Justiaan Swanevelder

A meta-analysis of the efficacy of preoperative surgical safety checklists to improve perioperative outcomes

BACKGROUND Meta-analyses of the implementation of a surgical safety checklist (SSC) in observational studies have shown a significant decrease in mortality and surgical complications. OBJECTIVE To determine the efficacy of the SSC using data from randomised controlled trials (RCTs). METHODS This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (CRD42015017546). A comprehensive search of six databases was conducted using the OvidSP search engine. RESULTS Four hundred and sixty-four citations revealed three eligible trials conducted in tertiary hospitals and a community hospital, with a total of 6 060 patients. All trials had allocation concealment bias and a lack of blinding of participants and personnel. A single trial that contributed 5 295 of the 6 060 patients to the meta-analysis had no detection, attrition or reporting biases. The SSC was associated with significantly decreased mortality (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.42 - 0.85; p=0.0004; I2=0%) and surgical complications (RR 0.64, 95% CI 0.57 - 0.71; p<0.00001; I2=0%). The efficacy of the SSC on specific surgical complications was as follows: respiratory complications RR 0.59, 95% CI 0.21 - 1.70; p=0.33, cardiac complications RR 0.74, 95% CI 0.28 - 1.95; p=0.54, infectious complications RR 0.61, 95% CI 0.29 - 1.27; p=0.18, and perioperative bleeding RR 0.36, 95% CI 0.23 - 0.56; p<0.00001. CONCLUSIONS There is sufficient RCT evidence to suggest that SSCs decrease hospital mortality and surgical outcomes in tertiary and community hospitals. However, randomised evidence of the efficacy of the SSC at rural hospital level is absent.

Extracorporeal membrane oxygenation (ECMO) in South Africa

Extracorporeal membrane oxygenation (ECMO) is an advanced modality of life support for neonatal, paediatric and adult patients with cardiopulmonary compromise resistant to conventional critical care management. This issue of SAJCC features a position statement proposing guidelines for the use of ECMO in South Africa, where unique clinical scenarios are often presented for critical care management. ECMO should be available for selected cases in advanced healthcare systems, and it should be performed in centres that have done the necessary planning, preparation and training.

Quadruple valve replacement in a patient with severe rheumatic heart disease

Summary We present a patient with rheumatic heart disease involving all the heart valves. An intraoperative transoesophageal echocardiography confirmed severe mitral stenosis, severe aortic regurgitation, severe tricuspid regurgitation and stenosis, and severe pulmonary stenosis. The patient underwent successful quadruple valve replacement during a single operation at the Groote Schuur Hospital, Cape Town, South Africa. Learning points: Rheumatic heart disease can affect all the heart valves including the pulmonary valve. Intraoperative transoesophageal echocardiography is key for diagnosis, monitoring and confirmation of successful surgical result during heart valve surgery. Combined surgical procedure of all four valves is possible though associated with long procedural time.

Evidence-based approach to the use of starch-containing intravenous fluids: an official response by two Western Cape University Hospitals

Circular 114/2013 issued by the Western Cape Pharmacy Services entitled, Suspension of use of infusion solutions containing hydroxyethyl starch at Western Cape Government Health Facilities until further notice, resulted in the the non-availability of starch-containing solutions for clinical use. The reasoning behind the circular was based on the Medicines and Healthcare Products Regulatory Agency (MHRA) class 2 recall of starch solutions and the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee, who stated that: “The benefits of infusion solutions containing hydroxyethyl starch no longer outweigh the risks, and (we) therefore recommend that the marketing authorisations for these medicines are suspended”. The two Western Cape University Hospitals have responded with a joint statement which is presented to SAJAA readers. The statement suggests withdrawals of corn-based starch solutions are based on flawed interpretation of the available data, particularly the suggestion that they cause renal dysfunction. The statement then interrogates why the use of corn-based starch solutions benefits patient care and improves outcome. Lastly, the problems of the alternative therapeutic options are examined. The conclusion reached is that the use of corn-based starch solutions should be reinstated. We believe this well-researched, evidence-based approach is worth publishing to a wider audience.