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- Volume 19, Issue 3, 2013
Southern African Journal of Anaesthesia and Analgesia - Volume 19, Issue 3, 2013
Volume 19, Issue 3, 2013
Author Nic Van der WaltSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 135 –136 (2013)More Less
Doctors practising in anaesthesia are constantly working in a high-fidelity, high-stakes environment. Causes for this are numerous, with long working hours, sustained vigilance, the unpredictability of stressful situations, fear of litigation, team work and production pressure. Chronic exposure to these stressors can lead to burnout syndrome.
The impaired clinician and the health and wellness of practitioners in anaesthesia and critical care : letter to the editorSource: Southern African Journal of Anaesthesia and Analgesia 19 (2013)More Less
Within the medical fraternity as a whole, but particularly within the fields of anaesthesia and critical care, the use of the term impaired, when referring to colleagues, engenders thoughts of a severely incapacitated state either induced by alcohol and/or drug addiction or severe physical or psychological affliction, that places both the patient and clinician at significant risk of injury or death.
Intraoperative neurophysiological monitoring for the anaesthetist
Part 1 : a review of the theory and practice of intraoperative neurophysiological monitoring : review articleSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 139 –144 (2013)More Less
Intraoperative neurophysiological monitoring (IONM) has become the gold standard for the monitoring of functional nervous tissue and mapping of eloquent brain tissue during neurosurgical procedures. The multimodal use of somatosensory-evoked potentials and motor-evoked potentials ensures adequate monitoring of anterior sensory and dorsal motor pathways. The use of IONM during spinal orthopaedic surgery has drastically reduced the incidence of postoperative neurological deficit and allowed radical resection of brain tumours. Evoked potentials (EPs) are analysed for increased latency (> 1 millisecond) and decreased amplitude (< 50%). Special considerations have to be made in the paediatric population who present with decreased myelination and morphological changes to the EPs. A thorough knowledge of the physics and physiology behind these techniques will ensure better outcomes and successful implementation in neurosurgical centres. In this two-part article series, we will provide a review of the most recent available literature on IONM. The different modalities that are available, their indications and application are presented in Part 1, while the different anaesthetic options that exist will be discussed and the basic approach to the planning of a successful anaesthetic outlined in Part 2.
Infection control in anaesthesia in regional, tertiary and central hospitals in KwaZulu-Natal. Part 2 : equipment contamination : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 146 –151 (2013)More Less
Objectives : Contaminated anaesthetic equipment has been implicated in the nosocomial transmission of infection. The aim of this study was to determine the prevalence of blood (occult or visible) and/or visible organic material contamination of anaesthetic equipment deemed to be ready for use in theatres in regional, tertiary and central hospitals in KwaZulu-Natal.
Design : All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website were visited (n = 15). Laryngoscope blades and handles, Magill's forceps, nasopharyngeal temperature probes and suction bowls were inspected for visible blood and/or organic matter. Those items that were not visibly contaminated were further tested for occult blood using the blood detector in urinalysis reagent strips.
Setting and subjects : All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website were visited (n = 15).
Results : The percentages of contamination with blood (occult or visible) and/or visible organic material of all examined laryngoscope blades, laryngoscope handles, Magill's forceps, nasopharyngeal temperature probes, and suction bowls, were 80% (45.5-100%), 74% (42.8-100%), 50% (0-100%), 80% (0-100%) and 90% (0-100%), respectively.
Conclusion : The contamination of ready-for-use anaesthesia equipment was extremely high. In light of the high prevalence of many infectious diseases in KwaZulu-Natal, and in particular human immunodeficiency virus, hepatitis B and tuberculosis, urgent tackling of the issue of reuse of contaminated equipment is critical.
Spinal anaesthesia for brachytherapy for carcinoma of the cervix : a comparison of two dose regimens of hyperbaric bupivacaine : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 154 –159 (2013)More Less
Objectives : Spinal anaesthesia can be suitably performed for a variety of day-stay (ambulatory) surgical procedures. The time taken for adequate recovery to allow discharge home from hospital is an important consideration. The purpose of this study was to compare the suitability of two different doses of hyperbaric bupivacaine for spinal anaesthesia for day-stay brachytherapy for carcinoma of the cervix.
