Browsing by Author "Reed, Anthony"
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- ItemOpen AccessCoagulopathy in severe, isolated traumatic brain injury: A prevalence study(2018) Lawrie, Ruchi; Reed, AnthonyIntroduction: Traumatic brain injury (TBI) is an important cause of morbidity and mortality in the developing world, and remains the leading cause of death and long-term disability in young adults. Hypocoagulopathy is a well described sequela of severe TBI and is associated with prolonged intensive care unit stays and poor outcomes. This study was conducted to determine the prevalence of coagulopathies in patients with severe, isolated TBI. The secondary outcome was to note any difference in the prevalence of detected coagulopathy between blunt and penetrating TBI. Methods: This is a prospective observational study of fifty patients with severe, isolated TBI (AIS head >3, AIS body <3), presenting to, or were referred to Groote Schuur Hospital. We drew blood for International Normalised Ratio (INR), activated partial thromboplastin time (aPTT), platelets count, sodium, potassium, urea and thromboelastography (TEG) on all patients at 12 hours (±3 hours), 36 hours (±3 hours) and eligible patients at 60 hours (±3 hours) post injury. Coagulopathy was defined as any one of the following: platelet count<120 x 109/L, INR>1.2, PTT>37 seconds, R time<4 minutes or >8 minutes, K time>4 minutes, α angle<47˚ or >74˚, maximum amplitude<54 mm or >72mm, EPL>15%, LY30>8 %, coagulation index<-3 or >3. Results: The patients were mostly male (n=47), with a mean age of 31 years. Median AIS head and body were 5 and 1, respectively. Thirty-six patients sustained blunt, and the remaining 14 penetrating trauma. Sixteen of the fifty patients demised during the course of the study. The cumulative prevalence of coagulopathy, as diagnosed by TEG, was 84% as diagnosed by TEG. Of the total 109 TEGs, 59 samples were hypercoagulable, 10 were hypocoagulable and the remaining 40 normal. There was poor correlation between laboratory-based coagulation assessments and TEG. Conclusions: Contrary to what is reported in the literature, we found little evidence of a hypocoagulable state as defined by TEG (10 of the 109 samples). Many patients were significantly hypercoagulable (59 of the 109 samples) according to criteria specified by the TEG manufacturer. When considering the CBT results, we had a much higher number of hypocoagulable samples (72 of the 109 samples), with none showing a hypercoagulable state. Moreover, there was poor correlation between coagulation status as measured by TEG described and that found on conventional blood testing. No significant differences in the prevalences of coagulopathy amongst blunt and penetrating mechanisms of injury were noted. Some differences in fluid balance and presenting vitals in the hypocoagulable group when compared to the normal and hypercoagulable groups were noticed, but this does not attain any statistical significance due to the small numbers of hypocoagulable patients in our study.
- ItemOpen AccessRetrospective observational study of the choice of anaesthesia for caesarean section in patients with eclampsia(2020) Jordaan, Meandra; Reed, Anthony; Dyer, Robert ABackground Anaesthesia for ceasarean section (CS) in women with eclampsia is a major clinical challenge, and there are limited data concerning the rationale for the choice of technique, and the short-term outcomes. A retrospective audit was performed on practice at a tertiary referral centre in Cape Town. Methods The primary outcome of the audit was the proportion of patients with eclampsia receiving either spinal anaesthesia (SA) or general anaesthesia (GA) for CS, and the assessment of the rationale for the choice of method. A convenience sample of the records of one hundred consecutive patients with eclampsia admitted to the Maternity Centre at Groote Schuur Hospital from 2009- 2013, were studied. Patient demographics, clinical details and outcomes (including relevant results of special investigations), were recorded. The number and percentage of patients receiving GA or SA were documented. The presence or absence of factors influencing selection of the method of anaesthesia, including Glasgow Coma Scale (GCS), degree of urgency of CS, trauma to the oropharynx, number of seizures, control of blood pressure, and the availability of and/or platelet count prior to anaesthesia, were noted. In addition, complications of anaesthesia were described, and short-term maternal and neonatal outcomes were recorded. Results