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- Volume 21, Issue 1, 2015
Southern African Journal of Anaesthesia and Analgesia - Volume 21, Issue 1, 2015
Volume 21, Issue 1, 2015
Source: Southern African Journal of Anaesthesia and Analgesia 21 (2015)More Less
Neuroprotection refers to strategies that prevent, antagonise, interrupt or slow the biochemical and molecular events which have the potential to cause the injury and death of brain cells.
Brain injury is an important adverse complication of anaesthesia and surgery, with variable clinical manifestation from postoperative cognitive decline, transient ischaemic attacks to cerebrovascular accidents (CVAs). Incidences vary according to the type of surgery, with up to 80% being reported in cardiac surgery. Although the injury mechanisms differ between neurosurgical and non-neurosurgical procedures, the common denominator is failure of glucose and oxygen supply, which triggers the cascades of inflammation, oxidative stress, mitochondrial dysfunction and excitotoxicity that lead to neuronal death by apoptosis and necrosis.
Author Bruce BiccardSource: Southern African Journal of Anaesthesia and Analgesia 21 (2015)More Less
Prof Chris Lundgren was the Editor-in-Chief of the Southern African Journal of Anaesthesia and Analgesia (SAJAA) for a remarkable 14 years from 2001-2015. Under her excellent guidance, the journal has developed and grown to the point that the Academy of Science for South Africa's (ASSAf ) review of scholarly publishing in South Africa found SAJAA to be worthy of continued accreditation with the Department of Higher Education and Training. During her editorship, applications were made to Medline and Thomson Reuters for inclusion in their databases, which were unsuccessful unfortunately. However, they generated useful feedback on both how to improve the standard of the journal and the importance thereof. The quality of the journal and the published articles has improved through subsequent implementation of these recommendations.
South African guidelines for the treatment of cancer pain : South African Cancer Pain Guidelines Working Group : guest editorialSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 6 –7 (2015)More Less
The production of these guidelines, written by South African medical practitioners, is a most welcome and important step in the treatment of cancer pain in this country. The overall prevalence of pain in cancer patients is estimated to be 53%, and 64% in patients with advanced and metastatic disease. Too often, the only guidelines available to us are those written by practitioners in other countries which may be inappropriate for implementation here owing to the differing availability of drugs or disease profile.
Author A.A. AbrahamSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 12 –14 (2015) http://dx.doi.org/http://dx.doi.org/10.1080/22201181.2014.984432More Less
The history of modern anaesthesia started on October 16, 1846 when WTG Morton demonstrated ether anaesthesia in Massachusetts General Hospital in USA. For about one month the new born branch of medicine was without a name. The word anaesthesia as we know of now as a science and art was suggested by Oliver Holmes Wendell in November 1846. New discoveries and inventions followed. Most of them needed new names or terminologies. Some of them were named by the people who discovered them, some by the people who did studies later. Few words existed before 1846 and majority naturally came after. A peep is made into the glorious past of anaesthesia which is one of mankind's greatest discoveries. This article salutes the great personalities who coined those words, which millions of tongues speak daily around the globe.
Author J.W. DippenaarSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 15 –20 (2015) http://dx.doi.org/http://dx.doi.org/10.1080/22201181.2015.1013321More Less
The use of herbal and alternative therapies is increasing all over the developed as well as the developing world. As pharmacological data on drug interactions involving herbal therapies becomes available, it is important to be familiar with the challenges that concomitant use of these medications may present within the peri-operative period. This review aims to shed light on the more commonly used herbal drugs, and to discuss drug interactions and complications that may be expected in their use.
Comparison of dexmedetomidine, pethidine and tramadol in the treatment of post-neuraxial anaesthesia shivering : researchSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 21 –26 (2015) http://dx.doi.org/http://dx.doi.org/10.1080/22201181.2015.1013323More Less
Objective: This study was performed to compare the effectiveness of intravenous dexmedetomidine with that of pethidine and tramadol in the treatment of post-neuraxial anaesthesia shivering.
Design: This was a prospective, randomised, double-blinded study.
Setting and subjects: One hundred and two patients of both genders, aged 18-70 years with American Society of Anesthesiologists physical status I and II undergoing spinal or combined spinal and epidural anaesthesia for elective surgery were enrolled in this study. Sixty of them developed shivering after an intrathecal injection of 0.5% hyperbaric bupivacaine 15 mg. They were then randomly allocated to receive either intravenous dexmedetomidine 0.5 µg/kg, pethidine 0.5 mg/kg or tramadol 0.5 mg/kg.
Outcome measures: The response rate to treatment, the degree of sedation and the side-effects were recorded.
Results: The response rate to treatment was highest in the dexmedetomidine group, and it was only significant when compared to tramadol group (p = 0.0012). It was noted that the response rate was higher in the pethidine than in the tramadol group. This difference was not statistically significant (p = 0.082). The sedation score post treatment was similar in all three groups, but more patients in the dexmedetomidine group developed hypotension and bradycardia (p < 0.05).
