Showing papers in "Southern African Journal of Anaesthesia and Analgesia in 2013"
TL;DR: In this article, the potential benefits of regional anaesthesia over more conventional methods are well recognised, but the level of evidence is small since there are few well designed randomised controlled studies on infants or children.
Abstract: Regional anaesthesia for children continues to grow in popularity. The potential benefits of regional anaesthesia over more conventional methods are well recognised, but the level of evidence is small since there are few well designed randomised controlled studies on infants or children. Practice patterns have changed over the past decade. Peripheral nerve blocks are increasingly more favoured than neuraxial blocks. This change has been fuelled by the lower reported incidence of complications associated with peripheral nerve blocks, and is also in keeping with the increase in laparoscopic and thoracoscopic surgery. There has been renewed interest in children following recently described transversus abdominis plane, maxillary nerve and lumbar plexus blocks. The analgesic effect of a “single-shot” block is limited to approximately five hours, irrespective of whether or not bupivacaine, ropivacaine or levobupivacaine are used. Peripheral nerve catheters and adjuvants are two options that are used to prolong the duration of analgesia. Clonidine and ketamine have essentially replaced opiates as the most popular adjuvant in many institutions. Technological advancements are likely to make regional anaesthesia both safer and easier to perform in the future.
17 citations
TL;DR: Doctors practising in anaesthesia are constantly working in a high-fidelity, high-stakes environment, where chronic exposure to stressors can lead to burnout syndrome.
Abstract: Doctors practising in anaesthesia are constantly working in a high-fidelity, high-stakes environment 1 Causes for this are numerous, with long working hours, sustained vigilance, the unpredictability of stressful situations, fear of litigation, team work and production pressure 2 Chronic exposure to these stressors can lead to burnout syndrome 3
12 citations
TL;DR: Guidelines for the prevention of tuberculosis in the theatre environment need to be followed to avoid placing staff and other patients in danger.
Abstract: Tuberculosis is a common problem in South Africa, and provides a number of challenges for the anaesthetist. Patients may present in a variety of ways. Constitutional and pulmonary symptoms are the most common. These may impact on fitness for surgery and choice of anaesthesia. Tuberculosis treatment has the potential for a number of significant drug interactions. These are primarily mediated through induction of the cytochrome P450 enzyme system by rifampicin. Guidelines for the prevention of tuberculosis in the theatre environment need to be followed to avoid placing staff and other patients in danger.
11 citations
TL;DR: Although somatosensory-evoked potentials are unaffected by muscle relaxants, they prevent the monitoring of MEPs and should be avoided during multimodal use, and the train-of-four ratio should be kept at 2/4 twitches and a T1 response at 10–20% of baseline, with use of a closed-loop system.
Abstract: The use of intraoperative neurophysiological monitoring (INM) during spinal orthopaedic and neurosurgical procedures provides a challenge to the attending anaesthesiologist. Since all anaesthetic agents affect synaptic function, the choice of agent will be determined by the type of surgery and the INM modality employed. Halogenated volatile agents decrease evoked potential (EP) amplitude and increase latency, and should be avoided in modalities that pass through cortical tracts. The effect on EPs is apparent at minimum alveolar concentrations of 0.3-0.5. Intravenous agents affect EPs in a dose-dependent manner, and should be titrated to response. Total intravenous anaesthesia with propofol and remifentanyl is the preferred technique. The risk of propofol infusion syndrome has not been shown to affect the choice of this agent. Compound muscle action potentials are abolished by barbiturates, and should be avoided during motor-evoked potential (MEP) monitoring. Although somatosensory-evoked potentials are unaffected by muscle relaxants, they prevent the monitoring of MEPs and should be avoided during multimodal use. When paralysis is required to ensure patient safety, the train-of-four ratio should be kept at 2/4 twitches and a T1 response at 10-20% of baseline, with use of a closed-loop system.
8 citations
TL;DR: JNAs remain a challenge for anaesthesiologists because of excessive intraoperative bleeding, and Anaesthetists should be aware of recent techniques to reduce tumour vascularity, such as embolisation of the feeding vessel and controlled hypotension.
