Showing papers in "Southern African Journal of Anaesthesia and Analgesia in 2005"

Seeking patients' consent in anaesthesiology: consent in clinical practice

Abstract: “I wish my life and decisions to depend on myself, not on external forces of whatever kind. I wish to be the instrument of my own, not other men’s act of will. I wish to be a subject, not an object; to be moved by reasons, by conscious purposes which are my own, not by causes which affect me, as it were, from outside. I wish to be somebody, not nobody ‐ a doer, deciding, not being decided for, self-directed and not acted upon by external nature or by other men”. 1 Summary The article explores the historical, legal and philosophical background and justification of informed consent. Anaesthesiologists have a responsibility to obtain separate informed consent, both to prevent litigation and to satisfy the requirement of rationality and respect for personal autonomy. The three-tiered model ‐ competence, information, and consent ‐ is described. The inherent nature and current practice of anaesthesiology problematizes proper informed consent. This includes timing, time-constraints, managed care, same-day surgery and emergencies. Wider use of pre-op clinics is advocated. There is a move towards written consent. Properly documented consent relieves the burden of proof, yet is neither a legal requirement nor confirmation of a proper interview. Authors generally advocate written consent in obstetric analgesic practice. Pre-printed forms do not replace an interview. The interview should be tapered to the needs and requirements of the particular patient. The reason why information is provided should be explained. Appropriate illustrative material and aids are advised. The uninformed patient cannot give consent. The supply of information empowers the patient to engage in an interactive conversation with the anaesthesiologist, and broadens the base for further discussions and questions. At least a full explanation of the procedure and techniques (particularly of all invasive procedures), information about the chances of success, incidence of complications, risks involved, available alternatives, the relative risks and complications of alternatives, costs, and the role of the anaesthesiologist is required. Particular reference to the training of students is mandatory. Separate consent is required for all research purposes.

The Intensive Care Unit of the University Teaching Hospital, Ilorin, Nigeria: A Ten Year Review (1991 - 2001)

Abstract: 3for the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD). By the 1960’s many institutions had developed “respiratory care units” to facilitate the management of patients requiring mechanical ventilation. At the same time, coronary care units were also established for the intensive postoperative care of patients who had undergone cardiac surgery while surgical units managed patients who had undergone major surgical procedures. Many tertiary hospitals in Nigeria have developed facilities for the care of the critically ill patient. The Intensive Care Unit (ICU) of the University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria, was initially established in 1991 for the management of surgical patients who required postoperative high care. Admission criteria included those who had prolonged surgery (4-6 hours), specialized surgery (cardiothoracic and neurosurgery), and complicated surgery associated with one or more of the following complications: major blood loss, massive fluid shifts, cardiac arrest, metabolic disorders and bronchospasm. Other admission criteria were complicated thyroid surgery and patients requiring inotropic support (for example septic shock). The unit was situated within the twin operating theatre complex. The 3-bedded UITH Intensive Care Unit moved to its present permanent site located adjacent to the operating theatre complex in 1994. It serves as a general ICU for all categories of patients.

Anaesthesia for MRI : ....child\'s play? : registrar communication

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 28-31

Anaphylaxis precipitated by intravenous morphine sulphate

Abstract: Morphine is a potent opioid that is used as one of the standard drugs for pain management in perioperative practice. It was first synthesised in 1952 and is the drug against which all other analgesic drugs are compared. It is also one of the most abused drugs worldwide. We present an interesting case of anaphylaxis that was precipitated by a morphine bolus and required aggressive resuscitation. The episode was temporally related to injection and confirmed biochemically by a raised tryptase result.

