Research Articles (Anaesthesiology)

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The importance of critical incident reporting in anaesthesia
(Medpharm Publications, 2025-02-28) Dippenaar, Johannes Marthinus (Tinus)
As a cornerstone of modern surgical and perioperative practice, anaesthesiologists are tasked with ensuring patient comfort and procedural safety during the perioperative period. Anaesthesia, however, remains a high-risk specialty where even minor lapses can lead to catastrophic outcomes. During the last three decades, critical incident reporting (CIR) has emerged as a vital tool in improving patient safety and refining anaesthetic practices.1,2 Despite its proven learning benefits, barriers remain within the anaesthetic community of practice in the implementation of CIR procedures. To address these obstacles, it first requires identification of specific barriers relevant to our own context, followed by cultivating a shift toward transparency, accountability, and continuous learning.
Determining the minimum dataset for surgical patients in Africa : a Delphi study
(Springer, 2023-03) Kluyts, Hyla-Louise; Bedwell, Gillian J.; Bedada, Alemayehu G.; Fadalla, Tarig; Hewitt-Smith, Adam; Mbwele, Bernard A.; Mrara, Busisiwe; Omigbodun, Akinyinka; Omoshoro-Jones, Jones; Turton, Edwin W.; Belachew, Fitsum K.; Chu, Kathryn; Cloete, Esther; Ekwen, Gerald; Elfagieh, Mohamed Ahmed; Elfiky, Mahmoud; Maimbo, Mayaba; Morais, Atilio; Mpirimbanyi, Christophe; Munlemvo, Dolly; Ndarukwa, Pisirai; Smalle, Isaac; Torborg, Alexandra M.; Ulisubisya, Mpoki; Fawzy, Maher; Gobin, Veekash; Mbeki, Motselisi; Ngumi, Zipporah; Patel-Mujajati, Ushmaben; Sama, Hamza D.; Tumukunde, Janat; Antwi-Kusi, Akwasi; Basenaro, Apollo; Lamacraft, Gillian; Madzimbamuto, Farai; Maswime, Salome; Msosa, Vanessa; Mulwafu, Wakisa; Youssouf, Coulibaly; Pearse, Rupert; Biccard, Bruce M.
BACKGROUND : It is often difficult for clinicians in African low- and middle-income countries middle-income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry. METHODS : A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds). RESULTS : Forty-one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk-adjusted perioperative mortality rate was also described. CONCLUSIONS : The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.
Comparing paediatric caudal injection simulation on a 3D-printed, gelatine-cast part-task trainer and the life/form® pediatric caudal injection simulator, to real anatomy, by specialist opinion
(Medpharm Publications, 2023-03) Janse van Rensburg, Henroe; Van der Merwe, Dawid J.; u27000975@tuks.co.za
BACKGROUND: Paediatric caudal anaesthesia is an established technique. Commercially, only one paediatric caudal part-tasktrainer (PTT) exists. In the South African context, access to caudal block simulation training is lacking. A reusable paediatric caudal anaesthesia trainer was produced through three-dimensional (3D) printing, silicone moulding and gelatine casting. This study compared the local and commercial trainers to patient-based anatomy, by specialist opinion. This was done to validate the locally manufactured PTT for potential anaesthesia training. METHODS: Specialist anaesthesiologists (n = 30) randomly performed a caudal block on each trainer. Visual analogue scales were completed for each PTT, comparing four variables to real patient anatomy (i.e. palpation of bony landmarks and sacral hiatus; simulation of soft tissue; loss of resistance to needle insertion into the epidural space; overall similarity of the experience to caudal injection on a real patient). As a secondary outcome, correct needle placement was confirmed using ultrasound on the 3D-printedtrainer.RESULTS: Bony landmark and sacral hiatus palpation rated a median of 36.50% for the 3D-printed trainer and a mean of 36.58% for the Life/form® trainer (p = 0.28). Soft tissue simulation rated a median of 56.75% for the 3D-printed trainer and a mean of 43.23%for the Life/form® trainer (p = 0.11). Loss of resistance rated a median of 56% and 48.50% for the 3D-printed and Life/form® trainers, respectively (p = 0.44). Overall similarity of the experience to real anatomy rated a median of 52% for the 3D-printed trainer and a mean of 41.97% for the Life/form® trainer (p = 0.23). Simultaneous comparison of all four variables between the two trainers showed no statistically significant difference (p = 0.64). Ultrasound confirmed correct needle placement for 86.67% of participants on the 3D-printed trainer. CONCLUSION: The two caudal anaesthesia PTTs demonstrated no significant difference in performance, as judged by specialist opinion. Both models need improvement in terms of fidelity, compared to real anatomy. Using 3D printing to produce PTTs may improve local availability.
