Southern African Journal of Anaesthesia and Analgesia - Volume 14, Issue 2, March 2008

This assumes that anaesthesia has, in fact, improved, and if one compares techniques from the early years of anaesthesia in 1846 then of course it has improved a great deal. However, one has to ask if anaesthesia is safer, as this is obviously our ultimate objective, and I think the answer to this is "it depends". It depends on which country and continent one is referring to

Topical lidocaine spray is commonly used to anaesthetise vocal cords and supraglottic structures, and to blunt the intubation and extubation responses. Application of local anaesthetic reduces the sympathetic response that occurs as a result of the stimulation of the larynx. Complications with this technique are rare. We encountered an unusual and unforeseen complication whilst using lidocaine spray in the airway of a patient undergoing microlaryngeal surgery (MLS) for a right vocal cord nodule.

The anaesthesiologist who is faced with anomalies of the face is confronted with the problem of safely securing the airway. Light sedation and the fibre-optic bronchoscopic technique might be useful in the facilitation of tracheal intubation in these patients. In children with an abnormal airway anatomy, the use of a laryngeal mask airway (LMA) has been advocated to secure the airway. In our institution, however, we do not have an LMA or other advanced airway devices. In this article, we report the airway management of a child with an encephalocoele at the root of the nose who presented for surgical correction of the lesion.

Background All the published Saving Mothers Reports generated by the National Committee of the Confidential Enquiries into Maternal Deaths in South Africa have associated anaesthesia-related maternal deaths with the lack of skills of the doctors administering the anaesthesia. The Reports have shown the Free State to be one of the provinces in South Africa with the highest rate of obstetric anaesthesia deaths. Therefore, the current study was performed to determine whether a deficiency exists in the training and experience of doctors administering obstetric anaesthesia. The identifying of such a deficiency would call for the implementation of remedial measures.

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Methods The study was performed in 2005 using questionnaires designed by the first two authors of this paper. All Level 1 and 2 hospitals in the Free State performing Caesarean sections (CSs) were visited. The doctors administering obstetric anaesthesiawere each asked to respond to a questionnaire. The questionnaires enquired about previous training and experience in anaesthesia and, more specifically, obstetric anaesthesia, as well as anaesthesia and nonanaesthesia qualifications. In addition, questions were asked regarding supervision, and whether other duties were performed while administering anaesthesia.

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Results The response rate was 69% (105/148 doctors). Of the respondents, 9.5% were interns, 24.7% community service doctors, 47.6% medical officers, 15.2% general practitioners (GPs) and 2.9% specialists. Twenty-three per cent of respondents had been in their present post for five years or more. Most doctors had received 4 weeks or less training in anaesthesia as an Intern, not including obstetric anaesthesia in 13 cases. Six doctors (GPs or medical officers) had been appointed in posts in which obstetric anaesthesia was required, without previously having administered obstetric anaesthesia. At the time of the survey, two doctors had never performed spinal anaesthesia and five had never administered general anaesthesia for CS, although all were regularly administering obstetric anaesthesia. Apart from the specialists, the Diploma in Anaesthesia was held by only one doctor, a medical officer. Half of the interns were not directly supervised while administering obstetric anaesthesia, while more than half the community service doctors were employed in hospitals where no senior support was available. The doctors frequently had both to administer the anaesthetic and to perform neonatal resuscitation. Twelve of the doctors concerned had often also to perform the surgery itself. Most of the doctors requested further training in obstetric anaesthesia and improved senior anaesthetic assistance.

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Conclusions There is a lack of experience, training and supervision amongst doctors administering obstetric anaesthesia in the Free State. Doctors regularly have to perform other duties, whilst administering obstetric anaesthesia, which may put the mother at risk from inadequate observation. These may be contributory factors to the high rate of maternal deaths from anaesthesia.

Background The aim of our study was to evaluate the effects of two different doses of rocuronium bromide (0.5 mg/kg and 0.9 mg/kg) on the length of neuromuscular block, on the haemodynamic stability and on the side effects in patients of different ages.