Qualitative study of the knowledge and expectations of the pain of labour, in urban Xhosa primigravidae : registrar communication

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 23

A comparison of EEG spectral entropy with conventional quantitative EEG at varying depths of sevoflurane anaesthesia

Abstract: Background and Aim: Recently an electroencephalographic (EEG) spectral entropy module (M-ENTROPY) for an anaesthetic monitor has become commercially available. We compared its performance as an indicator of the state of anaesthesia with that of an older conventional quantitative EEG (QEEG) module (M-EEG) by the same manufacturer (Datex-Ohmeda Division, Instrumentarium Corp., Helsinki, Finland). Methods: There were 40 ASA class I or II subjects, aged between 16-60 years, who underwent elective abdominal surgery. EEG data were collected from the printouts of the respective modules. The data presented here were related to four levels of anaesthesia: Pre-anaesthetic wakefulness (state A), 2% sevoflurane endtidal (ET) concentration after completion of surgery (state B), low ET sevoflurane concentrations (~ 0.5%) just prior to regaining responsiveness (state C), and post-anaesthetic responsiveness (state D). Results: In terms of the prediction probability (Pk statistic), response entropy (RE) and state entropy (SE) produced higher values (0.95-1.0) than the best performing QEEG variable, frontal amplitude (0.86-0.95). Only RE scores did not overlap between states A and B or between B and D. The misclassification of subjects between states C and D was far lower for RE (28%) than for any of the conventional QEEG measures (>90%). Conclusion: In on-line monitoring spectral entropy is superior in distinguishing states of anaesthesia and is also easier to use than conventional QEEG. It is speculated that the artefact rejection strategies accorded spectral entropy might significantly benefit conventional QEEG analysis.

Anaesthesia and Sirenomelia (Mermaid Syndrome)

Abstract: No Abstract Available. Southern African Journal of Anaesthesia & Analgesia Vol. 11 (3) 2005: 94-96

South African Neurosurgical Patient Management Survey

Abstract: No Abstract Available Southern African Journal of Anaesthesia & Analgesia Vol.11(2) 2005: 61-65

Needleless intravascular access

Abstract: Healthcare workers (HCWs) are at risk for needlestick injuries (NSIs), and in the modern context infections acquired in this manner may have lifethreatening sequelae. HCWs often do not report NSIs and this may explain the apathetic attitude that some authorities have adopted, regarding safer “needleless” systems in operating theatres. Completely “needleless” theatre environments can cause a dramatic escalation in costs. However, cheaper options such as drugs in plastic ampoules, blunt drawing-up needles, and three-way stopcocks for administration of drugs, although preventing injury to the HCW, are less effective in preventing contaminated injuries. The combination of the more expensive Engineered Sharps Injury Prevention Devices (ESIPDs)*, Needleless Intermittent Intravenous-access Systems (NIIS) *, and accessible at-hand sharps disposal bins, should also be available, since these decrease the incidence of percutaneous transmission of infection. It is the responsibility of each anaesthetist to insist that these items are always readily available. * ESIPDs : intravenous catheters with introducer needles with built-in safeguarded mechanisms. * NIIS : An example would be needle free fluid administration sets.

Predicting the need for blood during cardiopulmonary bypass

Abstract: Background: Haematocrit (Hct) values <18%-20% during cardiopulmonary bypass (HctCPB) are potentially unsafe. Aims: 1. To predict when banked-blood should be pre-issued. 2. To evaluate the sparing-effect of banked-blood by autologous blood transfusions. Methods: An equation for prediction of HctCPB (Hctpred), based on weight and pre-operative haemoglobin concentration was used to forecast which patients would develop HctCPB ≤20%. Perioperative blood and fluid administration were recorded in 80 patients requiring CPB. Blood and fluid administration strived for HctCPB≥ 18% on CPB and 33% in the ICU. Results: Hctpred bias and precision were 2.6% and 13.1%. A Hctpred cut-off value of 23% reliably forecast a HctCPB ≤ 20% (15 patients with mean HctCPB 16.5%). Despite a 31% false positive rate (FPR), there is emphasis on safety associated with the 23% Hctpred cutoff-point. (100% negative predictive value; zero negative likelihood ratio). Applying the same predictive criterion to all blood transfusions per...

Is a rethink of our approach to hypertension necessary

Abstract: Extracted from text ... South African Journal of Anaesthesia & Analgesia ? November 2005 117 GUEST EDITORIAL 1 Is a rethink of our approach to hypertension necessary? Introduction The risks and management of hypertensive patients for elective anaesthesia are often debated. There is a perception that patients with untreated or ineffectively treated hypertension are at risk, in particular for cardiac and cerebrovascular events. The change in internal to external diameter of the vasculature results in an altered vascular pressure-flow relationship in the hypertensive patient. This gives rise to the exaggerated hypertensive and hypotensive response seen. The hypotensive tendency is aggravated by the diastolic ..

