Browsing by Department "Department of Anaesthesia and Perioperative Medicine"

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    A descriptive study of the relationship between preoperative body temperature and intraoperative core temperature change in adults under general anaesthesia
    (2022) Steyn, Francois; Du Toit, Leon; Ross, Hofmeyr
    Background: Despite numerous guidelines on perioperative temperature management, perioperative hypothermia remains common. Prewarming to prevent redistribution hypothermia is supported by evidence, but not widely practiced. We investigate the measurement of preoperative mean body temperature as a potential tool for individualising the practise of prewarming. Methods: We hypothesised that patients who experience intraoperative hypothermia have a lower preoperative mean body temperature. A longitudinal study was conducted in adult patients presenting for ophthalmological surgery under general anaesthesia, to describe the relationship between the incidence of hypothermia within the first hour of anaesthesia and preoperative mean body temperature. Results: Sixty-five patients were enrolled. Twelve participants (18%) presented to the operating theatre hypothermic (core temperature <36.0°C). A further twenty-eight (43%) became hypothermic during the procedure. All hypothermia events occurred within sixty minutes after induction of anaesthesia, and half of the events occurred within nineteen minutes. The difference in preoperative mean body temperature between those with- and without intraoperative hypothermia was only -0.2°C (95% CI -0.4, 0.1). This is neither clinically relevant nor statistically noteworthy. In Cox proportional hazards analysis, BMI and ASA status compounded the observed association between preoperative mean body temperature and the incidence of intraoperative hypothermia. A higher BMI and ASA are associated with a lower incidence of hypothermia. Conclusion: We conclude that intraoperative hypothermia is common and occurs early after induction of anaesthesia. We observed no useful difference in preoperative mean body temperature to help distinguish between patients who become hypothermic and those who do not. Without a useful risk prediction tool, a generic approach to prewarming remains appropriate. Preoperative screening for pre-existing hypothermia should be practiced, even in cases considered as low risk.
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    A multicentre cross-sectional descriptive study evaluating the cardiovascular risk profile of preoperatively identified patients with hypertension
    (2021) Govender, Sarisha; Rayner, Brian; Dyer, Robert
    Background. The prevalence of hypertension in adults in South Africa (SA) is 35%. Hypertension is the most important modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD) in subSaharan Africa. However, 49% of people are unaware of their blood pressure status. Screening for hypertension prior to surgery provides a unique opportunity to diagnose and treat affected individuals. Furthermore, assessing overall CV risk identifies patients at highest risk for complications, and improves the utilisation of scarce resources. Objective. To evaluate the CV risk profile of hypertensive patients in the adult population of the Western Cape Province presenting for elective non-cardiac, non-obstetric surgery. Methods. This report documents the CV risk profile of patients recruited to the HASS-2 study (Hypertension and Surgery Study 2), which was undertaken in seven Western Cape hospitals. Patients were screened for hypertension and pharmacological treatment was initiated or adjusted in patients with stages 1 and 2 disease. Stage 3 patients were referred to a physician. In the present substudy, patients with stages 1 and 2 hypertension were assessed for associated CV risk factors, the presence of target organ damage, and documented CV or kidney disease; they received an overall risk stratification according to the 2018 European Society of Cardiology and the European Society of Hypertension Guidelines. Results. Sixty-one patients with stage 1 and 12 with stage 2 hypertension were analysed. Established CV disease was present in 13.7% of the study population, and CKD (eGFR <60 ml/min) in 10.8%. Seventy-one percent of the study group had a raised body mass index, and 55.9% underlying metabolic syndrome. Prediabetes and diabetes were present in 16.1% and 14.5% respectively. According to the 2018 European guidelines, 34.7% were at moderate, 33.3% at high and 16.7% at very high risk for a CV event in the following 10 years. Conclusions. The perioperative period is a critical time during which surgeons, nurses and anaesthetists can influence patients' CV risk of adverse events. This involves appropriate screening, education and treatment. In this study population, nearly 9 out of 10 elective surgical patients with stage 1 or 2 hypertension had CV risk factors placing them at moderate to very high risk. The simultaneous assessment of these additional CV risk parameters, in addition to diagnosis and management of hypertension, may further decrease the health and financial burden in resource-limited facilities in SA, and improve CV outcomes.
