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- Volume 19, Issue 2, 2013
Southern African Journal of Anaesthesia and Analgesia - Volume 19, Issue 2, 2013
Volumes & issues
Volume 19, Issue 2, 2013
Author Christina LundgrenSource: Southern African Journal of Anaesthesia and Analgesia 19 (2013)More Less
This edition of our journal is tinged with sadness at the tragic loss of our deputy editor, Dr Pieter le Roux. He has been an integral member of our anaesthetic community in South Africa, with a pivotal role on the editorial board of the Southern African Journal of Anaesthesia and Analgesia. His dedication, hard work and wonderful ideas will be sorely missed.
Anaesthesiology and research in South Africa : a proposal for a national collaborative anaesthesiology research group : review articleAuthor B.M. BiccardSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 89 –94 (2013)More Less
Anaesthesiology research is currently uncoordinated on a national level in South Africa. Recently, the Academy of Science of South Africa published a report on evitalising clinical research in South Africa, in which recommendations to increase clinical research in South Africa were made. In addition, the recent requirement for a research project as part of specialist training means that presently there is an incentive to increase clinical research in South Africa. Based on factors known to be associated with research productivity, a proposal is made for the establishment of a national, collaborative research group. To ensure the success of this venture, this collaborative group should address the six factors of research productivity identified by Kern: funding of the research; the quality of the investigators; the efficiency of the institution; the mix of the research projects based on novelty, incremental advancement and confirmatory studies; analytic accuracy and a passion for the research projects. A 'South African virtual perioperative research institute' is proposed to coordinate anaesthesiology research within South Africa. A research agenda, based on core research themes for South Africa, should be established. This national collaboration would ensure that all the necessary components for a productive research programme are addressed through a collaborative effort.
The perspectives of eThekwini public service anaesthetic doctors on the informed consent process for anaesthesia : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 96 –101 (2013)More Less
Objectives: This study aimed to ascertain the perspectives of anaesthetists with regard to their current practice of obtaining informed consent. The outcome of this study will eventually assist in creating a standardised system for informed consent which will be pivotal to the safe, ethical, medical and legally sound practice of anaesthesia.
Design: This was an observational descriptive study that assessed the perspectives of anaesthetists in public service using manually and electronically distributed questionnaires that consisted of open- and closed-ended questions.
Setting and subjects: The study canvassed the views of full-time anaesthetic doctors employed by state hospitals in the eThekwini municipality.
Outcome measures: The practice, general impression and overall skills in respect of informed consent obtained by anaesthetists were measured in four main areas: the preanaesthetic interview, optimisation of the process, influence of litigation on the process, and expertise in determining patients' competence for consent in 12 clinical scenarios.
Results: The current system of informal verbal consent was found to be unsatisfactory by 78.3% of the doctors. Most doctors (83.8%) advocated the recording of written consent on a specific anaesthetic consent form. While 93.8% of doctors were aware of the legal implications of not obtaining written consent, 61.8% of them admitted to not documenting important anaesthetic information. A doctor's ability to determine his or her patient's capacity to provide informed consent was determined by using a range of carefully constructed clinical scenarios. This assessment revealed that there were several areas of deficiency in respondents' knowledge.
Conclusion: The current process of obtaining informed consent for anaesthesia has been deemed by doctors in eThekwini to be substandard and legally indefensible. The process should be improved and standardised by creating a specific anaesthetic consent form on which written consent can be documented.
Patient and practitioner perspectives on postoperative pain control in Kumasi, Ghana : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 102 –107 (2013)More Less
Objective: The treatment of pain has gained momentum in health care around the world. Nevertheless, pain is undertreated, particularly in the developing world. We sought to compare patient and healthcare practitioner perspectives of postoperative pain and assess peri-operative analgesia utilisation in a tertiary care hospital in a resource-limited setting.
Design: We conducted a prospective observational study.
Setting and subjects: Postoperative patients and their respective recovery room nurses were studied at the Komfo Anokye Teaching Hospital in Kumasi, Ghana.
Outcome measures: Patients were surveyed 1-4 hours postoperatively. Pain severity on a numerical rating scale (NRS) and patient satisfaction with the pain control were assessed. Recovery room nurses who were responsible for administering the pain medications were surveyed on their perceptions of their patients' pain. Patient demographic information, diagnoses, surgery type, mode of anaesthesia and perioperative analgesia use were recorded.