The management of postoperative pain after musculoskeletal surgery - a narrative review
(Medpharm Publications, 2023-03) Dippenaar, Johannes Marthinus (Tinus); tinus.dippenaar@up.ac.za
Cost-effective care amidst the rapidly rising cost of medical services necessitates the implementation of a standardised multimodal analgesia plan to aid patient care. This review aims to address the physiology and pharmacological management of postoperative pain following musculoskeletal surgery.
“Belt and braces” : prophylactic vasoconstrictors after spinal blocks in the elderly
(Medpharm Publications, 2023) Milner, A.
No abstract available.
The management of postoperative pain after musculoskeletal surgery – a narrative review
(Medpharm Publications, 2023) Dippenaar, J.M.; tinus.dippenaar@up.ac.za
Cost-effective care amidst the rapidly rising cost of medical services necessitates the implementation of a standardised multimodal analgesia plan to aid patient care. This review aims to address the physiology and pharmacological management of postoperative pain following musculoskeletal surgery.
An evaluation of severe anesthetic-related critical incidents and risks from the South African paediatric surgical outcomes study : a 14-day prospective, observational cohort study of pediatric surgical patients
(Lippincott Williams and Wilkins, 2022-04) Cronje, Larissa; Torborg, Alexandra M.; Meyer, Heidi M.; Bhettay, Anisa Z.; Diedericks, Johan B.J.S.; Cilliers, Celeste; Kluyts, Hyla; Mrara, Busisiwe; Kalipa, Mandisa; Cloete, Esther; Burke, Annemie; Mogane, Palesa N.; Alphonsus, Christella S.; Mbeki, Motselisi; Thomas, Jennifer; Rodseth, Reitze; Biccard, Bruce M.
BACKGROUND : Severe anesthetic-related critical incident (SARCI) monitoring is an essential component of safe, quality anesthetic care. Predominantly retrospective data from low- and middle-income countries (LMICs) report higher incidence but similar types of SARCI compared to high-income countries (HIC). The aim of our study was to describe the baseline incidence of SARCI in a middle-income country (MIC) and to identify associated risk for SARCI. We hypothesized a higher incidence but similar types of SARCI and risks compared to HICs. METHODS : We performed a 14-day, prospective multicenter observational cohort study of pediatric patients (aged <16 years) undergoing surgery in government-funded hospitals in South Africa, a MIC, to determine perioperative outcomes. This analysis described the incidence and types of SARCI and associated perioperative cardiac arrests (POCAs). We used multivariable logistic regression analysis to identify risk factors independently associated with SARCI, including 7 a priori variables and additional candidate variables based on their univariable performance. RESULTS : Two thousand and twenty-four patients were recruited from May 22 to August 22, 2017, at 43 hospitals. The mean age was 5.9 years (±standard deviation 4.2). A majority of patients during this 14-day period were American Society of Anesthesiologists (ASA) physical status I (66.4%) or presenting for minor surgery (54.9%). A specialist anesthesiologist managed 59% of cases. These patients were found to be significantly younger (P < .001) and had higher ASA physical status (P < .001). A total of 426 SARCI was documented in 322 of 2024 patients, an overall incidence of 15.9% (95% confidence interval [CI], 14.4–17.6). The most common event was respiratory (214 of 426; 50.2%) with an incidence of 8.5% (95% CI, 7.4–9.8). Six children (0.3%; 95% CI, 0.1–0.6) had a POCA, of whom 4 died in hospital. Risks independently associated with a SARCI were age (adjusted odds ratio [aOR] = 0.95; CI, 0.92–0.98; P = .004), increasing ASA physical status (aOR = 1.85, 1,74, and 2.73 for ASA II, ASA III, and ASA IV–V physical status, respectively), urgent/emergent surgery (aOR = 1.35, 95% CI, 1.02–1.78; P = .036), preoperative respiratory infection (aOR = 2.47, 95% CI, 1.64–3.73; P < .001), chronic respiratory comorbidity (aOR = 1.75, 95% CI, 1.10–2.79; P = .018), severity of surgery (intermediate surgery aOR = 1.84, 95% CI, 1.39–2.45; P < .001), and level of hospital (first-level hospitals aOR = 2.81, 95% CI, 1.60–4.93; P < .001). CONCLUSIONS : The incidence of SARCI in South Africa was 3 times greater than in HICs, and an associated POCA was 10 times more common. The risk factors associated with SARCI may assist with targeted interventions to improve safety and to triage children to the optimal level of care.