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    A multicentre, cross-sectional study investigating the prevalence of hypertensive disease in patients presenting for elective surgery in the Western Cape, South Africa
    (2018) Van Der Spuy, Karen
    Background: Hypertension is common, affecting over one billion people worldwide. Importantly, in Sub-Saharan Africa hypertensive disease not only affects the older population group, but is becoming increasingly prevalent in younger patients. In South Africa, over 30% of the adult population has hypertension, making it the single most common cardiovascular risk factor and the predominant contributor to cardiovascular disease and mortality. In non-cardiac surgical patients, elevated blood pressure is the most common perioperative comorbidity encountered with an overall prevalence of 20-25%, and it remains poorly controlled in low and middle-income countries. Furthermore, hypertension in the perioperative setting may adversely affect patient outcome. It thus not only flags possible perioperative challenges to anaesthesiologists, but also identifies patients at risk of long-term morbidity and mortality. Objectives: The primary objective of this study was to determine the prevalence and severity of hypertension in elective adult surgical patients in the Western Cape. Results: The study population included all non-cardiac, non-obstetric, elective surgical patients from seven hospitals in the Western Cape during a one-week period. Hypertension, defined as having had a previous diagnosis of hypertension or meeting the blood pressure criteria of more than 140/90 mmHg, was identified in 51.8% of patients during the preoperative assessment. Significantly, newly diagnosed hypertension was present in 9.6% of all patients presenting for elective surgery. Although 98.1% of the known hypertensive patients were on antihypertensive therapy, 36.9% were inadequately controlled. Numerous reasons exist for this but notably 32% of patients admitted to forgetting to take their medication, making patient factors the most common cause for treatment non-compliance. Conclusion: This study suggests that the perioperative period may be an important opportunity to identify undiagnosed hypertensive patient. The perioperative encounter may have a significant public health implication in facilitating appropriate referral and treatment of hypertension to decrease long-term cardiovascular complications in South Africa.
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    A prospective study of paediatric preoperative fasting times at Red Cross War Memorial Children's Hospital
    (2021) Kouvarellis, Alison; Wilson, Graeme; Biccard, Bruce; van der Spuy, Karen
    Background. Fasting for liquids and solids is recommended prior to procedures requiring anaesthesia, to reduce the risk of pulmonary aspiration. Children often experience excessive fasting, which is associated with negative physiological and behavioural consequences, and patient discomfort. The duration of preoperative fasting in children in South Africa is unknown. Objectives. The aim of this study was to determine the compliance with fasting guidelines and fasting times of children prior to elective procedures performed under anaesthesia at a paediatric hospital in Cape Town, South Africa. The primary focus was fasting for clear liquid. The study also intended to identify the most common reasons for prolonged clear liquid fasting. Methods. Over a seven-week period, we prospectively captured fasting times of consecutive patients undergoing elective surgical, medical and radiological procedures at Red Cross War Memorial Children's Hospital (RCWMCH). Measurement outcomes were defined as the period from the last clear liquid, milk or solid feed to the start of anaesthesia. For analysis of compliance with preoperative fasting guidelines, institutional preoperative fasting target limits were established based on the standard 6-4-2 hour guideline. Results. The study included 721 elective paediatric cases. The mean (SD) fasting time for clear liquids (n=585) was 8.0 (4.8) hours, with an adherence rate of 25.5% (95% confidence interval (CI) 22-29%) to the institutional target of 2 to 4 hours. The mean (SD) fasting times for breast milk (n=92), formula milk (n=116) and solid feeds (n=560) were 7.1 (2.8), 8.8 (2.8) and 13.9 (3.6) hours respectively. The factors associated with clear liquid fasting >4 hours were: inadequate fasting instructions, poor adherence to fasting orders, procedural delays and fasting to promote theatre flexibility. Conclusion. This study demonstrates that children in a South Africa hospital experience excessive fasting times prior to elective procedures. To reduce fasting durations and improve the quality of perioperative care, quality improvement (QI) interventions are required to create an adaptable fasting system which allows individualised fasting. Improving preoperative fasting times in children is the responsibility of all health care professionals in the multi-disciplinary management team.
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    A Prospective, Descriptive Study Evaluating The Evolution Of Covid-19 Associated Coagulopathy In Mechanically Ventilated, Critically-Ill Patients Using Standard Laboratory Coagulation Studies And Thromboelastography
    (2023) Neethling, Colette; Miller, Malcolm; Opie Jessica
    Objectives: Few studies detail the evolution of Coronavirus disease 2019 (COVID-19) associated coagulopathy in critically-ill patients. We aimed to perform serial thromboelastography (TEG) and laboratory coagulation studies on critically-ill patients with COVID-19 over a 14-day period, comparing variables in 30-day survivors with those in non-survivors. Design: Prospective. Setting: Intensive care unit (ICU) in Cape Town, South Africa. Subjects: Forty patients with severe COVID-19 pneumonia admitted to ICU for mechanical ventilation. Interventions: None. Measurements & Main Results: On admission, TEG maximum amplitude (MA) with heparinase correction was above the upper limit of the reference range in 80% of patients while 82.5% presented with absent clot lysis. The functional fibrinogen MA was also elevated above the upper limit of the reference range in 92.5% of patients. All patients had elevated D-dimer and fibrinogen levels, prolonged prothrombin times (PT), normal platelet counts and activated partial thromboplastin times (aPTT). No significant differences in laboratory coagulation studies and TEG analysis were noted between survivors and non-survivors on admission. The heparinase MA decreased significantly with time and normalised in non-survivors on day 14 (p=0.01). The functional fibrinogen MA continued to increase in non-survivors compared to survivors on day 14 however this difference was not statistically significantly (p=0.07). No patients developed disseminated intravascular coagulation (DIC) according to the International Society on Thrombosis and Haemostasis (ISTH) after 14 days, however thrombosis and bleeding were each reported in 7.5% of patients. Conclusion: Critically-ill patients with COVID-19 admitted to ICU for mechanical ventilation were in a hypercoagulable state as demonstrated by TEG analysis. This state evolved over the 14-day observation period, emphasizing the importance of regular monitoring of coagulation parameters in these patients. A small group developed thrombotic complications despite therapeutic anticoagulation, however a similar proportion suffered a bleeding event, indicating that routine therapeutic anticoagulation should be practiced with caution.
