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- Volume 16, Issue 4, 2010
Southern African Journal of Anaesthesia and Analgesia - Volume 16, Issue 4, 2010
Volumes & issues
Volume 16, Issue 4, 2010
Author Christina LundgrenSource: Southern African Journal of Anaesthesia and Analgesia 16 (2010)More Less
This has been a very busy year for the South African Society of Anaesthesiologists (SASA) guidelines subcommittee. The first edition of the Acute Pain Guidelines was published in March. The fourth edition of the Adult Sedation Guidelines was revised this month and will soon be available electronically, on the SASA and SAJAA websites. The correspondence in this edition of our journal on issues pertaining to sedation relates to the third edition of the guidelines published earlier this year, which has now been revised. Finally, in November, the first edition of the Paediatric Sedation Guidelines will be launched at the PACSA congress in Johannesburg, and will be available in hard copy format for SASA members and PACSA attendees, and electronically on both the SASA and SAJAA websites.
Anaesthetic gas analysers : potential for confusion and errors if you live and work at moderate altitude : guest editorialSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 6 –8 (2010)More Less
In this issue of the SAJAA, Smith et al report on the effects of various end-tidal concentrations of nitrous oxide on the processed electroencephalogram (EEG) in the presence of approximately 1 MAC of sevoflurane. At low concentrations (10-60%), nitrous oxide had minor effects on 'state entropy' as measured by the M-entropy S/5 Module (GE Healthcare). However, at 70% there were statistically significant and clinically important decreases in entropy. Whereas previous studies have shown that nitrous oxide when given alone has few if any effects on EEG entropy, when administered with 1 MAC volatile anaesthetic agent, there is a threshold at which the effects of the volatile agent are potentiated by nitrous oxide. These findings are in accordance with other reports concerning studies of the clinical effects of combinations of nitrous oxide and oxygen.
Author A. AlbertsSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 9 –10 (2010)More Less
In a recent editorial, "The Recovery Room... a safe haven, or a disaster waiting to happen?" (SAJAA 2009, Volume 15, Number 2, April/May), the topic of ensuring a safe and satisfactory recovery period for our patients was revisited. In 2003, research from a group in Vancouver relating to discharge readiness after outpatient anaesthesia was published in SAJAA.
Author J.F. CoetzeeSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 10 –11 (2010)More Less
Publication of the SASA Sedation Guidelines 2010 (the Guidelines) is a welcome update. There is however a glaring deficiency, namely that no mention is made of the importance of regular assessment of the degree of sedation during procedures. Furthermore, there is no provision made for the writing down thereof on the included "Sedation-Monitoring Chart".
Response to "Sedation guidelines : a record of sedation scores is essential" : letters to the editorSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 11 –13 (2010)More Less
Thank you for giving us the opportunity to reply to Professor Coetzee's letter. We appreciate constructive advice regarding the South African Society of Anaesthesiologists (SASA) adult guidelines for procedural sedation and analgesia. However, we disagree that the omission of subjective sedation scoring systems is a "glaring deficiency" or an "important flaw" as the author suggests. Neither do we agree that the sedation scoring systems are essential, although we believe that they are desirable.
Entropy of the electroencephalogram as applied in the M-Entropy S/5 Module (GE Healthcare) during increases in nitrous oxide and constant sevoflurane concentrations : original researchSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 15 –21 (2010)More Less
Background : It has been suggested that spectral entropy of the electroencephalogram as applied in the M-Entropy S/5 Module (GE Healthcare) does not detect the effects of nitrous oxide (N2O). The aim of this study was to investigate the effect on entropy by graded increases in N2O concentrations in the presence of a constant concentration of sevoflurane, in the absence of surgical stimulation.
Method : This single-blind, randomised study was conducted at an altitude of approximately 1 400 m. Patients received sevoflurane 2% (1.7% at sea level) and N2O, at end-tidal concentrations of 0%, 10%, 20%, 30%, 40%, 50%, 60% or 70% (equivalent to 8.5%, 17%, 25.5%, 34%, 42.6%, 51.1% and 59.6% at sea level). Entropy was measured before, during and after N2O administration. The absolute changes and ratios o f entropy relative to the baseline were calculated. Between- and within-group comparisons were made using analysis of variance and covariance.
Results : None of the entropy variables differed significantly within and between groups before and after N2O administration. Within-group analysis revealed that entropy during N2O administration was signicantly lower than before or after N2O administration (P < 0.007). While a minor clinical but statistically significant linear relationship was observed between increasing N2O concentration and decreasing entropy from N2O 0% to 60%, a steeper and clinically important decrease (relative change > 20%) was noted at N2O > 60% (> 51% at sea level).
Conclusions : The M-Entropy Module S/5 responds to increasing concentrations of N2O in the presence of 2% (1.7% at sea level) sevoflurane, in the absence of surgical stimulation. There is a linear relationship between increasing N2O concentrations and decreasing entropy with a steep and clinically important decrease at N2O > 60% (> 51% at sea level). The influence of ambient pressure on the partial pressures, which determine the effects of anaesthetic agents, must be taken into account.
