Browsing by Department "Department of Anaesthesia"

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    Anaemia and blood transfusion in the ICU
    (2004) Wilson, Graeme Scott
    During the early part of the 20th century blood transfusion became a mainstay of clinical practice. The benefit of blood transfusion in surgery, as well as in other clinical settings, as was assumed, and blood transfusion was viewed as relatively risk free. Many advances in the treatment of patients especially in the field of surgery would have been impossible without the availability of blood products.
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    Anaesthesia and Beckwith-Weideman syndrome
    (2003) Bosenberg, A
    Synopsis of patient: A 15 hour old, 4.2 kg male presents for closure of a large exomphalos. He was delivered by C-section for foetal distress after a prolonged labour at a peripheral hospital. Apgars were recorded as 6 and 8. His mother was an unmarried primigravida who attended antenatal clinic on one occasion. Meconium aspiration was suspected at birth. Preoperative assessment revealed a large term baby with features of Beckwith-Weideman syndrome - a large tongue; a faint naevus on the forehead; and a skin crease on the ear lobe. Assessment of the liver and spleen was difficult in view of the large omphalocoele (5x6cm). The exomphalos was stained by the meconium in utero. He was tachypnoeic but the chest was clear. There was a 2/6 ejection systolic murmur at the left sternal border. Chest xray was normal apart from mild cardiomegaly. Blood sugar on admission was 1.2 mmol.l ; electrolytes were within normal limits. Haemoglobin was 17gm. (Hct 55).
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    Anaesthesia and Charcot-Marie-Tooth Disease
    (MedPharm Publications, 2006) Bösenberg, A; Larkin, K
    Charcot-Marie-Tooth disease is named after three neurologists. Charcot and Marie first described this unusual slowly progressive hereditary motor and sensory neuropathy in France in 18861 . The muscle atrophy was characterized by weakness and wasting of the feet and leg muscles, followed by involvement of the hands. Tooth, in England, also described this peroneal type of progressive muscular atrophy with essentially the same clinical features in the same year. Tooth correctly postulated correctly that the disease was due to a neuropathy and not a myelopathy as was proposed by Charcot and Marie.
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    Anaesthesia and familial dysautonomia with congenital insensitivity to pain
    (South African Society of Anesthesiologist, 2005) Bösenberg, A
    Synopsis of the patient: A six year old boy presented for cosmetic surgery to his nose, which had been fractured some months previously. The trauma had resulted in some deviation of the nasal septum and ugly scarring on the bridge of his nose. Mother explained that he was accident prone and very emotionally labile. Significantly he had developed a compartment syndrome following a tibial fracture at 4 years of age. The fracture went unnoticed initially because he continued to run around unperturbed. His mother was somewhat aggressive and distrustful of the medical fraternity as she had been suspected of child abuse in the past.
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    Anaesthesia and Sirenomelia (Mermaid Syndrome)
    (2005) Bösenberg, A
    A 2.4kg one day old, the product of a 36-week monozygotic twin pregnancy born to a 24 yr. old primigravida by C-section for foetal distress, presented for laparotomy. The child’s mother had attended antenatal clinic once during her otherwise uneventful pregnancy. No antenatal investigations were performed. The monozygotic twin sibling, a male weighing 2.65kg, was completely normal.
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    Anaesthesia for lung volume reduction surgery
    (MedPharm Publications, 2005) James, M F M; Dyer, R A
    Chronic obstructive pulmonary disease (COPD) is a common condition with high morbidity and mortality rates.1 The condition, which is primarily a complication of smoking, is a chronic, slowly progressive disorder characterised by airway obstruction.2 The definition includes chronic bronchitis and emphysema with permanent destructive enlargement of distal pulmonary airspaces. Consequently, there is loss of normal lung architecture resulting in loss of elastic recoil of lung tissue leading to collapse of small airways, expiratory airflow limitation, air trapping, hyperinflation of the lungs and progressive enlargement of the thoracic cage. Expansion of the thorax leads to flattening of the diaphragm, in-drawing of the lower ribs and compromised chest wall mechanics. The ribs are lifted and flattened leading to increased total lung capacity and residual volume, with reduced FEV1 and increased work of breathing. As the disease progresses, patients must breathe at a higher lung volume to achieve the flows necessary to meet ventilatory requirements. At end-stage disease, the patient is dyspnoeic and has a severely restricted exercise capacity.3 Once the patient has reached a stage where the FEV1 < 0.75 L, the 1-year mortality is in the region of 30%4 and the patient will require frequent hospital admission for treatment of exacerbations of the condition.
