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- Volume 18, Issue 2, 2012
Southern African Journal of Anaesthesia and Analgesia - Volume 18, Issue 2, 2012
Volumes & issues
Volume 18, Issue 2, 2012
Myocardial ischaemia during coronary artery bypass graft surgery : a review of the pathophysiology (part 1) : review articleAuthor P. MotshabiSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 70 –74 (2012)More Less
Myocardial mortality and morbidity during cardiac surgery is a devastating emotional phenomenon for both the medical team and the patient's family, often leading to dire financial consequences. Multiorgan dysfunction as a result of the effects of the neurohumoral system, triggered by surgery, anaesthesia, cardiopulmonary bypass, hypothermia and blood transfusion, can lead to prolonged intensive care unit and hospital stay. In this article, a literature review was embarked upon, to understand the pathophysiology and to find ways for early detection, of perioperative cardiac surgery-specific myocardial damage. It is important to appropriately understand and interpret the pattern of enzyme leakage as a marker of myocardial injury during cardiac surgery. Supplemented by clinical findings and echocardiographic evidence of possible causes of low cardiac output, earlier diagnosis may mean more prompt and goal-directed intervention, with a better outcome. A multidisciplinary approach to improve outcomes in this patient population is an absolute necessity. This can lead to modifications in surgical, anaesthetic, perfusion, and postoperative care strategies targeted at attenuating the effects of the neurohumoral insult. Often, the side-effect profile of pharmacological agents limits their use in this patient population, due to their labile haemodynamic profiles. More research is necessary to continue to interrogate the available information, and to produce new information, both in understanding the pathophysiology, and with regard to intervention strategies.
Author A.G. BeetonSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 77 –85 (2012)More Less
The major, costly, and catastrophic adverse consequences of anaesthesia are reviewed. The American Society of Anesthesiologists' closed claims registry yields valuable insights. The size and success of claims is determined by the standard of care, and extent of injury. Ongoing assessment of the pattern of claims allows determination of high-risk patients and interventions, as well as the formulation of protocols or practice guidelines to reduce risk. Injuries to previously healthy individuals are inevitably more costly. Respiratory mechanisms still account for the majority of serious adverse events. However, the focus has shifted from intubation problems to extubation and the recovery room. Emerging areas of concern are claims that relate to nerve injury, with or without regional anaesthesia, postoperative visual loss, and monitored anaesthesia care and sedation. An area of particular concern, namely spinal-epidural haematoma associated with central neuraxial blockade, is a typical example of the closed claims registry / taskforce / protocol approach. Specific risk factors, such as use of anticoagulants close to the time of performance of the neuraxial block, traumatic technique, elderly patients, and renal dysfunction, have been identified. Protocols have been devised for risk reduction.
The treatment of perioperative myocardial infarctions following noncardiac surgery : original researchSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 86 –93 (2012)More Less
Background: Perioperative myocardial infarction (PMI) is a common complication following noncardiac surgery, with a 30-day mortality of 10-20%. Effective therapeutic interventions are of public health importance.
Method: This is a systematic review, aimed to determine the evidence for therapies following PMI.
Results: A PubMed Central search up to May 2011 identified 20 case series and reports (89 patients). We extracted data on the type and timing of treatment and short-term mortality. Short-term mortality differed significantly between haemodynamically stable and unstable patients (0% and 32.2% respectively, p-value = 0.015). Significantly more haemodynamically unstable patients received acute coronary interventions (75.8% vs. 23.1%, p-value = 0.0006). Acute coronary intervention in haemodynamically unstable patients was not associated with improved short-term survival (p-value = 0.53). The high proportion of symptomatic and haemodynamically unstable patients suggests publication bias (χ2 = 16.29, p-value = 0 < 0001 and χ2 = 154.41, p-value < 0.0001, respectively).
Conclusion: This systematic review highlights the paucity of evidence for PMI management, and the need for future prospective trials.
Source: Southern African Journal of Anaesthesia and Analgesia 18, pp 96 –100 (2012)More Less
Background: Chronic use of opioids in opium abusers can cause poor pain control and increased analgaesic requirement. We compared the duration of spinal anaesthesia in chronic opium abusers and non-abusers.