Design : This was a prospective, randomised, double-blind study.
Setting and subjects : Forty female patients, presenting to Groote Schuur Hospital for brachytherapy for carcinoma of the cervix, were randomised to receive either 5 mg or 9 mg (1 ml or 1.8 ml) of 0.5% hyperbaric bupivacaine, plus 15 µg fentanyl via the L3/L4 interspace.
Results : Patients receiving the lower dose could be discharged from the recovery room in a shorter time (p-value < 0.01). The time taken to achieve hospital discharge criteria was significantly shorter in the group receiving the lower dose [a mean time of 235 (206-264) vs. 280 (263-297) minutes, p-value < 0.01]. There was significantly less motor block in the low-dose group (p-value < 0.001). Patient satisfaction regarding motor block was similar in the two groups (p-value = 0.96). There was a trend towards a higher number of inadequate spinal blocks in the low-dose group (p-value = 0.34).
Conclusion : Our study suggests that a dose that is closer or equivalent to that of the high-dose group (9 mg bupivacaine plus 15 µg fentanyl) is preferable for brachytherapy for carcinoma of the cervix in ensuring consistent and reliable spinal anaesthesia in this patient population.
The opinion of patients at a local South Africa teaching hospital on physician-industry relations : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 160 –163 (2013)More Less
Objectives : This study aimed to determine how South African patients at a regional state hospital perceived the practice of physicians accepting gifts from the pharmaceutical industry. The physician-patient relationship is built on trust, with an understanding that the physician will act ethically and in patients' best interests. This trust is violated when physicians make patient management decisions that are motivated by a desire for personal gain. Gift giving is a technique that is commonly used by the pharmaceutical industry to influence physician prescribing and procurement practice.
Design : This was an observational, cohort study that used a questionnaire among postoperative patients.
Setting and subjects : Written informed consent was obtained from 200 postoperative adult patients at Grey's Hospital, Pietermaritzburg.
Outcome measures : Patients' opinions regarding physician-industry relations focused on four main areas: acceptability of gift giving, the monetary value of gifts, patient knowledge of physicians' involvement with the medical industry, and the perceived potential influence of gifts on physicians decision-making.
Results : Sixty-two per cent of patients felt that it was unacceptable for physicians to accept a gift from a pharmaceutical company, and 80% believed that doctors were influenced by accepting gifts. Eighty-one per cent of patients preferred to be cared for by a doctor who had no relationship with, or did not accept gifts from, pharmaceutical companies.
Conclusion : The majority of patients in this study do not agree with the practice of gift giving, particularly when it led to personal gain for the physicians. Patients believed that when physicians accepted gifts it influenced their decision-making, and indicated that they would prefer to be cared for by physicians without ties to the medical industry.
Effectiveness of low-dose midazolam plus ketamine in the prevention of shivering during spinal anaesthesia for emergency lower limb surgery : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 164 –170 (2013)More Less
Objective : This study was conducted to compare the effectiveness of two different dosages of intravenous midazolam in combination with ketamine in the prevention of shivering during spinal anaesthesia for emergency lower limb surgery.
Design : This was a prospective, randomised, double-blind, placebo-controlled study.
Setting and subjects : We studied 90 patients with American Society of Anesthesiologists classification I and II, aged between 18 and 60 years old, and randomly allocated to receive either a combination of low-dose midazolam 0.02 mg/kg plus ketamine 0.25 mg/kg (Group A), or a combination of higher-dose midazolam 0.04 mg/kg plus ketamine 0.25 mg/kg (Group B), or normal saline as the control group (Group C), after an intrathecal injection of 0.5% hyperbaric bupivacaine 12.5-15 mg.
Outcome measures : The outcomes measured were the incidence and the degree of shivering, the effectiveness and the side-effects of two different dosages of the drugs in preventing shivering.