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    A quality improvement project evaluating the perioperative implementation of a hypertension management protocol by anaesthesiologists at seven government hospitals in the Western Cape. “a multi-center, cross-sectional quality improvement project: the peri-operative implementation of a hypertension protocol by anesthesiologists”
    (2021) Pfister, Claire-Louise; Biccard, Bruce; Dyer, Robert A; Rayner, Brian
    BACKGROUND: Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of life-style modification for the initial management of hypertension in the community. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. METHODS: In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis of hypertension and subsequent initiation or modification of anti-hypertensive therapy, or referral to a physician. The study was a multi-center, cross-sectional quality improvement project in seven hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult inpatients had two sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated blood pressure device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm, defined as initiation of the prescribed medication. An 80% adherence rate was considered successful implementation. The secondary outcome was the issue of the antihypertensive medication at discharge. RESULTS: Two hundred and ninety-eight patients were screened for hypertension. One hundred and six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline blood pressure readings, 43 (40.6%) had stage 1-, 22 (20.8%) stage 2-, and 4 (3.8%) stage 3 hypertension respectively. The adherence rate by the anesthesiologist was 84.0% (95% confidence interval (CI) 77.0% to 91.0%) for initiation of anti-hypertensive therapy. It was noted that 55.5% (95% CI 46.2% to 65.1%) received their medication upon discharge. CONCLUSIONS: Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multi-disciplinary team involving anesthesiologists, surgeons, nurses, pharmacists and physicians.
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    A randomised comparison of bolus phenylephrine and ephedrine for the management of spinal hypotension in patients with severe preeclampsia and a non-reassuring fetal heart rate trace
    (2018) Adams, Samantha; Dyer, Robert A
    Background: Studies in healthy patients undergoing elective caesarean delivery show that ephedrine used for spinal hypotension is associated with increased fetal acidosis compared with phenylephrine. This has not been investigated prospectively in severe preeclampsia. Methods: Patients with severe preeclampsia requiring caesarean delivery for a non- reassuring fetal heart tracing were randomised to receive bolus ephedrine (7.5-15 mg) or phenylephrine (50-100 μg) for spinal hypotension. The primary outcome was umbilical arterial base deficit. Secondary outcomes were umbilical arterial (UA) and venous (UV) pH and lactate level, venous base deficit, and Apgar scores. Results: A total of 133 women were included;; 64 required vasopressor treatment and were randomised to 2 groups of 32 with similar patient characteristics. Pre- delivery blood pressure changes were similar in the 2 groups. There was no difference in mean [SD] UA base deficit (-4.9 [3.7] vs -6.0 [4.6] mmol·L⁻¹ for ephedrine and phenylephrine respectively;; P = 0.29). Mean [SD] pH (UA and UV) and lactate levels were also similar between groups (7.25 [0.08] vs 7.22 [0.10], 7.28 [0.07] vs 7.27 [0.10], and 3.41 [2.18] vs 3.28 [2.44] mmol·L⁻¹ respectively). In addition, UV PO₂ was higher in the ephedrine group (2.8 [0.7] vs 2.4 [0.62]) kPa, P = 0.02). There was no difference in 1- or 5-minute Apgar scores, numbers of neonates with 1-minute Apgar scores < 7 (10/32 [31%] vs 12/32 [38%]), or with a pH < 7.2 (6/31 [19%] vs 8/29 [28%]). Conclusions: In patients with severe preeclampsia and fetal compromise, fetal acid-base status is independent of the use of bolus ephedrine vs phenylephrine to treat spinal hypotension.
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    A retrospective audit of pain assessment and management post caesarean section at New Somerset Hospital in Cape Town, South Africa
    (2022) Munsaka, Effraim Frackson; van Dyk, Dominique; Parker, Romy
    Background: The most common major surgical procedure performed worldwide is the caesarean section (CS). Effective pain management is a priority for women undergoing this procedure, to reduce the incidence of persistent pain, (a risk factor for postpartum depression), as well as optimize maternal-neonatal bonding and the successful establishment of breastfeeding. Multimodal analgesia is the gold standard for post-caesarean section analgesia. At present, no perioperative pain management protocols could be identified for the management of patients presenting for CS at regional hospitals in South Africa. This audit aimed to review the folders of patients who underwent CS, with reference to perioperative pain management guidelines for CS. Methods: A descriptive, retrospective, cross-sectional audit was conducted. Three hundred folders (10% of the annual number of caesarean procedures performed) from New Somerset Hospital, a regional hospital in Cape Town, South Africa were reviewed. Results: The women were a mean age of 30 years (SD 6.2). Median gravidity was 3 (IQR 2-3) and parity was 1 (IQR 1-2); 52% had previously undergone a CS. In 93.3%, spinal anaesthesia was employed for CS. Pain assessment was poor, with only 55 (18%) patients having their pain assessed on the day of the operation. Analgesia was prescribed in over 98% of the patients, however, medication was only administered as prescribed in 32.6%. Non-steroidal anti inflammatory drugs (NSAIDs) were prescribed in < 1.67% of cases. None of the patients received a patient-controlled analgesia (PCA), transversus abdominis plane (TAP) block, or wound infusion catheter as supplementary strategies. Conclusions: Pain management for post-CS patient at this hospital is lacking. There is the need for the implementation of a structured assessment tool to improve administration of analgesics in these patients. In addition, the reasons for the omission of NSAIDs from the analgesia regimen requires investigation. Hospitals require post-CS pain protocols to guide management especially in resource-limited settings.
