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- Volume 19, Issue 4, 2013
Southern African Journal of Anaesthesia and Analgesia - Volume 19, Issue 4, 2013
Volume 19, Issue 4, 2013
Author Christina LundgrenSource: Southern African Journal of Anaesthesia and Analgesia 19 (2013)More Less
It is often said that when Europe sneezes, South Africa gets a cold. I sincerely hope that this does not occur in the case of the hydoxyethyl intravenous starches, which have been withdrawn in most European countries. This decision is based on poor science, as has been pointed out so eloquently in the letter by our senior colleagues from the Western Cape published in this journal. Intravenous fluids need to be regarded in the same way as drugs are, and we as anaesthesiologists are trained to use them correctly and judiciously for the correct indications.
Evidence-based approach to the use of starch-containing intravenous fluids : an official response by two Western Cape University Hospitals : letter to the editorSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 186 –192 (2013)More Less
Circular 114/2013 issued by the Western Cape Pharmacy Services entitled, Suspension of use of infusion solutions containing hydroxyethyl starch at Western Cape Government Health Facilities until further notice, resulted in the the non-availability of starch-containing solutions for clinical use. The reasoning behind the circular was based on the Medicines and Healthcare Products Regulatory Agency (MHRA) class 2 recall of starch solutions and the European Medicines Agency's Pharmacovigilance Risk Assessment Committee, who stated that: "The benefits of infusion solutions containing hydroxyethyl starch no longer outweigh the risks, and (we) therefore recommend that the marketing authorisations for these medicines are suspended". The two Western Cape University Hospitals have responded with a joint statement which is presented to SAJAA readers. The statement suggests withdrawals of corn-based starch solutions are based on flawed interpretation of the available data, particularly the suggestion that they cause renal dysfunction. The statement then interrogates why the use of corn-based starch solutions benefits patient care and improves outcome. Lastly, the problems of the alternative therapeutic options are examined. The conclusion reached is that the use of corn-based starch solutions should be reinstated. We believe this well-researched, evidence-based approach is worth publishing to a wider audience.
Pioneers in South African anaesthesia : Professor Arthur Bull and the Taurus radiofrequency blood warmer : vignettes of South African anaesthesic historySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 194 –195 (2013)More Less
Arthur Barclay Bull graduated MBChB at the University of Cape Town (UCT) in 1943. After internship at the New Somerset Hospital he joined the SA Medical Corps during the 2nd World War where be developed an interest in clinical anaesthesia. From 1948 - 1951 he underwent training as a registrar in anaesthesia at Groote Schuur Hospital. In 1953 he obtained the Diploma in Anaesthesia of the College of Physicians and Surgeons in Ireland and in 1960 became one of the 40 Foundation Fellows of the Anaesthetists of the Royal College of Surgeons in Ireland. From 1954-1955 he was appointed the Nuffield Dominion Clinical Assistant for South Africa in the Department of Anaesthesia at Oxford under Sir Robert Macintosh.
Intraoperative neurophysiological monitoring for the anaesthetist
Part 2 : a review of anaesthesia and its implications for intraoperative neurophysiological monitoring : review articleSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 197 –202 (2013)More Less
The use of intraoperative neurophysiological monitoring (INM) during spinal orthopaedic and neurosurgical procedures provides a challenge to the attending anaesthesiologist. Since all anaesthetic agents affect synaptic function, the choice of agent will be determined by the type of surgery and the INM modality employed. Halogenated volatile agents decrease evoked potential (EP) amplitude and increase latency, and should be avoided in modalities that pass through cortical tracts. The effect on EPs is apparent at minimum alveolar concentrations of 0.3-0.5. Intravenous agents affect EPs in a dose-dependent manner, and should be titrated to response. Total intravenous anaesthesia with propofol and remifentanyl is the preferred technique. The risk of propofol infusion syndrome has not been shown to affect the choice of this agent. Compound muscle action potentials are abolished by barbiturates, and should be avoided during motor-evoked potential (MEP) monitoring. Although somatosensory-evoked potentials are unaffected by muscle relaxants, they prevent the monitoring of MEPs and should be avoided during multimodal use. When paralysis is required to ensure patient safety, the train-of-four ratio should be kept at 2/4 twitches and a T1 response at 10-20% of baseline, with use of a closed-loop system.
