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- Volume 17, Issue 3, 2011
Southern African Journal of Anaesthesia and Analgesia - Volume 17, Issue 3, 2011
Volumes & issues
Volume 17, Issue 3, 2011
Author Reitze RodsethSource: Southern African Journal of Anaesthesia and Analgesia 17, pp 219 –220 (2011)More Less
Modern clinical guidelines are developed from structured evidence reviews, with the aim of guiding clinical decision making. In an exhaustive and meticulous process, the International Liaison Committee on Resuscitation (ILCOR) considered 277 specific questions related to resuscitation, to arrive at a "state-of-the-art" international consensus statement on resuscitation science. It is from these recommendations that the new iteration of the American Heart Association (AHA) resuscitation guidelines have been developed. So, what's new?
Author Crichton GordonSource: Southern African Journal of Anaesthesia and Analgesia 17, pp 222 –223 (2011)More Less
The oil-on-canvas painting, entitled Surgery, was painted by Eastern Cape artist, Dorothy Kay, in 1937 and donated to UCT by her daughters. The original, depicting a patient undergoing a cholecystectomy, hangs in the UCT department of surgery.a The surgery depicted in the painting was performed by Dr Bruce Macrae, and assisted by Dr T Oates.
Author D. MohrSource: Southern African Journal of Anaesthesia and Analgesia 17, pp 225 –239 (2011)More Less
Failure to recognise the signs of sudden cardiac arrest or impending cardiac arrest will lead to delayed intervention. Cardiopulmonary resuscitation (CPR) must be initiated without delay, irrespective of the level of skill of the caregiver. The 2010 CPR guidelines emphasise the importance of chest compressions, which have now become the first step in the CPR sequence [compressions, airway, breathing or circulation, airway, breathing (CAB), instead of airway, breathing, compressions, or airway, breathing, circulation (ABC)]. Hands-only CPR should be encouraged where untrained caregivers are involved. Although ventilation may be an important step in some cases of arrest, e.g. primary asphyxia, excessive and inappropriate ventilation is detrimental. Rapid defibrillation is an essential life-saving step for specific arrest rhythms. Always consider reversible causes of cardiac arrest, and "find it, flag it, fix it and follow up!'' Ideally, and especially during an inhospital cardiac arrest, skilled providers should strive to work as a team. Team performance must be reviewed regularly to improve CPR efforts and ultimately outcome. Resuscitation and CPR during the perioperative period is unique, and therefore should be tailored individually to each specific clinical situation. A detailed knowledge of the most up-to-date resuscitation algorithms is essential. These are available from any resuscitation council.
Source: Southern African Journal of Anaesthesia and Analgesia 17, pp 242 –248 (2011)More Less
Background: This prospective study was carried out to evaluate the usefulness of oral ketamine for burn wound dressing in adult patients. The aim was to achieve a state-of-conscious sedation in which the patient would be communicative and cooperative, with minimal, or no pain during burn wound care procedures.
Method: Two hundred and forty wound care procedures were randomly assigned to six treatment groups of patients (groups A-F). The quantities of oral ketamine that they received were as follows: Group A, 0.5 mg/kg; B, 2 mg/kg; C, 4 mg/kg; D, 6 mg/kg; E, 8 mg/kg and F, 10 mg/kg. A five-point verbal rating scale was used to assess pain intensity: the AVPU (alert, voice, pain, unresponsive) scale for level of consciousness. The Likert scale was used for patient satisfaction. Blood pressure, pulse rate and oxygen saturation were monitored. Adverse effects were noted. Comparisons of the efficacy and safety of the different dosages of oral ketamine were made using the SPSS package. The efficacy criterion was verbal rating scale (VRS) ≤ 2, i.e no pain, mild pain or discomfort.
Results: Patients in groups A and B reported higher levels of pain, and in groups C, D, E and F, there were varying degrees of efficacy. Groups E and F had the best analgesic profiles, but at the higher doses, some patients became anaesthetised. The most common adverse effects reported were hallucination (37%) and hypersalivation (29.9%), which occurred more frequently in groups E and F. The patients' assessments of pain were best in Group D, and worst in Group A.
Conclusion: The minimum effective subanaesthetic dose of oral ketamine for analgesia during wound care procedures in adult patients with burns was 6 mg/kg.
The effects of incisional bupivacaine infusions on postoperative opioid consumption and pain scores after total abdominal hysterectomy : original researchSource: Southern African Journal of Anaesthesia and Analgesia 17, pp 250 –253 (2011)More Less
Background: The aim of this study was to determine opioid requirements and pain intensity scores in patients after a total abdominal hysterectomy (TAH) administered with a bupivacaine infusion for a 30-hour period, and then to compare the data with that of a control group.
Method: This was a prospective, parallel, single-blinded randomised trial which took place at the Rahima Moosa Mother and Child Hospital, Johannesburg. Thirty-six consenting patients, who underwent a TAH, were randomised to either having a 0.39% bupivacaine infusion in the incisional site or not. Morphine was administered via a patient-controlled analgesia pump (PCA) for rescue analgesia. Dynamic, static and worst pain scores were assessed one, six and 30 hours after surgery by using a visual analogue scale (VAS). Morphine consumption was recorded at set intervals.
Results: There were statistically significant differences between the two groups' dynamic VAS scores in the first hour and at 24 hours and 30 hours; in the static VAS score in the first hour; and in the VAS scores for the worst pain experienced since the patients were last seen in the first hour and six hours after the operation. There was no statistical difference between the two groups' opioid consumption at all set observation points.
Conclusion: The opioid requirements of the two groups were comparable, although participants who had the bupivacaine infusion experienced reduced pain intensity which lasted until six hours postoperatively, and also had reduced pain intensity when moving around 30 hours after the operation.