Paediatric anaesthesia care in Africa : challenges and opportunities
(Medpharm Publications, 2022) Gray, R.M.; Cronje, L.; Kalipa, Mandisa N.; Lee, C.A.; Evans, F.M.
In 2015, the World Health Organization and member states recognised surgery and anaesthesia care as a component of universal health coverage, yet 1.7 billion children and adolescents continue to lack access to safe surgical care. An overwhelming proportion of these children are from low- and middle-income countries (LMICs). In Africa, where almost 50% of the population is under the age of 15, children are disproportionately affected. Without sustained global efforts, these inequities and injustices will persist. Findings from previous studies suggest a 10–100 times increase in paediatric perioperative mortality in children in LMICs as compared to high-income countries (HICs). While pieces of the puzzle may be missing, it is clear that not only is access a problem, but also the safety and quality of the perioperative care provided is of concern.
The “knowing-doing gap” – preoperative assessments via telemedicine during COVID-19
(Medpharm Publications, 2022) Milner, A.
The phrase “knowing-doing gap” was first coined by Pfeffer and Sutton in 2000.1 They postulated that while big businesses often knew correct management principles, implementation of appropriate change was not always possible. This phrase has also been used by ecologists, highlighting humanity’s failure to control environmental catastrophes regarding global warming. It may be feasible to suggest that remote pre-anaesthetic evaluation (PAE) by South African anaesthesiologists during the COVID-19 pandemic could also be described as a “knowing-doing gap”. Mobile telephone use by anaesthetists is ubiquitous and these devices are mostly smartphones (computerised mobile telephones capable of making video calls). So, by inference, while most anaesthetists would know how to practice telemedicine, most do not practice it, hence the “gap”.
Prevalence and predisposing factors of post-traumatic stress symptoms in anaesthetists during the second wave of COVID-19 in South Africa
(Medpharm Publications, 2022) Lombard, Theodi; Spijkerman, Sandra; Van Rooyen, C.
BACKGROUND : Post-traumatic stress symptoms (PTSS) have been described in healthcare workers after disease outbreaks. Anaesthetists are at high risk of exposure to COVID-19 due to the nature of the airway procedures they perform. Anaesthetists are also at increased risk of mental health disorders, substance abuse and suicide. When the occurrence of PTSS is great in both number and severity, these become the key elements of the diagnostic criteria for post-traumatic stress disorder (PTSD). This study explores the prevalence and predisposing factors of PTSS in anaesthetists during the second wave of COVID-19 in South Africa. METHODS : Members of the South African Society of Anaesthesiologists (SASA) completed an electronic questionnaire regarding their sociodemographic information as well as COVID-19 exposure. The PTSD checklist for DSM-5 (PCL-5) was used to measure PTSS. The resulting score gave an indication of symptom severity, with a score of 33 or higher indicating a provisional diagnosis of PTSD. RESULTS : A total of 483 participants completed the questionnaire (23.8% response rate). Of these, 391 participants were included in the study and 69 participants (17.6%) received a provisional PTSD diagnosis. Participants who are younger and have less experience, who are female, who are single or who do not have children exhibited a greater prevalence of PTSD. Also, those participants who had pre-existing mental health conditions (p = 0.009), and those who reported loneliness (p < 0.001) and poor social support (p = 0.018) were more likely to receive a provisional PTSD diagnosis. Personal protective equipment (PPE) shortages were also associated with the development of PTSD (p = 0.009). CONCLUSION : The prevalence of PTSS is unacceptably high among South African anaesthetists, especially those with pre-existing mental health conditions and poor social support. This calls for support of vulnerable healthcare workers during disease pandemics.