Method: This prospective randomised study included 60 American Society of Anesthesiologists (ASA) Grade I or II adults undergoing surgery under spinal anaesthesia with 10 mg bupivacaine, and 25 μg fentanyl in non-opium abusers (Group A); and chronic opium abusers (Group B), and 40 μg fentanyl in chronic opium abusers (Group C). Patients were assessed for onset and duration of sensory and motor blockade and duration of effective analgesia.
Results: Mean time to onset of adequate analgesia in opium abusers was significantly longer in chronic opium abusers than in opium-naive patients. The duration of sensory block and motor block was significantly less in chronic opium abusers than in non-opium abusers. Duration of effective analgesia in groups A, B and C was 255.55 ± 26.84, 217.85 ± 15.15, and 268.20 ± 18.25 minutes, respectively; this difference was statistically significant.
Conclusion: In chronic opium abusers, the duration of spinal anaesthesia is significantly shorter than that in opium non-abusers. The duration of spinal anaesthesia with bupivacaine and fentanyl in chronic opium abusers can be improved by increasing the intrathecal fentanyl dose from 25 μg to 40 μg.
Source: Southern African Journal of Anaesthesia and Analgesia 18, pp 101 –104 (2012)More Less
Background: False alarms and sounds in the operating theatre (OT) that alert personnel to a crisis can be irritating. This can result in personnel ignoring genuine alarm warnings. This study was carried out to determine how alert OT personnel are in response to the pulse oximeter alarm.
Method: For the purposes of the study, 144 elective and 126 emergency cases, comprising 189 general anaesthesia and 81 regional anaesthesia cases, were included. After ensuring that the patients were physiologically stable, a false pulse oximeter alarm was activated. No other alarms were triggered. The first person to respond, time taken to respond, and the mode of action taken, were recorded. If no action resulted, the alarm was terminated a minute later.
Results: The anaesthesiologist was the most alert (p-value < 0.05), with a median time taken to respond of nine (4-14) seconds. The emergency OT personnel were significantly more alert than the elective OT personnel, with a p-value of < 0.001. The level of readiness was similar in both general anaesthesia and regional anaesthesia cases [ 9.5 seconds (4.0-14.05) vs. 10 seconds (5-15)]. In 53% of cases, the first person to respond attended to the patients; in 30.7% of cases, they checked the monitor; and in 5.6% of cases, the pulse oximeter alarm was deactivated. The pulse oximeter alarm was ignored, and no action taken, in 10.7% of cases.
Conclusion: The anaesthesiologists were the most alert in responding to the pulse oximetry alarm, although, alarmingly, no action was taken in 10.7% of cases.
Perioperative effect of epidural dexmedetomidine with intrathecal bupivacaine on haemodynamic parameters and quality of analgesia : original researchSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 105 –109 (2012)More Less
Background: The present study was a randomised controlled trial designed to evaluate the perioperative effect of epidural dexmedetomidine, in conjunction with intrathecal bupivacaine.
Method: In this trial, 60 male patients of American Society of Anesthesiologists' grades I and II, between 20-50 years of age, and posted for elective lower limb orthopaedic surgery, were selected. After written informed consent was obtained and a thorough preanaesthetic check-up carried out, the patients were randomly divided into two groups using the manual envelope randomisation technique. Group I received 2.5 ml of 0.5% bupivacaine intrathecally, plus 10 ml normal saline (NS) epidurally (control). Group II received 2.5 ml of 0.5% bupivacaine intrathecally, plus 2.0 μg/kg dexmedetomidine epidurally, made up to 10 ml with NS (study).
Results: We observed a significant prolongation in the duration of analgesia to 424.1 minutes (Group II) in patients receiving epidural dexmedetomidine, in comparison to 140.0 minutes in patients receiving saline (Group I). There was a significant fall in the pulse rate and mean arterial pressure five minutes following epidural dexmedetomidine in Group II patients, which lasted throughout the study period. The majority of the patients in Group II were sedated, yet arousable, by verbal commands or light tactile stimulus (sedation scale 3-4) 10 ± 5 minutes following administration of dexmedetomidine in the epidural space. This decrease in the level of consciousness lasted for 45 ± 5 minutes.