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    A retrospective descriptive analysis of prehospital advanced airway management in a South African private emergency medical service
    (2021) Araie, Farzana; Joubert, Ivan; Stassen, Willem
    Introduction: Emergency medical systems have evolved from mostly providing patient transport to healthcare facilities to the provision of emergency care interventions on scene or en route to a healthcare facility. Endotracheal intubation is one of these interventions but despite being performed in the prehospital setting for nearly two decades, the practice of prehospital ETI has not yet been examined on a national level. Methods: This is a retrospective chart review of prehospital ETI performed by non-physician prehospital providers of a ground-based emergency medical service that operates on a national level over a 12 month period. Results: Of the 806 cases recorded in the study period, 683 met the criteria for analysis. Male patients accounted for 67% of the cases. The majority of patients (56%) intubated were trauma patients while the remaining 44% were intubated for medical reasons. The first pass success rate was 74% and the overall success rate was 98%. Rapid sequence intubation was the method used to intubate 34% of patients. Approximately 29% received drug facilitated intubation and 27% of patients were intubated whilst being treated for cardiac arrest. Approximately 65% of patients had documented risk factors for difficult intubation. Clinical adverse events were recorded in 14% of cases. Discussion: The first pass success and overall success rates compare favourably with those reported in similar contexts. Adverse events were thought to be under-reported.
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    A study of the prevalence of preoperative anaemia and iron deficiency in adult elective surgical patients in hospitals in the western cape province, South Africa. “A multicentre prospective observational study of the prevalence of preoperative anaemia and iron deficiency in adult elective surgical patients in hospitals in western cape province, South Africa.”
    (2021) Conradie, Willem Stephanus; Roodt, Francois; Biccard, Bruce; Nejthardt, Marcin
    Background. Preoperative anaemia has been shown to be an independent risk factor for postoperative morbidity and mortality. Iron deficiency is the leading cause of anaemia globally. There are limited data describing the burden of perioperative anaemia and the relative contribution of iron deficiency in South Africa (SA). Objectives. To determine the prevalence and severity of preoperative anaemia in adults presenting for elective surgery in Western Cape Province, SA, and to investigate the contribution of iron deficiency as a cause of the anaemia. For this purpose, an investigative protocol from a recent consensus statement on the management of perioperative anaemia was applied. Methods. We performed a prospective, observational study in adult patients presenting for elective non-cardiac, non-obstetric surgery over a 5-day period at six Western Cape government-funded hospitals. The World Health Organization patient classification was applied, and patients with anaemia were investigated for iron deficiency. Results. The prevalence of preoperative anaemia was 28% (105/375; 95% confidence interval (CI) 23.5 - 32.5); 55/105 patients (52%) had moderate and 11/105 (11%) severe anaemia. Iron deficiency was the cause of anaemia in 37% (32/87; 95% CI 26.6 - 46.9), but only 9% of irondeficient patients received iron supplementation prior to surgery. Conclusions. Preoperative anaemia was common in this study, and more than half of the affected patients had moderate to severe anaemia. Iron deficiency was responsible for almost 40% of cases. Iron supplementation was under-utilised in the preoperative period as a means of increasing haemoglobin. The introduction of system-wide policies would empower perioperative physicians to mitigate the risk associated with preoperative anaemia in the Western Cape.