Abstract: Background: Juvenile nasopharyngeal angiofibroma (JNA) is a rare, benign, vascular tumour in adolescent males with potential life-threatening complications. Advances in endoscopic surgery, invasive monitoring and hypotensive anaesthesia have made JNAs amenable to endoscopic surgical resection. We present the anaesthetic management of endoscopic resection of 14 JNAs, together with a review.Method: The medical records of patients who underwent endoscopic excision of JNAs within the last seven years were reviewed retrospectively. Information was collected and analysed with regard to demographics, preoperative evaluation, intraoperative management, complications and postoperative course. Fourteen patients were included in the study. If the surgery needed to be converted to open surgery, the patients were excluded from the study.Results: The age of the patients ranged from 10–18 years. Two patients had preoperative embolisation of the feeding vessel. Standard anaesthesia induction technique, together w...
7 citations
TL;DR: The lack of training and experience of doctors in obstetric anaesthesia is highlighted and specific target groups for future support and training are identified at district hospitals in KwaZulu-Natal.
Abstract: Objectives: Suboptimal treatment as a result of lack of basic skills in anaesthesia and resuscitation contributes significantly to the continuing increase in anaesthetic-related maternal deaths in South Africa. This study aimed to determine the number of doctors providing obstetric anaesthesia at district and regional hospitals in KwaZulu-Natal, their level of experience and caseload, and to identify specific groups that could be targeted for support and training. Design: This was a prospective open cohort observational study of obstetric anaesthetic services in KwaZulu-Natal, which considered the human resources, caseloads and the experience of doctors. Setting and subjects: Two separate questionnaires, directed independently to medical managers and doctors providing operative obstetric services, were sent to 48 district and regional hospitals in KwaZulu-Natal. One third of the hospitals, selected by stratified randomisation, were visited to improve response rates. Outcome measures: Medical managers were asked for caseload and staffing data. Doctors were asked for details of their qualifications, experience and their current workload. Results: Thirty-eight (a 79% response rate) medical managers and 266 doctors (an estimated response rate of 65%) completed questionnaires. Community service medical officers (CSMOs) at rural district hospitals constituted 27% of fulltime staff. CSMOs at all responding district hospitals were expected to provide obstetric anaesthesia independently. Foreign medical graduates provided obstetric anaesthesia in 71% (27/38) of hospitals and constituted 27% of full-time staff at rural district hospitals. Twenty-four doctors (all foreign-trained) reported no anaesthesia training during their internship. District hospitals were more reliant on part-time (sessional) appointments. Fifty-eight per cent of all (22/38) hospitals reported that a number of sessional appointments provided obstetric anaesthesia. In October 2010, 58% (22/38 active during the month) of sessional appointments at district-level hospitals administered only one obstetric anaesthetic, whereas all 15 sessional appointments who were active at regional level administered two or more. Only 24% of responding doctors had more than five years’ experience in their current employment. Only 3% of responding doctors working in rural hospitals had a Diploma in Anaesthesia, compared to 26% in urban hospitals. Only one doctor with more than five years of employment history and a Diploma in Anaesthesia worked at district level. Conclusion: This study highlights the lack of training and experience of doctors in obstetric anaesthesia and documents workload patterns at district hospitals. It also identifies specific target groups for future support and training.
7 citations
TL;DR: Simple pain assessment tools and the early institution of intravenous postoperative analgesia may improve postoperative pain assessment and treatment.
Abstract: Objective: The treatment of pain has gained momentum in health care around the world. Nevertheless, pain is undertreated, particularly in the developing world. We sought to compare patient and healthcare practitioner perspectives of postoperative pain and assess perioperative analgesia utilisation in a tertiary care hospital in a resource-limited setting.Design: We conducted a prospective observational study.Setting and subjects: Postoperative patients and their respective recovery room nurses were studied at the Komfo Anokye Teaching Hospital in Kumasi, Ghana.Outcome measures: Patients were surveyed 1–4 hours postoperatively. Pain severity on a numerical rating scale (NRS) and patient satisfaction with the pain control were assessed. Recovery room nurses who were responsible for administering the pain medications were surveyed on their perceptions of their patients' pain. Patient demographic information, diagnoses, surgery type, mode of anaesthesia and perioperative analgesia use were recorded.Re...
