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- Southern African Journal of Anaesthesia and Analgesia
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- Volume 18, Issue 4, 2012
Southern African Journal of Anaesthesia and Analgesia - Volume 18, Issue 4, 2012
Volume 18, Issue 4, 2012
Source: Southern African Journal of Anaesthesia and Analgesia 18 (2012)More Less
A stethoscope placed over the precordium, or in the axilla, is one of the prescribed monitors to use during anaesthesia, since it monitors both the cardiac and breath sounds. However, currently, it is being used infrequently. We describe the anaesthetic management of a child in whom a critical incident was averted with the use of an axillary stethoscope.
A meta-analysis of intraoperative factors associated with postoperative cardiac complications : original researchSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 186 –191 (2012)More Less
Background : Preoperative cardiac risk is commonly determined with the help of risk scores and risk stratification tools. This predetermined cardiac risk may be profoundly changed by intraoperative surgical events. This meta-analysis aimed to identify intraoperative factors that independently predict postoperative cardiac complications in the presence of preoperative cardiac risk factors.
Method : A PubMed Central search was conducted from January 1966 to June 2010, to identify independent intraoperative predictors of postoperative cardiac complications in observational perioperative studies and randomised controlled trials which controlled for preoperative cardiac risk factors.
Results : Eleven studies were identified for inclusion in this meta-analysis. Intraoperative blood transfusion [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.8-3.4] was the only independent intraoperative risk predictor identified in more than one study. Other identified independent intraoperative factors included a > 20 mmHg fall in mean arterial blood pressure for < 60 minutes (OR 3.0, 95% CI 1.8-4.9), > 30% increase in baseline systolic pressure (OR 8.0, 95% CI 1.3-50), tachycardia in the recovery room (> 30 beats per minute from baseline for > 5 minutes) (OR 7, 95% 1.9-26), new onset atrial fibrillation (OR 6.6, 95% CI 2.5-20), hypothermia (OR 2.2, 95% CI 1.1-5) and remote ischaemic preconditioning (OR 0.22, 95% CI 0.07-0.67). None of these studies controlled for blood transfusion.
Conclusion : Both surgical and haemodynamic intraoperative events significantly increased the risk of postoperative cardiac complications. Intraoperative blood transfusion has the strongest evidence that supports this finding. It is possible that modification of these intraoperative risk factors by anaesthetists and surgeons might reduce postoperative cardiac events.
Efficacy of a single dose of a transdermal diclofenac patch as pre-emptive postoperative analgesia : a comparison with intramuscular diclofenac : original researchSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 194 –197 (2012)More Less
Background : We compared the analgesic efficacy of a transdermal diclofenac patch 100 mg (NuPatch® 100, Zydus Cadila, Ahmedabad, India) and intramuscular diclofenac sodium 75 mg (Voveran®, Novartis, India) for postoperative analgesia, and the associated side-effects of the transdermal diclofenac patch.
Method : Sixty participants in the study were randomly allocated to two groups of 30 each, by a computer-generated randomisation table. The anaesthetic procedure was standardised. A transdermal diclofenac patch 100 mg was applied to the participants in the study group at the beginning of the surgery. In the control group, 75 mg of diclofenac sodium was given intramuscularly half an hour before the end of surgery. Pain was assessed postoperatively at two-, six-, and 12-hour intervals using a visual analogue scale (VAS). An injection of tramadol 2 mg/kg was administered intramuscularly as rescue analgesia. The study ended when the patients asked for rescue analgesia, or when the VAS score was > 5.
Results : The mean duration of analgesia in the control group was 7 hours 28 minutes, and in study group, it was 8 hours 6 minutes, which was comparable (p-value < 0.341).
Conclusion : Intraoperative application of a single dose of 100 mg transdermal diclofenac patch is as effective as a single dose of intramuscular diclofenac (75 mg) for acute postoperative pain, without any significant side-effects.
Source: Southern African Journal of Anaesthesia and Analgesia 18, pp 199 –203 (2012)More Less
Background : Critical illness is associated with pituitary-adrenal axis dysfunction, and may cause adrenal insufficiency that manifests as septic shock that is poorly responsive to fluid or inotropic therapy. Administering a low-dose corticosteroid to these patients results in faster shock resolution, but there is controversy regarding its effect on patient mortality. This survey aimed to describe how survey respondents are interpreting the current literature and using corticosteroids in patient management.
