Overall Male to Female (M:F) ratio was 1.1:1 but females predominated in age group 21-30 years (M:F 1:1.2) and in an unspecified group of “Adults” (M:F 1:1.3). Records showed that only Rapid Enzyme Immunoassay and Latex agglutination t...
20 EAST AFRICAN MEDICAL JOURNAL January 2001 Table 1 Age and sex distribution of eighty nine pati... more 20 EAST AFRICAN MEDICAL JOURNAL January 2001 Table 1 Age and sex distribution of eighty nine patients with intussuception Sex Age (in months) M Total 0-3 4-6 7-9 10-12 Above 12 8 35 9 3 2 5 17 7 2 1 13 52 16 5 3 Total (%) 57(64%) 32(36%) 89(100%) Table 2 ...
Transfusion Alternatives in Transfusion Medicine, 2010
Bloodless surgery was introduced initially for the care of patients who refused blood transfusion... more Bloodless surgery was introduced initially for the care of patients who refused blood transfusion. Recently however, adverse outcome with blood transfusion has been reported in virtually all subspecialties of surgery and conversely, improved outcome with non-transfusion surgery. Thus blood conservation is the standard of care because it is evidence-based. Thyroid surgery is historically associated with blood loss, and a lower hematocrit would be expected postoperatively. We report a case of subtotal thyroidectomy for a large simple multinodular goiter using planned blood-conservation techniques tailored to the patient that resulted in maintenance of a normal hematocrit throughout the perioperative period. The patient received oral hematinics preoperatively, while acute normovolemic hemodilution and other techniques were used to minimize intraoperative blood loss. The outcome was an optimized hematocrit preoperatively, minimal blood loss intraoperatively, and hematocrit which remained optimal on the third postoperative day and 3 weeks postoperatively. No allogeneic blood was used at any stage. This suggests that maintenance of normal hematocrit can be regarded as an achievable goal in high-risk surgery through blood-conservation techniques. Avoiding allogeneic blood transfusion is possible in a resource-poor setting, where HIV prevalence is high and screening of blood may be suboptimal, and it is the ideal clinical approach as demonstrated in this case report.
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