7 citations
TL;DR: Although evidence is lacking from randomised controlled trials, applying protective ventilatory strategies seems to be a reasonable approach, based on the current understanding of mechanical ventilation and lung injury.
Abstract: Nonphysiological ventilation in healthy lungs induces acute lung injury (ALI). Protective lung ventilation in patients with ALI improves outcome. Protective lung ventilation in noninjured lungs and in the absence of a primary pulmonary insult may initiate ventilation-induced lung injury (VILI), as evidenced by inflammatory markers. VILI has important implications that are remote to the lungs and may be associated with significant morbidity and mortality. Volatile anaesthetics can have a lungprotective effect. Excess fluids may contribute to perioperative lung injury. Anaesthesiologists manage a heterogeneous group of patients in the perioperative period, from patients with healthy lungs and patients with at-risk lungs through to patients with established ALI. More patients are at risk for ALI during surgery than previously thought. Appropriate perioperative management may prevent or ameliorate this lung injury. Although evidence is lacking from randomised controlled trials, applying protective ventilatory strategies seems to be a reasonable approach, based on the current understanding of mechanical ventilation and lung injury.
6 citations
TL;DR: The contamination of ready-for-use anaesthesia equipment deemed to be ready for use in theatres in regional, tertiary and central hospitals in KwaZulu-Natal was extremely high and urgent tackling of the issue of reuse of contaminated equipment is critical.
Abstract: Objectives: Contaminated anaesthetic equipment has been implicated in the nosocomial transmission of infection. The aim of this study was to determine the prevalence of blood (occult or visible) and/or visible organic material contamination of anaesthetic equipment deemed to be ready for use in theatres in regional, tertiary and central hospitals in KwaZulu-Natal.Design: All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website were visited (n = 15). Laryngoscope blades and handles, Magill's forceps, nasopharyngeal temperature probes and suction bowls were inspected for visible blood and/or organic matter. Those items that were not visibly contaminated were further tested for occult blood using the blood detector in urinalysis reagent strips.Setting and subjects: All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website were visited (n = 15).Results: The per...
6 citations
TL;DR: Call for the standardised labelling of drugs in solution and for dosage calculation training in the medical curriculum is supported, as all students experienced the most difficulty with calculations when the drug concentration was expressed either as a ratio or a percentage.
Abstract: Objectives: A doctor's ability to calculate drug doses is a skill that is generally assumed. We assessed medical students' performance when given four types of dosing calculations typical of those required in an emergency setting.Design: Longitudinal study.Setting and subjects: Students were assessed at the beginning of the third year, and repeatedly during the third and fourth year while receiving training in dosage calculations. Competence was defined as correctly answering all four categories of calculation at any one time, i.e. a score of 100%. Failure to respond correctly to the individual questions was also analysed because an incorrect calculation could be equated with a “patient” receiving a wrong dose.Outcome measures: Outcome measures were the percentage of students achieving competence and the proportion of times students showed competence relative to their total number of opportunities. A further outcome was the percentage of calculations incorrect i.e. potential “patients” harmed.Resu...
6 citations
TL;DR: The case of a nine-year-old with UCMD who required operative intervention for progressive scoliosis is presented, and perioperative concerns relate to the surgical procedure primarily, including tailoring the intraoperative anaesthetic to facilitate neurophysiological monitoring.
Abstract: Ullrich congenital muscular dystrophy (UCMD) is one of a group of disorders known as congenital muscular dystrophies. Severe hypotonia and early diaphragmatic involvement may lead to respiratory failure early in the disease process. We present the case of a nine-year-old with UCMD who required operative intervention for progressive scoliosis. In these patients, anaesthetic issues relate to difficulties with endotracheal intubation, as well as the potential for postoperative respiratory failure, given early diaphragmatic involvement. As with other types of muscular dystrophy, succinylcholine is absolutely contraindicated, while a prolonged effect may be seen following routine doses of nondepolarising neuromuscular blocking agents. Additional perioperative concerns relate to the surgical procedure primarily, including tailoring the intraoperative anaesthetic to facilitate neurophysiological monitoring, as well as the use of techniques to limit intraoperative blood loss. The perioperative management of patients with UCMD is discussed and options for intraoperative anaesthetic care are reviewed.
