Time to face the book?: “Unfriending” IV fluids. Where are we currently with fluid administration in anaesthesia and critical care?

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Oxytocin – ensuring appropriate use and balancing efficacy with safety

Maternal deaths due to haemorrhage continue to increase in South Africa (SA). It appears that oxytocin and other uterotonics are not being used optimally, even though they are an essential part of managing maternal haemorrhage. Oxytocin should be administered to every mother delivering in SA. Awareness is required of the side-effects that can occur and the appropriate measures to avoid harm from these. Second-line uterotonics should also be available and utilised in conjunction with mechanical and surgical means to arrest haemorrhage in women who continue to bleed after the appropriate administration of oxytocin

‘But it’s just a spinal’: Combating increasing rates of maternal death related to spinal anaesthesia

The number of women dying as a result of spinal anaesthesia during  caesarean section in South Africa is steadily increasing in the triennial reports of the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD). This article postulates some of the reasons behind this phenomenon. The concern is raised that spinal anaesthesia is being undertaken inappropriately by poorly trained practitioners. A case is made for the rigorous application of known safety standards and for doctors to be appropriately trained in anaesthesia and to be solely responsible for the care of the mother during caesarean section. The need for doctors to be trained and prepared to administer general anaesthesia when required is noted

Difficult airways: a reliable “Plan B”

Percutaneous transtracheal jet ventilation (PTJV) is an accepted method of rescue ventilation following unsuccessful attempts to secure the airway through conventional methods. Pre-emptive use of PTJV in the difficult airway has also been described as using either a specifically designed jet ventilation catheter, or other cannulae, such as a central venous catheter (CVC). We report on the insertion of a single-lumen CVC to establish a means for PTJV or oxygen insufflation prior to induction of general anaesthesia in an 18-year-old man. He had an anticipated difficult airway and potentially difficult rescue airway access, having been booked for biopsy of neck masses and formal tracheostomy.Keywords: difficult airway, percutaneous jet ventilation, rescue ventilatio

Anaesthesia training for interns at a metropolitan training complex: does it make the grade?

Background: Most anaesthesia-related mortality that occurs in level 1 hospitals in South Africa is avoidable. Improving training during internship, and consequently the skills of community service officers, could lead to safer anaesthesia practices.Objectives: The objectives of the study were to determine whether or not the timing of the anaesthesia rotation during internship and other factors affected the outcome of the assessment at the end of the anaesthesia rotation, and to compare the perceptions of first- and second-year interns regarding their confidence levels at the end of their rotation.Method: We conducted a retrospective study that compared 298 intern assessments over a three-year period. It included the assessment of interns by senior doctors in respect of three cases, an overall assessment of the interns’ performance, and the number of cases carried out by them. In addition, a questionnaire was used to assess the interns’ confidence levels at the end of the rotation.Results: Little variation in the results was evident across comparisons of the year of internship, gender and age. Comparison according to university showed a slight variation. A wide variation in the number of obstetric cases (range 5–58) and endotracheal intubations (range 6–54) was observed. Over 80% of interns, regardless of the year, were confident enough to administer general anaesthesia and perform an endotracheal intubation. However, this perception of confidence by interns did not relate to the assessment of their competence.Conclusion: The variance in the ability of interns to perform anaesthesia could not be accounted for by the training year, institution of undergraduate study, age or gender. It is likely that the assessment technique used did not provide a true reflection of the acquired skills or longevity of knowledge by interns. Further research in this area is recommended.Keywords: anaesthesia, interns, training, standard

