Showing papers in "Southern African Journal of Anaesthesia and Analgesia in 2017"
TL;DR: TAP block reduced the VAS pain scores significantly both at rest and during stressors, and it is feasible to implement TAP block as part of a multimodal analgesia regimen after Caesarean section in a tertiary health care centre in a developing nation.
Abstract: Background: The primary objective of this study was to assess whether transversus abdominis plane (TAP) block is effective as part of multimodal pain management following Caesarean section in an ar...
14 citations
TL;DR: The perception of most patients is that anaesthesia is all about ‘putting patients to sleep and waking them up’, and there was poor knowledge of patients regarding the role of anaesthetists beyond the confines of the operating theatre.
Abstract: Background: Anaesthesia has always been misconstrued as a ‘behind the scenes’ specialty. Despite advancements in anaesthesia, there is inadequate public knowledge regarding the specialty, the scope...
13 citations
TL;DR: The cost of day of surgery cancellation was high in Burkina Faso based on income, and the causes of cancellation, financial cost and patients’ emotional response were assessed.
Abstract: Background: Cancellation of scheduled surgery creates a financial burden for hospitals, caregivers and patients. Cancellation causes emotional stress, which impacts on outcomes. In poor countries w...
11 citations
TL;DR: PMI but not MINS in these patients was significantly associated with hospital mortality, and MINS requires strict diagnostic criteria in the intensive care where other non-ischaemic pathologies may be associated with myocardial injury.
Abstract: Background: Perioperative myocardial infarction (PMI) and prognostically relevant myocardial injury following non-cardiac surgery (MINS) increases perioperative mortality. Studies in vascular patients show an increased incidence and mortality from PMI. However, there remains limited data on the relative prognostic importance of PMI and MINS in South African vascular surgical patients. The primary objective was to evaluate the incidence and prognosis of PMI and MINS in vascular surgical patients admitted to intensive care. The secondary objective was to identify predictors of PMI and hospital mortality.Methods: A retrospective electronic patient record review of all patients aged at least 45 years admitted to Inkosi Albert Luthuli Central Hospital (IALCH) intensive care unit (ICU) following vascular surgery between 1 January 2011 and 31 December 2013 was carried out.Results: A total of 140 vascular patients were reviewed; 24.3% of the patients had a PMI and a further 25% had MINS. PMI was associated with s...
10 citations
Journal Article•
TL;DR: In November 2010 the Subcommittee for Postgraduate Education and Training (Medical) under the auspices of the Health Professions Council of South Africa (HPCSA) decreed that for registrars who commenced training on or after 1 January 2011, “Completion of a research component” is a requirement for registration as a specialist.
Abstract: In November 2010 the Subcommittee for Postgraduate Education and Training (Medical) under the auspices of the Health Professions Council of South Africa (HPCSA) decreed that for registrars who commenced training on or after 1 January 2011, “Completion of a research component” is a requirement for registration as a specialist. 1
9 citations
Journal Article•
TL;DR: A South African Society of Anaesthesiologists (SASA) Guideline developed by the Obstetric Anaesthesia Special Interest Society (OASIS) .
Abstract: A South African Society of Anaesthesiologists (SASA) Guideline developed by the Obstetric Anaesthesia Special Interest Society (OASIS)
9 citations
TL;DR: This is the first reported description of Bardet–Biedl syndrome with the combination of a malacic bifid epiglottis and anterior laryngeal web and these are reviewed, focusing on features that manifest not only in BBS but across a spectrum of syndromes that impact airway management.
Abstract: This is the first reported description of Bardet–Biedl syndrome (BBS) with the combination of a malacic bifid epiglottis and anterior laryngeal web. Anaesthesia for BBS has numerous concerns and th...
8 citations
TL;DR: Overall in-ICU mortality in South Africa was 19.7% with a large trauma burden in a young population, and information pertaining to patient demographics and spectrum of illness provided novel information to further the understanding of the demand placed on critical care resources within South Africa.
Abstract: Background: The spectrum of illness and long-term outcome of critically ill patients admitted to intensive care units (ICUs) in South Africa remains largely unknown.Objectives: This study was desig...
7 citations
TL;DR: Intern training in anaesthesia is essential to create confident CSDs and feedback from previous interns should be used to improve intern training programmes.