TL;DR: Emergence agitation was significantly reduced by a sub-Tenon's lidocaine injection, regardless of the modality of anaesthesia used in children receiving sevoflurane or halothane anaesthesia for strabismus surgery.
Abstract: Objective: This study aimed to evaluate the effect of a sub-Tenon's lidocaine injection on emergence agitation in children receiving sevoflurane or halothane anaesthesia for strabismus surgery.Desi...
TL;DR: In this study, the use of ultrasound guidance alone for brachial plexus infraclavicular block provided rapid performance and yielded a high success rate without the aid of a nerve stimulator.
Abstract: This randomised, observer-blinded study compared brachial plexus infraclavicular block under ultrasound guidance with, or without, nerve stimulation, for patients undergoing below-elbow surgery.Sixty-six patients, aged 18–70 years, with American Society Anesthesiologists' status I, II or III, were randomised into two groups. Brachial plexus infraclavicular block achieved success rates of 76% in the ultrasound guidance without nerve stimulation group and 82% in the ultrasound guidance with nerve stimulation group, but was not significantly different (p-value 0.55). Block supplementation rates were 18.2% in the ultrasound guidance without nerve stimulation group vs. 12.2% in the ultrasound guidance with nerve stimulation group (p-value 0.55), resulting in 100% of the ultrasound guidance without nerve stimulation group reaching complete successful block, compared to 97% of the ultrasound guidance with nerve stimulation group. The mean performance time was significantly shorter in the ultrasound guida...
TL;DR: The i-gel™ was easy to insert, with a good first attempt success rate and acceptable insertion time, and can serve as an alternative conduit for fibreoptic-guided intubation.
Abstract: Objective: The i-gel™ superglottic airway (Intersurgical, Berkshire, UK) has been reported to function as an airway rescue device and as a conduit for fibre-optic intubation in predicted difficult airways. The wider and shorter stem of the i-gel™ and the absence of a grille at the distal end suggests that it may serve as an ideal channel for intubation using a fibrescope. The aim of this prospective study was to determine the feasibility of using fibreoptic-guided intubation through an i-gel™ airway in adult patients undergoing elective surgery.Design: A prospective clinical study.Subjects and setting: Sixty patients of both genders, aged 18–60 years, who presented for elective surgery in a tertiary care centre, were enrolled in the study.Outcome measures: The number of insertion attempts, ease of insertion and insertion time of the i-gel™, fibreoptic view through the i-gel™ tube, airway seal pressure, ease of tracheal tube placement with the help of a fibreoptic bronchoscope through the i-gel™, t...
TL;DR: RBC transfusion and postoperative ischaemia, but not postoperative BNP, were independent predictors of the composite outcome of all-cause mortality or postoperative troponin elevation.
Abstract: Objectives: It is unclear if there is value in measuring postoperative B-type natriuretic peptide (BNP) in patients risk-stratified using preoperative BNP.Design: Prospective observational study.Setting and subjects: Patients undergoing vascular surgery at Inkosi Albert Luthuli Hospital, Durban.Data on intraoperative risk predictors, i.e. the nature of the surgery, number of transfused red blood cell units and the duration of surgery, were collected. Preoperative and postoperative BNP, electrocardiographic and troponin I monitoring were performed. Multivariable analysis was conducted to identify independent predictors of adverse cardiac events and then tested using reclassification statistics.Outcome measures: The composite of troponin elevation within the first three postoperative days and all-cause mortality within 30 days of surgery.Results: In 149 eligible patients, the study outcome occurred in 27 patients and was independently predicted by red blood cell (RBC) transfusion [odds ratio (OR) 1....
TL;DR: It is suggested that a dose that is closer or equivalent to that of the high-dose group (9 mg bupivacaine plus 15 μg fentanyl) is preferable for brachytherapy for carcinoma of the cervix in ensuring consistent and reliable spinal anaesthesia in this patient population.