A cross-sectional observational study of endotracheal intubation and extubation practices among doctors treating adult COVID-19 and suspected COVID-19 patients in South Africa
(Health and Medical Publishing Group, 2022-01) Naidoo, K.; Spijkerman, Sandra; Wyngaard, J.; De Menezes-Williams, H.; Janse van Rensburg, C.
BACKGROUND. Patients with severe COVID-19 may require endotracheal intubation. Unique adjustments to endotracheal intubation and extubation practices are necessary to decrease the risk of SARS-CoV-2 transmission to healthcare workers (HCWs) while avoiding complications of airway management. OBJECTIVES. To investigate the practice of endotracheal intubation and extubation, resources available and complications encountered by clinicians performing endotracheal intubation and extubation of COVID-19 and suspected COVID-19 patients in South Africa (SA). METHOD. A cross-sectional observational study was conducted during the initial surge of COVID-19 cases in SA. Data were collected by means of a self-administered questionnaire completed by clinicians in the private and public healthcare sectors after performing an endotracheal intubation and/or extubation of a patient with confirmed or suspected COVID-19. RESULTS. Data from 135 endotracheal intubations and 45 extubations were collected. Anaesthetists accounted for 87.0% (n=120) of the study participants, specialist clinicians in their respective fields for 59.4% (n=82), and public HCWs for 71.0% (n=98). Cases from Gauteng Province made up 76.8% (n=106) of the database. Haemoglobin desaturation was the most frequent complication encountered during endotracheal intubation (40.0%; n=54). Endotracheal intubations performed at private healthcare institutions were associated with a significantly lower complication rate of 17.5% (n=7) compared with 52.6% (n=50) in the public healthcare sector (p <0.001). Propofol was used in 90 endotracheal intubations (66.7%), and its use was associated with fewer complications relative to other induction agents. Minimising the number of intubation attempts (p=0.009) and the use of checklists (p=0.013) significantly reduced the frequency of complications encountered during endotracheal intubation. Intravenous induction technique, neuromuscular blocking agent used, intubating device used and time at which intubation was performed did not affect the incidence of complications. The majority of endotracheal extubations were uncomplicated (88.9%). CONCLUSIONS. The study provides valuable insight into the resources used by clinicians and complications encountered when endotracheal intubations and/or extubations were performed. Data from this study may be used to guide future clinical practice and research, especially in resource-limited settings.
South African cardiovascular risk stratification guideline for non-cardiac surgery
(Health and Medical Publishing Group, 2021-10) Alphonsus, C.S.; Naidoo, N.; Chakane, P.Motshabi; Cassimjee, I.; Firfiray, L.; Louwrens, H.; Van der Westhuizen, J.; Malan, A.; Spijkerman, Sandra; Kluyts, Hyla-Louise; Cloete, N.J.; Kisten, T.; Nejthardt, M.B.; Biccard, Bruce McIure
The South African (SA) guidelines for cardiac patients for non-cardiac surgery were developed to address the need for cardiac risk assessment and risk stratification for elective non-cardiac surgical patients in SA, and more broadly in Africa. The guidelines were developed by updating the Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Non-cardiac Surgery, with a search of literature from African countries and recent publications. The updated proposed guidelines were then evaluated in a Delphi consensus process by SA anaesthesia and vascular surgical experts. The recommendations in these guidelines are: 1. We suggest that elective non-cardiac surgical patients who are 45 years and older with either a history of coronary artery disease, congestive cardiac failure, stroke or transient ischaemic attack, or vascular surgical patients 18 years or older with peripheral vascular disease require further preoperative risk stratification as their predicted 30-day major adverse cardiac event (MACE) risk exceeds 5% (conditional recommendation: moderate-quality evidence). 2. We do not recommend routine non-invasive testing for cardiovascular risk stratification prior to elective non-cardiac surgery in adults (strong recommendation: low-to-moderate-quality evidence). 3. We recommend that elective non-cardiac surgical patients who are 45 years and older with a history of coronary artery disease, or stroke or transient ischaemic attack, or congestive cardiac failure or vascular surgical patients 18 years or older with peripheral vascular disease should have preoperative natriuretic peptide (NP) screening (strong recommendation: high-quality evidence). 4. We recommend daily postoperative troponin measurements for 48 - 72 hours for non-cardiac surgical patients who are 45 years and older with a history of coronary artery disease, or stroke or transient ischaemic attack, or congestive cardiac failure or vascular surgical patients 18 years or older with peripheral vascular disease, i.e. (i) a baseline risk >5% for MACE 30 days after elective surgery (if no preoperative NP screening), or (ii) an elevated B-type natriuretic peptide (BNP)/N-terminal-prohormone B-type natriuretic peptide (NT-proBNP) measurement before elective surgery (defined as BNP >99 pg/mL or a NT-proBNP >300 pg/mL) (conditional recommendation: moderate-quality evidence). Additional recommendations are given for the management of myocardial injury after non-cardiac surgery (MINS) and medications for comorbidities.