The effects of intrathecal midazolam on the duration of analgesia in patients undergoing knee arthroscopy : original researchSource: Southern African Journal of Anaesthesia and Analgesia 17, pp 255 –259 (2011)More Less
Background: Spinal anaesthesia is a common anaesthetic technique for lower limb surgery. Many adjuvants have been tried to prolong the duration of analgesia provided by local anaesthetics when administered intrathecally. Midazolam has been shown to prolong the duration of analgesia when used as an adjuvant, providing the added advantages of mild sedation and amnesia, while being devoid of neurotoxicity, and the adverse effects of opioids. This study was designed to evaluate the effect of 2 mg preservative-free intrathecal midazolam added to spinal bupivacaine during postoperative analgesia, and the incidence of adverse effects, if any, in patients undergoing knee arthroscopies.
Method: Fifty consenting American Society of Anesthesiologists (ASA) physical status I or II patients of either gender (men = 19, women = 31), aged between 18-56 years, were randomly allocated to two groups (25 each). Group M received 0.5% hyperbaric bupivacaine with preservative-free midazolam 2 mg intrathecally, and Group S received 0.5% hyperbaric bupivacaine with saline intrathecally. Peak sensory level, total duration of analgesia, duration of motor blockade, pain score using the Visual Analogue Scale, and sedation score using the Observer Assessment Score of Sedation were assessed, along with vital parameters, namely heart rate and systolic, diastolic and mean blood pressure.
Results: The total duration of analgesia observed was significantly higher in Group M (399 ± 88.11 minutes) vs. Group S (301.60 ± 110.14 minutes), and the pain score was lower in Group M (33.6 ± 4.68 mm) vs. Group S (56.6 ± 8.64 mm).
Conclusion: The addition of preservative-free midazolam 2 mg to intrathecal 0.5% hyperbaric bupivacaine prolongs the duration of analgesia without any observed adverse effects in patients undergoing knee arthroscopies.
Anaesthesia with dexmedetomidine and remifentanil in a child with mitochondrial myopathy : case studySource: Southern African Journal of Anaesthesia and Analgesia 17, pp 262 –264 (2011)More Less
Patients with mitochondrial disorders have complex physiological issues which create a challenging scenario with regard to the safe provision of anaesthetic care. Within the spectrum of mitochondrial disorders, patients can be susceptible to multiple adverse effects and drug reactions from medications used during general anaesthesia. Although recent evidence suggests that inhalational anaesthetic agents may be used in patients with mitochondrial disorders, there is still a preference among some anaesthesia providers to use total intravenous anaesthesia (TIVA). In most scenarios, when TIVA is chosen, propofol is a major component. However, as a result of using propofol, patients with mitochondrial disorders may be susceptible to an acute metabolic crisis. It has been postulated that propofol, especially when given in large dosages, or when infused for prolonged periods of time, can adversely affect the function of the abnormal mitochondria that are present in patients with mitochondrial disorders.
We present our experience with the use of dexmedetomidine as the primary component of a general anaesthetic regimen in a 10-year-old girl with a mitochondrial disorder and dystonia, who required anaesthetic care during a urological procedure. Previous reports on the use of dexmedetomidine as part of TIVA in patients susceptible to malignant hyperthermia are reviewed, and its benefits in patients with mitochondrial disorders, discussed. Additional concerns regarding the perioperative care of patients with mitochondrial disorders are deliberated.
Potentially fatal tricuspid valve aspergilloma detected after laparoscopic abdominal surgery : case studySource: Southern African Journal of Anaesthesia and Analgesia 17, pp 266 –268 (2011)More Less
Fungal endocarditis accounts for 1.3-6% of all cases of infective endocarditis. The most common causative organism is Candida, followed by Aspergillus and other mould fungi. Aspergillus endocarditis is usually associated with high morbidity and mortality. Establishing a definitive and timely diagnosis remains difficult and there are many reports of undetected aspergillomas leading to fatalities in the perioperative period. We present a case report of preoperatively undiagnosed large mobile tricuspid valve aspergilloma obstructing the right ventricular inlet, diagnosed incidentally on the second postoperative day after laparoscopic pancreatic abscess drainage.
Insertion of a temperature probe into the ProSeal® laryngeal mask airway drainage tube : scientific letterSource: Southern African Journal of Anaesthesia and Analgesia 17, pp 271 –272 (2011)More Less
Background: Temperature monitoring is one of the minimum mandatory monitoring standards of anaesthesiology. Intraoperative hypothermia and hyperthermia can both be detrimental for patients. We introduced a temperature probe into a Proseal® laryngeal mask airway (LMA) drainage tube, and measured patient temperatures and evaluated temperature dynamics.
Methods: After obtaining informed consent, a thermistor probe (Datex S5®) was inserted into the drainage tube of a Proseal®LMA. This was done to monitor the intraoperative core body temperature in the distal one-third of the oesophagus, and was undertaken prospectively in 123 patients in whom the placement of an orogastric tube was not mandatory (e.g. orthopaedic, gynaecological and ophthalmic surgery). To confirm the position of the thermistor probe, a fibre-optic bronchoscope was inserted in the drainage tube immediately after removal of the temperature probe.
Results: An increase in temperature, of 2°C ± 1.2°C, was observed from the midpoint to the tip of the drainage tube in more than 95% of cases. As the thermistor crossed the distal end of the drainage tube and entered the lower third of the oesophagus, there was a rapid increase in temperature.
Conclusion: This is a useful method for monitoring core temperature in cases where a gastric tube is not required intraoperatively. This method can be used in all supraglottic devices that have a drainage tube, and is effective, cheap and reliable, with easy accessibility for accurate core temperature measurement.