Abstract: Objectives : Spinal anaesthesia can be suitably performed for a variety of day-stay (ambulatory) surgical procedures. The time taken for adequate recovery to allow discharge home from hospital is an important consideration. The purpose of this study was to compare the suitability of two different doses of hyperbaric bupivacaine for spinal anaesthesia for day-stay brachytherapy for carcinoma of the cervix. Design: This was a prospective, randomised, double-blind study. Setting and subjects: Forty female patients, presenting to Groote Schuur Hospital for brachytherapy for carcinoma of the cervix, were randomised to receive either 5 mg or 9 mg (1 ml or 1.8 ml) of 0.5% hyperbaric bupivacaine, plus 15 μg fentanyl via the L3/L4 interspace. Results : Patients receiving the lower dose could be discharged from the recovery room in a shorter time (p-value < 0.01). The time taken to achieve hospital discharge criteria was significantly shorter in the group receiving the lower dose [a mean time of 235 (206-264) vs. 280 (263-297) minutes, p-value < 0.01]. There was significantly less motor block in the low-dose group (p-value < 0.001). Patient satisfaction regarding motor block was similar in the two groups (p-value = 0.96). There was a trend towards a higher number of inadequate spinal blocks in the low-dose group (p-value = 0.34). Conclusion: Our study suggests that a dose that is closer or equivalent to that of the high-dose group (9 mg bupivacaine plus 15 μg fentanyl) is preferable for brachytherapy for carcinoma of the cervix in ensuring consistent and reliable spinal anaesthesia in this patient population. Keywords: spinal, anaesthesia, bupivacaine, brachytherapy, ambulatory, day case
TL;DR: The two Western Cape University Hospitals have responded with a joint statement which is presented to SAJAA readers and suggests withdrawals of corn-based starch solutions are based on flawed interpretation of the available data.
Abstract: Circular 114/2013 issued by the Western Cape Pharmacy Services entitled, Suspension of use of infusion solutions containing hydroxyethyl starch at Western Cape Government Health Facilities until further notice, resulted in the the non-availability of starch-containing solutions for clinical use. The reasoning behind the circular was based on the Medicines and Healthcare Products Regulatory Agency (MHRA) class 2 recall of starch solutions and the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee, who stated that: “The benefits of infusion solutions containing hydroxyethyl starch no longer outweigh the risks, and (we) therefore recommend that the marketing authorisations for these medicines are suspended”. The two Western Cape University Hospitals have responded with a joint statement which is presented to SAJAA readers. The statement suggests withdrawals of corn-based starch solutions are based on flawed interpretation of the available data, particularly the suggestion that they cause renal dysfunction. The statement then interrogates why the use of corn-based starch solutions benefits patient care and improves outcome. Lastly, the problems of the alternative therapeutic options are examined. The conclusion reached is that the use of corn-based starch solutions should be reinstated. We believe this well-researched, evidence-based approach is worth publishing to a wider audience.
TL;DR: These patients may present with various clinical findings with which it is important for the anaesthesiologist to be familiar in order to manage such cases during the intraoperative and postoperative period.
Abstract: Transverse myelitis is an acute or subacute inflammatory disorder involving the spinal cord. Clinical signs are due to the involvement of the ascending and descending tracts in the transverse plane of the spinal cord. The most common cause is autoimmune. These patients may present with various clinical findings with which it is important for the anaesthesiologist to be familiar in order to manage such cases during the intraoperative and postoperative period. This report discusses issues relating to management of such cases.
TL;DR: Low-dose midazolam 0.02 mg/kg plus ketamine 0.25mg/kg was equally effective in preventing shivering during spinal anaesthesia for emergency lower limb surgery and more sedated and had a higher incidence of nystagmus than those in Group C.
Abstract: Objective: This study was conducted to compare the effectiveness of two different dosages of intravenous midazolam in combination with ketamine in the prevention of shivering during spinal anaesthesia for emergency lower limb surgeryDesign: This was a prospective, randomised, double-blind, placebo-controlled studySetting and subjects: We studied 90 patients with American Society of Anesthesiologists classification I and II, aged between 18 and 60 years old, and randomly allocated to receive either a combination of low-dose midazolam 002 mg/kg plus ketamine 025 mg/kg (Group A), or a combination of higher-dose midazolam 004 mg/kg plus ketamine 025 mg/kg (Group B), or normal saline as the control group (Group C), after an intrathecal injection of 05% hyperbaric bupivacaine 125–15 mgOutcome measures: The outcomes measured were the incidence and the degree of shivering, the effectiveness and the side-effects of two different dosages of the drugs in preventing shiveringResults: In this study,
TL;DR: The majority of patients in this study do not agree with the practice of gift giving, particularly when it led to personal gain for the physicians, and believed that when physicians accepted gifts it influenced their decision-making.