Infection control in anaesthesia in regional, tertiary and central hospitals in KwaZulu-Natal. Part 3 : decontamination practices : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 204 –211 (2013)More Less
Background : Anaesthetic equipment is a potential vector for the transmission of disease. This study was undertaken to observe current infection control practices among anaesthetic nurses regarding the decontamination of anaesthetic equipment in regional, tertiary and central hospitals in KwaZulu-Natal.
Method : All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website (15 in total) were visited. All available anaesthesia nurses were invited to participate in a structured interview.
Results : Thirty-four anaesthesia nurses were interviewed. Results revealed that decontamination of anaesthetic equipment and other infection control practices were inadequate or inappropriate in several of the hospitals. Practices varied from one healthcare facility to another, as well as within the same facility.
Conclusion : Current infection control practices among anaesthesia nurses regarding the decontamination of anaesthetic equipment in the observed hospitals are poor. In light of the high prevalence of many infectious diseases, in particular human immunodeficiency virus, hepatitis B and tuberculosis in KwaZulu-Natal, it is critical that issues relating to decontamination practices are urgently addressed.
Source: Southern African Journal of Anaesthesia and Analgesia 19, pp 212 –215 (2013)More Less
Primary hypothesis : A single, maximal hand squeeze of the Macintosh® laryngeal spray atomiser bulb may deliver a toxic dose of local anaesthetic to the oral mucosa of small infants.
Method : Two anaesthetists, A and B, completed 10 single maximal bulb squeezes per individual Macintosh® atomiser (five for each anaesthetist). Seven atomisers in daily use at a children's hospital were tested. Spray volumes were compared between devices and individual anaesthetists, using a repeated measures analysis of variance model.
Results : The mean volume ± standard deviation of 2% lignocaine spray delivered per single maximal squeeze of the seven Macintosh® atomiser bulbs by anaesthetists, A and B, was 0.54 ± 0.7 ml, and 0.31 ± 0.4 ml, respectively. The range was 0.025-2 ml. This is equivalent to 10.8 mg ± 14 mg and 6.2 mg ± 8 mg of lignocaine, respectively. The difference between the two anaesthetists was statistically significant (p-value < 0.0001) and ranged from a maximum of 1.0 ml to a minimum of 0.05 ml.
Conclusion : There is a difference in the amount of local anaesthetic delivered when two anaesthetists use a single maximal squeeze of the Macintosh® spray atomiser bulb from the seven Macintosh® spray devices tested. The dose delivered was not dependent upon the user. In order to prevent a toxic dose being administered, it is recommended that the plastic chamber of the atomiser is filled with a safe dose of local anaesthetic calculated for each child, particularly small infants, before the upper airway is sprayed.
Peripheral nerve stimulator-induced electrostimulation at the P6 point reduces the incidence of post-spinal hypotension in patients undergoing post-trauma orthopaedic surgery : original researchSource: Southern African Journal of Anaesthesia and Analgesia 19, pp 216 –218 (2013)More Less
Objectives : Sympathetic block following spinal anaesthesia is often associated with a fall in blood pressure. This fall has been shown to be attenuated by using transcutaneous nerve stimulation at the P6 point in patients receiving spinal anaesthesia for Caesarean section. The aim of this study was to evaluate the efficacy of stimulation at the P6 point, using peripheral nerve stimulator (PNS), for the prevention of a fall in blood pressure in trauma patients undergoing surgery under spinal anaesthesia.
Design : Randomised, open-label, parallel-assignment, interventional trial.
Setting and subjects : Thirty-two American Society of Anesthesiologists I and II young adult patients of either sex, who were scheduled for elective post-trauma lower limb orthopaedic surgery under spinal anaesthesia, were randomised into two equal groups. The control group (group A) received no P6 stimulation, while the study group (group B) received train-of-four electrical stimulation using the peripheral nerve stimulator (PNS) immediately prior to spinal anaesthesia until the completion of surgery.
