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- Volume 20, Issue 4, 2014
Southern African Journal of Anaesthesia and Analgesia - Volume 20, Issue 4, 2014
Volume 20, Issue 4, 2014
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 4 –5 (2014)More Less
Fashions, fads and memes come and go. Some, like PacMan or lava-lamps, nostalgically bring a smile to the lips; while others, like neon leg warmers and pet rocks, have slunk off into obscurity without even so much as a backward glance. We, in the medical community, are not immune to the phenomenon of the fad. From "Tar Water" and "Metallic Tractors" to control pain (Hutchison BMJ 1925) to early goal directed therapy (Rivers et al. NEJM 2001) and intensive insulin therapy in critically ill patients (van den Berghe et al. NEJM 2001), the latest and greatest sweep through our communities at regular intervals.
Source: Southern African Journal of Anaesthesia and Analgesia 20 (2014)More Less
We read with interest the study by Marais et al. In their paper, the authors state that the reason for their study was to address the research gap in the efficacy of trans- versus abdominis plane [TAP] blocks in resource poor settings, because the standard of post-operative analgesia care for abdominal hysterectomy is high, as this involves neuroaxial blocks and high care beds. In their study, they used patient controlled analgesia [PCA] as the standard.
Author J. ProzeskySource: Southern African Journal of Anaesthesia and Analgesia 20, pp 10 –12 (2014)More Less
Increasing concern about the effect of anaesthesia on the infant and young child is raised by health care practitioners as well as the public immature neurons exposed to anaesthesia may lead to apoptosis and long-term neurobehavioural deficits in animals. The majority of anaesthetic agents work by influencing GABA or NMDA receptors and may induce animal neuro apoptosis. The search for neuroprotective strategies to reverse or counter act the effect of anaesthesia, so far, has not been very successful. Dexmedetomidine is an α-2 adrenoreceptor and may have neuroprotective effects. The available human studies have failed to prove any long-term neurobehavioural deficiencies caused by anaesthetic exposure. Large international prospective studies are currently on the way that may change the practice of paediatric and obstetric anaesthesiologists in the future.
Author D.G. BishopSource: Southern African Journal of Anaesthesia and Analgesia 20, pp 14 –17 (2014)More Less
Hypotension under spinal anaesthesia for Caesarean section remains a common problem with attendant maternal and foetal morbidity attached to it. This review examines some of the issues surrounding the prediction of spinal hypotension, including concerns with current evidence, debate regarding the mechanism of hypotension and the utility of prediction in this group of patients. It will then cover some of the more conventional and established preoperative predictors of hypotension. Particular attention will be paid to the assessment of autonomic function and some of the novel methods being used as predictors of severe maternal hypotension. The implications of autonomic dysfunction and areas for future research are discussed.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 18 –22 (2014)More Less
Background : Neuraxial analgesia is currently considered the most effective method of labour analgesia. While well studied in developed countries, it is uncertain whether the results, particularly regarding epidural analgesia complication rates, can be extrapolated to the context of the South African public hospital.
Method : A retrospective one-year audit reviewed available records for indications for-, complications of-, and patient satisfaction with labour epidural analgesia at Tygerberg Hospital, Western Cape.
Results : During the period audited, 157 (2.2%) of 7 005 parturients received labour epidural analgesia. One hundred and forty nine records were retrieved for analysis. Epidural analgesia was not provided on patient request. Rather, specific indications for epidural analgesia in 73.2% of these cases were preeclampsia, cardiovascular disease and morbid obesity. The incidence of complications was 32.3%, comprising hypotension (13.4%) and all other complications (18.9%). Most complications were minor and self-limiting (97.9%). One serious adverse event (cardiac arrest) due to accidental intravenous infusion of bupivacaine was recorded. Resuscitation with lipid emulsion was successful. Parturients reported being "happy" or "very happy" (50% and 36% respectively) with epidural analgesia.
Conclusions : At this tertiary referral hospital in the Western Cape, only 2.2% of parturients received labour epidural analgesia, possibly because of personnel time constraints. Indications comprised predominantly preeclampsia, cardiovascular disease and morbid obesity. The incidence of complications from labour epidural analgesia was in line with that observed in developed countries. Most patients were happy with their analgesia. This audit identifies an urgent need for improvement of the labour epidural service at this institution.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 25 –30 (2014)More Less
Background : This study investigated maldistribution of concentrated 15% potassium chloride after injection into one-liter, flexible, Ringer's lactate bags.
Methods : Twenty milliliters of concentrated 15% potassium chloride was injected into suspended, flexible, liter bags of Ringer's lactate. The potassium was injected by hand, over either four ("fast") or twenty ("slow") second periods. The effect of two successive bag inversions on maldistribution was also investigated. A simulated infusion at 600 ml per hour was controlled using a volumetric pump. Sampling occurred at 5-minute intervals for the first 20 minutes and at 10-minute intervals thereafter until 90 minutes. Potassium concentrations were measured using an accurate, calibrated wide range analyzer not requiring specimen dilution. This experiment was repeated once. A duplicate set of experiments was performed with Bonney's blue dye added to the potassium concentrate. Bonney's blue distribution was evaluated visually.
Results : Significant maldistribution occurred. Maldistribution was not dependent on the injection rate. After 20 to 30 minutes of commencing the infusion, maldistribution resulted in delivery of up to 64 to 85% respectively of the available potassium. Two bag inversions effectively homogenised the solution. The distribution of Bonney's blue stained concentrated potassium was inconsistent with measured potassium concentrations.
Conclusions : In cardiac and other surgery, point of care potassium supplementation is frequently required. Anaesthetists should be cognisant of eliminating not only errors of substitution, but also maldistribution of concentrated potassium. Potassium infusion rates should be controlled, preferably using an electronic infusion controller.
Source: Southern African Journal of Anaesthesia and Analgesia 20, pp 32 –36 (2014)More Less
The choice of blood sugar control technique in the ICU has long been debated. Intensive insulin therapy to achieve normoglycaemia has been shown to reduce mortality, morbidity and the length of ICU stay; but, at the same time it also requires frequent glucose monitoring, adjustment of insulin dose and increase in the medical personnel workload. Despite its clinical benefits, intensive glucose control (IGT) is, however, not favoured by the intensivist, because of the risk of hypoglycaemia. This article provides the reader with an interesting thought: Can intensive blood sugar control be implemented in the ICU, while avoiding hypoglycaemia, and without an increase in hospital cost, and thus change existing blood sugar control protocols in the ICU? Is this possible with the use of continuous glucose monitoring (CGM) devices, which have recently emerged as a tool to maintain proper glucose levels? If further developed, CGM technology could ultimately prove clinically useful in the ICU. However, further research is warranted to confirm its benefits in the implementation of tight glucose control policies in the ICU.