Safety and efficacy of insertion of supraglottic devices in anaesthetised patients by first-time users : original researchSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 23 –26 (2010)More Less
Background : Over the years, several supraglottic devices have been developed, but the most recent one is the i-gel®. It is a new device with some distinctive features that set it apart from many of its competitors. This study was designed to determine the safety and efficacy of placing different airway devices by first-time users.
Methods : Fifty volunteer doctors who are regularly involved in cardiopulmonary resuscitation and emergency medicine were divided into two groups on the basis of their experience and were timed to insert the two supraglottic devices, i-gel® and laryngeal mask airway (LMA), in ASA grade I, II and III anaesthetised patients under expert guidance. The haemodynamic parameters were recorded and the volunteers were asked to complete a questionnaire.
Results : In both the groups, i-gel® was inserted in less time than LMA. The time taken for insertion of i-gel® by both the groups was not significant. The success rate of inserting i-gel® by both groups was not significant (p > 0.05). Ninety-six percent of participants in both the groups found that i-gel® was easier to insert and required minimal adjustment.
Conclusion : Our results suggest that i-gel® is rapidly inserted by novices, and produces haemodynamic changes compared to those resulting from insertion of classic LMA. We suggest that the device is safe and can be used by first-time users and experts in cardiopulmonary resuscitation and in emergencies.
Patients' perception and knowledge of anaesthesia and anaesthetists - a questionnaire survey : original researchSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 28 –31 (2010)More Less
Background : Most surgical patients do not recognise the role played by anaesthetists in the perioperative period because of poor public knowledge of anaesthesia as a medical discipline. This study was conducted to determine patients' knowledge of anaesthesia and of the qualifications and role of anaesthetists in patient care.
Methods : A cross-sectional questionnaire survey of 229 consecutive adult patients aged 18 years and above, scheduled for elective surgery at the University College Hospital, Ibadan, Nigeria, was conducted over a three-month period.
Results : Of the 229 patients studied, 90 (39.3%) were males and 139 (60.7%) were females. Ninety-nine (43.2%) had a history of previous anaesthesia and surgery, while 130 (56.8%) had no previous experience of anaesthesia. One-third (33 of 99) of patients who had past experience of anaesthesia knew that anaesthesia is administered by qualified anaesthetists. Among 130 patients without a history of previous anaesthetics, 63 (48.5%) had no idea of what the role of the anaesthetist was, 31 (23.8%) listed putting patients to sleep, monitoring vital signs and offering pain relief, and 25 (19.2%) knew that anaesthetists should administer anaesthetics. Patients who had tertiary education (44.1%) had a significantly higher knowledge of the anaesthetist's role than those with only secondary (33.2%) or primary education (15.7%, p < 0.05).
Conclusion : Patients have poor knowledge of anaesthesia and the role of anaesthetists in the care of surgical patients. This knowledge deficit should be addressed and made part of the general preoperative care to enable patients to cope better with a view to improving the outcome of surgical procedures.
Source: Southern African Journal of Anaesthesia and Analgesia 16, pp 33 –36 (2010)More Less
We report the case of a 10-day-old male child weighing 3.5 kg, with mass over the sternal region, a set of four limbs and an omphalocoele that had undergone surgical separation. An exoparasitic twin had fully developed hind limbs, well-developed genitalia, one fully developed upper limb and another, underdeveloped upper limb. Echocardiography and a computed tomographic scan revealed no gross cardiac anomaly and the sharing of any other major organ was absent. The limbs of the parasite were lying in front of the neck and interfered with holding the mask in position. One anaesthetist held these limbs apart. We avoided the use of muscle relaxant out of fear that the large mass could hamper ventilation. The neonate was intubated successfully under deep inhalation anaesthesia. He had an uneventful recovery.
Author A. MilnerSource: Southern African Journal of Anaesthesia and Analgesia 16, pp 38 –41 (2010)More Less
While undergoing conscious sedation for a gastroscopy, an 18-year-old female developed severe hypotension and loss of consciousness. This occurred shortly after an intravenous dose of hyoscine-N-butylbromide (Buscopan®). Resuscitation was performed over a period of 10 minutes and was successful. Once conscious, the patient complained of severe lower abdominal pain. Except for a significant metabolic acidosis (BE = -10), initial investigations were negative. She was transferred to the Intensive Care Unit (ICU) where the abdominal pain continued and the urine output was scanty for the first 12 hours. Investigations were done to exclude : anaphylaxis, mesenteric ischaemia, angioneurotic oedema, pregnancy, porphyria, autoimmune disease and myocardial ischaemia. Finally it was postulated that the drug had either caused an anaphylactoid reaction or grossly augmented cardiovagal nervous inhibition. This resulted in hypotension which caused mesenteric ischaemia that in turn resulted in severe abdominal pain and a degree of renal shutdown.
Source: Southern African Journal of Anaesthesia and Analgesia 16, pp 43 –47 (2010)More Less
We present a case of a parturient infected with human immunodeficiency virus, who developed amniotic fluid embolism during the delivery of her twins by elective Caesarean section. Our management and the available literature are briefly discussed, and consideration is given to a possible association between the two pathologies.