Abstract: Objectives: This study aimed to determine how South African patients at a regional state hospital perceived the practice of physicians accepting gifts from the pharmaceutical industry. The physician-patient relationship is built on trust, with an understanding that the physician will act ethically and in patients’ best interests. This trust is violated when physicians make patient management decisions that are motivated by a desire for personal gain. Gift giving is a technique that is commonly used by the pharmaceutical industry to influence physician prescribing and procurement practice. Design: This was an observational, cohort study that used a questionnaire among postoperative patients. Setting and subjects: Written informed consent was obtained from 200 postoperative adult patients at Grey’s Hospital, Pietermaritzburg. Outcome measures: Patients’ opinions regarding physician-industry relations focused on four main areas: acceptability of gift giving, the monetary value of gifts, patient knowledge of physicians’ involvement with the medical industry, and the perceived potential influence of gifts on physicians decision-making. Results: Sixty-two per cent of patients felt that it was unacceptable for physicians to accept a gift from a pharmaceutical company, and 80% believed that doctors were influenced by accepting gifts. Eighty-one per cent of patients preferred to be cared for by a doctor who had no relationship with, or did not accept gifts from, pharmaceutical companies. Conclusion: The majority of patients in this study do not agree with the practice of gift giving, particularly when it led to personal gain for the physicians. Patients believed that when physicians accepted gifts it influenced their decision-making, and indicated that they would prefer to be cared for by physicians without ties to the medical industry.
TL;DR: The different modalities that are available, their indications and application are presented in Part 1, while the different anaesthetic options that exist will be discussed and the basic approach to the planning of a successful anaesthetic outlined in Part 2.
Abstract: Intraoperative neurophysiological monitoring (IONM) has become the gold standard for the monitoring of functional nervous tissue and mapping of eloquent brain tissue during neurosurgical procedures. The multimodal use of somatosensory-evoked potentials and motor-evoked potentials ensures adequate monitoring of anterior sensory and dorsal motor pathways. The use of IONM during spinal orthopaedic surgery has drastically reduced the incidence of postoperative neurological deficit and allowed radical resection of brain tumours. Evoked potentials (EPs) are analysed for increased latency (> 1 millisecond) and decreased amplitude (< 50%). Special considerations have to be made in the paediatric population who present with decreased myelination and morphological changes to the EPs. A thorough knowledge of the physics and physiology behind these techniques will ensure better outcomes and successful implementation in neurosurgical centres. In this two-part article series, we will provide a review of the most recent available literature on IONM. The different modalities that are available, their indications and application are presented in Part 1, while the different anaesthetic options that exist will be discussed and the basic approach to the planning of a successful anaesthetic outlined in Part 2.
TL;DR: There is a need to consider other differential diagnoses other than that of a postpartum headache and to conduct early neuroimaging, since the headache may be the first indication of an unsuspected, potentially fatal lesion.
Abstract: A postpartum headache is commonly seen in clinical practice, especially after a subarachnoid block. Generally, it is treated as a postdural puncture headache. We report on a case of a 24-year-old primigravida who underwent emergency Caesarean delivery under spinal anaesthesia. She developed a headache on the third postoperative day, which responded to conservative management. On the sixth day, she developed a severe headache which did not respond to analgesics and bed rest. Magnetic resonance imaging of the brain revealed a subdural haematoma. In such situation, there is a need to consider other differential diagnoses other than that of a postpartum headache and to conduct early neuroimaging, since the headache may be the first indication of an unsuspected, potentially fatal lesion.
TL;DR: Current infection control practices among anaesthesia nurses regarding the decontamination of anaesthetic equipment in the observed hospitals are poor, and in light of the high prevalence of many infectious diseases, in particular human immunodeficiency virus, hepatitis B and tuberculosis in KwaZulu-Natal, it is critical that issues relating toDecontamination practices are urgently addressed.
