G Lamacraft

Prevention and treatment of cardiovascular instability during spinal anaesthesia for caesarean section

Spinal anaesthesia is the method of choice for caesarean section. There is however a significant associated morbidity and mortality in South Africa, particularly in inexperienced hands. This review provides recommendations for safe practice for anaesthetists at all levels of expertise, with particular reference to the management of haemodynamic instability.

Training and experience of doctors administering obstetric anaesthesia in the Free State Level 1 and 2 Hospitals

ABSTRACT Background All the published Saving Mothers Reports generated by the National Committee of the Confidential Enquiries into Maternal Deaths in South Africa have associated anaesthesia-related maternal deaths with the lack of skills of the doctors administering the anaesthesia. The Reports have shown the Free State to be one of the provinces in South Africa with the highest rate of obstetric anaesthesia deaths. Therefore, the current study was performed to determine whether a deficiency exists in the training and experience of doctors administering obstetric anaesthesia. The identifying of such a deficiency would call for the implementation of remedial measures. Methods The study was performed in 2005 using questionnaires designed by the first two authors of this paper. All Level 1 and 2 hospitals in the Free State performing Caesarean sections (CSs) were visited. The doctors administering obstetric anaesthesia were each asked to respond to a questionnaire. The questionnaires enquired about previous training and experience in anaesthesia and, more specifically, obstetric anaesthesia, as well as anaesthesia and nonanaesthesia qualifications. In addition, questions were asked regarding supervision, and whether other duties were performed while administering anaesthesia. Results The response rate was 69% (105/148 doctors). Of the respondents, 9.5% were interns, 24.7% community service doctors, 47.6% medical officers, 15.2% general practitioners (GPs) and 2.9% specialists. Twenty-three per cent of respondents had been in their present post for five years or more. Most doctors had received 4 weeks or less training in anaesthesia as an Intern, not including obstetric anaesthesia in 13 cases. Six doctors (GPs or medical officers) had been appointed in posts in which obstetric anaesthesia was required, without previously having administered obstetric anaesthesia. At the time of the survey, two doctors had never performed spinal anaesthesia and five had never administered general anaesthesia for CS, although all were regularly administering obstetric anaesthesia. Apart from the specialists, the Diploma in Anaesthesia was held by only one doctor, a medical officer. Half of the interns were not directly supervised while administering obstetric anaesthesia, while more than half the community service doctors were employed in hospitals where no senior support was available. The doctors frequently had both to administer the anaesthetic and to perform neonatal resuscitation. Twelve of the doctors concerned had often also to perform the surgery itself. Most of the doctors requested further training in obstetric anaesthesia and improved senior anaesthetic assistance. Conclusions There is a lack of experience, training and supervision amongst doctors administering obstetric anaesthesia in the Free State. Doctors regularly have to perform other duties, whilst administering obstetric anaesthesia, which may put the mother at risk from inadequate observation. These may be contributory factors to the high rate of maternal deaths from anaesthesia.

Obstetric anaesthesia: The source of the crisis

The Saving Mothers Reports have consistently shown that, out of all the provinces of South Africa, the Free State has one of the highest rates of maternal deaths arising from anaesthesia.The provinces Department of Health requested the University of the Free States Department of Anaesthesiology to investigate the problem. We examined possible factors, including training and experience of doctors administering anaesthesia, availability of suitable anaesthetic drugs and equipment, and use of regional anaesthesia. All the level 1 and 2 hospitals in which caesarean sections (CSs) were being performed were investigated. The foremost problems identified were lack of training and experience in administering obstetric anaesthesia, and lack of senior anaesthetic assistance South African Medical Journal Vol. 98 (2) 2008: pp. 123-124

The link between acute postoperative pain and chronic pain syndromes

Surgery is frequently performed because a patient presents with pain. This may be acute pain, due to appendicitis, or chronic pain, because of spinal degeneration. Once the offending part of the body has been removed, or surgically corrected, the patient expects to be pain-free. Some operations are performed without a patient experiencing pain beforehand, for example a vasectomy, and these patients do not wish to suffer chronic pain as a result of such an operation. Unfortunately, whether or not an operation is performed to address pain, a certain proportion of patients who have succumbed to the scalpel, will experience chronic pain thereafter. A survey of UK pain clinics found that for patients with chronic pain, surgery was the contributory cause in 22.5% of cases, the second most common cause after degenerative disease (34.2%), and a more common cause than trauma (18.7%). 1 Why some patients, and not others, experience chronic postsurgical pain (CPSP) is the question. Any surgical incision will result in tissue damage, and activation of pain pathways. The problem is that in patients who experience CPSP, these pathways, once activated, remain activated, and do not deactivate as they should, with time and normal healing.

Complications associated with regional anaesthesia for Caesarean section

Extracted from text ... REVIEW Southern African Journal of Anaesthesia & Analgesia - February 2004 15 Complications associated with regional anaesthesia for Caesarean section Complications of Regional Anaesthesia for CS The three categories of RA currently employed for CS are: 1. Spinal (subarachnoid), 2. Epidural, and 3. Combined Spinal-Epidural (CSE) anaesthesia. In the public sector most Caesarian Sections are performed using SA. In this setting, epidural anaesthesia for labour is infrequently used, so relatively few epidurals are extended for CS. Both maternal and fetal complications may occur as a consequence of the use of RA. These may develop during administration of the RA, ..