Results : In this study, the incidence of shivering was 46% in Group C, which was significantly higher than that in Group A (16%) and Group B (10%) (p-value < 0.05). However, there was no difference between Group A and B (p-value = 0.704). The number of patients with shivering grade ≥ 2 was significantly higher in Group C than it was in Groups A and B (p-value < 0.05), but not between Group A and Group B. It was also found that there was no difference in the haemodynamic parameters in all three groups. However, patients in Groups A and B were more sedated (p-value < 0.05), and had higher incidence of nystagmus than those in Group C (p-value < 0.001).
Conclusion : Low-dose midazolam 0.02 mg/kg plus ketamine 0.25 mg/kg was equally effective when compared with a higher dose of midazolam 0.04 mg/kg plus ketamine 0.25 mg/kg in preventing shivering during spinal anaesthesia for emergency lower limb surgery. There were no significant changes in the haemodynamic parameters in all three groups. However, patients in the midazolam plus ketamine groups were more sedated and had a higher incidence of nystagmus.
Anaesthesia for scoliosis correction surgery complicated by severe recalcitrant bradycardia upon prone positioning in an adolescent with Prader-Willi syndrome : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 171 –173 (2013)More Less
A 13-year-old adolescent presented for correction of an 85-degree idiopathic thoracic scoliosis. She was known to have Prader-Willi syndrome. Previous general anaesthesia for non-spinal surgery had been uneventful. On two occasions following uneventful induction and total intravenous anaesthesia (TIVA) maintenance, she developed severe recalcitrant bradycardia with hypotension that was resistant to anticholinergics, inotropes and vasopressors upon prone positioning. Immediate resolution occurred upon a return to the supine position. On each occasion, she emerged from anaesthesia with no untoward sequelae. Cardiac investigations, including echocardiography, electrocardiography (ECG), troponin and creatine kinase-MB fraction levels were all within the normal range, and ventricular function was good. It was necessary to urgently proceed with the surgery as the scoliosis was progressive, with risks of cardiovascular and respiratory compromise. Additionally, she was scheduled to recommence growth hormone therapy postoperatively to treat her growth retardation. Ultimately, she received propofol for induction of anaesthesia and TIVA with propofol and remifentanil infusions for the maintenance of anaesthesia. Post-induction, a transvenous pacing wire was placed under ECG guidance. A transoesphageal probe was inserted and cardiac function monitored throughout the procedure. Upon prone positioning, she again developed a bradycardia which responded to pacing and surgery was carried out uneventfully. Clinical examination and extensive investigations had failed to demonstrate any specific underlying cause for her repeated positional arrhythmia. Therefore, we deduced that the bradycardia was due to a hypervagal response provoked by prone positioning and because of the severity of the scoliosis. We are unaware of reports of such a complication in the literature.
The use of intraoperative transoesophageal echocardiography as a monitor for haemodynamic instability during pulmonary hydatid cyst excision : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 174 –177 (2013)More Less
We present the case of a patient with bilateral, pulmonary hydatid cysts who presented for cystectomy and developed life-threatening, haemodynamic instability when turned into the lateral decubitus position. Intraoperative transoesophageal echocardiography allowed for rapid interpretation of the haemodynamic collapse and proved to be valuable in surgical and anaesthetic decision-making. Human immunodeficiency virus co-infection in patients with Echinococcus infection has been implicated in the development of a more severe and disseminated clinical course in hydatid disease.
Utility of neuroimaging in postpartum headache work-up : case report and diagnostic considerations : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 178 –180 (2013)More Less
A postpartum headache is commonly seen in clinical practice, especially after a subarachnoid block. Generally, it is treated as a postdural puncture headache. We report on a case of a 24-year-old primigravida who underwent emergency Caesarean delivery under spinal anaesthesia. She developed a headache on the third postoperative day, which responded to conservative management. On the sixth day, she developed a severe headache which did not respond to analgesics and bed rest. Magnetic resonance imaging of the brain revealed a subdural haematoma. In such situation, there is a need to consider other differential diagnoses other than that of a postpartum headache and to conduct early neuroimaging, since the headache may be the first indication of an unsuspected, potentially fatal lesion.