Pd Gopalan

The role of transversus abdominis plane blocks in women undergoing total laparoscopic hysterectomy: A retrospective review

Introduction:  The transversus abdominis plane (TAP) local anaesthetic block is beneficial in patients undergoing open pelvic surgery; however, there are no data on its use in women undergoing laparoscopic gynaecologic surgery.

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.

Infection control in anaesthesia in regional, tertiary and central hospitals in KwaZulu-Natal. Part 2: Equipment contamination

Abstract Objectives: Contaminated anaesthetic equipment has been implicated in the nosocomial transmission of infection. The aim of this study was to determine the prevalence of blood (occult or visible) and/or visible organic material contamination of anaesthetic equipment deemed to be ready for use in theatres in regional, tertiary and central hospitals in KwaZulu-Natal. Design: All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website were visited (n = 15). Laryngoscope blades and handles, Magills forceps, nasopharyngeal temperature probes and suction bowls were inspected for visible blood and/or organic matter. Those items that were not visibly contaminated were further tested for occult blood using the blood detector in urinalysis reagent strips. Setting and subjects: All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website were visited (n = 15). Results: The percentages of contamination with blood (occult or visible) and/or visible organic material of all examined laryngoscope blades, laryngoscope handles, Magills forceps, nasopharyngeal temperature probes, and suction bowls, were 80% (45.5–100%), 74% (42.8–100%), 50% (0–100%), 80% (0–100%) and 90% (0–100%), respectively. Conclusion: The contamination of ready-for-use anaesthesia equipment was extremely high. In light of the high prevalence of many infectious diseases in KwaZulu-Natal, and in particular human immunodeficiency virus, hepatitis B and tuberculosis, urgent tackling of the issue of reuse of contaminated equipment is critical.

Contrast-induced acute kidney injury

The need for radiological studies using contrast media has increased. Diagnostic radiological procedures remain an essential part of patient assessment, while interventional radiology is a burgeoning field that is replacing open procedures, especially in high-risk patients. Contrastinduced acute kidney injury (CIAKI) has subsequently become the third most common reason for the development of in-hospital acute kidney injury in the USA, accounting for 12% of cases. 1 Consequently, anaesthesiologists are more likely to encounter patients who are either at risk of developing CIAKI, or who have already acquired it.

The informed consent process for anaesthesia: perspectives of elective surgical patients at Inkosi Albert Luthuli Central Hospital, Durban, South Africa

Abstract Background: Amongst state hospitals in the eThekwini municipality, obtaining informed consent for anaesthesia is often an informal interaction between the patient and anaesthetist, lacking structure and standardisation. Objectives: To evaluate the informed consent process from the patients’ perspective in an attempt to modify current practice. Methods: Competent adult patients presenting for elective surgery were presented pre- and postoperatively with structured questionnaires addressing various aspects of the consent process. Results: Of 143 included patients, only 57% of patients were given information about their anaesthetic preoperatively. With regard to complications experienced during anaesthesia, 36% of patients preferred not to be informed of any possible sequelae, while 17% wanted to be informed of all possible complications. In total, 83% of patients who had signed the surgical consent form with the surgeon thought that they had signed an anaesthetic form with the anaesthetist. Some 56% of patients felt that written consent on a specific standardised anaesthetic consent form should be introduced. Conclusion: Even though the majority of patients are being seen preoperatively by the anaesthetist, the quality of this assessment is concerning, in terms of the amount and depth of information imparted and the lack of standardisation of information given.

Infection control in anaesthesia in regional, tertiary and central hospitals in KwaZulu-Natal. Part 3: Decontamination practices

Abstract Background: Anaesthetic equipment is a potential vector for the transmission of disease. This study was undertaken to observe current infection control practices among anaesthetic nurses regarding the decontamination of anaesthetic equipment in regional, tertiary and central hospitals in KwaZulu-Natal. Method: All hospitals that were classified as regional, tertiary and central hospitals on the KwaZulu-Natal Department of Health website (15 in total) were visited. All available anaesthesia nurses were invited to participate in a structured interview. Results: Thirty-four anaesthesia nurses were interviewed. Results revealed that decontamination of anaesthetic equipment and other infection control practices were inadequate or inappropriate in several of the hospitals. Practices varied from one healthcare facility to another, as well as within the same facility. Conclusion: Current infection control practices among anaesthesia nurses regarding the decontamination of anaesthetic equipment in the observed hospitals are poor. In light of the high prevalence of many infectious diseases, in particular human immunodeficiency virus, hepatitis B and tuberculosis in KwaZulu-Natal, it is critical that issues relating to decontamination practices are urgently addressed.

