Southern African Journal of Anaesthesia and Analgesia - Volume 19, Issue 5, January 2013

Health research is highly regulated and controlled. The South African legal framework consists of the Bill of Rights, the National Health Act, and two sets of Department of Health guidelines, Medical Research Council Ethical Guidelines Book 1, and South African Health Professions Council General Ethical Guidelines for Health Researchers (Booklet 6) add an ethical overlay to the care and protection of research participants. These acts, regulations and guidelines are based on accepted international ethical guidelines and principles. This article notes the historical background to the development of these guidelines, evaluates the South African Acts/regulations/guidelines as they pertain to anaesthesia and ICU research, and discusses attendant difficulties and pitfalls with reference to informed consent in this context. There are general requirements for participants' consent and health research ethics oversight, but a waiver of individual consent is possible under certain circumstances. The regulations/guidelines restrict ICU research on temporary incompetent patients to minimal risk therapeutic research. Yet, there is increasing need for fundamental clinical ICU research which falls outside this limitation. Health research ethics committees (HRECs) generally apply their minds and may allow surrogate decision making (i.e. consent by a person other that the participant), but this can also be problematic since relatives may not know what the participant may have wanted, may object to the added responsibility of providing consent for research on top of consent for clinical treatment, and other surrogates may be subject to conflicts of interest. The regulatory framework should be brought into line with the requirements of the real world, international trends and practices. Section 71 of the NHA was recently promulgated. If applied, it would mandate informed consent in all health research, disallowing surrogate consent and waivers of consent, and would halt almost all research on children since ministerial approval would be required for all non-therapeutic research. The hope is that ministerial approval might be delegated to health research ethics committees.

Thomas James "Tom" Voss was born in Windhoek, Namibia, on 26 March 1926. He matriculated in South Africa from Pretoria Boys High School, and qualified with a Bachelor of Medicine, Bachelor of Surgery degree from the University of Cape Town (UCT) in 1950. After passing the Conjoint Diploma in Anaesthesia in London, he was appointed as a registrar in the Department of Anaesthesia at Groote Schuur Hospital in 1954. He was appointed as a specialist at Groote Schuur Hospital in 1958, and developed a special interest in the relatively new discipline of paediatric anaesthesia. In 1961, he became Head of Department at the Red Cross War Memorial Children's Hospital, taking over from his mentor, Arthur Bull. In 1975, he was promoted ad hoc to Associate Professor at UCT.

Mankind's imminent occupation of low Earth orbit beyond that of a scientific outpost and daring engineering nature that will land astronauts on Mars, will pose significant challenges to anaesthesia providers. The increased number of space tourists and workers who spend extended periods in zero gravity will present with surgical disease, either in orbit or shortly after return to Earth. A thorough understanding of the physiological changes to which these individuals are susceptible, as well as the effects of anaesthetic agents on this relatively unknown population, is warranted. By actively participating and informing ourselves of the future of space medicine, we will lay the groundwork for an entirely new field of medicine. This article provides a succinct overview of some of these physiological challenges and casts light on some of the anaesthetic and surgical concerns pertaining to space flight. It aims to pique the interest of the reader at a time when privatisation of the space race and space tourism by British and American entrepreneurs is providing new frontiers for anaesthetic science to explore.

Objectives: A doctor's ability to calculate drug doses is a skill that is generally assumed. We assessed medical students' performance when given four types of dosing calculations typical of those required in an emergency setting.

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Design: Longitudinal study.

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Setting and subjects: Students were assessed at the beginning of the third year, and repeatedly during the third and fourth year while receiving training in dosage calculations. Competence was defined as correctly answering all four categories of calculation at any one time, i.e. a score of 100%. Failure to respond correctly to the individual questions was also analysed because an incorrect calculation could be equated with a "patient" receiving a wrong dose.

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Outcome measures: Outcome measures were the percentage of students achieving competence and the proportion of times students showed competence relative to their total number of opportunities. A further outcome was the percentage of calculations incorrect i.e. potential "patients" harmed.

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Results: Of the 364 students, 23% were competent at the beginning, while 66% achieved competence at least once by the end of the study. Students were competent 31% of the time and calculated the wrong dose for 34% of "patients". Eighty-two students were competent at baseline, 157 became competent and 125 never achieved competence. They calculated the wrong dose for 9%, 31% and 51% of "patients" respectively. Although race and home language were predictors of performance at baseline, both associations had been lost by the time competence was achieved. All students experienced the most difficulty with calculations when the drug concentration was expressed either as a ratio or a percentage.

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Conclusion: Our findings support calls for the standardised labelling of drugs in solution and for dosage calculation training in the medical curriculum.

Objectives: The primary study aim was to determine whether or not a statistically significant relationship exists between pain severity and satisfaction with life in patients with chronic pain. The second aim was to explore the extent to which coping responses might influence this relationship.

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Design: A cross-sectional non-experimental research design was employed.

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Setting and subjects: A sample of 172 adults suffering from chronic pain was recruited from the outpatient clinic at the Pain Control Unit at Universitas Hospital in Bloemfontein.

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Outcome measures: Participants completed measures of pain severity (Pain Severity Scale of the West-Haven-Yale Multidimensional Pain Inventory), satisfaction with life (Satisfaction with Life Scale) and coping responses (Coping Responses Inventory-Adult version).

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Analysis: Pearson correlation coefficients were calculated between the measures of pain severity and satisfaction with life. Regression analyses were employed to explore the effect of coping responses on the relationship between pain severity and satisfaction with life.