SARS-CoV-2 infection prevalence in healthcare workers and administrative and support staff: The first-wave experience at three academic hospitals in the Tshwane district of Gauteng Province, South Africa
(Health and Medical Publishing Group, 2021-11) Mdzinwa, Nasiphi; Voigt, M.; Janse van Rensburg, Dina Christina; Paruk, Fathima
BACKGROUND : The availability of well and functional healthcare workers (HCWs) and support staff is pivotal to a country’s ability to manage the COVID-19 pandemic effectively. While HCWs have been identified as being at increased risk for acquisition of SARS-CoV-2 infection, there is a paucity of data pertaining to South African (SA) HCW-related infection rates. Global and provincial disparities in these numbers necessitate local data in order to mitigate risks. OBJECTIVES : To ascertain the overall SARS-CoV-2 infection rates and outcomes among all hospital staff at three hospitals in the Tshwane district of Gauteng Province, SA, and further determine associations with the development of severe COVID-19 disease. METHODS : This retrospective audit was conducted across three academic hospitals in the Tshwane district for the period 1 June - 31 August 2020. Deidentified data from occupational health and safety departments at each hospital were used to calculate infection rates. A more detailed analysis at one of the three hospitals included evaluation of demographics, work description, possible source of SARS-CoV-2 exposure (community or hospital), comorbidities and outcomes. RESULTS : The period prevalence of SARS-CoV-2 infections ranged from 6.1% to 15.4% between the three hospitals, with the average period prevalence being 11.1%. The highest incidence of SARS-CoV-2 infections was observed among administrative staff (2.8 cases per 1 000 staff days), followed by nursing staff (2.7 cases per 1 000 staff days). Medical doctors had the lowest incidence of 1.1 cases per 1 000 staff days. SARS-CoV-2 infections were categorised as either possibly community or possibly healthcare facility acquired for 26.6% and 73.4% of the infections, respectively. The administrative group had the highest proportion of possible community-acquired infections (41.8%), while doctors had the lowest (6.1%). The mean age of individuals with mild and severe disease was 41 years and 46.1 years, respectively (p=0.004). The presence of comorbidities was significantly associated with severity of disease (p=0.002). CONCLUSIONS : This study highlights that hospital staff, including administrative staff, are clearly at high risk for acquisition of SARS-CoV-2 infection during a surge.
Development of a clinical prediction model for high hospital cost in patients admitted for elective non-cardiac surgery to a private hospital in South Africa
(Medpharm Publications, 2021) Kluyts, Hyla-Louise; Becker, Piet J.
INTRODUCTION : Clinicians may find early identification of patients at risk for high cost of care during and after surgery useful, to prepare for focused management that results in optimal clinical outcome. The aim of the study was to develop a clinical prediction model to identify high and low hospital cost outcome after elective non-cardiac surgery using predictors identified from a preoperative self-assessment questionnaire. METHODS : Data to develop a clinical prediction model were collected for this purpose at a private hospital in South Africa. Predictors were defined from a preoperative questionnaire. Cost of hospital admission data were received from hospital administration, which reflected the financial risk the hospital carries and which could be reasonably attributed to a patient’s individual clinical risk profile. The hospital cost excluded fees charged (by any healthcare provider), and cost of prosthesis and other consignment items that are related to the type of procedure. The cost outcome measure was described as cost per total Work Relative Value Units (Work RVUs) for the procedure, and dichotomised. Variables that were associated with the outcome during univariate analysis were subjected to a forward stepwise regression selection technique. The prediction model was evaluated for discrimination and calibration, and internally validated. RESULTS : Data from 770 participants were used to develop the prediction model. The number of participants with the outcome of high cost were 142/770 (18.4%). The predictors included in the full prediction model were type of surgery, treatment for chronic pain with depression, and activity status. The area under the receiver operating curve (AUROC) for the prediction model was 0.83 (95% confidence interval [CI]: 0.79 to 0.86). The Hosmer–Lemeshow indicated goodness-of-fit (p = 0.967). The prediction model was internally validated using bootstrap resampling from the development cohort, with a resultant AUROC of 0.86 (95% CI: 0.82 to 0.89). CONCLUSION : The study describes a clinical risk prediction model developed using easily collected patient-reported variables and readily available administrative information. The prediction model should be validated and updated using a larger dataset, and used to identify patients in which cost-effective care pathways can add value.