Psychological aspects of chronic pain: a literature review

Abstract: The influence of psychological variables on the experience of chronic pain continues to be underestimated by many healthcare practitioners. This literature review attempts to highlight the applicability of the conceptualization of chronic pain within the biopsychosocial model and diathesis-stress framework. Within these paradigms the emotional disorders more frequently associated with the experience of chronic pain are explored. Attention is also paid to mechanisms underlying the development and maintenance of chronic pain-related emotional disorders. Finally, the implications of a more holistic conceptualization of chronic pain for clinical practice are investigated.

Human Immunodeficiency Virus Needlestick Injury: Knowledge and Management in a Population of Nigerian Anaesthetists

Abstract: Objective: To determine the knowledge of HIV transmission and of post exposure management, following an HIV- infected needlestick injury, in a population of Nigerian anaesthetists. Subjects and Method: A cross-sectional, prospective assessment was conducted voluntarily in anaesthetists at an annual healthcare provider's forum, and at a major general hospital, using a structured questionnaire. Results: 63 Anaesthetists participated in the study. One anaesthetist knew the percentage of infected HIV needlestick injury that would result in HIV infection. ALL the high risk body fluids were correctly identified by 7 (11.1%) respondents. Twelve (19.0%) knew the correct immediate management when injured by a HIV-infected needlestick. Fifty eight (92.1%) were aware of post exposure prophylaxis (PEP), 25 (39.7%) had a PEP policy in their institutions and 57 (90%) knew when to commence PEP. Conclusion: Nigerian anaesthetists, though acutely aware of post exposure prophylaxis, are not aware of the fluids at r...

Balanced anaesthesia 2005: Avoiding the Transition from Acute to Chronic Pain

Abstract: When general anaesthesia consisted of the administration of a volatile anaesthetic agent according to clinical parameters usually preceded by premedication, was chronic post-operative pain a significant problem? Have we, by working hard to deliver balanced anaesthesia and rapid recovery lost sight of the fundamental importance of abolishing noxious reflexes at the spinal level? We need to identify, ameliorate and manage specific features and risk factors, including the severity of the acute pain experience, for individuals at risk for the development of a chronic pain syndrome. Anaesthetists’ actions and the drugs they use have multiple and profound effects to be taken into account, appropriately modified and controlled, combined with excellent postoperative analgesia, particularly for those patients or procedures at high risk to minimise the transition of acute to chronic pain following surgery. Acute nociceptive pain is the risk for the transition to chronic neuropathic pain.

Epidural abscess: diagnosis and management

Abstract: No Abstract Available. Southern African Journal of Anaesthesia & Analgesia Vol. 11 (3) 2005: 109-110

Anaesthesia for lung volume reduction surgery

Abstract: natural history of the disease or reduce mortality. Bronchodilators improve lung function, exercise capacity, and quality of life in patients with COPD, but are of limited ben- efit to patients without reversible airway disease. As the medi- cal management of these patients appears to offer only lim- ited benefits, various attempts have been made to improve the quality of life and possibly to reduce mortality through a vari- ety of surgical techniques over the past 90 years including pneumoperitoneum formation, phrenic nerve paralysis, thora- coplasty, denervation of the lung, and stabilization and fixa- tion of the trachea. None of these techniques resulted in any substantial benefit to the patients. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a common condition with high morbidity and mortality rates. 1 The con- dition, which is primarily a complication of smoking, is a chronic, slowly progressive disorder characterised by airway obstruction. 2 The definition includes chronic bronchitis and emphysema with permanent destructive enlargement of distal pulmonary airspaces. Consequently, there is loss of normal lung architecture resulting in loss of elastic recoil of lung tis- sue leading to collapse of small airways, expiratory airflow limitation, air trapping, hyperinflation of the lungs and pro- gressive enlargement of the thoracic cage. Expansion of the thorax leads to flattening of the diaphragm, in-drawing of the lower ribs and compromised chest wall mechanics. The ribs are lifted and flattened leading to increased total lung capac- ity and residual volume, with reduced FEV 1 and increased work of breathing. As the disease progresses, patients must breathe at a higher lung volume to achieve the flows necessary to meet ventilatory requirements. At end-stage disease, the patient is dyspnoeic and has a severely restricted exercise capacity. 3 Once the patient has reached a stage where the FEV 1 < 0.75 L, the 1-year mortality is in the region of 30% 4 and the patient will require frequent hospital admission for treatment of exacer- bations of the condition. Medical management options The goals of therapy in emphysema are to halt the progressive decline in lung function, prevent exacerbations of the disease, improve exercise capacity and quality of life, and prolong sur- vival. The only treatment shown to alter the rate of progres- sion of COPD is cessation of smoking. 5 Exacerbations of dis- ease are treated with antibiotics, steroids, β-adrenergic ago- nists, theophylline, and anticholinergics. Although these in- terventions shorten the duration of individual episodes and minimize symptoms, there is little evidence that they alter the