Abstract: Background: Community service doctors (CSDs) are often expected to administer anaesthesia after minimal training and with very little support, especially in rural hospitals. This leads to unnecessary stress on these junior doctors and may lead to poor anaesthesia outcomes.Objectives: The aim of this study was to understand the experiences of CSDs administering anaesthesia. This feedback will be used to improve the current intern training programme for anaesthesia and to structure the rotation according to their needs.Methods: A questionnaire was sent to Pietermaritzburg (PMB) interns who completed their anaesthesia intern rotation between 2008 and 2010. Two data sets were collected: quantitative data (this will be reported on in another paper) and qualitative data. The qualitative data included five open-ended questions about the intern rotation in anaesthesia.Results: Between 2008 and 2010, 298 interns completed an anaesthetic rotation. The survey was sent to 259 doctors of whom 189 responded (73%). The ...
6 citations
TL;DR: In this study of predominantly asymptomatic patients scheduled for Caesarean delivery, only pre-eclampsia was predictive of mild thrombocytopenia.
Abstract: Background: Peri-partum thrombocytopenia significantly impacts anaesthetic technique and increases the risk of perioperative bleeding. However, as less than 5% of normal pregnancies have significant thrombocytopenia, routine platelet testing incurs great cost for a relatively low yield. Determining whether clinical predictors, in particular HIV status, are associated with thrombocytopenia may assist clinicians in rationalising preoperative testing. Methods: This was a prospective, observational, single-centre study at a South African regional hospital. We evaluated five variables as candidate predictors for mild preoperative thrombocytopenia ( 70 000/μl. Keywords: Caesarean delivery, HIV, obstetrics, pregnancy, thrombocytopenia
6 citations
TL;DR: The authors report 15.4% of the study’s pregnant population to be at intermediate risk and 3% at high risk of OSA, and the association between the hypertensive disorders and OSA must be considered and screening implementation considered.
Abstract: Background: Obstructive sleep apnoea (OSA) in pregnancy is associated with an increased morbidity and mortality to both mother and foetus. In the South African setting the proportion of pregnant females suffering from OSA has not been well studied; nor has the association with pre-eclampsia. This study aimed to determine the prevalence of OSA in females before 35 weeks gestation using the STOP-BANG questionnaire and to determine the association with pre-eclampsia in a local South African setting.Methods: A cross-sectional analytical study including 234 patients was conveniently sampled from Kalafong Hospital’s antenatal ward, clinic and labour ward. Participants were of more than 20 weeks and less than 35 weeks gestation. All participants were interviewed with a modified STOP-BANG questionnaire. Patients were consecutively enrolled without prior knowledge of the presence of pre-eclampsia. At Kalafong hospital all pregnant patients are routinely screened and investigated for pre-eclampsia according to stan...
TL;DR: It is argued that these moral attributes of anaesthesiologists may best be understood with reference to Aristotle’s notion of virtue ethics—the idea that character and virtue are important in ethics.
Abstract: Anaesthesiologists are well trained and equipped to practise a high standard of care and contribute significantly to positive perioperative outcomes. Professionalism is characterised first by exper...
TL;DR: Biomarkers of delirium are emerging as tools to diagnoseDelirium, stratify severity, monitor progress, and predict outcomes, potentially changing the way the healthcare provider has an understanding ofdelirium in ICU.
Abstract: Delirium poses a significant burden on our healthcare, with patients in the intensive care unit (ICU) at an increased risk for developing this disorder. In addition, the ICU environment poses unique challenges in the assessment of delirium. It is paramount that the healthcare provider has an understanding of delirium in ICU, and monitors for it vigilantly. There have been various scoring systems developed to assist in this regard. However, the most commonly used and validated tools for the assessment of delirium are the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). Biomarkers of delirium are emerging as tools to diagnose delirium, stratify severity, monitor progress, and predict outcomes, potentially changing the way we approach delirium in the future.
TL;DR: This case report describes the successful anaesthetic management of an infant with Dandy–Walker Syndrome without postoperative intensive care admission.
Abstract: Dandy–Walker Syndrome (DWS) is a rare congenital brain anomaly affecting the cerebellum and the fourth ventricle. The chief components of the syndrome include cystic dilatation of the fourth ventricle and agenesis or hypoplasia of the cerebellar vermis. These abnormalities are typically associated with hydrocephalus. Patients often present in infancy for cerebrospinal fluid shunt procedures. Anaesthetic concerns include those related to other frequently associated congenital abnormalities. Airway management requires particular attention. The limited literature on this subject suggests that these patients require postoperative intensive care admission. This is not always possible in the resource-limited environment. This case report describes the successful anaesthetic management of an infant with Dandy–Walker Syndrome without postoperative intensive care admission.