Anaesthetic nurse training in South Africa and the role of the anaesthetist
(Medpharm publications, 2021-02-24) Spijkerman, Sandra; sandra.spijkerman@up.ac.za
One night during a polytrauma theatre case, I asked the anaesthetic nurse to run a blood gas analysis in a nearby intensive care unit. He returned with saline, glucose and insulin, announcing from the door that “we need to crank up the respiratory rate a bit and shift the potassium”. To me, that was the embodiment of the anaesthetic nurse. He referred to “we” because he saw himself as part of the team. In that one moment, he displayed not only his knowledge of physiology and pharmacology but every category of non-technical skill defined in the anaesthetists’ non-technical skills (ANTS) framework – teamwork, situational awareness, task management and decision-making.1 Of course it was not his first day on the job. He drew on years of experience, training and inquisitive self-learning.
The Cardiothoracic Anaesthetic Society of South Africa practice advisory for the perioperative management of pacemakers and implantable cardioverter defibrillators in South Africa
(Medpharm Publications, 2021) Keene, A.R.; Motshabi, P.; Mdadla, N.; Swanevelder, J.; Turton, E.; Maakamedi, Hendrick; Murfin, D.; Vorster, A.; Drummond, L.A.
Pacemakers (PM) and implantable cardioverter defibrillators (ICDs) are likely to be encountered by anaesthetists in South Africa in everyday practice because of increasing rates of implantation of these cardiac implantable electronic devices (CIEDs) for an expanding group of conditions that qualify for their use. These devices are becoming increasingly sophisticated and anaesthetic perioperative management is changing with these developments. Traditionally, PM functions have been changed preoperatively to asynchronous modes because of the fear that electromagnetic interference (EMI) from the electrosurgical unit (ESU or diathermy) may cause oversensing and loss of pacing in patients who are PM-dependent. ICDs have had their anti-tachyarrythmia modes deactivated preoperatively to prevent inadvertent shocks delivered as a result of the misinterpretation of EMI as ventricular tachycardia (v-tach) or ventricular fibrillation (v-fib). Programming these devices in this manner may result in patient harm due to R-on-T phenomenon in PM set in asynchronous mode and in ICDs, undiagnosed v-tach and v-fib going untreated in patients who have anti-tachyarrythmia therapies switched off. Depending on the site of surgery, PM-on and ICD-on strategies may be acceptable. Magnet use intraoperatively can be used safely to change PM and ICD settings with the advantage that reversal to normal settings can be achieved by removal of the magnet once EMI is no longer in use. Intraoperative magnet use mandates that the device is interrogated preoperatively and that the results of magnet application are known to the anaesthetist in advance. Where management protocols stated may be controversial, the American Society of Anesthesiologists (ASA) survey of an expert consultant panel as well as member anaesthetists is published, as well as the Cardiothoracic Anaesthetic Society of South Africa (CASSA) committee responses to these controversies.