Oxygenation during one-lung ventilation

Abstract: Extracted from text ... REGISTRAR COMMUNICATION Oxygenation during one-lung ventilation These equations may be combined into a single equation.1 Qs/Qt CaO2 = CcO2 - (VO2/Qt) * ---------- Equation-4 10*(1 - Qs/Qt) Equation-4 may be used to construct plots to illustrate the relationship between arterial oxygen content and cardiac output. In addition, it is possible to illustrate by means of these plots how varying Qs/Qt, [Hb] and VO2, influences CaO2. All the variables contained in Equation 4 should be controlled by the anaesthesiologist to maintain adequate arterial oxygenation during OLV. Note that the most important determinant of CcO2 is the haemoglobin concentration. An important ..

A case that underwent bilateral video-assisted thoracoscopic surgical biopsy combined with left pneumonectomy

Abstract: A case that underwent bilateral video-assisted thoracoscopic surgical (VATS) biopsy combined with pneumonectomy is presented. The patient developed hypoxia during the contralateral VATS biopsy. His hypoxia was treated with positive expiratory pressure (PEEP) to the dependent lung and apneic oxygen insufflation to the operative lung. The cause was probably airway obstruction due to his intraluminal tumor plus secretions. This case report contains interesting aspects in the anesthetic management.

Do the COX-2 inhibitors still have a role to play?

Abstract: No Abstract Available Southern African Journal of Anaesthesia & Analgesia Vol.11(2) 2005: 55-60

Anaesthesia and Rubinstein-Taybi syndrome

Abstract: Extracted from text ... South African Journal of Anaesthesia & Analgesia ? November 2005 135 SYNDROMIC VIGNETTES IN ANAESTHESIA Anaesthesia and Rubinstein-Taybi syndrome Synopsis of patients Case 1: An 11 month old boy was admitted for probing and syringing of the lacrimal ducts. He had presented with history of recurrent infections of the right eye and a mucocoele of right lacrimal sac. On examination, the patient was noted to have micrognathia, heavy eyebrows, blepharophimosis, an epicanthus, broad thumbs and clinodactyly. There was no obvious micrognathia or microstomia but he was noted to have a high arched palate. His milestones were delayed - he ..

The Sheppard Oxygen Mask: Efficient oxygen enrichment in the PACU

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 21

The Sheppard Oxygen Mask : efficient oxygen enrichment in the PACU : registrar communication

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 21

The HIV Airway

Abstract: (2005). The HIV Airway. Southern African Journal of Anaesthesia and Analgesia: Vol. 11, No. 1, pp. 21-21.

Anaesthesia and familial dysautonomia with congenital insensitivity to pain

Abstract: No Abstract Available Southern African Journal of Anaesthesia & Analgesia Vol.11(2) 2005: 66-67

The role of anaesthetists in paediatric intensive care units : registrar communication

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 25-26

The Ghosts of Acetylcholine : structure-activity relationships of muscle relaxants : registrar communication

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 23

Consciousness: The flipside of anaesthesia

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 33-35

The Ghosts of Acetylcholine : Structure- activity relationships of Muscle Relaxants

Abstract: No Abstract Available Southern African Journal of Anaesthetics and Analgesia Vol.11(1) 2005: 23