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    A Systematic Review and narrative synthesis of the methods used to teach adult airway management skills to novices
    (2021) Grunewald, Kevin; Duys, R; Hofmeyr, R
    Background: Airway management is an essential skill for healthcare providers across many disciplines. Inadequate airway management leads to adverse events and deaths. Clear guidance on the use of evidence-based educational methods to train novice airway managers is limited. Best evidence suggests using a “deliberate practice for mastery learning” approach to produce expertise in complex skills. Objectives: Our primary outcome is a narrative synthesis of the evidence evaluating instructional design elements employed to train novices in airway management. Our secondary outcome is a description of how these techniques employ deliberate practice principles. These data will inform recommendations for future airway training. Methods: We conducted a systematic review of English language studies published by June 2019. Studies evaluating educational interventions to improve airway management by novices were included. Studies were excluded if they only reported learner reactions to training (Kirkpatrick Level 1 outcomes). Data extraction was performed in duplicate using a standardised form and critical appraisal of the included studies was performed using a tool developed by Hawker, et al. Due to the heterogeneity of the data and in order to best highlight important themes, we performed a narrative synthesis of included studies. Further, we explicitly reviewed the studies using a deliberate practice lens to extract features consistent with this framework. Results: Our search yielded 506 studies of which 42 were eligible for inclusion. Most studies were rated poor quality and used small convenience samples. Studies included participants from a range of disciplines who were trained using multiple different interventions on part-task trainers, manikins and real patients. Most studies (60%) used overall intubation success rate as the primary outcome measure with only 21% of studies reporting first-pass success rate. Only 10% of studies explicitly mentioned deliberate practice. Important emerging themes include using checklists as scaffolding for progression, using video laryngoscopy to augment teaching, and using different manikins to mimic variations in human anatomy. Conclusions: Reported studies evaluating airway training are of poor quality. However, available evidence offers usable instructional design elements associated with durable learning and improved expertise. We have made suggestions for incorporating deliberate practice into future airway training. A commitment to evidence-based educational design could improve expertise in this critical skill. (Prospero registration: CRD42017077843)
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    A systematic review of outcomes associated with withholding or continuing angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) prior to noncardiac surgery
    (2019) Hollmann, Caryl; Biccard, Bruce
    Introduction The global rate of major noncardiac surgical procedures is increasing annually, and of those patients presenting for surgery increasing numbers are taking either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin receptor blocker(ARB). The current recommendations whether to continue or withhold ACE-I and ARB in the perioperative period are conflicting. Previous metaanalyses have linked preoperative ACE-I /ARB therapy to the increased incidence of post induction hypotension, however have failed to correlate this with adverse patient outcomes. The aim of this meta-analysis was to determine whether continuation or withholding ACE-I or ARB therapy in the perioperative period is associated with mortality and major morbidity. Methods This meta-analysis was prospectively registered on PROSPERO (CRD42017055291). A comprehensive search of MEDLINE (PubMed), CINAHL (EBSCO host), ProQuest, Cochrane database, Scopus and Web of Science was conducted on 06 December 2016. We included adult patients >18years, on chronic ACE-I or ARB therapy who underwent noncardiac surgery, where ACE-I or ARB was either withheld or continued on the morning of surgery. Primary outcomes included all-cause mortality and major cardiac events (MACE). Secondary outcomes included the risk of congestive heart failure (CHF), acute kidney injury, stroke, intra/postoperative hypotension and the length of hospital stay (LOS). Results Following abstract review, the full text of 25 studies were retrieved, of which nine fulfilled the inclusion criteria; five were randomized control trials (RCTs) and four cohort studies. These studies included a total of 6022 patients on chronic ACE-I/ARB therapy prior to noncardiac surgery. 1816 patients withheld treatment the morning of surgery and 4206 continued their ACE-I/ARB. Preoperative demographics were similar between the two groups. Withholding ACE-I/ARB therapy was not associated with a difference in mortality (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.62-1.52; I2 =0%) or MACE (OR 1.12; 95% CI 0.82-1.52; I2 =0%). Withholding therapy was however associated with significantly less intra-operative hypotension (OR 0.63 95% CI 0.47;0.85, I 2 =71%). No effect estimate could be pooled concerning length of hospital stay and CHF. Conclusions This meta-analysis did not demonstrate an association between perioperative administration of ACEI/ARB, and mortality or MACE. It did however confirm the current observation that perioperative continuation of ACE-I/ARBs is associated with an increased incidence of intra-operative hypotension. A large randomized control trial is necessary to determine the appropriate perioperative management of ACE-I and ARBs.
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    An audit of the prevalence of abnormal fasting blood glucose levels in patients presenting for elective surgery at a selection of Western Cape government hospitals
    (2019) Biesman-Simons, Tessa; Nejthardt, Marcin; Biccard, Bruce; Roodt, Francois
    Background. Diabetes mellitus (DM) is a common condition. The high burden of undiagnosed DM and lack of large population studies make accurate prevalence estimations difficult, especially in the surgical environment. Furthermore, poorly controlled DM is associated with an increased risk of perioperative complications and mortality. Objectives. The primary objective was to establish the prevalence of DM in elective adult non-cardiac, non-obstetric surgical patients in Western Cape hospitals. The secondary objectives were to assess the glycaemic control and compliance with treatment of known diabetics. Methods. This was a five-day, multicentre, prospective observational study performed at six government-funded hospitals in the Western Cape. Screening for DM was done using fingerprick capillary blood glucose (CBG) testing. Patients found to have a CBG of ≥ 6.5 mmol/L had an HbA1c level done. DM was diagnosed based on the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) diagnostic criteria. Patients known with DM had an HbA1c performed and Morisky Medication Adherence Scale (MMAS-4) questionnaires completed, to assess glycaemic control and compliance with treatment. Results. Of the 379 participants, 61 were known diabetics (16.15%; 95% CI 12.4-19.8%). After exclusion of eight patients with incomplete results, a new diagnosis of DM was made in five out of 310 patients (1.6%; 95% CI 0.2-3.0%). Overall prevalence of DM was 17.8% (66/371; 95% CI 13.9-21.7%). HbA1c results were available in 57 (93.4%) of the 61 known diabetics. Of these 27 (47.4%; 95% CI 34.4-60.3%) had an HbA1c level≥8.5% and 14 (24.6%; 95% CI 13.4 - 35.8%) had an HbA1c ≤7%. Based on positive responses to two or more questions on their MMAS-4 questionnaires, 12 out of 60 participants (20%) were deemed non-compliant. Conclusion. There is a low rate of undiagnosed DM in our elective surgical population; however there is a large proportion of poorly controlled DM. Since poorly controlled DM is known to increase postoperative complications, this likely increases the burden of perioperative care. Resources should be focused on improvement of long-term glycaemic control in patients presenting for elective surgery.