Results: One hundred and four patients aged 42.1 years ± 17.8 were interviewed over an eight-week period in 2010. Of the 104 patients, 58 (55.8%) underwent general anaesthesia and 39 (37.5%) spinal anaesthesia. Seventy-eight patients (75%) received intraoperative analgesia. Eighty-nine patients (86.5%) were prescribed postoperative analgesia. Only 27 (26%) had received any analgesia by the time they were surveyed. All postoperative analgesia was administered intramuscularly. Thirty six patients (34.6%) rated their pain as severe (NRS 7-10). Overall, nurses perceived patients' pain to be lower than patients' own rating [a mean difference 1.26 units, 95% confidence interval (CI): 0.57-1.95, p-value < 0.001]. Patients were 2.77 times as likely to rate their pain as severe compared to nurses (relative risk: 2.77, 95% CI: 1.56-4.91).
Conclusion: There was significant discrepancy in the perception of pain between patients and healthcare providers. Simple pain assessment tools and the early institution of intravenous postoperative analgesia may improve postoperative pain assessment and treatment.
The effect of intrathecal midazolam on the characteristics of bupivacaine spinal block and postoperative analgesia in gynaecological procedures : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 110 –113 (2013)More Less
Objectives: The present study was undertaken to determine the onset of sensory block, the time to achieve the maximum level of sensory block and the analgesic efficacy of intrathecal midazolam when given in combination with bupivacaine, and also to observe any undesirable side-effects produced by the midazolam-bupivacaine combination.
Setting and subjects: One hundred patients [American Society of Anesthesiologists (ASA) I and ASA II] aged 45-60 years and posted for elective gynaecological surgery, were randomly allocated to two groups of equal size. Group 1 (n = 50) received 12.5 mg of 0.5% hyperbaric bupivacaine with 0.4 ml of normal saline in the L3-L4 interspace, while Group 2 (n = 50) received 12.5 mg (2.5 ml) of 0.5% hyperbaric bupivacaine with 0.4 ml (2 mg) of preservative-free midazolam. Standard monitoring of haemodynamic parameters was recorded throughout the procedure.
Outcome measures: The onset of sensory block, the time to achieve maximum sensory block and the level of block were also chronicled. The sedation scores were noted every two minutes for 20 minutes and then every 10 minutes until the end of surgery. Pain assessment was carried out according to the visual analogue scale (VAS) score. The duration of the painfree period up to rescue analgesia, or a VAS score greater than 40 mm, was documented. Unwanted side-effects were also recorded.
Results: There was no significant difference in the demographic distribution of the patients. There was no statistically significant difference in the onset of the sensory block (p-value = 0.735) and time to achieve maximum level of sensory block in both groups (p-value = 0.45). The sedation score was comparable in both groups. There was a significantly higher duration of pain-free period in Group 2 (274.9 ± 18.07 minutes) than in Group 1 (187.2 ± 16.8 minutes) (p-value < 0.05). The number of rescue medications that were required was also significantly lower in the study group than in the controls. The number of patients who developed bradycardia and hypotension was comparable.
Conclusion: The addition of midazolam to intrathecal bupivacaine prolonged the duration of postoperative analgesia in this study, without affecting the onset of block and without increasing the risk of side-effects.
Sub-Tenon's lidocaine injection improves emergence agitation after general anaesthesia in paediatric ocular surgery : original researchAuthor A.S. ElgebalySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 114 –119 (2013)More Less
Objectives: This study aimed to evaluate the effect of a sub-Tenon's lidocaine injection on emergence agitation in children receiving sevoflurane or halothane anaesthesia for strabismus surgery.
Design: : A prospective, randomised study
Setting: : The study setting included a hospital where a surgical team performed strabismus surgery
Subjects: : Our study enrolled 520 children, aged 4-12 years, who were scheduled for strabismus surgery. Patients were randomised into four groups. Group S/S received sevoflurane and an isotonic saline injection, group S/L received sevoflurane and a lidocaine injection, group H/S received halothane anaesthesia and an isotonic saline injection, and group H/L received halothane anaesthesia and a lidocaine injection. Anaesthesia was maintained with sevoflurane (groups S/S and S/L) or halothane (groups H/S and H/L), and at the end of surgery, the surgeon injected 1 ml of isotonic saline (groups S/S and H/S) and topical proxymethocaine 0.5% or 2% lidocaine (groups S/L and H/L) and a topical placebo (balanced salt solution) into the sub-Tenon's space. Emergence behaviour was assessed in the post-anaesthesia care unit using a five-point scale (1: asleep, 2: awake and calm, 3: irritable behaviour or consolable crying, 4: inconsolable crying, and 5: severe restlessness). We defined a score of 4 or 5 as emergence agitation. The incidence of emergence agitation was analysed using the χ2 test and Fisher's exact test.