A survey of nurses' basic life support knowledge and training at a tertiary hospital

Objective: Survival after cardiac arrest is related to time taken for resuscitation, and defibrillation, to commence. At many hospitals, the healthcare worker most likely to be present when a patient suffers a cardiac arrest is a nurse. This study was performed to assess BLS knowledge and training of nurses, and thus to determine whether further action is required to improve their BLS competency. Method: The study was a cross-sectional survey. A questionnaire was distributed, on one day, to nurses in the wards, out-patient-departments and theatres. Completion of the form was voluntary and confidential. The forms were all returned that day. Results: Questionnaires were completed by 338 of the 405 nursing personnel on duty that day (83.4% response rate). Administrators and student nurses were excluded as well as incomplete questionnaires , leaving a final sample size of 286 nurses. A pass mark of 80% was achieved by 11% of responders. Training in BLS had been available for 77.5% of nurses and of these 93.1% had attended a course, 60.9% within the last year. Training in the use of a defibrillator had not been received by 32% of nurses and there was generally a poor understanding of the significance of defibrillation in resuscitation. Conclusion: Despite a relatively good rate of attendance at recent BLS courses, over a fifth of nurses remain without any BLS training. In addition few nurses have retained the BLS knowledge required for competency. Action is needed to ensure all nurses receive BLS training and practice this skill regularly.

An Audit of the Use of Regional Anaesthesia for Caesarean Section in the Free State: from 2002 to 2004

ABSTACT Background Regional anaesthesia (RA) is associated with a lower mortality than general anaesthesia (GA) for obstetric anaesthesia.1 Accordingly, the Saving Mothers Report 1999–2001 proposed that 75% of Caesarean section (CS) should be performed under RA.2 An initial audit found that in the Free State, 71% of CSs were performed under RA in 2002. Various educational interventions promoting the use of RA for CS were then instituted and the audit repeated for 2004, to determine whether there had been any change in the use of RA for CSs from 2002 to 2004 and the 75% target achieved.

Intravenous paracetamol — waste not, want not: a retrospective audit on the appropriate use of intravenous paracetamol at Universitas Academic Hospital Complex—Bloemfontein

Background: Paracetamol can be given both orally and intravenously (IV) with similar clinical efficacy, but the IV formulation is 360 times more expensive. IV paracetamol is therefore only recommended when the oral route is not available. This study investigated whether IV paracetamol was being used appropriately and whether there had been a change in prescribing patterns between 2008 and 2015 after the introduction and update of a prescribing protocol at an academic hospital complex in Bloemfontein, South Africa. Methods: A retrospective comparative audit of patient files was undertaken. The prescribing and administration habits of IV paracetamol were compared for two consecutive months, seven years apart, including 88 and 83 patients, respectively, who had received IV paracetamol. Results: IV paracetamol was administered appropriately in 37.5% of patients in 2008 and in 43.4% of patients in 2015 (p = 0.43). There was an improvement in the duration that IV paracetamol was prescribed for, which decreased from a median two days in 2008 to one day (p < 0.01) in 2015. In total, 55 (32.4%) patients had a concomitant oral and IV paracetamol prescription, of which 37 (21.6%) patients also received concomitant paracetamol administration. Twenty patients exceeded the 24-hour maximum dose. Seventeen patients weighed less than 40 kg; six of these patients (three paediatric and three adult) did not receive the correct weight adjusted dose of paracetamol, 15 mg/kg, resulting in excessive doses of paracetamol being administered (21–32.3 mg/kg). Conclusions: Patients are receiving IV paracetamol when the oral route is available; this is an unnecessary waste of money. Excessive doses of paracetamol were administered due to concomitant oral and IV paracetamol prescription and administration, and a failure to calculate dose of paracetamol according to body weight in low body weight patients. Further remedial interventions are therefore required.

The prevalence of skin scars in patients previously given intramuscular diclofenac injections attending the Pain Clinic at Universitas Academic Hospital, Bloemfontein, South Africa

Intramuscular (IM) diclofenac rarely causes scarring (reported incidence <0.05%). Some patients attending the Pain Clinic at Universitas Academic Hospital, Bloemfontein, South Africa, presented with scars that had developed after IM diclofenac injections. We investigated the prevalence of scars in patients at the clinic and how the injections had been obtained. Patients attending the clinic over a period of 9 months who said they had received diclofenac (N=131) were included. Information was collected using a questionnaire and physical examination. Data obtained from 118 patients who were certain that they had received diclofenac were analysed. Ninety-three patients (78.8%) indicated they had not been warned about the possibility that a diclofenac injection could result in scarring. Scarring had occurred in 10 patients (8.5%). Two-thirds of the patients who had obtained diclofenac from a pharmacy had never had a prescription for it. Four patients had required medical treatment for an ulcer or abscess, of whom two had undergone surgery. The risk of skin lesions associated with IM diclofenac is higher than reported previously. Contrary to regulations, diclofenac injections were often dispensed to patients without a prescription.

South African guidelines for the treatment of cancer pain: South African Cancer Pain Guidelines Working Group

The production of these guidelines, written by South African medical practitioners, is a most welcome and important step in the treatment of cancer pain in this country. The overall prevalence of pain in cancer patients is estimated to be 53%, and 64% in patients with advanced and metastatic disease. Too often, the only guidelines available to us are those written by practitioners in other countries which may be inappropriate for implementation here owing to the differing availability of drugs or disease profile.