Development of a clinical prediction model for in-hospital mortality from the South African cohort of the African surgical outcomes study
(Springer, 2021-02) Kluyts, Hyla-Louise; Conradie, Wilhelmina; Cloete, Estie; Spijkerman, Sandra; Smith, Oliver; Alli, Ahmed; Koto, Modise Z.; Montwedi, Daniel; Govender, Komalan; Cronje, Larissa; Grobbelaar, Mariette; Omoshoro-Jones, Jones A.; Rorke, Nicolette F.; Anderson, Philip; Torborg, Alexandra; Alphonsus, Christella; Alexandris, Panagiotis; Peter, Aunel Mallier; Singh, Usha; Diedericks, Johan; Mrara, Busisiwe; Reed, Anthony; Davies, Gareth L.; Davids, Jody G.; Van Zyl, Hendrik A.; Govindasamy, Vishendran; Rodseth, Reitze; Matos-Puig, Roel; Bhat, Kajake A.P.; Naidoo, Noel; Roos, John; Jaworska, Magdalena; Steyn, Annemarie; Dippenaar, Johannes Marthinus (Tinus); Pearse, R.M.; Madiba, Thandinkosi; Biccard, Bruce McIure
BACKGROUND : Data on the factors that influence mortality after surgery in South Africa are scarce, and neither these data nor data on risk-adjusted in-hospital mortality after surgery are routinely collected. Predictors related to the context or setting of surgical care delivery may also provide insight into variation in practice. Variation must be addressed when planning for improvement of risk-adjusted outcomes. Our objective was to identify the factors predicting in-hospital mortality after surgery in South Africa from available data. METHODS : A multivariable logistic regression model was developed to identify predictors of 30-day in-hospital mortality in surgical patients in South Africa. Data from the South African contribution to the African Surgical Outcomes Study were used and included 3800 cases from 51 hospitals. A forward stepwise regression technique was then employed to select for possible predictors prior to model specification. Model performance was evaluated by assessing calibration and discrimination. The South African Surgical Outcomes Study cohort was used to validate the model. RESULTS : Variables found to predict 30-day in-hospital mortality were age, American Society of Anesthesiologists Physical Status category, urgent or emergent surgery, major surgery, and gastrointestinal-, head and neck-, thoracic- and neurosurgery. The area under the receiver operating curve or c-statistic was 0.859 (95% confidence interval: 0.827–0.892) for the full model. Calibration, as assessed using a calibration plot, was acceptable. Performance was similar in the validation cohort as compared to the derivation cohort. CONCLUSION : The prediction model did not include factors that can explain how the context of care influences post-operative mortality in South Africa. It does, however, provide a basis for reporting risk-adjusted perioperative mortality rate in the future, and identifies the types of surgery to be prioritised in quality improvement projects at a local or national level.
Adapted full-face snorkel masks as an alternative for COVID-19 personal protection during aerosol generating procedures in South Africa
(Elsevier, 2021-12) Herselman, Ronel; Lalloo, Vidya; Ueckermann, Veronica; Van Tonder, Daniel Johannes; De Jager, Edwin John; Spijkerman, Sandra; Van der Merwe, Wanda; Du Pisane, Marizane; Hattingh, Fanie; Stanton, David; Hofmeyr, Ross; ronel.herselman@up.ac.za
INTRODUCTION : SARS-CoV-2 has resulted in increased worldwide demand for personal protective equipment (PPE). With pressure from ongoing epidemic and endemic episodes, we assessed an adapted snorkel mask that provides full-face protection for healthcare workers (HCWs), particularly during aerosol-generating procedures. These masks have a custom-made adaptor which allows the fitment of standard medical respiratory filters. The aim of this study was to evaluate the fit, seal and clinical usability of these masks. METHODS : This multicentre, non-blinded in-situ simulation study recruited fifty-two HCWs to don and doff the adapted snorkel mask. Negative pressure seal checks and a qualitative fit test were performed. The HCWs completed intubation and extubation of a manikin in a university skills training laboratory, followed by a webbased questionnaire on the clinical usability of the masks. RESULTS : Whilst fit and usability data were generally satisfactory, two of the 52 participants (3.8%) felt that the mask did not span the correct distance from the nose to the chin, and 3 of 34 participants (8.8%) who underwent qualitative testing with a Bitrex test failed. The majority of users reported no fogging, humidity or irritation. It was reportedly easy to speak while wearing the mask, although some participants perceived that they were not always understood. Twenty-one participants (40%) experienced a subjective physiological effect from wearing the mask; most commonly a sensation of shortness of breath. DISCUSSION : A fit-tested modified full-face snorkel mask may offer benefit as a substitute for N95 respirators and face shields. It is, however, important to properly select the correct mask based on size, fit testing, quality of the three-dimensional (3D) printed parts and respiratory filter to be used. Additionally, HCWs should be trained in the use of the mask, and each mask should be used by a single HCW and not shared.