TL;DR: Differences in unsafe practices among anaesthesiologists who had read the guidelines were statistically significant but clinically inconsequential, highlighting a need for greater publicity, emphasising their practical importance.
Abstract: Background: Propofol lipid emulsion supports bacterial growth and various outbreaks of postoperative infection are attributed to extrinsic contamination. This study’s objectives were to ascertain p...
Journal Article•
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TL;DR: Clinicians voice vociferous support for the sentiments expressed by Biccard, Dyer, Swanevelder, Coetzee and Shafer in their editorial, “Is the HPCSA requirement for a research dissertation for specialist registration the best option?”
Abstract: “When the marketplace is full of dangerous and defective goods, there is no free market because the trust requisite to support a market has evaporated” 1
As clinicians with a passion for research and training we wish to voice our vociferous support for the sentiments expressed by Biccard, Dyer, Swanevelder, Coetzee and Shafer in their editorial, “Is the HPCSA requirement for a research dissertation for specialist registration the best option?” 2
TL;DR: In this paper, the authors explored individual personal and professional reactions amongst a group of senior anaesthetic trainees in their fourth year of specialist training in the University of KwaZulu-Natal Department of Anaesthesia.
Abstract: Background: A perioperative death can be a devastating event for which anaesthetists’ training does not necessarily prepare them. Previous authors have documented a range of reactions to this event. This study set out to explore individual personal and professional reactions amongst a group of senior anaesthetic trainees.Methods: A qualitative methodology was employed and purposive sampling used to select participants. Ten registrars in their fourth year of specialist training in the University of KwaZulu-Natal Department of Anaesthesia were interviewed. Transcripts of the interviews were thematically analysed.Results: Themes expressed by participants fell into three broad categories: professional role (responsibility, coping, functioning after a death), relationships with patients and families (nature of the case, emotional distress, bearing bad news), and personal impact (guilt, physical sequelae, support, desensitisation).Conclusion: Participants’ perceptions supported the notion of potential second (a...
TL;DR: In this article, the authors compared the incidence and severity of emergence agitation in the paediatric age group under sevoflurane or isof lurane anaesthesia using PAED Scale (Pediatric Anaesthesia Emergence Delirium Scale) and its correlation with pre-induction agitation as well as its association with pain using the FLACC (Face Legs Activity Cry Consolability) score.
Abstract: Background: Emergence agitation (EA) is a well-recognised phenomenon often observed in children following general anaesthesia. The aim of this study was to compare the incidence and severity of EA in the paediatric age group under sevoflurane or isoflurane anaesthesia using the PAED Scale (Pediatric Anaesthesia Emergence Delirium Scale) (the primary outcome) and its correlation with preinduction agitation as well as its association with pain using the FLACC (Face Legs Activity Cry Consolability) score (the secondary outcome).Method: In this randomised controlled trial, 60 children aged between 2 and 6 years were enrolled and randomly divided into two groups. All patients were induced with sevoflurane, relaxed with atracurium and the airway secured with an appropriate device. Anaesthesia was maintained with O2, N2O and sevoflurane or isoflurane. Adequate analgesia was ensured. Post-procedure, they were observed in the post-anaesthesia care unit (PACU) for development of EA. The statistical package SPSS® ve...
TL;DR: Preoperative agitation, non-African race and ENT surgery were predictors of postoperative agitation and postoperative vomiting, which correlates with the trend seen in adults, even though incidence difference between African and non- African patients was not statistically significant.
Abstract: Background: It has been suggested that preoperative agitation in children may be a risk factor for postoperative delirium and postoperative vomiting. Previous studies have suggested that adult African patients have a lower incidence of postoperative nausea and vomiting, but no such association has been shown in children.Aim: To determine the incidence of both postoperative delirium and postoperative vomiting in elective paediatric surgical patients in a South African hospital and their association with preoperative agitation and patient race.Methods: A retrospective database analysis was undertaken of patients 1–12 years of age undergoing elective surgery. The Watcha behavioural scale was used to assess pre- and postoperative agitation. A Watcha score > 2 defined significant preoperative agitation or postoperative delirium. Multivariable logistic regression evaluated ENT surgery, sex, age, volatile type, significant preoperative agitation and race as predictors of postoperative delirium. Sex, race, signif...
TL;DR: Short-term outcomes of the applied 3-in-1 procedure are promising for improvement of symptoms secondary to FBSS and may ultimately prove to be recommended as the therapeutic modality for such a challenging clinical problem.
