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- Volume 20, Issue 1, 2014
Southern African Journal of Anaesthesia and Analgesia - Volume 20, Issue 1, 2014
Volumes & issues
Volume 20, Issue 1, 2014
Author Christina LundgrenSource: Southern African Journal of Anaesthesia and Analgesia 20 (2014)More Less
It is very exciting to be writing the editorial at the start of our twentieth year of existence as a journal. It is fortuitous that this is our 2014 Congress edition, with a feast of superb contributions from South African and international colleagues on a variety of topics, which I am sure that you, our readers, will enjoy.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 6 –7 (2014)More Less
The recently published European Surgical Outcomes Study (EuSOS) was a collaborative study designed to assess outcomes following non-cardiac surgery across Europe. It showed that the mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. This is because clinical outcomes following non-cardiac surgery had previously been poorly described at national level. There was evidence of heterogeneity between hospitals and healthcare systems which suggests that there is potential to improve the outcome for surgical patients. South African outcome data are particularly sparse following non-cardiac surgery. It is likely that non-cardiac surgery in South Africa is associated with a larger morbidity burden than that seen in Europe. Until such time as the public health morbidity burden associated with non-cardiac surgery in South Africa is understood, it will be impossible to appropriately prioritise interventions to improve patient outcomes.These points provide the rationale behind conducting a similar study to EuSOS in South Africa. This study will be known as the South African Surgical Outcomes Study (SASOS).
Pioneers in South African Anaesthesia : Dr Heyman Harold (Heymie) Samson, anaesthetic innovator : vignettes of South African anaesthesic historySource: Southern African Journal of Anaesthesia and Analgesia 20, pp 10 –12 (2014)More Less
Dr Heymie Samson was born in Cape Town in 1911, matriculated at the South African College School in 1928, and studied medicine at London University. In 1938, he returned to general practice in Cape Town and married his wife, Phyllis. He volunteered for military service when war broke out in September 1939. He became the first South African to be awarded a Member of the Order of the British Empire (MBE) for gallantry in the North African Campaign. His interest in anaesthesia flourished during this period. He registered as a specialist anaesthetist in 1943, and in the same year while stationed at Voortrekkerhoogte became a founder member of the South African Society of Anaesthesiologists. After the war, he went into private practice in Johannesburg, while maintaining his academic link as an honorary member of the anaesthetic staff at the Johannesburg General Hospital until 1950. He returned to academic medicine as a part-time senior anaesthetist in the Johannesburg department in the early 1960s, a position which he held until 1980.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 14 –18 (2014)More Less
We present a nine-step process to assist with developing an idea into a research protocol. This process ensures that evidence-based medicine practice is followed to prevent redundant research questions. The first step is to identify broad research ideas with a potentially "weak" evidence base, rather than starting with a specific research question. The second step is to identify the knowledge gap within the intended field of research by examining the background literature. Thirdly, the focus will be on the "foreground knowledge" needed to frame a potential research question. The fourth step uses this potential research question to conduct a comprehensive literature research, and aims to determine whether or not the question has been asked before. The fifth step entails writing a study one-page summary which provides a succinct summary of what is intended. The sixth step involves writing the protocol. The rigid process of protocol writing will ensure that a number of important practical study issues are dealt with timeously. The seventh step is to discuss the protocol with experts. Their input will make the protocol more robust. The eighth step necessitates making a "social contract" that requires public commitment to the project. The final step is to write a grant application for the study. This serves to allow the researcher to identify the funding priorities of potential grant-funding agencies, thereby allowing the researcher to frame his or her research in such a manner that the financial support necessary for the success of the project will hopefully be ensured.
Author J.B. CarlisleSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 20 –21 (2014)More Less
When considering evidence-based anaesthesia, the following questions need to be asked:
- Does it work?: Is there reliable evidence that thisintervention provides patients with benefits that they think important?
- Can I use it?: Can I, and the system in which I work, deliver this intervention so that patients realise these benefits?
- Should I use it?: Does this particular patient, when informed of the potential harms and benefits, want me to use it? Does the society in which I work want me to use this intervention, as opposed to other competing interventions?
Author B.M. BiccardSource: Southern African Journal of Anaesthesia and Analgesia 20 (2014)More Less
Objectives: The objective was to determine the diagnostic criteria of a prognostically important troponin elevation following non-cardiac surgery.
Conclusion: Myocardial injury after non-cardiac surgery should be considered a new clinical entity. A troponin leak alone is considered to be prognostically important. The presence of ischaemic features should not be considered as a criterion for intervention in troponin-positive patients following non-cardiac surgery.
Temperature monitoring : the consequences and prevention of mild perioperative hypothermia : SASA refresher course textsSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 25 –31 (2014)More Less
Homeothermic species require a nearly constant internal body temperature. Significant deviations from "normal" internal temperature cause the metabolic function to deteriorate. Usually, the human thermoregulatory system maintains a core body temperature within 0.2°C of normal, near 37°C. Hypothermia results from exposure to cold, or exposure combined with drugs or illness that decrease thermoregulatory efficacy. Exposure to a cold operating room environment during anaesthesia and surgery commonly combines with anaesthetic-induced inhibition of thermoregulation to produce hypothermia. The prevention and management of temperature-related complications is expedited by an understanding of both normal and drug-influenced thermoregulation.