Conclusion: Dexmedetomidine 0.5 µg/ml was more effective than tramadol 0.5 mg/ml and pethidine 0.5 mg/ml, and both tramadol and pethidine were found to have similar efficacy, in the treatment of post-neuraxial anaesthesia shivering. However, dexmedetomidine caused a higher incidence of hypotension and bradycardia.
Low-dose spinal anaesthesia provides effective labour analgesia and does not limit ambulation : researchSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 27 –30 (2015) http://dx.doi.org/http://dx.doi.org/10.1080/22201181.2015.1013322More Less
Background: While epidural analgesia for labour pain is standard in high-resource countries, minimal to no analgesia is usually provided in low-resource countries. Intrathecal local anaesthetics provide good pain relief, but the potential impact on ambulation is of concern. Our objective was to determine if a low-dose local anaesthetic combined with an opioid would provide reasonable pain relief, while allowing ambulation in a low-resource setting.
Method: This prospective, observational study was conducted at the Tamale Teaching Hospital in Tamale, Ghana. Spinal analgesia was administered to healthy women in labour using a pencil-point 25-G spinal needle at the L3-L4 or L4-L5 interspace, with patients in the sitting position. The intrathecal mixture contained 25 µg of fentanyl, 2.5 mg of bupivacaine and 0.2 mg of morphine. The patient's ability to ambulate following the administration of a low-dose spinal injection was the primary outcome measured. Pain ratings, blood pressure, nausea, vomiting, pruritus, headaches and foetal bradycardia were also recorded.
Results: Three hundred and thirty-two parturients consented to participate. Following spinal injection, 328 women (98.8%) experienced mild to no pain, and 4 (1.2%) moderate pain. The administration of spinal analgesia had no effect on ambulation in 291 (87.7%) patients, and a mild effect in 41 (12.3%) patients. Intrathecal analgesia did not severely limit ambulation in any of the patients.
Conclusion: Low-dose intrathecal analgesia can provide effective analgesia for labouring patients in low-resource settings without limiting ambulation.
Anaesthesiologists, fees and complaints to the Health Professions Council of South Africa : SASA refresher course textSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 32 –33 (2015)More Less
Anaesthesiologists are reputedly the most complained about single speciality to the Health Professions Council of South Africa (HSPCA). The majority of complaints include unhappiness with either the consent process itself or involve the amount that the patient was charged and how the patient felt that there was inadequate disclosure during the consent process on the financial aspects pertaining to the procedure. The question is asked if anaesthesiologists are over-represented, and if so, are there potentially any reasons why anaesthesiologists as a group are more vulnerable to criticism? The South African Society of Anaesthesiologists and the Medical Protection Society are working on ways of diminishing the risk of complaints to the HSPCA about anaesthesiologists. However, in doing so, it is important to reflect upon the factors which may play a role.
Author J. ThomasSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 34 –36 (2015)More Less
The Children's Act of 2005 was a watershed in establishing the rights of the child in South Africa. This legal document makes provision for the care and protection of children, and defines parental responsibilities and rights. It also defines who is a "parent," and what should be considered when requesting consent for anaesthesia and surgery prior to an operation. Current laws provide a balance of parents' wide discretionary authority in raising their children with the laws to protect children against abuse and neglect. There are two parts to this Act : the Children's Act 38 of 2005 and the Children's Amendment Act 41 of 2007, some of which came into force in 2007, and the associated regulations in 2010. The two acts have now been combined into one, called the Children's Act 38 of 2005 (as amended by Act 41 in 2007).
Source: Southern African Journal of Anaesthesia and Analgesia 21, pp 38 –39 (2015)More Less
As with all drugs, fluid therapy must be regarded as context sensitive. If a drug is given in the wrong context to the wrong patient and without a proper indication, only the side-effects of the drug will be seen, with probable demonstrable harm. Fluids, as with all drugs, should only be administered in the proper context in which consideration is given to the pharmacological properties of the agent being administered, the condition for which the drug is being given, and the expected benefits and possible harm. Without clear consideration of the context, drug administration is negligent and harmful.
Author D. BishopSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 40 –42 (2015)More Less
Obstetric airway management continues to provide a challenge to anaesthetists. The incidence of difficult and failed intubations has either remained static, or improved slightly, in specific settings in recent years. Established dogma is being challenged and practice continues to evolve and adapt to new evidence. Rapid sequence induction, while still the standard of care for airway management in obstetrics, is no longer considered to be essential in all cases. Supraglottic airway devices are being used in subcategories of patients as a first-line airway device, and are increasingly being accepted as a rescue device. In addition, novel devices, such as the video laryngoscope, are becoming increasingly commonplace in obstetric theatres. This review will briefly outline the problems with obstetric airway management, and then focus on a few of the areas where controversy still exists.
Author B. DayaSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 43 –47 (2015)More Less
Obesity is a complex, multi-system disorder that results from a positive energy imbalance. The World Health Organization (WHO) classifies obesity based on body mass index (BMI), measured as weight (kg) divided by height squared (m2)(Table I).
