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- Volume 21, Issue 3, 2015
Southern African Journal of Anaesthesia and Analgesia - Volume 21, Issue 3, 2015
Volumes & issues
Volume 21, Issue 3, 2015
Author C. HillermannSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 4 –5 (2015)More Less
Medical simulation offers innovative and reproducible training experience for anaesthetists at all levels. It is established in medical curriculums across the globe, providing a platform from which to teach the introduction of new skills, critical incident training and multiprofessional team training. However, despite its widespread use in medical and anaesthesia education, well conducted research and subsequent publication is scarce.
Coeliac plexus neurolysis for upper abdominal malignancies using an anterior approach : review of the literature : researchSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 6 –16 (2015) http://dx.doi.org/10.1080/22201181.2015.10More Less
Background: Coeliac plexus neurolysis (CPN) helps to diminish pain arising from malignancy of upper abdominal viscera. Imaging modalities have increased the success rates by enhancing technical accuracy including fluoroscopy, computed tomography and ultrasound. Advancement in the imaging modalities used has helped in the accurate depiction of anatomy and position of the needle tip.
Methods: In an anterior approach, the patient lies supine and the needle is inserted through the anterior abdominal wall into the retropancreatic space. The needle often traverses the stomach, liver or pancreas before reaching the coeliac plexus due to anatomical considerations. The literature has been reviewed regarding various imaging modalities using an anterior approach to coeliac plexus block with regard to success rate, improvement in pain scores, duration of pain relief and analgesic consumption.
Results: Successful pain relief in abdominal malignancies with an anterior approach using various imaging modalities varies between 54% and 94% of patients. Following neurolysis, many patients can be weaned off opioids. This procedure improves quality of life and reduces the risk of drug-related side effects. The duration of pain relief after an anterior approach is six to eight weeks.
Conclusion: The use of various imaging modalities in an anterior approach has improved the technical accuracy in reaching the coeliac plexus, thereby avoiding the needle piercing crucial structures and avoiding deposition of drug in the retrocrural space, thereby reducing the risk of neurological complications. Coeliac plexus neurolysis via an anterior approach using different imaging modalities does not completely abolish pain, rather it diminishes pain, helping to reduce opioid requirements and improving survival in patients with upper abdominal malignancy.
The development of a scoring tool for the measurement of performance in managing hypotension and intra-operative cardiac arrest during spinal anaesthesia for caesarean section : researchSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 17 –23 (2015) http://dx.doi.org/10.1080/22201181.2015.1More Less
Background: At level one hospitals in South Africa a high annual number of maternal deaths occur due to the unrecognised/ untreated complications of spinal anaesthesia. The authors developed a clinical scenario and scoring system to measure intern performance in managing hypotension and cardiac arrest during spinal anaesthesia for caesarean section on a human patient simulator. This system was then subjected to tests of validity and reliability.
Methods: The simulator-based clinical scenario was developed by two specialist anaesthesiologists. A modified Delphi technique was used to achieve consensus among 10 anaesthetic specialists regarding a standardised scoring system. A total of 20 medical officers with a Diploma in Anaesthesiology and 20 interns completed the scenario and were scored by two senior anaesthesiologists.
Results: Medical officers scored an average of 252 and 246 points, whereas interns scored an average of 216 and 215 points (p = 0.005 and p = 0.013, respectively). The scoring instrument demonstrated high inter-assessor reliability with an intra-class correlation coefficient of 0.983.
Conclusions: The scoring tool was shown to be valid and reliable. It offers a standardised assessment process and may be used to refine institutional intern training programmes, with a view to improving anaesthesia skills in community service medical officers.
Predictors of peri-operative risk acceptance by South African vascular surgery patients at a tertiary level hospital : researchSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 24 –30 (2015) http://dx.doi.org/10.1080/22201181.2015.1More Less
Background: Vascular surgical patients have an elevated cardiac risk following non-cardiac surgery. The decision whether to proceed with surgery is multidimensional. Patients must balance the considerations in favour of surgery with those favouring conservative treatment, which requires weighing peri-operative risk against morbidity associated with non-surgical treatment.
Methods: The aim of this prospective correlational study was to determine the proportional contributions of (i) pain, (ii) impulsivity, (iii) patients' perception of the benefits of surgery, (iv) patients' perception of peri-operative risk and (v) the predicted peri-operative risk on acceptance of peri-operative risk by vascular surgical patients. Sixty patients were prospectively recruited by convenience sampling from the Inkosi Albert Luthuli Central Hospital vascular surgery clinic between April 2014 and June 2014. Written informed consent was obtained. Patients completed a questionnaire which documented demographics, pain assessment, impulsivity screen (Barratt Impulsiveness Scale 11), patients' perception of surgery, predicted peri-operative risk (South African Vascular Surgical Cardiac Risk Index) and acceptance of peri-operative risk. Data were analysed using descriptive statistics and linear regression (SPSS version 22).
Results: The patients' perception of the benefits of surgery (β 0.36, 95% CI 0.14-0.70, p = 0.005) was the only predictor of peri-operative risk acceptance. The associations between the other potential predictors and the outcome were insignificant.
Conclusion: The perceived benefit of surgery was the most important predictor of acceptance of peri-operative risk in this cohort.