Abstract: Objectives: To evaluate the short-term outcome of a 3-in-1 procedure including percutaneous facet radiofrequency, percutaneous spinal fixation and steroid with hyaluronidase enzyme injection versus percutaneous spinal fixation alone for cases with failed back surgery syndrome (FBSS).Patients and methods: The study included 50 patients who had had previous spinal surgery since a mean duration of 39.7 ± 8.5 months and developed recurrent back pain since a mean duration of 10 ± 2.1 months. Patients were randomly allocated into two groups; group A underwent percutaneous spinal fixation only and group B underwent the 3-in-1 procedure. Outcome was evaluated at the end of six months postoperatively (PO) using a pain numeric rating scale (NRS), the Oswestry Disability Index (ODI) and Odom’s criteria for evaluation of surgical outcome with evaluation of patients’ satisfaction by outcome.Results: All patients showed progressive decrease of NRS pain and ODI scores compared with preoperative scores. However, patients...
TL;DR: An association between a cheap and widely available educational vehicle, and an increase in nurse knowledge scores is demonstrated, and the use of mobile telephones in medical education in limited-resource settings should be explored further.
Abstract: Background: Anaesthesia nurses form a critical part of the team providing perioperative care to patients, but no accredited training exists for them in South Africa. In this setting, short in-service training interventions are a pragmatic attempt at improving nurse performance and patient outcomes. Traditional didactic teaching formats have limitations, and mLearning (the use of mobile telephones to facilitate education) has proved equivalent or superior to traditional teaching methods in several settings. Despite very high levels of mobile phone ownership amongst healthcare workers in Africa, this form of educational delivery has not been tested in the hospital-based nursing population.Methods: A telephonic true/false pre-test was performed with 12 nurses of varying levels of training, to assess their pre-existing knowledge of anaesthesia. A pre-learning package was then delivered to them in the form of daily SMSs for a month, covering relevant anaesthesia content. A telephonic post-intervention test was...
TL;DR: Sevoflurane at 1-MAC minimally decreases the Tei index, which implies that, overall, myocardial mechanics/performance in healthy individuals is not negatively affected by sevofLurane anaesthesia.
Abstract: Background: The myocardial performance (Tei) index is a simple, reproducible and easily performed measure of cardiac performance. Its ease of use and proven clinical application make this an attractive measure perioperatively. For appropriate use of this index under sevoflurane anaesthesia, drug effects on normal values need to be defined.Methods: A total of 38 ASA 1 patients were consecutively included in this study. Induction was by sevoflurane inhalation. Steady state was defined as 3–5 min spontaneous tidal ventilation with an end-tidal sevoflurane concentration of at least 2.3%. Baseline and steady-state measurements included haemodynamics and four-chamber transthoracic echocardiographic image acquisition. Offline analysis focused on tissue Doppler studies of the lateral mitral annulus. Discrete variables before and after induction were compared.Results: Changes in simple haemodynamic variables were as expected (Systolic blood pressure: mean [95% CI] –11.62 [–15.96 to –7.27]; diastolic blood pressure...
TL;DR: The case illustrates the challenges of managing a severely compromised airway and presents an alternative technique for consideration that may obviate the requirement for a challenging surgical attempt to secure the airway.
Abstract: Background: This case report details the management of a patient with a threatened airway booked for an emergency awake tracheostomy but successfully managed with a percutaneous tracheostomy technique. The case illustrates the challenges of managing a severely compromised airway and presents an alternative technique for consideration that may obviate the requirement for a challenging surgical attempt to secure the airway.Methods: A 42-year-old male presented with a threatened airway as a consequence of complicated dental sepsis extending into the neck. Extensive head and neck swelling was assessed as severe enough to make bag-mask ventilation, direct laryngoscopy and rescue with a supraglottic airway (SGA) impossible. Critical narrowing of the pharynx, identified on CT scan, made fibre-optic intubation risky in terms of completely obstructing the airway during the attempt. The airway was secured by a percutaneous tracheostomy technique with local anaesthetic under ultrasound guidance with the pati...
TL;DR: The findings indicate that anaesthetists adhere to current recommendations regarding glucose management, and confirmed the safety of intraoperative administration of 0–2.5% dextrose in isotonic solution to healthy infants.
Abstract: Background: Infants may be at risk of hypoglycaemia in the perioperative period. Current evidence has led to the global use of maintenance fluid with low-concentration dextrose in these patients. T...
TL;DR: A retrospective follow-up audit was conducted from June 2014 to December 2015 and included data on epidural rates, indications, complications and patient satisfaction to evaluate the impact of change on care provided and to recommend future changes.