Conclusion: The addition of 2 μg/kg dexmedetomidine epidurally to 2.5 ml of intrathecal bupivacaine prolongs the duration of analgesia, and decreases the requirement of rescue analgesics in patients undergoing lower-limb orthopaedic surgery, with a significant fall in pulse rate and mean arterial pressure.
Tramadol and postoperative shivering in patients undergoing open and laparoscopic cholecystectomy under general anaesthesia : original researchSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 111 –114 (2012)More Less
Background: For many years, shivering after anaesthesia has been recognised, and is one consequence of perioperative hypothermia. Shivering affects a number of physiological parameters. The aim of the study was to evaluate the severity of hypothermia after open and laparoscopic cholecystectomy, and to determine the efficacy of injection tramadol hydrochloride (HCl) in preventing postanaesthetic shivering.
Method: Eighty American Society of Anesthesiologists (ASA) Grade I and II patients scheduled to undergo either laparoscopic cholecystectomy, (Group A, n = 40) or open cholecystectomy (Group B, n = 40), were included in this randomised prospective study. Patients were further allocated randomly to two groups, to receive either tramadol 1 mg/kg (treatment group, Group A1 and B1, n = 40, 20 patients in each group), or the equivalent volume of normal saline (control group, Group A2 and B2, n = 40, 20 patients in each group), at the time of wound closure.
Results: Fall in temperature was significantly more in the laparoscopic cholecystectomy group (0.70°C and 0.81°C), than in the open cholecystectomy group (0.32°C and 0.275°C). The incidence of postanaesthetic shivering was comparable in the treatment groups (A1 and B1), but was significantly higher in the control groups (A2 and B2). Incidence of sedation was not significantly different between treatment and control groups.
Conclusion: Tramadol significantly reduced the incidence and severity of shivering, following open and laparoscopic cholecystectomy operations.
Source: Southern African Journal of Anaesthesia and Analgesia 18, pp 115 –118 (2012)More Less
The authors present the anaesthetic management of two infants with pyruvate dehydrogenase complex deficiency (PDCD), a rare genetic disorder of carbohydrate metabolism leading to lactic acidosis and neurological impairment. In the first case, a seven-month-old infant, undergoing closed reduction of a dislocated hip, received general anaesthesia with a volatile agent. In the second case, spinal anaesthesia was administered to a six-month-old infant undergoing Achilles tendon lengthening. There were no adverse outcomes in both cases. Key components of perioperative care included minimising perioperative stress, and avoiding exacerbation of the lactic acidosis. Previous reports regarding the perioperative care of such patients are reviewed, and recommendations for anaesthetic care discussed.
Source: Southern African Journal of Anaesthesia and Analgesia 18, pp 119 –123 (2012)More Less
Ehlers-Danlos syndrome (EDS) consists of a group of connective tissue disorders characterised by hyperelasticity of the skin and hypermobile joints. Parathyroid adenoma results in increased parathyroid hormone secretion. We report the case of a 20-year-old male patient with EDS and parathyroid adenoma, who underwent surgery to excise the tumour. A thorough preoperative evaluation, stabilisation, and necessary precautions and monitoring during the intraoperative period, ensured an uneventful postoperative period.
Klippel-Feil syndrome for scoliosis surgery : management of a potentially difficult paediatric airway,and report of false-negative motor-evoked potential : case studyAuthor P.C.S. TanSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 124 –127 (2012)More Less
A six-year-old girl with Klippel-Feil syndrome and throcacolumbar scoliosis was scheduled for growing rod insertion. Inhalational induction and tracheal intubation were carried out, with her neck in a neutral position. However, the patient woke up with paraplegia, despite normal intraoperative neurophysiological monitoring, which necessitated immediate revision surgery. Intravenous induction was performed for the second surgery. We discuss the management of a potentially difficult paediatric airway, and report on false-negative motor-evoked potential.