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    An observational study to assess coagulation abnormalities in patients with elevated levels of urea and/or creatinine secondary to renal failure, presenting for renal biopsy – challenging conventional testing using visco-elastic testing
    (2018) Rodrigues, Jacques; Miller, Malcolm
    Introduction Coagulation abnormalities are well described in patients with elevated levels of urea and/or creatinine secondary to renal failure. These range from hypercoagulable to hypocoagulable states due to a range of mechanisms well described in the literature. Conventional tests of coagulation such as INR and PTT do not adequately assess these disorders of coagulation. Thromboelastography (TEG®) has proven to be a suitable alternative test of coagulation that serves as a dynamic test of global coagulation including assessment of thrombus formation as well as its breakdown. TEG® and ROTEM® assesses the visco-elastic properties of blood in vitro to define in vivo coagulability. The standard of care in our institution to assess the bleeding risk in patients with renal failure (defined by a raised urea and/or creatinine level) presenting for a renal biopsy is to use the conventional tests of coagulation, including a bleeding time if their creatinine is above 300 µmol/L. The aim of this study is to evaluate the conventional standard laboratory tests of coagulation (including a bleeding time where available), TEG® and ROTEM® in assessing coagulation disorders in patients with elevated levels of urea and/or creatinine presenting for renal biopsy. Methodology Patients with elevated levels of urea and/or creatinine presenting for a renal biopsy will be identified by the nephrology team responsible for their medical management. Prior to the renal biopsy, these patients will be approached by the study team and reviewed for inclusion into the study. Informed consent will be obtained on agreement to participate in the study. We will collect a blood sample for the TEG® and ROTEM® and this test will be performed by a laboratory technician in the Department of Anaesthesia. The clinician/nephrologist performing the biopsy will not be influenced by the outcome of these viscoelastic tests. A convenience sample of a minimum of 25 patients with renal impairment presenting for a renal biopsy will be included in this study. Results A total of 44 adult participants was entered into this observational study. Results for 1 participant were excluded from this study as their biopsy was delayed, allowing their renal function to improve and return to normal with medical management on the day that they presented for a renal biopsy. 43 patients were worked up for a renal biopsy but only 38 patients proceeded to a renal biopsy. Of these, only 31 patients had a bleeding time performed on the day of their renal biopsy. The participants ages ranged from 24 to 69 years and included 24 male and 19 female participants. Renal biopsies were cancelled by the consultant nephrologist in 5 patients on the day of their biopsy. Control samples, from 10 members in the Department of Anaesthesia, fell within the specified range of the various manufacturers. An interesting TEG® result was an average MA result of 74.22 mm (normal range 64 – 72 mm), which lies above the upper limit of normal. Two patients developed a small renal haematoma on ultrasound after the biopsy, with 1 of these patients also developing haematuria. Conclusion TEG® and ROTEM® provides a global assessment of coagulation and might be helpful in assessing coagulation defects in patients with elevated levels of urea and/or creatinine presenting for a renal biopsy, with possible extension to the surgical patient with abnormal renal function presenting for a surgical procedure to assess their risk of bleeding, especially in those who are being considered for a regional or neuraxial technique - as this could be an unacceptable risk in this population sub-group .
