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- Volume 13, Issue 4, 2007
Southern African Journal of Anaesthesia and Analgesia - Volume 13, Issue 4, 2007
Volume 13, Issue 4, 2007
Author A.C. LundgrenSource: Southern African Journal of Anaesthesia and Analgesia 13, pp 5 –10 (2007)More Less
Source: Southern African Journal of Anaesthesia and Analgesia 13, pp 15 –19 (2007)More Less
A 35 year-old female with Marfan's Syndrome, presented for medical termination of pregnancy at 8 weeks' gestation. She had no family history of Marfan's. Despite having undergone dental work for teeth overcrowding, her first medical presentation was with severe aortic regurgitation and cardiac failure in 2003. At that time she underwent urgent aortic valve and aortic root replacement. She has been followed up bi-annually, relatively uneventfully, at cardiac clinic. She is well controlled on furosemide and a beta-blocker, Carvedilol. She had no symptoms of congestive cardiac failure (CCF) and was graded as NYHA class 2. She is also taking warfarin and haematinics.
Although she is in regular contact with the health care system, she claims to have little knowledge regarding her diagnosis in terms of prognosis, natural history and lifestyle issues. The patient informed cardiologists of her plans to fall pregnant, but appeared not to have been advised against this. Only on referral to cardiology, once already pregnant, was she sternly advised to terminate the pregnancy in order to avoid potentially catastrophic cardiovascular consequences associated with pregnancy in patients with Marfan's syndrome.
On examination she is a tall, thin lady with a "wingspan" greater than her height. She has long spidery fingers, dental overcrowding and a high-arched palate. Skeletal anomalies included kyphoscoliosis, pectus carinatum, hypermobility of her joints and pes planus. She had a sternotomy scar, regular pulse, mechanical second heart sound, a soft systolic murmur but no evidence of cardiac failure. Her chest was clear. She had no striae or hernias. ECG showed no significant abnormalities.
Warfarin was changed to heparin prior to the termination. Heparin was stopped 6 hours prior to surgery. No premedication was ordered. She was carefully positioned to reduce the risk of joint trauma or dislocation. She received an intravenous induction with propofol / fentanyl and maintenance with isoflurane, while breathing spontaneously via a face mask. The procedure was uneventful. While she remained in hospital for re-warfarinizing, she complained of a visual field disturbance. This was diagnosed as retinal detachment. She subsequently underwent uneventful surgical correction of the retinal detachment prior to discharge.
An audit of the use of regional anaesthesia for caesarean section in the Free State : from 2002 to 2004 : original researchSource: Southern African Journal of Anaesthesia and Analgesia 13, pp 21 –26 (2007)More Less
Regional anaesthesia (RA) is associated with a lower mortality than general anaesthesia (GA) for obstetric anaesthesia. Accordingly, the Saving Mothers Report 1999-2001 proposed that 75% of Caesarean section (CS) should be performed under RA. An initial audit found that in the Free State, 71% of CS's were performed under RA in 2002. Various educational interventions promoting the use of RA for CS were then instituted and the audit repeated for 2004, to determine whether there had been any change in the use of RA for CS's from 2002 to 2004 and the 75% target achieved.
Source: Southern African Journal of Anaesthesia and Analgesia 13, pp 29 –32 (2007)More Less
Background : Smoking is considered a risk factor not only for anaesthesia, but for general health. On the other hand, it was demonstrated that smoking reduces postoperative nausea and vomiting. In our study, we have investigated this effect in patients undergoing laparoscopic cholecystectomy. Moreover, we have looked to see if there is a relationship between the number of cigarettes smoked daily and the antiemetic effect.
Methods : 71 patients scheduled for elective laparoscopic cholecystectomy under general anaesthesia were divided into 2 groups: group 1 (n=40) included non-smokers and group 2 (n=31) included the smokers. Each group was randomized for propofol and thiopentone as an induction agent. In addition, the smokers were further divided into heavy smokers, for patients smoking more than 20 cigarettes daily and smokers for patients smoking less than 20 cigarettes daily. The incidence of postoperative nausea and vomiting and the severity of pain (on Visual Analogue Score) were both assessed for the first 24 hours postoperatively.
Results : Postoperative nausea and vomiting occurred in 31 patients (77.5%) in the non-smokers' group, as compared with 12 patients (38.7%) in smokers' group (p<0.05). The mean maximum degree of pain (5,82) was significantly lower in the smokers' group as compared with non-smokers where this was 2.8 (p<0.05).
Conclusions : A history of current smoking significantly reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. Smoking also reduced the incidence of postoperative pain. Despite these favorable effects, we would like to emphasize that our study is not intended to promote smoking.
Source: Southern African Journal of Anaesthesia and Analgesia 13, pp 33 –43 (2007)More Less
The growing prevalence of atherosclerosis means that perioperative myocardial infarction (PMI) is a significant issue for the anesthesiologist. Perioperative revascularization (if indicated medically), beta blocker (in high risk patients) and statin therapy are therapeutic modalities that are currently employed to reduce PMI. Statins not only lower low density lipoprotein levels but, via their actions on the isoprene pathway, also exhibit pleiotrophic effects anti-inflammatory effects, thereby stabilizing vulnerable plaque and improve functioning of the endothelium in atherosclerosis. These effects appear to reduce perioperative complications of atherosclerotic lesions. It is important to have an understanding of newer developments in the pathophysiology of atherosclerosis to be able to appreciate the mechanisms of action of statins. The focus has changed from identification of stenotic coronary lesions to the identification of vulnerable plaque. This review is divided into 2 parts. The first part focuses on the pathophysiology of atherosclerosis while the second part discusses the pharmacology of statins and the mechanisms of how they may reduce PMI.