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    Anaesthesia Preoperative Clinic (APOC) Audit
    (2016) Dass, Deshandra; Nejthardt, Marcin B; Roodt, Francois
    Background: Preoperative assessment clinics have been employed in many institutions to manage perioperative risks1. These clinics provide an opportunity to stratify patients on the basis of risk prior to surgery, to make timely multidisciplinary referrals where appropriate, and to prescribe medical therapies according to the current best evidence resulting, in fewer last-minute cancellations for medical reasons2 and a shorter inpatient pre-operative stay3. The Anaesthetic Pre-Operative Clinic (APOC-GSH) was introduced to Groote Schuur Hospital in 2009 with the aim of assessing and optimising high risk patients undergoing intermediate or high risk surgery. The vision of the clinic is to decrease perioperative morbidity and mortality, rationally and costconsciously investigate patients, as well as to reduce theatre cancellations of inappropriately assessed and managed patients. The clinic, together with relevant role players, attempts to risk stratify patients in making an informed decision whether the intended perioperative risks are acceptable. Patients referred to the clinic fall into two categories. Either the surgical date has been scheduled and patients are referred to APOC-GSH for optimization, or the referral is for assessment of suitability to undergo an anaesthetic and thus the treatment modality hinges on the fitness for surgery. Objective The intention of the audit is to create a database of the patients seen at APOC-GSH during 2014. Primary objectives are: 1 Referral pattern: - What proportion of patients are referred for improvement of medical condition? - What proportion of patients are referred for an assessment of operability? 2 What interventions were recommended? - What was the influence of interventions on operability and timing of surgery? - Does the clinic improve theatre efficiency by reducing cancellations of patients who required further interdisciplinary discussion and investigations? Methods: Data collection will be based on the review of APOC-GSH clerking notes and hospital patient records. The following information will be collected and entered into an Excel spread sheet: the surgical discipline referring the patient, the proposed surgery, patient co-morbidities, the lead-time from the first APOC-GSH assessment to surgery, number of visits to APOC-GSH by each patient, the investigations and additional interventions instituted at APOC-GSH. We shall also calculate the proportion of patients that would have likely been cancelled had they not attended APOC-GSH but rather been assessed by an anaesthetist the day before surgery. The record of the APOC-GSH consultation will be documented on a clerking sheet established for use within the clinic (Addendum A). The original form will be included in the patients' file and a duplicate will be stored within the access controlled Department Of Anaesthesia offices at GSH. The duplicate records will be used to obtain the information for the audit. Ethical approval will be sought from the UCT Human Research Ethics Committee for the establishment of the database and retrospective review of the APOC-GSH records on the understanding that patient records would be kept confidential and that the data obtained would be stored in a password protected spreadsheet. Access to the spreadsheet will be limited to the investigators involved and no identifiable patient details will be included. Patients will be counselled as to the nature of the study and will be expected to submit signed consent forms allowing their records to be reviewed. Patients will be informed that they will not be disadvantaged by refusal to sign the consent form and that the appropriate standard of care will still be applied. No remuneration will be provided for partaking either. Consent will be documented on the consent form specifically designed for use in the APOC-GSH. (Addendum B) Statistical analysis will be performed using an Excel® spreadsheet. Means, medians, rates and percentages will be used to describe the discrete categorical data. Output and future work The audit will provide an objective assessment of the population profile referred to APOC-GSH. It may guide future implementation of APOC-GSH protocol changes and assist with resource allocation depending on the surgical discipline requirements. Patient and surgeon satisfaction ratings may be embarked at a later stage juxtaposed against an adequate assessment in a cost and time conscious manner.