One hundred patient records were screened, and there were 11 exclusions; therefore 89 patient records were analysed. Seven/89 (7.9%) received SA and 82/89 (92.1%) GA. One patient required conversion to GA because of the occurrence of a seizure during attempted SA. All patients receiving spinal anaesthesia were stable and had no postoperative complications. Overall, 63 (70.8%) had a preoperative GCS< 14, and 26 (29.2%) patients had GCS ≥14. Seven patients in the subgroup with GCS ≥14 had SA, and the remaining 19 received GA. GA was performed because there was no platelet count available in 3, pulmonary oedema in 2, difficult airway due to a bitten tongue during a seizure in 2, fetal bradycardia in 2, HELLP syndrome in 1, renal failure in 1, and patient refusal in 1 patient. In 7 women, there was no clear reason why GA was chosen. The median [IQR] Apgar scores at 1 minute were lower in patients receiving GA [(5) (1-9) and 4 (1-9)] in patients with GCS ≥14 and < 14 respectively, versus 8 (6-9) for SA. The number (%) of neonates with Apgar scores ≥ 7 at 1 minute in patients who had SA, was 6 (85.7), compared with 3 (13.6) and 12 (17.9) in patients having GA with GCS ≥14 and < 14 respectively. There were 2 stillbirths and 2 neonatal deaths in the GA group. The median [IQR] length of stay in patients with GCS ≥ 14 was 1 day in the group receiving SA and 2 days in those who had GA; patients with GCS< 14 were ventilated for 3 days. No patients receiving SA required postoperative ventilation, whereas 5/19 (26.3%) patients with GCS ≥14 who received GA required ventilation, for 2 days. Seven patients with GCS< 14 had cerebral oedema, and 2 had cerebral infarcts. There were 2 maternal deaths. Conclusions In this audit, a small percentage of women with eclampsia received SA for CS. A review of the case records suggests that more patients could have safely received SA. A larger prospective audit is required to establish factors influencing safety of spinal anaesthesia for CS in women with eclampsia.
- ItemOpen AccessA study comparing paracervical block with procedural sedation in the surgical management of incomplete/missed miscarriages(2014) Naiker, Manasri; Petro, Gregory; Reed, AnthonyObjective: To compare the analgesic efficacy of Paracervical Block (1% lidocaine) with procedural sedation (Midazolam/Fentanyl) in the surgical management of incomplete/ missed miscarriages. Study design: An efficacy trial with a naturally occurring control group who received what is standard practice. The study compared two methods of analgesia. The study group received paracervical block and the control group received procedural sedation. The study ran over two consecutive months (December 2012/January 2013). Setting: Groote Schuur Hospital, a level three hospital situated in Cape Town, South Africa. Population: All women between 18 and 55 years of age that were admitted to Groote Schuur Hospital requiring a uterine evacuation following either a spontaneous incomplete or a missed miscarriage that were not excluded by any of the exclusion criteria. Methods: Over the two month period recruited participants (those patients who fit the inclusion criteria and were agreeable to participate) were allocated to either the control group (month 1) or the intervention group (month 2), depending on which month they had the uterine evacuation. Data was collected from the uterine evacuations of the recruited participants over the two month study period. Main outcome measure: The participants perceived pain during and after uterine evacuation (10 minutes and two hours), scored by the participant on an eleven point numerical pain scale. Secondary outcomes were the surgeons’ satisfaction with the analgesia, duration of procedure and complications/ side effects of the two methods of analgesia under study. Results: A total of 111 participants were recruited over the study period, 57 in the control group and 54 in the intervention group. The average pain score during the procedure was lower in the Paracervical block group compared with the procedural sedation group, but this difference was not statistically significant at a 5% level (t=-1.8495, p=0.0671). For the Paracervical block group, the ‘’pain during” mean and the standard deviation (SD) were 5.56 and 2.50 respectively, whilst for the Procedural sedation group, the mean and SD were 6.49 and 2.81 respectively. Conclusion: Paracervical block using 1% lidocaine is an effective and safe alternative to procedural sedation in the surgical management of incomplete/missed miscarriages.