Clinical anatomy of the superior cluneal nerve in relation to easily identifiable bony landmarks : researchSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 31 –34 (2015) http://dx.doi.org/10.1080/22201181.2015.1More Less
Background: Lower back pain (LBP) remains a common ailment among adult populations and a superior cluneal nerve (SCN) entrapment accounts for 10% of reported LBP cases. The diagnostic criteria for SCN entrapment include anaesthesia of the area supplied by the SCN after performing a nerve block. Several surgical reports describe the anatomy of the SCN but purely anatomicalstudies of the course of the SCN are rare. This study aimed to describe the location of the SCN in relation to easily identifiable bony landmarks.
Methods: The SCN was identified as it pierced the thoracolumbar fascia and crossed over the posterior part of the iliac crest on both sides of 27 adult cadavers. A sliding dial calliper was used to measure the distance from the posterior superior iliac spine (PSIS) to the SCN and from the midline lumbar spinous processes to the nerve.
Results: The PSIS to SCN measurement was found to be 69.6 ± 15.0 mm (mean ± SD) while the midline to SCN measurement was 72.1 ± 10.2 mm.
Discussion: This study showed clear gender differences in the PSIS to SCN measurement, due to the sexual dimorphism of the bony pelvis. There was also found to be a positive correlation between the height of the sample and the distances of the SCN from both the midline and PSIS. This study provides a clear anatomical description of the course of the SCN as it crosses the iliac crest, which will allow for the successful identification of the SCN.
Endotracheal tube cuff pressures in adult patients undergoing general anaesthesia in two Johannesburg academic hospitals : researchSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 35 –38 (2015) http://dx.doi.org/10.1080/22201181.2015.10565More Less
Background: Endotracheal tube (ETT) cuff pressure commonly exceeds the recommended range of 20-30 cm H₂O during anaesthesia. A set volume of air will not deliver the same cuff pressure in each patient and the pressure exerted by the ETT cuff can lead to complications, with either over- or under-inflated cuffs. These can include a sore throat and cough, aspiration, volume loss during positive pressure ventilation, nerve palsies, tracheomalacia and tracheal stenosis. No objective means of ETT cuff pressure monitoring is available in the operating theatres of Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Chris Hani Baragwanath Academic Hospital (CHBAH). The ETT cuff pressure of patients undergoing general anaesthesia is therefore unknown.
Method: ETT cuff pressure of 96 adult patients undergoing general anaesthesia without nitrous oxide at CMJAH and CHBAH was measured by one researcher. A RUSCH Endotest manometer was used to measure ETT cuff pressure in size 7.0 - 8.5 mm ETTs. The cuff inflation technique that was used by the anaesthetist was also documented.
Results: The mean ETT cuff pressure recorded was 47.5 cm H₂O (range 10-120 cm H₂O). ETT cuff pressures exceeded 30 cm H₂O in 64.58% of patients. Only 18.75% of patients had ETT cuff pressures within the recommended range of 20-30 cm H₂O. There was no statistically significant difference between the ETT cuff pressures measured at the two hospitals. Minimal occlusive volume was the most frequent technique used to inflate the ETT cuff (37.5%); this was followed by inflating the ETT cuff with a predetermined volume of air in 31.25% of cases and palpation of the pilot balloon (27.08%). There was no statistically significant difference between the ETT cuff pressure measured and the inflation technique used by the anaesthetist.
Conclusion: ETT cuff pressures of the majority of patients undergoing general anaesthesia at two academic hospitals were higher than the recommended range. ETT cuff pressure should routinely be measured using a manometer.
Source: Southern African Journal of Anaesthesia and Analgesia 21, pp 39 –41 (2015) http://dx.doi.org/10.1080/22201181.2015.1056More Less
Β-Thalassaemia is a rare hereditary disease caused by partial or complete deficiency of β-haemoglobin chain synthesis. There is a lot of literature regarding anaesthetic management in other haemoglobinopathies (i.e. sickle cell disease), especially in the paediatric population, but there is scarce information regarding β-thalassaemia major in adults. With current medical management, β-thalassaemia major patients survive to adulthood and may present for a variety of surgical procedures, even unrelated to their disease process. It is important for the anaesthetist to be familiar with the pathophysiology of β-thalassaemia major and how the disease itself and its treatment or complications (iron deposition from multiple transfusions) can affect anaesthesia. A case of a 51-year-old woman with severe β-thalassaemia undergoing laparoscopic cholecystectomy is presented. The anaesthetic management and systematic review of the perioperative concerns in severe β-thalassaemia are discussed.
Source: Southern African Journal of Anaesthesia and Analgesia 21, pp 42 –44 (2015) http://dx.doi.org/10.1080/22201181.2015.105650More Less
This case report demonstrates the challenges of the paediatric airway, and useful, practical solutions in the management of tracheostomies in children. A six-year-old child underwent a tracheostomy, where an inappropriately large tracheostomy tube was inserted. The choice was guided by the internal diameter (ID) of the tracheostomy tube (TT) rather than the external diameter of the TT (which is much larger than the external diameter (ED) of an endotracheal tube (ETT)). The reduced diameter of the paediatric airway led to complications following the tracheostomy insertion.
The TT needed to be exchanged to a smaller size to provide reliable access to the trachea. Access to the airway had to be maintained during the exchange process, as there was extensive head and neck swelling, which would have made re-intubation from above impossible. The conduit chosen for the tube exchange was a section of tubing from a high-capacity fluid administration set. Fixation of the tube was difficult, but finally achieved by a modified cable tie.
Tracheostomy is a potentially hazardous procedure in children. The correct size TT needs to be selected with consideration of the ED rather than ID of the TT. This case report also demonstrates the utility of the tubing of a high-capacity fluid administration set for TT exchange and the use of a modified cable tie for fixation of the ETT.