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    Analgesia : a prospective audit on patient satisfaction with postoperative analgesia in a South African tertiary hospital
    (2015) Van der Westhuizen, Christo; Montoya-Pelaez, L F; Dyer, Robert A
    Background: The vast majority of patients will be admitted to general wards after their surgical procedures. Ward staff will provide the prescribed analgesia. The researchers would like to ascertain whether the patient population is satisfied with the analgesia that they receive. Methods: Fifty-two postoperative patients consented to taking part in a prospective audit that enquired about pain using a Numeric Rating Scale (NRS) on discharge from the theatre recovery room as well as on day one postoperatively. Additionally patients were asked to indicate whether the analgesia was 'good', 'fair' or 'poor' and were interviewed about their expectations regarding pain. Results: The mean age was 45 (SD 14) years and median surgical duration was 100 (IQR 75- 150) minutes. Mean NRS score was 3 (SD 3) on discharge from recovery as well as on day one postoperatively. 'Good' analgesia was reported by 69.2% of patients and 71.2% reported that they had less pain than expected. The median time from recovery room discharge to first dose of analgesia was 135 (IQR 65-400) minutes. Conclusion: Sixty seven per cent of patients indicated that they were satisfied with the analgesia provided. There are, however, still problems with long waiting times to first doses of analgesia. The relatively low overall pain scores and high levels of satisfaction are encouraging.
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    An assessment of the impact of large goitres on perioperative and postoperative airway management: a retropsective review
    (2017) Golding, Tarryn; Haylett, Revyl; James, Michael F M
    It is widely assumed in the literature that large thyroid goitres pose a significant risk to the airway perioperatively. They are of concern to anaesthetists because of anticipated difficulty relating to intubation, ventilation and post-thyroidectomy tracheomalacia. They are of concern to surgeons because of the anticipated risk of difficult dissection and increased risk of surgical complications including haemorrhage, laryngeal nerve injury and tracheomalacia. Objectives: To analyse the folders of patients who have undergone anaesthesia and surgery for large, nonmalignant goitre, to assess the impact of large goiters on perioperative and postoperative management. An attempt will also be made to identify possible predictive markers/ patient characteristics associated with difficult intubation. Design: A retrospective folder review Setting: Groote Schuur Hospital Participants: All patients who had thyroidectomies performed at Groote Schuur Hospital between Jan 2010 and June 2016 for large, non-malignant goitres. Measurements and main results: Of the patients who underwent a thyroidectomy procedure at Groote Schuur Hospital between Jan 2010 and June 2016, 196 were identified as having non-malignant goitre and size in one dimension of greater than fifty millimeters. There were seven documented difficult intubations and only one case of failed intubation. This case was subsequently put onto cardiopulmonary bypass and intubated successfully using a rigid fibreoptic bronchoscope. Of the one hundred and nighty-six cases, four were intubated using a fibreoptic bronchoscope, eight with a videolaryngoscope, and six cases, a bougie. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed via a collar incision with no requirement to proceed to sternotomy. There was only one patient requiring blood intraoperatively and only four reported cases of postoperative haematomas. There were no instances of tracheomalacia. Two patients suffered long term recurrent laryngeal nerve injury with voice changes. Conclusion: The data shows that, in patients with large, benign goitre undergoing thyroidectomy, airway difficulties at intubation and surgical and anaesthetic complications postextubation are rare. Intravenous induction and direct laryngoscopy is a safe technique in appropriately experienced hands.
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    Audit of acute limb ischaemia in a paediatric intensive care unit
    (2016) Mumba, Jesse Musokota; Hodges, Owen; Thomas, Jenny
    Objective:Iatrogenic acute limb ischaemia in paediatric patients is a well-recognised complication of vascular access. This retrospective review of a paediatric intensive care unit identified patients who developed iatrogenic acute limb ischaemia between January 2008 and July 2013. Methods: The medical records of inpatients diagnosed with acute limb ischaemia during the study period were reviewed. Patients with other causes of acute limb ischaemia were excluded. A descriptive analysis of demographics, primary diagnosis, type of vascular access used, affected anatomical region, clinical presentation, type of therapy, type of block, response to intervention used and outcomes was conducted. Results:A total of 28 patients presented with signs of acute limb ischaemia, of whom 28.6% were aged <30 days, 46.4 % were between one and 12 months and 25% were between one and five years old; 78.6% of the affected limbs were lower limbs. Four patients had resolution of ischaemia upon removal of the vascular access devices. 23 patients received various forms of pharmacological sympathectomy, in addition to conservative therapy. One patient had missing data on the type of sympathectomy that was done. The response to the sympathectomies was: 60.9% good, 8.7% moderate, 8.7% poor and in 21.7% no responses. Documented tissue loss related to the ischaemia occurred in six (21.4%) of the 28 patients. Conclusions: Iatrogenic acute limb ischaemia in children are usually managed without surgical intervention. Pharmacological sympathectomies lead to increased blood flow to the affected limb via vasodilatation of collateral vessels, with an added advantage of reducing ischemic pain. The improved blood flow is postulated to avoid and/or minimise the amount of tissue loss. Pharmacological sympathectomies may, thus, have a role to play in th e management of iatrogenic acute limb ischaemia in the paediatric population.