- ItemOpen AccessStudy of efficacy of ketamine analgesia for surgical management of incomplete miscarriages(2013) Krick, Daniela; Petro, Gregory; Reed, AnthonyObjective: To compare the analgesic efficacy of ketamine with Fentanyl/Midazolam in women requiring uterine evacuation for incomplete miscarriage as measured by the patients’ perceived pain. Study design: An efficacy trial with a naturally occurring control group who received what is currently standard practice. The study ran over two 4-week periods (25/06/2012 to 19/08/2012). Setting: Groote Schuur Hospital (a tertiary hospital) situated in Cape Town, South Africa. Population: All women between the ages of 18 and 55 years admitted to Groote Schuur Hospital for uterine evacuation following a spontaneous incomplete miscarriage or missed miscarriage that were not excluded by any of the exclusion criteria. Methods: Over a 2 month period (two 4-week periods), all patients meeting the inclusion criteria were allocated to either the control group (month 1) or the study group (month 2). Data was collected from all these evacuations during the study period at Groote Schuur Hospital.
- ItemOpen AccessThe costing of operating theatre time in a secondary level, state sector hospital: A quantitative observational study(2020) Samuel, John Philip; Reed, AnthonyBackground: There is no established costing model for operating theatres in South Africa, yet both sectors have existing charges for operating theatre (OT) time: in the state sector, Uniform Patient Fee Schedule (UPFS) rates, and in the private sector, Rands/minute (R/min) rates for OT time. Understanding the cost of providing the separate components of a health service is important for planning and funding purposes. Objective: The primary objective of this study was to develop a costing model that would allow the calculation of the R/min cost of OT time. The secondary objective was to determine the actual costs, in order to establish the comparable costs that would be included in the R/min charges for OTs in the private health sector. Method: The OTs in a secondary level, state sector hospital in Cape Town were used in this quantitative observational study to develop a top-down costing model for OTs in South Africa. The inclusive costing model was developed in a consultative process with professionals, managers and experts from the state and private sector. The model was then populated with utility measurements (water and electricity) for the month of August 2018, staff salaries, excluding surgeons and anaesthetists, and other costs for the 2018/19 financial year. Results: Costs were considered in the categories of full costs, shared costs and capital or annualised costs. Due to uncertainty in costing of OTs, two models - with different annualisation times assigned to the capital costs - were developed to demonstrate the difference. For shared costs, correction factors were determined using either an activity based (work-load) factor, or a more generic estimation of workload using theatre nursing staff as a percentage of total hospital nursing staff. To determine a R/min cost of creating a minute of available theatre time, all the annual costs were divided by minutes that the OTs are explicitly available, each year, to provide patient care. The model was then populated with costs using the appropriate correction factors. The longer annualisation model costed OT time at R31,46 per minute, and the shorter annualisation model at R33,77 per minute. In both the longer and shorter capital annualisation models, nursing was the largest contributor to costs at 36% and 33% respectively, followed by construction costs at 9% and 11%, and then OT equipment at 8% and 11%. Conclusion: An inclusive, top-down costing model for OTs in South Africa was developed. This costing model will support work to develop costing for individual procedures, the appropriate charge for planned and emergency OT time, and to better determine budgeting for OT services. Meaningful critique of the model will improve its fidelity, and likely increase its utility, especially as SA moves towards universal health coverage.