Predicting postoperative haemoglobin changes after burn surgery

Background. Burn surgery is associated with significant blood loss and fluid shifts that cause rapid haemoglobin (Hb) changes during and after surgery. Understanding the relationship between intraoperative and postoperative (day 1) Hb changes may assist in avoiding postoperative anaemia and unnecessary peri-operative blood transfusion.Objective. To describe the Hb changes into the first day after burn surgery and to identify factors predictive of Hb changes that would guide blood transfusion decisions.Methods. This was a single-institution, retrospective cohort study that included 158 patients who had undergone burn surgery. Hb was measured at the start and end of surgery, and on the first day (16 - 32 hours) after surgery, and the results were analysed. Peri-operative factors (Hb at the end of surgery, total body surface area operated on (TBSA-op), fluid administration and intraoperative blood administration) were evaluated to determine their association with Hb changes on the first day after surgery.Results. The mean (standard deviation) preoperative Hb was 10.6 (2.29) g/dL, the mean postoperative Hb was 9.4 (2.01) g/dL, and the mean Hb on the first day after surgery was 9.2 (2.19) g/dL. Median total burn surface area was 7% (interquartile range 9%, min. 1%, max. 45%), with a mean body surface area operated on (debridement area plus donor area) of 9.7%. Of the 158 patients, 26 (16%) had an Hb <7 g/dL (transfusion trigger) on the first day after surgery. For patients with a high (≥9 g/dL), intermediate (≥7 - <9 g/dL), or low (<7 g/dL) Hb measurement at the end of burn surgery, those with an Hb below the transfusion trigger on the first day after burn surgery were 0%, 27%, and 75%, respectively. End-of-surgery Hb and TBSA-op strongly predicted the first day Hb level. In the intermediate group, 55% of patients with a TBSA-op ≥11% had an Hb below the transfusion trigger on the first day after surgery.Conclusion. Hb at the end of burn surgery was the best predictor of Hb on the first day after surgery. Patients with an Hb <7 g/dL remained as such on the first postoperative day. Half of the patients with an end-of-surgery Hb ≥7 - <9 g/dL and who had ≥11% TBSA-op had an Hb <7 g/dL on the first postoperative day

Effect of COVID-19 pandemic decisions on tertiary-level surgical services in Pietermaritzburg, KwaZulu-Natal Province, South Africa

Background. The COVID-19 pandemic has led to the implementation of restrictive policies on theatre procedures, with profound impacts on service delivery and theatre output.Objectives. To quantify these effects at a tertiary hospital in KwaZulu-Natal Province, South Africa.Methods. A retrospective review of morbidity and mortality data was conducted. The effects on emergency and elective caseload, intensive care unit (ICU) admissions from theatre, theatre cancellations and regional techniques were noted.Results. Theatre caseload decreased by 30% from January to April 2020 (p=0.02), ICU admissions remained constant, and theatre cancellations were proportionally reduced, as were the absolute number of regional techniques.Conclusions. The resulting theatre case deficit was 1 260 cases. It will take 315 days to clear this deficit if four additional surgeries are performed per day

Anticipatory Feelings in Intertemporal Choice on Consumption: A Dynamic Experiment

Following the evaluation of anticipatory feelings in Scitovsky\u2019s Joyless Economy, we explored a specific interpretation of reversals in intertemporal choice. Anticipatory feelings can be explained as the feeling experienced by the agent while awaiting an upcoming event. We adopted a dynamic experiment where individuals made decisions of consumption at multiple points of time: three experimental sessions in three different dates at two-week intervals. We elicited the initial plans of the same sample in three different sessions over a one-month period and tracked how they implemented their plans as the anticipated event drew closer. The paper innovates with respect to the literature on intertemporal decision making in that the motivation for a varying discount rate, caused by anticipation or procrastination, has been elicited with both monetary and non-monetary (consumption) incentives and within a dynamic setting. We found that anticipatory feeling is a significant possible explanation behind choice reversal. The results remained significant after controlling the other explanatory factors such as risk aversion, uncertainty and time inconsistency

Guest Editorial: The Obstetric Anaesthesia Special Interest Society: renewed commitment to improving obstetric anaesthesia in South Africa

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'But it's just a spinal': Combating increasing rates of maternal death related to spinal anaesthesia

The number of women dying as a result of spinal anaesthesia during caesarean section in South Africa is steadily increasing in the triennial reports of the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD). This article postulates some of the reasons behind this phenomenon. The concern is raised that spinal anaesthesia is being undertaken inappropriately by poorly trained practitioners. A case is made for the rigorous application of known safety standards and for doctors to be appropriately trained in anaesthesia and to be solely responsible for the care of the mother during caesarean section. The need for doctors to be trained and prepared to administer general anaesthesia when required is noted