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    Audit of transfusion practice during burns surgery at the Red Cross War Memorial Children's Hospital
    (2017) Spies, Anri; Bester, Kotie
    Rationale: Major burn surgery can be associated with significant blood loss, often requiring transfusion of blood products. In an effort to decrease aforementioned blood loss, various blood conservation strategies have been developed, rendering older formulae to predict intraoperative blood loss ineffective and outdated. Currently there are no clear guidelines on when to transfuse burn victims but, the trend is towards employing a more conservative transfusion practice in an attempt to reduce transfusion related complications. The predicament has become one of containing cost by not ordering blood unnecessarily and/or excessively, versus putting a patient at risk by not having blood available when he or she needs it. A guideline, based on haemoglobin and extent of surgery, was drawn up at the Red Cross War Memorial Children's Hospital in an effort to rationalise preoperative blood ordering. The aim of this audit was to assess how well the implemented guideline was adhered to, and how accurately the guideline predicted the need to have blood products available in theatre during burns surgeries of varying extent. Methods: After a guideline, based on expert opinion, had been drawn up and implemented, a prospective audit of practice was done from April 2014 to June 2015. Two hundred separate burn surgeries were audited. Data collected included haemoglobin levels, extent of surgery, pre-and intra-operative instructions to blood bank, and whether patients were transfused. Pre-operative instructions were compared to the guideline to test adherence, and to the ultimate need for blood to test accuracy. Additional data recorded were the adherence to surgical plan (extent of surgery). Results: Five of the 200 cases were excluded due to incomplete data, leaving 195 cases. Blood was ordered according to the guideline in 131 (67.2%) cases. There were two groups where adherence was particularly poor. In these patients the guideline suggested that only a group and screen was necessary - a category for which it would also be difficult to assess how accurately the guideline predicts the need for blood. After excluding these two groups, the preoperative instructions to the blood bank were appropriate in 119 (94.4%) of the 126 cases where the guideline was followed. Blood was ordered preoperatively in 83 of the 195 cases, but only used in 50 cases (60.2%). Of the 33 cases where blood was not used, 23 cases were not in keeping with the guideline. In 50 (83%) of the 60 cases where blood was ordered according to the guideline, it was appropriate. The performed surgery proceeded as planned in 162 (83.1%) cases. Discussion: Blood transfusion exposes the recipient to transfusion-related risks and is expensive. In an attempt to avoid these risks there has been a trend towards conservative transfusion practices. It has been shown to be cost effective and safe to employ a restrictive transfusion practice during major paediatric burn surgery. During our study period one unit of blood cost R1096,00 and a group and screen R172,00. Significant savings could therefore be incurred if blood is ordered according to the proposed guideline. Conclusion: This audit confirmed that the guideline is an appropriate one to use for preoperative ordering of blood products for burns surgery at the Red Cross War Memorial Children's Hospital.
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    A balanced view of balanced solutions
    (BioMed Central Ltd, 2010) Guidet, Bertrand; Soni, Neil; Rocca, Giorgio; Kozek, Sibylle; Vallet, Benoit; Annane, Djillali; James, Mike
    The present review of fluid therapy studies using balanced solutions versus isotonic saline fluids (both crystalloids and colloids) aims to address recent controversy in this topic. The change to the acid-base equilibrium based on fluid selection is described. Key terms such as dilutional-hyperchloraemic acidosis (correctly used instead of dilutional acidosis or hyperchloraemic metabolic acidosis to account for both the Henderson-Hasselbalch and Stewart equations), isotonic saline and balanced solutions are defined. The review concludes that dilutional-hyperchloraemic acidosis is a side effect, mainly observed after the administration of large volumes of isotonic saline as a crystalloid. Its effect is moderate and relatively transient, and is minimised by limiting crystalloid administration through the use of colloids (in any carrier). Convincing evidence for clinically relevant adverse effects of dilutional-hyperchloraemic acidosis on renal function, coagulation, blood loss, the need for transfusion, gastrointestinal function or mortality cannot be found. In view of the long-term use of isotonic saline either as a crystalloid or as a colloid carrier, the paucity of data documenting detrimental effects of dilutional-hyperchloraemic acidosis and the limited published information on the effects of balanced solutions on outcome, we cannot currently recommend changing fluid therapy to the use of a balanced colloid preparation.