Outcome measures : The primary outcome measure was mean arterial pressure (MAP) and the secondary outcome measure was heart rate and use of vasopressors.
Results : Of the 32 patients, there was a fall in mean arterial pressure (MAP) from basal value following spinal anaesthesia in 16 patients receiving P6 stimulation (group B), as well as in those not receiving it (group A). However, the onset of significant fall in MAP was not only delayed (20 minutes vs. 10 minutes), but was also of shorter duration (10 minutes vs. 50 minutes), in group B patients, than it was in patients in the non-stimulated group (group A), respectively.
Conclusion : Electrostimulation by PNS of the P6 point successfully attenuates the severity and duration of hypotension after spinal anaesthesia during post-trauma orthopaedic surgery.
Accidental deposition of local anaesthetic in the subdural space following caudal block : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 220 –222 (2013)More Less
The incidence of accidental injection of local anaesthetic into the subdural space during neuraxial blockade is rare. The presentation of unexplainable clinical signs that do not match the clinical picture of subarachnoid or intravascular injection of the local anaesthetic agent should invoke high suspicion of unintentional subdural block. We report on a case of a six-month-old infant who developed motor block and unconsciousness with haemodynamic stability, following a caudal block for postoperative analgesia. The report will help to illustrate the mechanism behind the complication of subdural deposition of the drug, its detection, treatment and possible avoidance.
Carcinoid heart disease secondary to ovarian tumour : a logical sequence of management? : case studySource: Southern African Journal of Anaesthesia and Analgesia 19, pp 224 –226 (2013)More Less
There are only few reported cases of carcinoid heart disease caused by ovarian tumours. The main cause of morbidity and mortality in these patients is right heart failure. Most cases of carcinoid heart disease have liver metastases and undergo cardiac surgery, followed by liver resection. Ovarian carcinoids cause heart lesions without liver metastasis. Hence, we managed the primary tumour first under octreotide cover, followed by cardiac surgery with a favourable result.
Left retromolar approach using the GlideScope® insertion : a novel technique for patients with loose or buck teeth : letter to the editorSource: Southern African Journal of Anaesthesia and Analgesia 19 (2013)More Less
Buck teeth or loose teeth are always one of the difficult laryngoscopy predictors, even if there is an adequate mouth opening. Such teeth abnormalities often pose difficulties with the airway devices or techniques that are selected to prevent further harm. We routinely follow the recommended manoeuvre described by Ron Walls for ease of endotracheal tube (ETT) insertion, while using a GlideScope®. This technique describes the insertion of the GlideScope® from the midline of the tongue to the epiglottis, and produces a Macintosh® indirect lift of the epiglottis or a Miller lift. The ETT is then inserted from the right side, with a premounted manufacturer's stylet. Even with this manoeuvre, we encountered numerous problems when introducing the GlideScope® blade in patients with loose or buck teeth.
Use of gum elastic bougie through the intubating laryngeal mask airway : an unconventional way of securing the airway in an emergency : letter to the editorSource: Southern African Journal of Anaesthesia and Analgesia 19 (2013)More Less
The intubating laryngeal mask airway (LMA) has been advocated for use in expected difficult airways and adds the benefit of ventilation during intubation attempts with minimum neck movement during insertion. The Fastrach silicone wire-reinforced tube, a reusable and relatively expensive tube, has been designed to be used with the intubating LMA. Polyvinyl chloride (PVC) tubes and armoured tubes have been used with intubating LMAs. Concerns have been raised about the safety of this practice. A case of death due to airway trauma from the Fastrach silicone wire-reinforced tube has been reported. We present the case of a patient with ossified posterior longitudinal ligament, who we attempted to intubate with an intubating LMA, but an unexpected malfunction of the Fastrach silicone wire-reinforced tube forced us to resort to unconventional methods.