Abstract: Background: A 2012 audit on labour epidural analgesia rates in Tygerberg Hospital (TBH) revealed that only 2.2% of labouring parturients received epidural analgesia. This unacceptably low number necessitated a dedicated epidural service that was subsequently initiated in June 2014 by the Department of Anaesthesiology and Critical Care to improve the quality of care in labouring patients.Methods: A retrospective follow-up audit was conducted from June 2014 to December 2015 and included data on epidural rates, indications, complications and patient satisfaction. Comparison was made with the 2012 data to evaluate the impact of change on care provided and to recommend future changes.Results: Labour epidural rates improved to 5.16% for the audit period, with 2014 and 2015 rates of 7.44% and 3.89% respectively. Daytime epidurals doubled in 2014/2015 and complication rates decreased from 32.3% in 2012 to 16%. Primary indications for epidural analgesia included pre-eclampsia, morbid obesity, primigravidit...
TL;DR: The study showed that CSDs play an important role in provision of anaesthesia services, especially in rural areas, however, they work largely unsupervised and receive little further training or support.
Abstract: Background: Anaesthesia-related maternal mortality remains unacceptably high, especially in district hospitals. Community service doctors (CSDs) play an important role in the provision of anaesthesia in these hospitals. The purpose of this study was to understand the experience of doctors providing anaesthesia during community service. Identifying deficiencies in the performance of anaesthesia by CSDs can lead to remedial actions.Methods: A prospective, questionnaire-based study was done of doctors who had done their anaesthesia rotation during their internship in Pietermaritzburg, between 2008 and 2010. Quantitative data were collected regarding their performance of anaesthesia during community service. The data included details concerning the provision of anaesthesia, supervision and training, and whether CSDs felt adequately prepared to perform anaesthesia during community service. Qualitative data were also collected, which will be reported in another article.Results: The study response rate was 72.9%...
TL;DR: Blind tracheal intubation through ILMA is a possible option for airway management in patients with a semi-rigid cervical collar in the face of fixed cervical spine immobilisation.
Abstract: Background: Cervical spine immobilisation with a semi-rigid cervical collar imposes difficulty in tracheal intubation. There is increasing use of the Intubating Laryngeal Mask Airway (LMA- FastrachTM) for intubation in patients with difficult airways. The present study was conducted to assess its potential role for tracheal intubation in simulated fixed cervical spine patients.Method: After obtaining approval from the ethics committee and patients’ consent, this observational study was performed on 35 adult patients of either sex of ASA physical status I and II scheduled to undergo surgery under general anaesthesia requiring tracheal intubation. A two-piece semi-rigid cervical collar of appropriate size was positioned around the neck of patients. A standard anaesthesia protocol comprising glycopyrrolate, propofol and vecuronium was used for induction of anaesthesia. ILMA placement and blind tracheal intubation through this was attempted by using dedicated silicone tube provided with the ILMA set. Success ...
Journal Article•
TL;DR: The dichotomous choice between growth and safety applies equally to the pursuit of excellence in anaesthesia: Do the authors safely stick with what they know, or grow the discipline by developing new knowledge, techniques and devices?
Abstract: “In any given moment, we have two options: to step forward into growth, or to step back into safety.”
Abraham Maslow
Psychologist Abraham Maslow may have fared well as an anaesthesiologist, recognising the hierarchy of human needs as commencing with maintenance of essential physiological homeostasis, followed by promoting safety of the individual, and later providing for psychological needs. Although addressing the concept of selfactualisation, his dichotomous choice between growth and safety applies equally to our pursuit of excellence in anaesthesia: Do we safely stick with what we know, or grow the discipline by developing new knowledge, techniques and devices?
Journal Article•
TL;DR: Guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in children and adults are published.
Abstract: Guidelines for the safe use of procedural sedation and analgesia for diagnostic and therapeutic procedures in children
TL;DR: This case report presents a female neonate, 35 weeks post-conception, weighing 2080 g who presented on day four of life for anaesthesia, who had the five anatomical defects characteristic of Pentalogy of Cantrell.
Abstract: Pentalogy of Cantrell, a rare congenital thoracoabdominal disruption, consists of a supraumbilical abdominal wall defect, lower sternal defect, agenesis of the anterior portion of the diaphragm, an absence of the diaphragmatic part of the pericardium, and a malformation of the heart, typically as an ectopia cordis. This case report presents a female neonate, 35 weeks post-conception, weighing 2080 g who presented on day four of life for anaesthesia. She had the five anatomical defects characteristic of Pentalogy of Cantrell.