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    Clinical utility of B-type natriuretic peptide (NP) in paediatric cardiac surgery: a systematic review
    (2014) Afshani, Nura; Thomas, Jenny; Biccard, Bruce M
    B-type natruiretic peptide (NP) is a biomarker that has gained widespread use in several patient populations and clinical situations. It is a hormone secreted primarily by ventricular myocytes in response in myocyte stretch or ischaemia.
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    Coagulation for the clinician
    (Health and Medical Publishing Group, 2006) Ruttmann, Tom
    The integrity of the circulation is maintained through the provision of a rapid, potent, but tightly localised coagulation response to vascular damage. There is, however, one extraordinary problem in the regulation of haemostasis – blood flows. Normal haemostasis is the ability of the haemostatic system to control activation of clot formation and clot lysis in order to prevent haemorrhage without causing thrombosis.
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    Combined Anaesthesia in Surgery
    (1933) Van Zyl, F F du Toit
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    A comparative study of ROTEM-EXTEM results obtained from EDTA-treated whole blood samples and Sodium Citrate-treated whole blood samples in healthy volunteers
    (2016) Du Preez, Marlize; James, Michael Frank Mansel; Dyer, Robert A
    Background: A number of anticoagulants are available in clinical use to preserve blood samples in liquid form until a suitable time for laboratory testing. Rotational thromboelastography is usually performed on a blood sample that has been anticoagulated with sodium citrate and then recalcified immediately prior to testing. In our institution we have had shortages of citrated Vacutainer® sample tubes. The use of a single in vitro anticoagulant promises to cut costs, simplify laboratory processes as well as limit the amount of blood drawn from patients. This together with the known problems with using citrate as an anticoagulant for viscoelastic testing (VET) prompted us to investigate the suitability of EDTA as anticoagulant for VET. Method: Blood samples from 20 healthy volunteers were divided into citrated and EDTA Vacutainer® tubes. A ROTEM EXTEM® assay was performed on each sample in both groups following the manufacturer's guidelines. Clotting time (CT), clot formation time (CFT), alpha angle (α-angle) and maximum clot firmness (MCF) results were compared. Ionised calcium concentrations were measured on each sample before and after recalcification with CaCl2 to determine if there was a significant difference in post - recalcification ionised calcium concentrations between the groups. Results: The results from the two groups were treated by Bland-Altman analysis. Apart from MCF values there was significant bias between all parameters measured in the two groups. The limits of agreement for all parameters apart from MCF were unacceptable. Conclusion: We found that ROTEM EXTEM® results from EDTA samples were not comparable to or interchangeable with those from citrated samples. The difference in results is not due to differences in ionised calcium concentration levels in the samples post-recalcification as the ionised calcium concentrations in both groups post-recalcification were adequate for coagulation. EDTA samples did show superior consistency in all parameters and may be a suitable alternative for sample preservation for VET if reference ranges can be established.
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    Conscious sedation v. monitored anaesthersia care - 20years in the South African context
    (2006) Stefanutto, Tish; Ruttmann, Tom
    Sedation of patients for minor procedures is here to stay. However, it is the responsibility of every physician to be aware of the potential complications associated with the combination of drugs administered and to practise in an environment where no risks are taken and no procedures performed outside the circle of safety. Furthermore, as an anaesthetic service, monitored anaesthesia care (MAC) is clearly distinct from moderate sedation and it is important for patient safety that these differences are recognised and adhered to. In essence, all practitioners must observe the strict distinctions between sedation and MAC to prevent the drift into deeper sedation under inappropriate circumstances.
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    Conscious sedation v. monitored anaesthersia care - 20years in the South African context
    (2006) Stefanutto, Tish; Ruttmann, Tom
    Sedation of patients for minor procedures is here to stay. However, it is the responsibility of every physician to be aware of the potential complications associated with the combination of drugs administered and to practise in an environment where no risks are taken and no procedures performed outside the circle of safety. Furthermore, as an anaesthetic service, monitored anaesthesia care (MAC) is clearly distinct from moderate sedation and it is important for patient safety that these differences are recognised and adhered to. In essence, all practitioners must observe the strict distinctions between sedation and MAC to prevent the drift into deeper sedation under inappropriate circumstances.