Abstract: Background: Anaesthetic equipment is a potential vector for the transmission of disease. This study was undertaken to observe current infection control practices among anaesthetic nurses regarding the decontamination of anaesthetic equipment in regional, tertiary and central hospitals in KwaZulu-Natal.Method: All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website (15 in total) were visited. All available anaesthesia nurses were invited to participate in a structured interview.Results: Thirty-four anaesthesia nurses were interviewed. Results revealed that decontamination of anaesthetic equipment and other infection control practices were inadequate or inappropriate in several of the hospitals. Practices varied from one healthcare facility to another, as well as within the same facility.Conclusion: Current infection control practices among anaesthesia nurses regarding the decontamination of anaesthetic equipment in the observe...
TL;DR: In this article, an observational descriptive study that assessed the perspectives of anaesthetists in public service using manually and electronically distributed questionnaires that consisted of open-and closed-ended questions.
Abstract: Objectives: This study aimed to ascertain the perspectives of anaesthetists with regard to their current practice of obtaining informed consent The outcome of this study will eventually assist in creating a standardised system for informed consent which will be pivotal to the safe, ethical, medical and legally sound practice of anaesthesiaDesign: This was an observational descriptive study that assessed the perspectives of anaesthetists in public service using manually and electronically distributed questionnaires that consisted of open- and closed-ended questionsSetting and subjects: The study canvassed the views of full-time anaesthetic doctors employed by state hospitals in the eThekwini municipalityOutcome measures: The practice, general impression and overall skills in respect of informed consent obtained by anaesthetists were measured in four main areas: the preanaesthetic interview, optimisation of the process, influence of litigation on the process, and expertise in determining patient
TL;DR: It is emphasised that counting breathing rates is an unreliable index of OIVI is that the quality of breathing should be assessed, and that sedation occurs before OivI, is clinically obvious, therefore, monitoring and recording a sedation score at regular intervals is essential.
Abstract: Pain is now regarded as the “fifth vital sign” and pain relief to be a basic human right. Patient-controlled anaesthesia (PCA) is effective because it enables self-titration to individual requirements. PCA is perceived to be inherently safe because of the lockout interval, and because sedation purportedly stops the patient from pressing the button. Nevertheless, because of respiratory depression, increasing numbers of adverse events are serious cause for concern. Respiratory depression comprises three components: central respiratory depression, airway obstruction and sedation. Together, these effects result in opioid-induced respiratory impairment (OIVI). Strategies for safety improvement include an understanding of opioid pharmacokinetics and pharmacodynamics, appropriate dosing regimens, establishing guidelines and written orders, appropriate monitoring and record-keeping, staff training for PCA competency, preoperative patient education and oxygen administration when appropriate, e.g. sleeping patients. Initial postoperative analgesia should be established personally by the attending practitioner who should titrate small doses of opioid to the desired effect. It is emphasised that counting breathing rates is an unreliable index of OIVI is that the quality of breathing should be assessed, and that sedation occurs before OIVI, is clinically obvious. Therefore, monitoring and recording a sedation score at regular intervals is essential. During opioid administration, sedation should be regarded as the “sixth vital sign”.
TL;DR: Satisfaction with life significantly correlates with pain severity in patients with chronic pain and approach coping moderates this relationship, while avoidance coping appeared to have no significant effect on this relationship.
Abstract: Objectives: The primary study aim was to determine whether or not a statistically significant relationship exists between pain severity and satisfaction with life in patients with chronic pain. The second aim was to explore the extent to which coping responses might influence this relationship.Design: A cross-sectional non-experimental research design was employed.Setting and subjects: A sample of 172 adults suffering from chronic pain was recruited from the outpatient clinic at the Pain Control Unit at Universitas Hospital in Bloemfontein.Outcome measures: Participants completed measures of pain severity (Pain Severity Scale of the West-Haven-Yale Multidimensional Pain Inventory), satisfaction with life (Satisfaction with Life Scale) and coping responses (Coping Responses Inventory-Adult version).Analysis: Pearson correlation coefficients were calculated between the measures of pain severity and satisfaction with life. Regression analyses were employed to explore the effect of coping responses on...