Results: : The incidence of emergence agitation in groups S/L and H/L was significantly lower than that in groups S/S and H/S (p-value = 0.022, 0.038). The lidocaine-injected group showed a significantly lower occurrence of emergence agitation (10.4%) than the saline-injected group (27.2%, p-value = 0.002). Emergence agitation was significantly higher following sevoflurane (25%) than halothane anaesthesia (13.1%, p-value = 0.046).
Conclusion: : Emergence agitation was significantly reduced by a sub-Tenon's lidocaine injection, regardless of the modality of anaesthesia used.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 120 –123 (2013)More Less
Objective: The i-gelTM superglottic airway (Intersurgical, Berkshire, UK) has been reported to function as an airway rescue device and as a conduit for fibre-optic intubation in predicted difficult airways. The wider and shorter stem of the i-gelTM and the absence of a grille at the distal end suggests that it may serve as an ideal channel for intubation using a fibrescope. The aim of this prospective study was to determine the feasibility of using fibreoptic-guided intubation through an i-gelTM airway in adult patients undergoing elective surgery.
Design: A prospective clinical study.
Subjects and setting: Sixty patients of both genders, aged 18-60 years, who presented for elective surgery in a tertiary care centre, were enrolled in the study.
Outcome measures: The number of insertion attempts, ease of insertion and insertion time of the i-gelTM, fibreoptic view through the i-gelTM tube, airway seal pressure, ease of tracheal tube placement with the help of a fibreoptic bronchoscope through the i-gelTM, time taken for tracheal tube placement and any evidence of airway injury, were determined.
Results: Successful insertion of the i-gelTM was achieved in 96.66% of patients. The mean time of insertion of the i-gelTM was 9.09 ± 4.17 seconds. Ease of tracheal tube placement via the i-gelTM was found to be easy in 91.4% of cases. The mean total tracheal tube placement time through the i-gelTM was recorded as 89.16 ± 8.29 seconds.
Conclusion: The i-gelTM was easy to insert, with a good first attempt success rate and acceptable insertion time. The success rate for fibreoptic-guided intubation through the i-gelTM was also acceptable. Hence it can serve as an alternative conduit for fibreoptic-guided intubation.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 124 –126 (2013)More Less
Complications relating to spinal anaesthesia following antiplatelet therapy are unclear. We report on a patient with a known history of chronic obstructive airway disease with respiratory tract infection who presented for emergency pseudoaneurysm repair. He underwent recent coronary stent implantation and was treated with clopidogrel and aspirin. Despite dual antiplatelet therapy, spinal anaesthesia was administered safely with prior platelet transfusion. Therefore, regional anaesthesia can be considered in selected patients with prior platelet transfusion on dual antiplatelet drugs when it is deemed to be necessary.
Anaesthetic considerations in a prematurely born infant with congenital hypothyroidism presenting for cataract surgery : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 127 –129 (2013)More Less
Anaesthetic management of the premature infant is a challenge. This is owing to the immaturity of his or her organ systems and the possible presence of sequelae of premature birth, such as broncho pulmonary dysplasia, apnoea, patent ductus arteriosus and intra ventricular haemorrhage. The premature infant is at risk of developing postoperative apnoea, hypothermia and hypoglycaemia until his or her post gestational age is more than 60 weeks. Conditions such as congenital bilateral cataract and congenital hypothyroidism may be associated with other birth defects and syndromes. Recommendations for early cataract surgery may necessitate an aesthetising premature infants with post conceptional ages less than 60 weeks, or those who have had recently diagnosed medical conditions, such as hypothyroidism. We describe the anaesthetic considerations in a, so far, unreported scenario of a premature infant with bilateral congenital cataract and congenital hypothyroidism who presented for cataract surgery.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 130 –132 (2013)More Less
We report on the anaesthetic management of a child with Rubenstein-Taybi syndrome who required eye surgery. This is a rare congenital syndrome characterised by severe learning difficulties, cardiac abnormalities, gastrooesophageal reflux and craniofacial abnormalities, e.g. microganathia and a small mouth. There is the possibility of a difficult intubation.