Fitness for purpose in anaesthesiology: a review

The purpose of this review is to explore how fitness for purpose can be defined for anaesthesiology graduates and to delineate the parameters of this concept for anaesthesiology. Newly qualified anaesthesiology graduates experience difficulties with the transition from trainee to specialist, with perceptions of unpreparedness especially in non-technical skills. This may be deleterious to the individual, the patient, colleagues and the workplace. It is possible that graduates may be deemed competent yet are unable to fulfil all their specialist roles. Fitness for purpose and its relationship with competence, expertise and excellence in anaesthesiology have been poorly defined in the literature. These concepts are not synonymous but provide a hierarchical framework for the development of a specialist from a beginner to an expert. The uncertainties surrounding competence are numerous, with generic competency frameworks not addressing all aspects unique to anaesthesiology. The applicability of such frameworks in areas outside which they were originally designed and, in particular, in anaesthesiology, is questionable and requires further investigation. Defining fitness for purpose in anaesthesiology will assist training departments, curriculum designers, assessors and regulators to produce specialists that are experts in their chosen field without any deficiencies and thus able to perform all their required roles.

Preoperative serum sodium measurements and postoperative inpatient mortality: A case-control analysis of data from the South African Surgical Outcomes Study

BACKGROUND Abnormal preoperative serum sodium measurements have been shown to be associated with increased postoperative mortality in US and European surgical populations. It is possible that such measurements are also associated with increased postoperative mortality in a South African (SA) setting, but this is yet to be confirmed. Establishing whether preoperative serum sodium measurements are associated with postoperative mortality could have implications for perioperative risk stratification in SA settings. OBJECTIVES To determine whether preoperative serum sodium measurements are associated with postoperative mortality in SA surgical patients. METHODS This was an unmatched case-control study of patient data (demographics, comorbidities, procedure-related variables, and preoperative serum sodium measurements) collected during the South African Surgical Outcomes Study. Data were analysed using recommended statistical methods for unmatched case-control studies. RESULTS The study population comprised 103 patients and 410 controls. Cases were defined as patients who suffered postoperative inpatient mortality, while controls were defined as patients who did not suffer postoperative inpatient mortality. Preoperative hypernatraemia (i.e. a preoperative serum sodium measurement >144 mEq/L) was independently associated with a four-fold higher risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement of 135 - 144 mEq/L (odds ratio (OR) 4.21, 95% confidence interval (CI) 1.19 - 14.83, p=0.025). Preoperative hyponatraemia (i.e. a preoperative serum sodium measurement <135 mEq/L) was not independently associated with a higher or lower risk of postoperative inpatient mortality compared with a normal preoperative serum sodium measurement (OR 1.39, 95% CI 0.70 - 2.76, p=0.346). CONCLUSIONS Preoperative hypernatraemia, but not preoperative hyponatraemia, is a risk factor for postoperative inpatient mortality in SA surgical patients.

Perceptions of final-year UKZN medical students about anaesthesia as a specialty choice

Background: South Africa suffers from a drastic shortage of anaesthesiologists. This shortage has a major impact on the provision of safe, timeous and appropriate surgery for the population. One factor implicated in this shortage may be the difficulty in appropriate recruitment of trainees. Methods: A questionnaire-based cross-sectional study was conducted among the final-year medical students at the University of KwaZulu-Natal (UKZN), for the year 2013. Results: At total of 112 final-year medical students participated in the study. The majority (93%) of the medical students would like to specialise in the future. Anaesthesiology ranked fourth in popularity among the specialties presented to the students. The students’ opinion of the key positive attributes of anaesthesiology was that it was interesting (26.8%), mentally challenging (22.3%) and afforded good working hours (18.8%). The key negative attributes of anaesthesiology highlighted by the students were that it was boring (21.4%), stressful (20.5%) and frightening (15.2%). The biggest influence on the medical students’ perceptions of anaesthesiology was the medical school rotation, with the need for longer duration of exposure, highlighted by 24 (21.4%) of the students. Conclusion: The perceptions of medical students concerning anaesthesia are multi-faceted, with the undergraduate anaesthetic rotation viewed as the biggest influence on their perceptions regarding anaesthesia. All anaesthetists should strive to improve the discipline profile, change the misconceptions and enhance the attractiveness of the specialty amongst medical students from foundation level upwards.

Postoperative neuromuscular function following non-depolarising muscle blockade in patients at Inkosi Albert Luthuli Central Hospital, Durban

Background: Residual neuro-muscular blockade after the end of general anaesthesia may occur when non-depolarising muscle relaxant (NDMR) drugs are used. Train-of-four (TOF) stimulation is used to quantify the degree of residual paralysis, with a TOF ratio of less than 0.9 postoperatively associated with increased morbidity in patients. The aim of this study was to survey the degree of residual paralysis in patients in the post-anaesthesia care unit (PACU) at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, over the survey period. Methods: This cross-sectional observational study was performed over a two-month period at IALCH, assessing the postoperative neuromuscular function of patients who had received NDMR drugs (rocuronium (n = 64) or cisatracurium (n = 6)) intraoperatively. Muscle function was assessed using acceleromyography and TOF stimulation, utilising a TOF Watch SX device, with function grouped according to previously defined targets as less than a ratio of 0.7, less than a ratio of 0.9 and less than a ratio of 1.0. Results: Recovery to a TOF ratio of less than 0.7, 0.9 or 1.0 was observed in 5 (7.1%), 20 (28.6%) and 44 (62.9%) of patients respectively. Conclusions: Although the results obtained compare favourably with other studies in similar patient populations, a considerable subset of patients still arrive in the PACU with inadequate return of neuromuscular function.