Never trust a drug that can be pronounced in three different ways : medication errors in anaesthesia : SASA refresher course textsAuthor R. RawSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 32 –34 (2014)More Less
Medication errors cause patient death or injury. The worst medication errors involve patient-adverse events with an unknown medication error. This leads to wrong factors being incorrectly blamed and to the development of an illogical adverse event preventive protocol. Most medication errors cause no patient harm. There is a higher risk of medication errors occurring in paediatric than in adult anaesthesia as more drugs need to be diluted.
Time to face the book? : "Unfriending" IV fluids.
Where are we currently with fluid administration in anaesthesia and critical care? : SASA refresher course textsAuthor Z. FarinaSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 36 –38 (2014)More Less
The half-life of medical knowledge is known to be short, and yet the recent collapse in many of the basic tenets of fluid administration has come as a surprise to many. It is fairly clear that we need to change our practice with regard to fluid administration. However, a solid and reliable evidence base to inform the exact direction of this change does not exist yet. There are indications of where the underlying problems have been in fluid administration, and some pragmatic recommendations can be made.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 40 –42 (2014)More Less
Current shock resuscitation strategies require titration of fluid in combination with inotropes and vasopressors to counteract the actual pattern of circulatory abnormality in the patient, and to restore the circulation to a level that is adequate to prevent organ ischaemia. Used incorrectly or in excessive doses, vasoactive agents may cause patient harm. The mechanisms of shock, appropriate resuscitation goals, and some aspects of how common available vasoactive agents in South Africa can be used for optimal safely to help to achieve these goals are discussed.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 44 –47 (2014)More Less
If the World Health Organization (WHO) global maternal mortality by cause is examined for the period 1997-2007, haemorrhage constitutes 35% of deaths. Published data from the triennium 2008-2010 in South Africa indicate that if non-pregnancy-related sepsis is excluded, haemorrhage still ranks with hypertension as the most common cause of maternal deaths (24%). So how can anaesthetists improve this situation and save lives? Sadly, the main reason for the appalling figures in respect of maternal deaths in sub-Saharan Africa is poor access to basic obstetric care, blood products and basic commodities, such as electricity, for the refrigeration of blood and drugs such as oxytocin. Nevertheless, there are many areas where management, and hence outcomes, could be improved. This article addresses the crucial issues of predicting haemorrhage, assessing blood loss, point-of-care monitoring and transfusion protocols. Surgical techniques and oxytocic therapy are equally important, and are the subject of many other reviews.
Author E. HodgsonSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 48 –51 (2014)More Less
Revised guidelines for the management of heart failure (HF) were published in 2013. HF arises due to a reduction in cardiac output secondary to a reduction in stroke volume (SV). Systolic HF (SHF) arises due to overfilling of a dilated left ventricle (LV) and/or right ventricle with inadequate ejection, and thus a reduced ejection fraction (EF). SHF progressively limits activity and results in increasing back pressure and secondary congestion of the pulmonary and/or systemic venous circulation. However, the majority of patients with HF have preserved or even exaggerated systolic function, with a normal or increased EF owing to diastolic heart failure (DHF). SV is reduced because of underfilling of a stiff LV. Sudden-onset dyspnoea in response to stress or exercise occurs as a result of raised LV end-diastolic pressure (LVEDP). Congestion owing to an intermittent or persistent increase in LVEDP is thus an early, prominent feature of diastolic dysfunction.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 52 –54 (2014)More Less
In distinct contrast to preventable anaesthetic mortality, which thankfully is now rare, all-cause postoperative mortality is surprisingly high. Approximately 5% of surgical patients die in the year following surgery. Mortality is roughly 10% in those who are older than 65 years of age. In other words, mortality in the year after surgery is approximately 10 000 times more common than preventable anaesthetic mortality. Thus, it is reasonable to ask to what extent anaesthetic management might influence long-term outcomes. The distinction being made here is between the classical definition of anaesthetic complications, which is restricted to the immediate perioperative period, perhaps extending to a few days after surgery, and the potential effects of anaesthetic management on events weeks, months or even years after surgery. Given that modern anaesthetic drugs are uniformly short acting, it is by no means obvious that the consequences of anaesthetic management could last more than hours or days after surgery. The long-term consequences of anaesthesia were not seriously considered until relatively recently. There is increasing evidence that some intraoperative anaesthetic management decisions have long-term consequences, and that others might as well.
