Zane Farina

Maternal death and caesarean section in South Africa: Results from the 2011 - 2013 Saving Mothers Report of the National Committee for Confidential Enquiries into Maternal Deaths

BACKGROUND In the latest (2011-2013) Saving Mothers report, the National Committee for Confidential Enquiries into Maternal Deaths in South Africa (SA) (NCCEMD) highlights the large number of maternal deaths associated with caesarean section (CS). The risk of a woman dying as a result of CS during the past triennium was almost three times that for vaginal delivery. Of all the mothers who died during or after a CS, 3.4% died during the procedure and 14.5% from haemorrhage afterwards. Including all cases of death from obstetric haemorrhage where a CS was done, there were 5.5 deaths from haemorrhage for every 10,000 CSs performed. OBJECTIVE To scrutinise the contribution or effect of the surgical procedure on the ultimate cause of death by a cross-cutting analysis of the 2011-2013 national data. METHODS Data from the 2011-2013 triennial review were entered into an Excel database and analysed on a national and provincial basis. RESULTS There were 1,243 maternal deaths where a CS was the mode of delivery and 1 471 deaths after vaginal delivery. More mothers died as a result of CS in the provinces where there is a low overall CS rate. The following CS categories were identified as specific problems: bleeding during or after CS, pre-eclampsia and eclampsia, anaesthesia-related deaths, pregnancy-related sepsis and acute collapse and embolism. CONCLUSION This is an area of concern, and a concentrated effort should be done to make CS in SA safer. Several recommendations are

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.

Anaesthesia-related maternal deaths in South Africa

The National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) has assessed maternal deaths in South Africa since 1997. Reports have been produced since 1999, culminating in the latest triennial report (2008-2010). The anaesthetic chapter from this report is published in SAJAA to improve dissemination of the information.

Anaesthesia-related maternal deaths in South Africa Chapter Seven of the 5th Saving Mothers Report 2008–2010

Abstract The number of reported deaths due to anaesthesia continues to increase. There were 121 reported this triennium. This represents 2.5% of all maternal deaths and 5.4% of deaths directly related to complications of pregnancy. One hundred and eighteen of these were available for review and 92 were assessed as being directly due to anaesthesia. Spinal anaesthesia accounted for 73 (79%) of the deaths and general anaesthesia 16 (17%). Two deaths were associated with sedation and one with epidural anaesthesia. The percentage of deaths caused by spinal anaesthesia increased in this triennium to 79%. Again, two thirds of these deaths resulted from poor treatment of well-recognised complications of spinal anaesthesia (hypotension and high motor block). The most common cause of death following general anaesthesia was difficult or failed intubation, which occurred in 50% of cases. Lack of basic skills in anaesthesia, including assessment and resuscitation, were identified. As in previous triennia, most anaesthesia-related deaths occurred at level 1 hospitals (70%). This reflects the need for skilled qualified anaesthetic care at these hospitals.

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.

Difficult airways: a reliable “Plan B”

Abstract 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.

Creating the perfect intern anaesthesia rotation: a survey using feedback from past interns

Background: Community service doctors (CSDs) are often expected to administer anaesthesia after minimal training and with very little support, especially in rural hospitals. This leads to unnecessary stress on these junior doctors and may lead to poor anaesthesia outcomes. Objectives: The aim of this study was to understand the experiences of CSDs administering anaesthesia. This feedback will be used to improve the current intern training programme for anaesthesia and to structure the rotation according to their needs. Methods: A questionnaire was sent to Pietermaritzburg (PMB) interns who completed their anaesthesia intern rotation between 2008 and 2010. Two data sets were collected: quantitative data (this will be reported on in another paper) and qualitative data. The qualitative data included five open-ended questions about the intern rotation in anaesthesia. Results: Between 2008 and 2010, 298 interns completed an anaesthetic rotation. The survey was sent to 259 doctors of whom 189 responded (73%). The first three questions were about the structure of the intern rotation in anaesthesia. The responses were analysed together. The following feedback was common: more autonomy, longer duration of the anaesthesia rotation and more practical exposure during the rotation. Questions 4 and 5 were about the impact of internship and community service on future career choice. Community service had a greater impact on career choice than internship. Conclusion: Intern training in anaesthesia is essential to create confident CSDs. Feedback from previous interns should be used to improve intern training programmes.

Practising anaesthesia as a community service doctor: a survey-based assessment

Background: Anaesthesia-related maternal mortality remains unacceptably high, especially in district hospitals. Community service doctors (CSDs) play an important role in the provision of anaesthesia in these hospitals. The purpose of this study was to understand the experience of doctors providing anaesthesia during community service. Identifying deficiencies in the performance of anaesthesia by CSDs can lead to remedial actions. Methods: A prospective, questionnaire-based study was done of doctors who had done their anaesthesia rotation during their internship in Pietermaritzburg, between 2008 and 2010. Quantitative data were collected regarding their performance of anaesthesia during community service. The data included details concerning the provision of anaesthesia, supervision and training, and whether CSDs felt adequately prepared to perform anaesthesia during community service. Qualitative data were also collected, which will be reported in another article. Results: The study response rate was 72.9%. Roughly half of the respondents performed anaesthesia during community service, of which two-thirds did more than 50 cases. Obstetric anaesthesia was the most common procedure performed. CSDs worked largely unsupervised, 63% had very little supervision and 62% received no further training in anaesthesia during community service. CSDs felt adequately prepared to administer obstetric anaesthesia, but less well prepared to perform general anaesthesia for appendicectomies and ectopic pregnancies. Discussion: CSDs perform a large proportion of the anaesthesia in rural hospitals, where they work largely unsupervised. Furthermore, CSDs feel less well prepared to perform general anaesthesia than spinal anaesthesia. To meet the needs of patients in these areas, intern training needs to be aimed at improving anaesthesia delivery in rural hospitals and guidelines need to be established regarding the performance of anaesthesia by CSDs. Conclusion: The study showed that CSDs play an important role in provision of anaesthesia services, especially in rural areas. However, they work largely unsupervised and receive little further training or support. A large proportion do not feel comfortable in administering general anaesthesia. Intern training should be adjusted to meet the needs of CSDs.

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.

The impact of introducing drug labelling at Grey's Hospital Theatre over a six-month period

The use of standardised drug labels has been recommended by the South African Society of Anaesthesiologists to prevent drug errors in theatre and ICU. 1 (Full text available online at www.medpharm.tandfonline.com/ojaa ) South Afr J Anaesth Analg 2016; DOI: 10.1080/22201181.2016.1168613