TL;DR: Recovery after anaesthesia must be monitored carefully, and patients should be assessed before they are discharged to the ward or some other area where they are less likely to receive the same level of care.
Abstract: Recovery after anaesthesia must be monitored carefully, and patients should be assessed before they are discharged to the ward or some other area where they are less likely to receive the same level of care. While the anaesthetist is responsible for his or her patient until he or she is discharged from the recovery room, the decision to make the release is usually delegated to a responsible trained nurse. Therefore, strict discharge criteria are essential.
TL;DR: The addition of midazolam to intrathecal bupivacaine prolonged the duration of postoperative analgesia in this study, without affecting the onset of block and without increasing the risk of side-effects.
Abstract: Objectives: The present study was undertaken to determine the onset of sensory block, the time to achieve the maximum level of sensory block and the analgesic efficacy of intrathecal midazolam when given in combination with bupivacaine, and also to observe any undesirable side-effects produced by the midazolam-bupivacaine combination.Setting and subjects: One hundred patients [American Society of Anesthesiologists (ASA) I and ASA II] aged 45–60 years and posted for elective gynaecological surgery, were randomly allocated to two groups of equal size. Group 1 (n = 50) received 12.5 mg of 0.5% hyperbaric bupivacaine with 0.4 ml of normal saline in the L3-L4 interspace, while Group 2 (n = 50) received 12.5 mg (2.5 ml) of 0.5% hyperbaric bupivacaine with 0.4 ml (2 mg) of preservative-free midazolam. Standard monitoring of haemodynamic parameters was recorded throughout the procedure.Outcome measures: The onset of sensory block, the time to achieve maximum sensory block and the level of block were also ...
TL;DR: A 13-year-old adolescent presented for correction of an 85-degree idiopathic thoracic scoliosis developed severe recalcitrant bradycardia with hypotension that was resistant to anticholinergics, inotropes and vasopressors upon prone positioning and was deduced to be due to a hypervagal response provoked byprone positioning and because of the severity of the scolia.
Abstract: A 13-year-old adolescent presented for correction of an 85-degree idiopathic thoracic scoliosis. She was known to have Prader-Willi syndrome. Previous general anaesthesia for non-spinal surgery had been uneventful. On two occasions following uneventful induction and total intravenous anaesthesia (TIVA) maintenance, she developed severe recalcitrant bradycardia with hypotension that was resistant to anticholinergics, inotropes and vasopressors upon prone positioning. Immediate resolution occurred upon a return to the supine position. On each occasion, she emerged from anaesthesia with no untoward sequelae. Cardiac investigations, including echocardiography, electrocardiography (ECG), troponin and creatine kinase-MB fraction levels were all within the normal range, and ventricular function was good. It was necessary to urgently proceed with the surgery as the scoliosis was progressive, with risks of cardiovascular and respiratory compromise. Additionally, she was scheduled to recommence growth hormone therapy postoperatively to treat her growth retardation. Ultimately, she received propofol for induction of anaesthesia and TIVA with propofol and remifentanil infusions for the maintenance of anaesthesia. Post-induction, a transvenous pacing wire was placed under ECG guidance. A transoesphageal probe was inserted and cardiac function monitored throughout the procedure. Upon prone positioning, she again developed a bradycardia which responded to pacing and surgery was carried out uneventfully. Clinical examination and extensive investigations had failed to demonstrate any specific underlying cause for her repeated positional arrhythmia. Therefore, we deduced that the bradycardia was due to a hypervagal response provoked by prone positioning and because of the severity of the scoliosis. We are unaware of reports of such a complication in the literature.
TL;DR: Airway surgery provides a unique challenge in that the airway is shared between the anaesthetist and surgeon, and the threat of hypoxia, retained carbon dioxide and complete airway obstruction is present pre-, intra- and postoperatively.
Abstract: Airway surgery provides a unique challenge in that the airway is shared between the anaesthetist and surgeon. Patients may experience airway obstruction, often at extremes of age, following aspiration of a foreign body by the young or tumourrelated impediments in the elderly which are complicated by smoking-related heart and lung disease. The threat of hypoxia, retained carbon dioxide and complete airway obstruction is present pre-, intra- and postoperatively.