The association between preoperative anemia and postoperative morbidity in pediatric surgical patients : a secondary analysis of a prospective observational cohort study
(Wiley, 2020-07) Meyer, Heidi M.; Torborg, Alexandra; Cronje, Larissa; Thomas, Jennifer; Bhettay, Anisa; Diedericks, Johan; Cilliers, Celeste; Kluyts, Hyla-Louise; Mrara, Busisiwe; Kalipa, Mandisa N.; Biccard, Bruce McIure
BACKGROUND : The prevalence of anemia in the South African pediatric surgical population is unknown. Anemia may be associated with increased postoperative complications. We are unaware of studies documenting these findings in patients in low- and middle-income countries (LMICs). AIM : The primary aim of this study was to describe the association between preoperative anemia and 26 defined postoperative complications, in noncardiac pediatric surgical patients. Secondary aims included describing the prevalence of anemia and risk factors for intraoperative blood transfusion. METHOD : This was a secondary analysis of the South African Paediatric Surgical Outcomes Study, a prospective, observational surgical outcomes study. Inclusion criteria were all consecutive patients aged between 6 months and <16 years, presenting to participating centers during the study period who underwent elective and nonelective noncardiac surgery and had a preoperative hemoglobin recorded. Exclusion criteria were patients aged <6 months, undergoing cardiac surgery, or without a preoperative Hb recorded. To determine whether an independent association existed between preoperative anemia and postoperative complications, a hierarchical stepwise logistic regression was conducted. RESULTS : There were 1094 eligible patients. In children in whom a preoperative Hb was recorded 46.2% had preoperative anemia. Preoperative anemia was independently associated with an increased risk of any postoperative complication (odds ratio 2.0, 95% confidence interval: 1.3-3.1, P = .002). Preoperative anemia (odds ratio 3.6, 95% confidence interval: 1.8-7.1, P < .001) was an independent predictor of intraoperative blood transfusion. CONCLUSION : Preoperative anemia had a high prevalence in a LMIC and was associated with increased postoperative complications. The main limitation of our study is the ability to generalize the results to the wider pediatric surgical population, as these findings only relate to children in whom a preoperative Hb was recorded. Prospective studies are required to determine whether correction of preoperative anemia reduces morbidity and mortality in children undergoing noncardiac surgery.
Intubating conditions following four different doses of propofol in children
(MedPharm Publications, 2020) Du Preez, T.; Dippenaar, Johannes Marthinus (Tinus)
BACKGROUND : Day case surgery offers advantages to the patient, the family and the performing institution. Children are excellent candidates since they are generally healthy and often require brief surgical interventions. Day case surgery requires rapid emergence from anaesthesia, minimal delay in recovery and rapid readiness for discharge from the ward. The ideal anaesthetic agents should have rapid onset, short duration, minimal side effects and minimal residual effects. The pharmacodynamics and -kinetics of propofol and alfentanil are well suited for day case surgery and may obviate the need for muscle relaxants. The purpose of our study was to determine the optimal dosing schedules for intubation following propofol combined with alfentanil and sevoflurane anaesthesia while maintaining haemodynamic stability as these dosing schedules still warrant refinement. METHODS : We conducted a randomised prospective blinded study in which fifty-nine children (aged 3–10 years) presenting for dental extractions were induced with sevoflurane (in 50% oxygen/nitrous oxide), then received propofol (0.5, 1, 1.5 or 2 mg/kg) and alfentanil (10 μg/kg) to aid intubation. For each dose of propofol, the ease of intubation (assessed by the Helbo-Hansen score) was correlated with blood pressure and pulse rate (prior, during and after intubation) to determine the optimal propofol dosage allowing adequate intubation conditions with the least haemodynamic effects. RESULTS : Overall adequacy of intubating conditions improved significantly (p = 0.0079) as propofol dose increased. Similarly, decrease in vocal cord movement (p = 0.0341), incidence of coughing (p = 0.0379) and limb movement (p = 0.0165) was observed. Ease of laryngoscopy and jaw relaxation did not improve significantly (p = 0.1319 and 0.1971 respectively). Changes in systolic, diastolic and mean arterial pressure as propofol dose increased were not statistically significant. CONCLUSION : Propofol in a dose of 1.5 to 2 mg/kg (when used in conjunction with alfentanil 10 μg/kg, after sevoflurane induction) allowed adequate intubating conditions whilst maintaining cardiovascular stability. The decrease in blood pressure, although not statistically significant, may become clinically relevant in children with underlying cardiovascular disease. This drug combination seems to be a reasonable means for avoiding the need for muscle relaxation for children who require tracheal intubation for brief surgical procedures.

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