CME : Your SA Journal of CPD - Volume 26, Issue 3, 2008
Volume 26, Issue 3, 2008
Author Bridget FarhamSource: CME : Your SA Journal of CPD 26 (2008)More Less
The issue of the health of migrants is a pertinent one - not only in the developing world, but also in countries such as our own, which take large numbers of migrants, legal and otherwise, from elsewhere in Africa. And we will continue to do so as long as there are wars and poor economic conditions to the north of us.
Author Zane FarinaSource: CME : Your SA Journal of CPD 26 (2008)More Less
It is with great pride that the South African Society of Anaesthesiologists is hosting the 2008 World Congress of Anaesthesia in Cape Town. To coincide with this event the South African Medical Association has devoted this edition of the Continuing Medical Education Journal to anaesthesia.
Author Gillian LamacraftSource: CME : Your SA Journal of CPD 26, pp 124 –126 (2008)More Less
Most anaesthesia-related deaths occurred in previously healthy patients.
Severe pre-eclampsia and morbid obesity are the commonest co-morbid conditions associated with maternal anaesthesia-related deaths in level 1 hospitals.
Referral pathways must be agreed upon and adhered to so that these patients can be transferred perioperatively to an appropriate level hospital.
Ergotamine must not be given to hypertensive patients.
Spinal anaesthesia should only be given to cardiovascularly stable patients.
Avoid spinal anaesthesia in case of potential severe haemorrhage, e.g. suspected ruptured uterus.
Patients with cardiac disease should be referred to a level 3 hospital.
All anaesthesia-related deaths should have a postmortem examination.
Author Bruce Biccard'sSource: CME : Your SA Journal of CPD 26, pp 130 –133 (2008)More Less
Cardiovascular disease is a leading cause of perioperative morbidity in South Africa.
Unstable cardiovascular conditions need to be identified preoperatively and further evaluated.
Unstable cardiovascular conditions include unstable coronary syndromes, decompensated cardiac failure, significant arrhythmias and severe valvular heart disease.
Perioperative cardiac morbidity is related to the medical condition and functional capacity of the patient, and the extent of the surgery.
Cardiac clinical risk predictors include a history of ischaemic heart disease, heart failure, stroke, diabetes and renal dysfunction.
Patients undergoing low-risk surgery and patients with good functional capacity are generally good surgical candidates.
One should always first consider the risk versus benefit before deferring an intermediate-risk patient.
Attention to simple perioperative factors such as analgesia, temperature and postoperative oxygen is important.
In high-risk cases anaesthesia must be provided by the most experienced doctor possible within the limitation of the health service.
Author Paul BorgdorffSource: CME : Your SA Journal of CPD 26, pp 134 –136 (2008)More Less
Postoperative pain is a common concern among patients and their families.
Pain levels should be assessed objectively by using pain scales.
Opioids are often avoided because of fears of side-effects or addiction, both of which are rare in postoperative patients.
In the management of postoperative pain, the intention is to target different mechanisms of pain with different analgesics (multimodal analgesia) by combining analgesics with different modes of action.
The patient should be informed about the expected level of postoperative pain associated with the operation, and about the methods of providing analgesia.
One of the objectives of premedication is to initiate analgesic management before surgical tissue damage has occurred.
After all surgical procedures, the aim is to achieve a pain score of 4 or less.
If severe postoperative pain is anticipated the preferred management is by means of an epidural catheter or continuous plexus anaesthesia, or, if unavailable, by patient-controlled analgesia using intravenous morphine.
Anti-emetic therapy is required if opioids are used to control postoperative pain.
Patients are entitled to high-quality postoperative management which is possible to achieve with current techniques.
Source: CME : Your SA Journal of CPD 26, pp 137 –140 (2008)More Less
The injured brain is susceptible to insults that, under physiological conditions, would not cause damage.
Preventing and treating secondary insults seems to offer the most hope for optimising outcome following TBI.
Prevention of hypoxia, hypotension, seizures and the rapid evacuation of intracranial haematomas offer the best advantages.
Hypothermia, routine hyperventilation and steroids offer no benefit.
Life-saving surgery may take priority over the TBI.
Non-life-saving surgery should be delayed until the TBI has stabilised, ideally 48 - 72 hours or more after injury.
If used carefully most anaesthetic techniques and drugs are suitable, with a few exceptions.
Attention to the general principles of care, especially avoiding hypotension, is key to maximising the neurological outcome.
Author Johan DiedericksSource: CME : Your SA Journal of CPD 26, pp 141 –144 (2008)More Less
Cardiac murmurs in children may have serious haemodynamic implications during anaesthesia and surgery.
Innocuous and pathological murmurs have characteristics that differ, but there is unfortunately also overlap.
Most murmurs (>70%) are innocuous and anaesthesia can be safely administered.
It is essential to investigate any murmur detected preoperatively to exclude dangerous murmurs.