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Methods We recruited 80 patients who underwent laparoscopic surgery (cholecystectomy, appendicectomy, varicocelectomy) belonging to ASA I-II classes and divided them into four groups:

• 20 adults (A0.5) who received rocuronium bromide 0.5 mg/kg
• 20 elderly patients (E0.5) who received rocuronium bromide 0.5 mg/kg
• 20 adults (A0.9) who received rocuronium bromide 0.9 mg/kg
• 20 elderly patients (E0.9) who received rocuronium bromide 0.9 mg/kg

Intubation conditions, continuous monitoring of HR, NIBP, SpO2, EtCO2 were recorded. Onset time, REC 25%, TOF-ratio 0.70 were analysed by TOF-WATCH.

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Nerve-evoked muscle tension and neuromuscular paralysis extension were expressed by strength of contraction of adductor pollicis, in response to a direct stimulation of the ulnar nerve (TOF).

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Results The results showed that in elderly patients the effect of rocuronium bromide, at two different doses, was similar. Significant differences regarding the onset time was found among the groups showing that with the same dose of rocuronium bromide, the onset time was prolonged in elderly patients compared to adult patients. Moreover, increasing the dose, the onset time was reduced in both groups (p < 0.05). Forty per cent of adult group A0.5 showed excellent intubation conditions versus 60% of A0.9 (p < 0.05); elderly patients did not show any significant difference in the intubation procedure after different doses of rocuronium bromide.

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Conclusions The results from the four groups showed that in elderly patients 0.5 mg/kg of rocuronium bromide resulted in a good recovery, while 0.9 mg/kg increased the recovery time. Moreover, in adults the high dose was more effective because it reduced the number of injections and post-operative recovery time.

Loco-regional anaesthesia is commonly used for both intraocular and extraocular surgical procedures, although the provision and use of the anaesthetic technique varies worldwide. Injection techniques (retrobulbar, peribulbar and sub-Tenon's blocks) are associated with significant pain; indeed, many patients have a fear of pain. Discomfort during injection can, however, be reduced and patients can be made comfortable through reassurance, careful performance of the technique and the provision of sedation and / or analgesia. In this article, the authors describe common loco-regional anaesthetic techniques and measures to reduce discomfort during injection, thus improving patient satisfaction.

HIV has reached pandemic proportions in Southern Africa. Great emphasis is placed on the prevention and containment of HIV transmission by suppressing virus replication using highly active anti-retroviral therapy (HAART). HAART has proven to be highly effective if taken correctly, and has lead to increased life expectancy. Increasing numbers of HIV-positive patients on antiretroviral (ARV) therapy or HIV-exposed individuals taking prophylaxis present for surgery and critical care management. The anaesthesiologist should be familiar with the anaesthetic implications of HIV as well as the possible drug interactions while on ARV treatment. This article focuses specifically on the anaesthetic implications of the patient on HAART.

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HAART is HIV treatment with a combination of three or more ARV drugs from five broad classes. The specific HAART regimen in use in South Africa is considered in detail in this article. The pharmacokinetics of the ARV drugs is complex, and subject to interactions at many different sites. Serious drug interactions are possible, including drugs commonly used in anaesthesia. Drug interactions and recommendations are discussed in detail.

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ARVs are known to cause multiple systemic side effects, including lactic acidosis, Immune Reconstitution Inflammatory Syndrome (IRIS), premature atherosclerosis and increased cardiovascular risk, hyperlipidaemia, insulin resistance, skeletal disorders, hepatotoxicity, lipodystrophy, mitochondrial abnormalities, allergic reactions and pancreatitis.

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Non-compliance is common, and leads to the rapid development of resistance. The anaesthesiologist may inadvertently exacerbate this in the perioperative period. Recommendations regarding the interruption of treatment and fasting are made. Alternative routes for HAART administration are also explored. The management of the critically ill patient on a HAART regimen is discussed.

Pneumopericardium, and especially tension pneumopericardium, are relatively rare consequences of penetrating, blunt or iatrogenic injury. Despite its rarity and the compressibility of air, pneumopericardium can result in life threatening cardiac tamponade. We present two recent cases of this rare condition with divergent aetiologies from which lessons can be learned. The pathophysiology, diagnosis and treatment of pneumopericardium are reviewed.