Method : A survey was conducted during the 2011 annual congress of the South African Society of Anaesthesiologists.
Results : Of the 65 respondents who completed the survey, all (except one specialist) had a background in anaesthesia or critical care. The majority of respondents agreed with the Surviving Sepsis Campaign definitions for sepsis and septic shock. A "typical" respondent would administer a total daily dose of 200 mg hydrocortisone, in boluses, to septic shock patients requiring inotropic support, or who were poorly responsive to inotropes. They would not use an adrenocorticotropic hormone stimulation test to identify these patients. Once shock resolved, or inotropes were no longer required, they would wean the hydrocortisone. More than 40% of respondents would use corticosteroids in clinical scenarios in which no patient benefit has been shown, and which might cause patient harm.
Conclusion : Respondents use corticosteroids as recommended by the Surviving Sepsis Campaign guidelines, but would extend this use to other clinical scenarios, i.e. sepsis without hypotension and for non-septic shock, which might cause patient harm. When making clinical decisions, more emphasis should be placed on patient-important outcomes than on surrogate outcomes.
Observational study of choice of anaesthesia and outcome in patients with severe pre-eclampsia who present for emergency Caesarean section : original researchSource: Southern African Journal of Anaesthesia and Analgesia 18, pp 206 –212 (2012)More Less
Objectives : Recent evidence in the literature suggests that regional anaesthesia may be the preferred choice over general anaesthesia for patients with severe pre-eclampsia who present for a Caesarean section. This study was conducted to determine if this applied to our population and to assess outcomes.
Design : A retrospective comparative observational study was conducted.
Setting and subjects : The study was carried out at the King Edward VIII Hospital and included patients with severe pre-eclampsia who presented for emergency Caesarean section. Eighty-four charts were analysed.
Outcome measures : The type of anaesthetic that was administered was determined and compared for maternal intraoperative haemodynamic changes and maternal and neonatal outcomes.
Results : Sixty-nine per cent of patients received spinal anaesthesia and 25% general anaesthesia (GA). Intraoperative systolic blood pressures of < 100 mmHg were recorded in 19% of GA and in 27.6% of spinal anaesthesia cases. A > 20% fall in mean arterial pressure from baseline was noted in 66.7% of GA and in 75.9% of spinal anaesthesia cases. There was no maternal mortality and one case of morbidity (a spinal anaesthesia case). An Apgar score of < 7 was recorded in 66.7% of GA cases and in 19% of spinal anaesthesia cases. Neonatal morbidity and mortality occurred in 33.3% of GA and in 10.3% of spinal anaesthesia cases.
Conclusion : Maternal morbidity and mortality were not significantly different between the two groups. Neonatal outcomes were poorer in the GA group, but neonates in the GA group had significantly lower birthweights and gestational ages. Their mothers also had more severe disease. This study supports spinal anaesthesia as an appropriate anaesthetic choice in patients with severe pre-eclampsia.
Source: Southern African Journal of Anaesthesia and Analgesia 18, pp 214 –216 (2012)More Less
Myotonic dystrophy is not commonly encountered in anaesthetic practice and its existence in a patient can easily go undetected, leading to intraoperative and postoperative complications. We report a case of a 45-year-old female without any typical features of myotonic dystrophy, who presented at our hospital for a laparoscopic cholecystectomy. Postoperatively, on account of a delayed recovery, she was diagnosed with myotonic dystrophy.
The adverse effects of inadvertent intraoperative intravenous phenylephrine administration : a case report : case studySource: Southern African Journal of Anaesthesia and Analgesia 18, pp 218 –220 (2012)More Less
Inadvertent intravenous injection of 1% phenylephrine (10 mg) induced severe hypertension and tachycardia in a previously healthy female patient undergoing elective gynaecological surgery. This medical error was investigated using the critical-incident technique that is available in our department. This case report highlights the cardiovascular sequelae of phenylephrine overdose and the human factor that is associated with a medication error. We discuss these two factors, as well as the organisational factors that contributed to this medical error, in order to prevent its recurrence.