An appropriate history and thorough clinical examination will enable diagnosis of most innocuous murmurs.
For some cardiac lesions perioperative antimicrobial prophylaxis is necessary for some procedures.
Patients should be referred for postoperative evaluation and follow-up.
Patients and parents should be informed of the implications and need for prophylaxis and follow-up.
Author C. HammerschlagSource: CME : Your SA Journal of CPD 26, pp 146 –150 (2008)More Less
Regional anaesthesia, from plexus blocks to skin infiltration, can be used to provide analgesia for most surgery.
Cognisance must be taken of the following when choosing the dose of local anaesthetic agent:
- potency and toxicity of the drugs
- the site of injection
- the volume needed for the block
- the desired characteristics of the block (motor or sensory block)
- the patient's physiology.
Author M.F.M. JamesSource: CME : Your SA Journal of CPD 26, pp 151 –154 (2008)More Less
Modern fluid therapy requires an understanding of the underlying physiological abnormalities induced by acute illness, the nature of the fluids to be administered, the differences between the various intravenous fluid preparations and concepts regarding appropriate amounts of volume to be given.
Crystalloid solutions expand the extracellular fluid (ECF) space and are redistributed between the intravascular and extracellular compartments in a ratio of 1:4 in proportion to the normal distribution of fluid between these two spaces.
The most widely used crystalloids, 0.9% saline and balanced salt solutions such as Ringer's lactate, fall well short of the desired composition.
'Normal' saline is significantly hypertonic (osmolality 308 mOsm/l) and has a very high chloride content (154 mmol/l; normal plasma range 95 - 105 mmol/l).
Infusions of as little as 2 litre 0.9% saline during surgical procedures will produce a significant, metabolic acidosis owing to the chloride load.
Ringer's lactate (or acetate), like 0.9% saline, is not an ideal solution. The Cl- content is substantially higher than plasma chloride (111mmol/l), the Na+ content lower (131 mmol/l) and the osmolarity of the solution is 274 mOsm/l.
Colloids are suspensions of particles of various sizes that aim to maintain plasma volume by maintaining the colloid osmotic pressure in plasma, thus retaining the administered volume within the circulation.
Recently the 'third space' concept has been questioned and attention has focused on the potential adverse effects of excess administration of crystalloid solutions.
Intravenous fluid loading is often used as first-line therapy for patients with hypotension or circulatory failure, but in only half of patients does cardiac output respond positively after fluid challenge. For the remainder of patients fluid loading may be associated with adverse consequences.
Mechanically ventilated patients have a higher mean CVP, more indicative of mean intrathoracic pressure than of cardiac filling or intravascular fluid status.
The patient who demonstrates a positive response to passive leg raising has been reliably shown to benefit from the administration of intravenous fluid.
It has recently been established that not only systolic pressure variation but also several analogous derivatives provide valuable clinical information on a continuous basis.
The predictive value of systolic pressure variation is well attested to in ventilated patients. Patients breathing spontaneously demonstrate the same phenomenon, but critical assessment is more difficult.
Author J.L.A. RantloaneSource: CME : Your SA Journal of CPD 26, pp 155 –156 (2008)More Less
Author Jenny KingSource: CME : Your SA Journal of CPD 26, pp 155 –156 (2008)More Less
Author Lauren BurnsSource: CME : Your SA Journal of CPD 26, pp 160 –163 (2008)More Less
The field of cognitive rehabilitation is much less understood than the physical modalities.
Cognitive disorders following TBI are extremely common.
Neurobehavioural deficits of many brain-injured patients represent their most significant obstacles to community and vocational reintegration.
Changes in cognition, behaviour and personality after TBI are considered by clinicians to be among the most difficult disabilities tomanage effectively.
Patients with little or no physical fallout from a TBI may have significant cognitive impairments.
Research strongly suggests that the bulk of neurological recovery from acute brain injury occurs within the first 6 months after injury.
Memory impairments are among the most common, most persistent and most handicapping of the cognitive deficits after TBI.
Patients with cognitive impairments may be completely unaware of their deficits and limitations.
The role of family members and caregivers is critical in the effective management of patients with cognitive impairment.
Source: CME : Your SA Journal of CPD 26, pp 160 –163 (2008)More Less
Complementary and alternative medicines and dietary supplements are not regulated by the Food and Drug Administration (FDA) or the Medicine Control Council as rigorously as conventional prescription and over-the-counter drugs. Although not permitted to market unsafe products, the manufacturers of herbal medicines currently do not have to prove that their products are safe and effective.
Source: CME : Your SA Journal of CPD 26, pp 164 –166 (2008)More Less
In 2005, WHO re-emphasised the importance of chronic (non-communicable) diseases as a neglected global health issue. Chronic diseases (mainly cardiovascular disease, cancer, chronic respiratory disease, diabetes and stroke) were estimated to cause more than 60% (35 million) of all deaths in 2005; more than 80% of these deaths occurred in low-income and middleincome countries.