The overall prevalence of overweight and obesity is high in South Africa, with more than 29% of men and 56% of women being obese. BMI was found to be higher in people living in urban areas and in those with increasing age. An analysis of medical claims data for South Africans during 2010 associated obesity with significantly increased healthcare expenditure.
"What knob is this?" - Intensive care unit ventilation for the non-intensivist : SASA refresher course textAuthor R.P. Von RahdenSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 48 –51 (2015)More Less
Indications for intensive care unit (ICU) mechanical ventilation differ from those for intraoperative mechanical ventilation. Always, the fundamental goal is the provision of life-sustaining oxygen saturation, with the avoidance of ventilator-induced trauma. Once past the initial stabilisation phase, a high priority must be placed on liberating the patient from mechanical ventilation. Encouraging patient-ventilator synchrony may accelerate this. Modern ICU ventilators have a number of modes and tools which may be useful in facilitating both initial mechanical ventilation optimisation and accelerate subsequent weaning, and these are generically reviewed within a discussion of the general conduct of ICU ventilation.
Source: Southern African Journal of Anaesthesia and Analgesia 21, pp 54 –55 (2015)More Less
The issue of the safety of regional anaesthetic techniques can only be addressed by a careful examination of the complications that may occur. These injuries can be caused by a variety of mechanisms, including sharp and blunt trauma, drug neurotoxicity (including the wrong drug), compressive injury (notably spinal haematomas), stretch injury and nerve ischaemia. The nature of the regional technique is a major determinant of the risk of injury, and neuraxial techniques have been studied to a far greater extent than those involving peripheral nerve blockade. The major problem in studying the safety of regional techniques is that the standard tools of randomised controlled trials and meta-analysis are inappropriate for a proper assessment of rare events, such as neurological injury. Most of the references to adverse effects, particularly those associated with peripheral procedures, are to be found as single case reports, and thus are difficult to assess using standard trial methodology.
Author R. GraySource: Southern African Journal of Anaesthesia and Analgesia 21, pp 56 –58 (2015)More Less
This paper considers how the physiology, as it alters with age, may affect the choice of colloid given to a child. The evidence surrounding the use of natural protein and synthetic colloids available for use in children is examined and personal recommendations regarding paediatric colloid use are given.
Author H. KluytsSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 59 –61 (2015)More Less
eHealth is the use of information and communication technologies for health. mHealth is the use of mobile technology in health. As with all information technology (IT), advances in development are rapidly taking place. The application of such technology to individual ambulatory anaesthesia practice should improve the delivery of quality patient care to the patient. Improved multilevel communication and information exchange should not be to the detriment of patient confidentiality. There are various opportunities throughout the perioperative ambulatory care process for the individual anaesthesiologist to participate in eHealth. The most important contributions may manifest with improved preoperative communication, intraoperative recordkeeping and postoperative tracking of outcomes data. However, it is crucial that development in the health IT field is coordinated to ensure interoperability.
Source: Southern African Journal of Anaesthesia and Analgesia 21, pp 62 –63 (2015)More Less
The use of highly active antiretroviral therapy (HAART) in people infected with the human immunodeficiency virus (HIV) has resulted in a significant increase in life expectancy since the roll-out programmes were initiated in 1996. Increased life expectancy has resulted in increasing optimism and the aggressive management of these patients. Thus, admissions to the intensive care unit (ICU) are increasing, with better outcomes than those achieved in the pre-antiretroviral therapy (ART) era. Although, the reasons for critical illness have shifted from acquired immune deficiency syndrome (AIDS)-related opportunistic infections to chronic non-AIDS co-morbidities, opportunistic infections still contribute significantly to the HIV related ICU morbidity burden in developing countries.
Source: Southern African Journal of Anaesthesia and Analgesia 21 (2015)More Less
Nitrous oxide (N2O) interferes with vitamin B12 and folate metabolism. This impairs the production of methionine (from homocysteine), used to form tetrahydrofolate and thymidine during DNA synthesis. N2O increases postoperative homocysteine levels. Chronic hyperhomocysteinaemia is associated with cardiovascular disease, and we have demonstrated that N2O leads to postoperative endothelial dysfunction.
Which evidence-based strategies reduce perioperative morbidity and mortality? : SASA main conferenceSource: Southern African Journal of Anaesthesia and Analgesia 21 (2015)More Less
Evidence-based medicine (EBM) depends on well-designed studies with reliable results. Good-quality evidence from large randomised trials and systematic reviews is available, and their uptake into anaesthetic practice can work, and should be adopted to reduce serious complications after surgery.
Author B.M. BiccardSource: Southern African Journal of Anaesthesia and Analgesia 21, pp 70 –71 (2015)More Less
The new 2014 American College of Cardiology (ACC) and American Heart Association (AHA) guideline for the perioperative cardiovascular evaluation and management of patients undergoing non-cardiac surgery was published in 2014.
There are a number of fundamental changes to this guideline, of which the practising anaesthetist should be aware. Furthermore, the changes in the guideline give an idea of the change in the philosophy of cardiovascular risk stratification and risk reduction in the USA. This paper reviews the changes to the algorithm, and the publications that resulted in these recommendations.