- ItemOpen AccessThe role of perioperative critical care support in a regional hospital: a prospective survey at new Somerset Hospital(2018) Delport, Kathleen Georgia; Reed, AnthonyBackground: Postoperative critical care support is required for emergency and elective cases having either major surgery, with poor physiological states or significant comorbidities, and for support following unexpected surgical or anaesthetic complications. Research suggests that as many as 48% of all critical care unit (CCU) admissions occur postoperatively, yet limited literature is available regarding the support role that onsite critical care availability provides for surgery. Research into this area is therefore necessary to understand the impact of accessible critical care support, especially in hospitals at regional and district level. Objectives: The objective of this research is to contribute to the literature on perioperative critical care by presenting data quantifying and describing the patients requiring postoperative critical care at New Somerset Hospital (NSH) - a regional hospital in Cape Town, in the Western Province of South Africa. Further to this, the research aims to identify cases that would not have proceeded here if the option of on-site postoperative critical care did not exist. Methods: Data was collected using a prospective survey spanning a six-month period from June 2015 to November 2015. The data represented two sets of patients: 1) every case done, documenting whether they would have proceeded at NSH without the presence of a critical care unit; 2) each admission to a critical care service directly from theatre, describing their indications for admission and their postoperative critical care pathway, interventions and outcomes. Results: A total of 3247 complete cases were included in the analysis. Of the total sample of cases assessed, 66 (2%) were supported by critical care at NSH, of which roughly half (31 cases) would not have proceeded at NSH without availability of a critical care bed. Of these patients, 7 did not have a bed reserved preoperatively, and were not admitted, highlighting an important subgroup of patients: those not admitted to a CCU, but yet received surgery at NSH solely due to the potential of postoperative critical care support there. New admissions amounted to 48 (1.5%) of all cases of which 43 were emergencies, and 14 were unplanned. 45% of admissions required monitoring or epidural care only, for which High Care would have been sufficient, while 55% received cardiorespiratory support. Conclusion: These results confirm that at NSH, an on-site CCU allows for cases to proceed that would otherwise have been transferred elsewhere. Of note, obstetrics accounted for 3 of the unplanned admissions, confirming that a level 2 obstetric service requires critical care support despite treating otherwise low risk patients. This data indicates that critical care plays a beneficial role in supporting a regional theatre service. 6 Further research is required in this field to determine whether these results can be generalised to other regional hospitals. This survey should help as baseline data, especially for studies to better assess quality and outcomes against national and international metrics.
- ItemOpen AccessTiming of complications following elective craniotomies(2021) Claassens, Caren; Reed, Anthony; Semple, PatrickBackground: Conservative prolonged observation periods after elective craniotomies with admission to neurosurgical higher or intensive care units (ICU) have been the norm for many decades. This practice is neither evidence based nor a cost-effective use of medical resources. This observational audit aimed to establish the incidence and timing of serious complications after elective craniotomies in a low-middle income country context. Methods: The medical records of adult patients who had elective craniotomies for the 2-year period of March 2016-February 2018 at Groote Schuur Hospital were reviewed. Complication incidence and timing was analysed in all patients admitted to either the neurosurgical high care unit (HCU) or ICU post-operatively for the initial 24hr period. The specific complications in our audit was defined as: a decrease in Glascow Coma Scale (GCS) of more than 2 points from the preoperative baseline score, new onset or worsening motor deficit, seizures, diabetes insipidus, haemodynamic instability, severe hypertension, tracheal intubation or noninvasive ventilatory support, and death. Statistical analysis was primarily descriptive. Results: A total of 189 elective craniotomy patients were included in our audit for the 2-year period mentioned. In this study 37/189 (19.6%) patients developed 1 or more major complications during the initial 24 hr post-operative period. Of these 37 patients, 31 (83.8% [95% CI 71.9-95.7]) patients developed their first onset complication within six hours of admission to the HCU or ICU, and the remaining 6 (16.2% [95% CI 4.3-28.1]) in the subsequent 18 hours. All patients who developed life threatening complications (airway, ventilation or haemodynamic support) had their first onset complication (“red flag”) within six hrs of admission. Conclusion: Our audit suggests that consideration should be given to discharge patients to a general neurosurgical ward after an uncomplicated six hour postoperative ICU stay. While a significant amount of first onset complications may occur if a patient is discharged to the neurosurgical ward after this time period, these complications were unlikely to be immediately life threatening and should not require more than standard neurosurgical ward observations to detect.