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    Anaemia in a South African colorectal ERAS programme – identifying the prevalence and predictors of preoperative anaemia and the effect on post-operative complications and length of stay
    (2023) Nieuwenhuis, Kathryn; Gibbs, Matthew; Louw, Vernon; Alphonsus; Warden, C; Boutall, A; Bannister, S
    Background: Anaemia is a widespread public health problem associated with increased mortality and morbidity. In a surgical population, the prevalence of preoperative anaemia often exceeds that of the general population. Elective colorectal patients often have multiple risk factors for preoperative anaemia. The fourth updated ERAS Society guidelines for optimal perioperative care in colorectal surgery include specific recommendations for screening and treatment of preoperative anaemia as well as utilising restrictive blood transfusion practice. Assessing the prevalence and predictors of anaemia and outcomes in this population may allow for improved preoperative assessment and treatment of colorectal patients in a resource limited setting. Objectives: The primary objective of this retrospective study was to determine the prevalence of anaemia in the colorectal surgical population who were part of the enhanced recovery after surgery (ERAS) programme at a tertiary level hospital in the Western Cape, South Africa. Secondary objectives were to determine independent risk factors of preoperative anaemia, and the effect of anaemia on post-operative complications and length of stay after elective colorectal surgery. Methods: We performed a secondary analysis of data collected for the colorectal surgical ERAS programme. Data of 260 patients was reviewed from the initiation of the database 01 September 2016 to 30 September 2019. Three regression analyses were performed as part of the secondary objective to determine the risk factors for preoperative anaemia and predictors for postoperative complications and length of hospital stay. Patients were defined as anaemic if their haemoglobin was less than 13.0 g/dL. Results: The prevalence of preoperative anaemia was 157/260 (60.3%). Female sex (odds ratio (OR) 2.44, 95% confidence interval (CI) 1.43 – 4.18; p=0.001) and the presence of malignancy (OR 2.42, CI 1.26- 4.67; p=0.008) showed a significant association with anaemia. Anaemia was not associated with increased risk of post-operative complications or length of hospital stay. Conclusion: South African colorectal surgical patients in an enhanced recovery after surgery programme have a higher prevalence of preoperative anaemia compared to the general surgical population. Predictors of preoperative anaemia in this population included female sex and the presence of malignancy. Long waiting lists for patients awaiting elective colorectal surgery allow time for evaluation and optimisation of patients at risk for anaemia preoperatively
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    Anaesthesia providers accessibility and usage of video
    (2023) Young, Matthew; Hofmeyr, Michael
    Introduction Approaches to airway management have undergone a dramatic transformation since the advent of video laryngoscopy (VL). Access to VLs for anaesthesia providers (AP) in operating theatres in South Africa has not previously been described, and the current usage is unknown. Methods We designed a cross-sectional survey investigating AP access and type of VL, as well as AP usage of VL in general, in obstetric anaesthesia, and in patients infected with SARS CoV-2. By using a combination of survey and direct contact audit we atempted to contact all medical facilities with an operating theatre in South Africa. Results 98% (661/676) of hospitals provided responses to the survey or were contacted directly via telephone. Of the total 559 hospitals with operating theatres, 65% (362/559) had access to a VL. 84% (1983/2357) of theatres are found in hospitals which have access to a VL. Larger hospitals are more likely to have video laryngoscopes. The C-MAC® and GlideScope® VL account for 85% of devices found in South Africa. 71% (395/559) of hospitals reported providing obstetric theatre services, while 58% (229/395) of these reported having access to a VL. 54% (301/559) of hospitals reported performing intubatons on patients infected with SARS-CoV-2, of these 79% (238/301) reported having access to a VL. Discussion Our data quantified the expected inequality in the distributon of VLs. There are large discrepancies between the different provinces, as well as between state and privately funded hospitals in South Africa. Despite having become a common device, VL is underutilized, even in high-risk populations.
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    Anaesthetic complications in gastroschisis
    (2025) Heald, Andrew; Gray, Rebecca; Meyer , Heidi
    Introduction: Patients with gastroschisis (GS) are a vulnerable population who present to the operating theatre for pathology or central venous access related indications. Little is known about anaesthesia-related adverse events (ARAEs) in children from low- and middle-income countries (LMICs). Methods: We performed a single-centre retrospective observational study at Red Cross War Memorial Children's Hospital (RCWMCH), in Cape Town, South Africa. Data was collected from patient folders from the hospital's GS database. Each general anaesthetic exposure (GAE) was treated as an independent event and a binary logistic regression analysis was performed to assess the association between indication for GAE and the odds of an ARAE. A mixed-effects logistic regression model was used to analyse the association between adverse complications and key predictor variables in paediatric anaesthesia. Results: Seventy folders were collected between 2012 and 2021. The median gestational age was 36 weeks and median birthweight 2270g. 56 (80%) patients survived to full enteral feeds and the median duration of TPN was 18 days (IQR 12-29). There were 196 GAEs, of which pathology-related indications comprised 59%. There was a total of 94 ARAEs. At least one ARAE occurred in 79 (40%) of the 196 GAEs. Cardiovascular instability was the most common ARAE, comprising 76% of the total ARAEs. Respiratory events comprised 18% of the ARAEs, with reintubation predominating. Patients presenting for pathology related indications were associated with an unadjusted 6-fold odds increase (95% CI = 3.10, 12.27) in the odds of ARAEs compared to patients with CVC-related indications (p<0.001), however at least one ARAE occurred in 18% of CVC related GAEs. No statistically significant association with ARAE was found for gestational age, birth weight or sex. Conclusion: At RCWMCH, many patients with GS experience a complicated clinical course, requiring multiple general anaesthetic exposures. They have a high prevalence of anaesthetic related adverse events, particularly instances of CVS instability and reintubation. Establishing a multidisciplinary management protocol for these patients may decrease intervention frequency and improve outcomes.