Blood is thicker than water : coagulation challenges in the perioperative period : SASA refresher course textsAuthor Chakane P. MotshabiSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 56 –58 (2014)More Less
Author P.S.A. GlassSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 59 –61 (2014)More Less
Although many advances have occurred in anaesthesia within the last 50 years, the movement of surgical procedures from a hospital setting to an ambulatory environment has had a major impact on general health care. Several factors have driven this process, including advances in anaesthesia and technology, the desire by payers to reduce healthcare costs, the demonstration of patient safety and the positive experience of patients undergoing same-day surgery. The safety of ambulatory anaesthesia and surgery is well established. Greater emphasis is placed on minor side-effects, quality of life and patient satisfaction. Advances in technologies,which continue to move procedures out of the operating room and into imaging suites and the office, are driving the future of ambulatory anaesthesia and surgery. The Society for Ambulatory Anesthesia's Clinical Outcomes Registry database was established to enhance the quality of ambulatory anaesthesia, develop benchmarks and establish best practice. The future and growth of ambulatory anaesthesia is secure with the ageing population and advances in technology.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 62 –64 (2014)More Less
Point-of-care devices offer an increasing number of analytical tests more quickly than laboratory analysis, but clinicians must be aware of the limitations of these devices, especially for critical threshold-level decisions. Glucometers are susceptible to a wide range of errors, and only a few haemoglobin-measuring devices have accuracy approaching that of laboratory analysis. Activated coagulation time remains a useful but error-prone test for heparin effects. Thromboelastography and thromboelastometry offer insight into coagulation defects superior to conventional assays. Multi-function testers provide cardiac enzyme and lactate analysis that is becoming vital for intraoperative decision-making.
New innovations in interventional cardiac procedures - role of intraprocedural echocardiography : SASA refresher course textsSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 66 –68 (2014)More Less
The field of interventional cardiac procedures is rapidly growing. Since the "first in men" catheter-based implantation of a biological aortic valve by Cribier, the number of transcatheter based aortic replacements (TAVR) exceeds several thousand implantations per year worldwide. Beside this percutaneous treatment of mitral regurgitation (MitraClip®), closure of the left atrial appendage, and closure of a patent foramen ovale have been developed. Whereas MitraClip® procedures require general anaesthesia, percutaneous closure of the left atrial appendage as well as closure of a patent foramen ovale are usually performed without the help of anaesthesiologists and will therefore not be discussed furthermore. The transapical NeoChord DS 1000 system (NeoChord Inc, USA) is a new treatment option for patients with severe mitral regurgitation and prolapse of the posterior mitral leaflet that can be done off-pump.
Author J.F. CoetzeeSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 69 –72 (2014)More Less
It has long been realised that linear dosing according to total body weight (TBW) results in oversdosing the obese and underdosing small children. As far back as 1969, in a study on induction doses of thiopentone, Wulfsohn and Joshi concluded that thiopentone was better administered according to lean body mass (LBM) than TBW. They reasoned that endomorphic somatotypes required less thiopentone than mesomophs and ectomorphs of the same TBW, because they had less LBM. They pointed out that there is a strong association between LBM, cardiac output and basal metabolic rate, and suggested that the LBM contained the "pharmacologically active mass". Recently, several publications have emerged that suggest that dosing of other anaesthetic drugs to obese patients, such as remifentanil and propofol, should be based on LBM.
Author W. PearceSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 74 –76 (2014)More Less
After spending nearly seven years in private practice in South Africa, I moved to the USA to work at a "non-profit" academic hospital. My chief reason for so doing was that I felt that my role in private practice assumed more and more that of being a living lubricant for the cogs of a conveyor belt that brought fabulous wealth, by the standards of most South Africans, to a number of our practice's important "customers" and my colleagues. And my role became less and less that of an anesthesiologist. However, with hindsight, in many respects, I have moved from one conveyor belt and industrial process, to another.
The LMA Classic as a conduit for tracheal intubation in adult patients : a review and practical guide : review articleAuthor A.N.J. AlbertsSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 77 –88 (2014)More Less
Unexpected difficulty in maintaining an open airway following induction of anaesthesia remains an ever-present hazard. Repetitive attempts at direct laryngoscopy and intubation are generally acknowledged to be inappropriate. The LMA Classic is recognised as a rescue ventilation device in failed intubation scenarios and its specific role is well defined in international airway management protocols. Should clinical conditions dictate the need for tracheal intubation following placement of an LMA Classic, it may be retained to serve as a conduit for intubation. Utilising the LMA Classic as a conduit for intubation is considered a rescue manoeuvre, only resorted to when conventional methods such as direct laryngoscopy have failed. Therefore, it is important that this approach to intubation has a high success rate and that airway management specialists are familiar with the different available options, the relevant limitations and the pitfalls. A short description of the components of the LMA Classic, specifically relating to its function as an intubating conduit, is provided in this review. Its limitations as a conduit are then listed, followed by a description of the most popular techniques of intubation via the LMA Classic. By adhering to a number of basic principles outlined in this review, limitations may be overcome, pitfalls avoided, and an escape conduit added for the anaesthetist who is faced with a difficult-to-intubate airway.