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Results: A statistically significant negative correlation was apparent between pain severity and satisfaction with life. Approach coping was found to moderate the relationship between pain severity and satisfaction with life, while avoidance coping appeared to have no significant effect on this relationship. The relationship between pain severity and satisfaction with life appears to change as a function of the level of approach coping exhibited by individuals suffering from chronic pain.

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Conclusion: Satisfaction with life significantly correlates with pain severity in patients with chronic pain. Approach coping moderates this relationship.

Objectives: Suboptimal treatment as a result of lack of basic skills in anaesthesia and resuscitation contributes significantly to the continuing increase in anaesthetic-related maternal deaths in South Africa. This study aimed to determine the number of doctors providing obstetric anaesthesia at district and regional hospitals in KwaZulu-Natal, their level of experience and caseload, and to identify specific groups that could be targeted for support and training.

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Design: This was a prospective open cohort observational study of obstetric anaesthetic services in KwaZulu-Natal, which considered the human resources, caseloads and the experience of doctors.

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Setting and subjects: Two separate questionnaires, directed independently to medical managers and doctors providing operative obstetric services, were sent to 48 district and regional hospitals in KwaZulu-Natal. One third of the hospitals, selected by stratified randomisation, were visited to improve response rates.

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Outcome measures: Medical managers were asked for caseload and staffing data. Doctors were asked for details of their qualifications, experience and their current workload.

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Results: Thirty-eight (a 79% response rate) medical managers and 266 doctors (an estimated response rate of 65%) completed questionnaires. Community service medical officers (CSMOs) at rural district hospitals constituted 27% of fulltime staff. CSMOs at all responding district hospitals were expected to provide obstetric anaesthesia independently. Foreign medical graduates provided obstetric anaesthesia in 71% (27/38) of hospitals and constituted 27% of full-time staff at rural district hospitals. Twenty-four doctors (all foreign-trained) reported no anaesthesia training during their internship. District hospitals were more reliant on part-time (sessional) appointments. Fifty-eight per cent of all (22/38) hospitals reported that a number of sessional appointments provided obstetric anaesthesia. In October 2010, 58% (22/38 active during the month) of sessional appointments at district-level hospitals administered only one obstetric anaesthetic, whereas all 15 sessional appointments who were active at regional level administered two or more. Only 24% of responding doctors had more than five years' experience in their current employment. Only 3% of responding doctors working in rural hospitals had a Diploma in Anaesthesia, compared to 26% in urban hospitals. Only one doctor with more than five years of employment history and a Diploma in Anaesthesia worked at district level.

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Conclusion: This study highlights the lack of training and experience of doctors in obstetric anaesthesia and documents workload patterns at district hospitals. It also identifies specific target groups for future support and training.

This randomised, observer-blinded study compared brachial plexus infraclavicular block under ultrasound guidance with, or without, nerve stimulation, for patients undergoing below-elbow surgery. Sixty-six patients, aged 18-70 years, with American Society Anesthesiologists' status I, II or III, were randomised into two groups. Brachial plexus infraclavicular block achieved success rates of 76% in the ultrasound guidance without nerve stimulation group and 82% in the ultrasound guidance with nerve stimulation group, but was not significantly different (p-value 0.55). Block supplementation rates were 18.2% in the ultrasound guidance without nerve stimulation group vs. 12.2% in the ultrasound guidance with nerve stimulation group (p-value 0.55), resulting in 100% of the ultrasound guidance without nerve stimulation group reaching complete successful block, compared to 97% of the ultrasound guidance with nerve stimulation group. The mean performance time was significantly shorter in the ultrasound guidance without nerve stimulation group compared to the ultrasound guidance with nerve stimulation group (8.9 ± 3.9 minutes and 14.7 ± 3.3 minutes, respectively, p-value 0.001). Block onset time was 24.39 ± 4.3 minutes and 21.51 ± 2.4 minutes for the ultrasound guidance without nerve stimulation group and the ultrasound guidance with nerve stimulation group, respectively. The block onset time was significantly different between the groups (mean difference of 2.88, p-value 0.023). However, there was no difference in the time to readiness for surgery or surgical analgesia between the groups: ultrasound guidance without nerve stimulation (33.3 ± 8 minutes), and ultrasound guidance with nerve stimulation (36 ± 6 minutes) (p-value 0.09). Patients' satisfaction was 93.9% vs. 87.9% in the ultrasound guidance without nerve stimulation group and the ultrasound guidance with nerve stimulation group, respectively (p-value 0.39). In this study, the use of ultrasound guidance alone for brachial plexus infraclavicular block provided rapid performance and yielded a high success rate without the aid of a nerve stimulator.

This report presents an unusual case of ST elevation on induction of anaesthesia in a patient undergoing an elective, non-cardiac surgical procedure. Through scrutiny of this case and its unanticipated events, together with the subsequent workup and management, the diagnosis of coronary artery vasospasm may be appreciated as an important entity of coronary artery disease. It serves to highlight coronary artery vasospasm as an under-appreciated diagnosis, to allow the anaesthetist to anticipate it as a potential risk in certain populations, and to distinguish it from other coronary artery disease and to institute appropriate management.

We describe airway management in a patient who had a Montgomery^® T tube in situ. The main concern pertaining to these patients is the inadequate depth of anaesthesia and ventilation, in view of loss of volume of air and gases, as well as dilution through the proximal end of the Montgomery^® T tube. To circumvent these problems, we describe another method of providing ventilation, through the extraluminal horizontal limb of the Montgomery^® T tube by introducing an uncuffed endotracheal tube and minimising the loss of carrier gases to the larynx, together with a review of literature for the same.