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    Are Groote Schuur Hospital anaesthesiologist burnt out? A cross-sectional study of prevalence and risk
    (2021) Groenewald, Michael Burger; Van, Nugteren Janieke
    Background: Burnout and physician wellness are becoming increasingly topical. While some surveys have been performed with South African anaesthesiologists, these have been conducted in limited samples. While Burnout is often measured, there is a paucity of research on contributory risk and protective factors. Method: A contextual, prospective, cross-sectional study was conducted. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and the Areas of Work-Life Survey (AWS) were used to assess Burnout and contributory organizational risk factors amongst state-employed anaesthesiologists working at Groote Schuur Hospital. Results: Out of a possible 127 members of staff (Medical officers, Registrars and Consultants), 81 responded with 75 completing the full survey (59% response rate). Only 4% of respondents were classified as “burnt out”, defined as scoring 8 high in all three domains of Burnout: High Emotional Exhaustion and Depersonalization and Low Personal Accomplishment. However, 67% of respondents scored high for at least one of the components of Burnout, indicating the majority of the respondents are at risk for developing clinically significant Burnout. The Areas of Work-Life survey showed that respondents found their workload inappropriate. However, responses for the categories of Control, Reward, Community, Fairness and Values were all in the acceptable range. Conclusion: While the overall rate of Burnout was low, the majority of respondents were at risk of developing Burnout. High perceived workload appeared to be a particular contributory factor. Protection against Burnout in this group may be provided by a combination of few organisational risk factors together with feelings of personal accomplishment.
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    Audit of peripheral neuromuscular stimulators at the hospitals staffed by the department of anaesthesia and perioperative medicine at the University of Cape Town
    (2018) Joubert, Andries Thomas; Porrill, Owen
    Rationale: Inadequate monitoring of neuromuscular blockade (NMB) may result in worse patient outcomes, therefore NMB monitor availability is a minimum requirement for perioperative care according to the South African Society of Anaesthesiologists’ (SASA) 2018 Practice Guidelines. The authors performed an audit of peripheral nerve stimulators (PNS) functionality and availability at their institution. In the researcher’s experience the peripheral nerve stimulators (PNS) in use at his institution are not always easily available and some units malfunction at times. There are also not many units that can give a graphical display of a train of four ratio. This observation spurred the idea to do an audit on neuromuscular monitoring at this institution, by focusing on the availability and functionality of peripheral nerve stimulators. Methods: After ethics approval was obtained, an audit was performed. In order to assess function, the PNS were attached to an electrical circuit with a skin equivalent resistance. The resultant current impulses generated using Train-of-Four (TOF) mode and Double Burst Stimulation modes (DBS) were recorded with a voltage scope meter and visually assessed that the TOF was present and appeared equal. PNS availability was assessed in theatre and recovery areas against the SASA guideline standard of nerve stimulator availability. Results: Of the 65 PNS units assessed, 39 units were deemed to be dysfunctional and 26 units fully functional. The most frequent fault found (30 units) related to faulty or absent PNS electrode cables. Eight functional PNS units with TOF ratio display capability were found. The working PNS showed good inter-device peak voltage measurement correlation. Of the 59 areas identified where PNS should be easily available, only 37 areas met the PNS availability criteria suggested in the SASA guidelines. Discussion: This audit revealed that overall there were not enough functional PNS available at the institution, when measured against the SASA standard. The clinical significance of these findings would vary depending on the actual usage rate of NMBs in the area concerned. The logistics of tracking aPNS unit’slocationalso turnsoutto be paramountinsituationswherenerve stimulators have to be shared between areas. From a technical point of view, the working PNS were found to be very consistent in their delivered voltage bursts. Future use of the first generation PNS (without TOF ratio display) will continue to decline, because of their inability to monitor neuromuscular function bymodern standards, and the poor availability ofreplacement parts for models no longer manufactured. The cost and availability of repairs and cable replacementsshould be factored into the decision when acquiring more PNS units. Conclusion: This audit highlighted the need for more new generation PNS with TOF-ratiodisplay- ability to align the institution with the recommendations from SASA standards and the anaesthetic literature. It also highlighted the accuracy and consistency of delivered current bursts by the working PNS devices.
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    Barriers to clinical research in Africa, a quantitative and qualitative survey of 27 African countries
    (2019) Conradie, Aletta; Duys, Rowan; Biccard, Bruce M
    Background There is a need for high quality research to improve perioperative patient care in Africa. The aim of this study was to understand the particular barriers to clinical research in this environment. Methods Electronic survey of African Surgical Outcomes Study (ASOS) investigators, including 29 quantitative Likert scale questions and eight qualitative questions with subsequent thematic analysis. Protocol compliant and non-compliant countries were compared according to the WHO statistics for research and development, health workforce data and world internet statistics. Results Responses were received from 134/418 invited researchers in 24/25 (96%) participating countries, and three non-participating countries. Barriers included the lack of a dedicated research team (47.7%), reliable internet access (32.6%), staff skilled in research (31.8%) and team commitment (23.8%). Protocol compliant countries had significantly more physicians per 1000 population (4 vs 0.9 p<0.01), internet penetration (38% vs 28% p=0.01) and published clinical trials (1461 vs 208 p<0.01) compared to non-compliant countries. Facilitators of research included establishing a research culture (86.9%), simple data collection tools (80%) and ASOS team interaction (77.9%). Most participants are interested in future research (93.8%). Qualitative data reiterated human resource, financial resource, and regulatory barriers. However, the desire to contribute to an African collaboration producing relevant data to improve patient outcomes, was expressed strongly by the ASOS investigators. Conclusions: Barriers to successful participation in ASOS related to resource limitations and not the motivation of clinician investigators. Practical solutions to individual barriers may increase the success of multi-centre perioperative research in Africa.