Research Articles (Anaesthesiology and Critical Care)

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Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive adults
(John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration, 2017) Van Hoving, Daniel J.; Meintjes, Graeme; Takwoingi, Yemisi; Griesel, Rulan; Maartens, Gary; Ochodo, Eleanor A.
This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: To determine the diagnostic accuracy of abdominal ultrasound as a standalone test for detecting abdominal TB or disseminated TB with abdominal involvement in HIV-positive adults. • To determine the diagnostic accuracy of combinations of abdominal ultrasound and existing tests (chest radiograph, full blood count) for detecting abdominal TB or disseminated TB with abdominal involvement in HIV-positive adults. • To investigate potential sources of heterogeneity in test accuracy, including clinical setting, ultrasound training level, and type of reference standard.
Acute postoperative pain in 1 231 patients at a developing country referral hospital : incidence and risk factors
(Medpharm Publications, 2016) Murray, Adriaan Albertus; Retief, Francois Wilhelm
Background: Postoperative pain is poorly studied in developing countries. At a Western Cape referral hospital, it was aimed to determine the incidence of acute postoperative pain, to identify populations associated with a higher risk thereof (in order to guide resource allocation) and to investigate whether inexpensive analgesic modalities are currently utilised maximally. Methods: Patients completed visual analogue scales 24 h after surgery for pain immediately after surgery, maximum pain since surgery and current pain. The incidence of moderate or severe pain and median pain scores were calculated for each scale and for different patient populations. Post hoc logistic regression was performed. Morphine prescriptions were compared with the actual administration thereof. Results: Of 1 231 patients, 62% indicated their maximum pain as moderate or severe. Procedures with the highest incidences were caesarean section and lower limb orthopaedic surgery (> 80%). Younger age, female gender, emergency surgery, and surgery to the abdomen and lower limbs were associated with higher incidences. Patients experiencing moderate or severe pain received 46% of their prescribed morphine. Conclusion: In this institution, the incidence of postoperative pain is high as expected. Associations with postoperative pain are identified, which may guide resource allocation. At least one low-cost analgesic modality is currently underutilised.
Administration of depolarizing muscle relaxants after non-depolarizer reversal: when is it safe?
(Health & Medical Publishing Group, 1982-04) De Roubaix, J. A. M.
ENGLISH ABSTRACT: In the light of studies on the duration of action and pharmacokinetics of intravenous neostigmine, it is recommended that, depending upon the dosage administered, at least 1 hour should elapse before a depolarizer can safely be given after neuromuscular reversal with neostigmine, and at least 90-120 minutes after reversal with physostigmine. It is suggested that a diluted test dose of depolarizer be given first, and its effect monitored with a peripheral nerve stimulator because fasciculations will not occur.
Aetiology of pulmonary dysfunction in total hip replacement operations: The influence of nifedipine on the factors involved
(Health & Medical Publishing Group, 1987-05) Du Toit, H. J.; Macfarlane, C. M.; Taljaard, J. J. F.; King, J. B.; Cooper, R. C.
ENGLISH ABSTRACT: Patients undergoing total hip replacement surgery who developed pulmonary dysfunction (PD) demonstrated evidence of a complement activation and increased thromboxane A2 (TXA2) synthesis. In a double-blind study nifedipine (Adalat; Bayer-Miles) was shown to inhibit complement activation and TXA2 synthesis and thus appears to offer protection against PD.
Anaesthesia and the diabetic patient
(HMPG, 1985) Roelofse, J. A.; Erasmus, F. R.
Since it is estimated that 1 out of every 2 diabetic patients will require surgery at some point in his lifetime, it is imperative that the anaesthetist should understand the disease process as well as the anaesthetic problems associated with it. This article emphasizes the medical, surgical and anaesthetic aspects of the treatment of patients with diabetes mellitus.
Anaesthesia for abdominal hysterectomy in Charcot-Marie-Tooth disease : a case report
(Health & Medical Publishing Group, 1985) Roelofse, J. A.; Shipton, E. A.
A 44-year-old white woman with Charcot-Marie-Tooth disease underwent an abdominal hysterectomy. The pre-operative preparation and anaesthetic management are presented, and the specific problems discussed.
Anaesthesia for congenital lobar emphysema resection : a case report
(Health and Medical Publishing Group -- HMPG, 1984-09) Payne, K.; Van Zyl, W.; Richardson, M.
[No abstract available]
Anaesthesia in connective tissue disorders
(Health and Medical Publishing Group -- HMPG, 1985-03) Roelofse, J. A.; Shipton, E. A.
Patients with the more common connective tissue disorders require surgical operations more frequently than has been realized. They may present the anaesthetist with many potential problems. A few minutes of careful questioning and examination pre-operatively may prevent a tragic situation. A history of drug therapy is essential pre-operative information, particularly since many of these patients will need augmentation or coverage with steroid drugs. The anaesthetist must be aware of the patient's general state of health and must search for evidence of pulmonary, cardiac or haematological abnormalities.
Anaesthetic induction with propofol: How much? How fast? How slow? What determines anesthetic induction dose? It’s the Front-End Kinetics, Doctor!
(Medpharm Publications, 2019) Coetzee, J. F.
ENGLISH ABSTRACT: It has long been realised that linear dosing according to total body weight (TBW) results in overdosing obese patients and under-dosing small children. Injected drug doses calculated on a mg.kg-1 body weight basis work well only for patients of normal habitus. As long ago as 1969, in a study of induction doses of thiopentone, ulfsohn and Joshi2 concluded that thiopentone was better administered according to lean body mass (LBM) than to TBW. They reasoned that endomorphic somatotypes required less thiopentone than mesomorphs and ectomorphs of the same TBW, because they had less LBM. They pointed out that there is a strong association between LBM, cardiac output and basal metabolic rate, and suggested that the LBM contained the “pharmacologically active mass”. Obese patients can perhaps be loosely regarded as ordinary individuals entrapped in a cocoon of fat into which hardly any injected drug is distributed. However the LBM of obese persons also increases as they accumulate fat, mainly due to increased muscle mass, as well as enlargement of other organs and blood volume. The dilemma is that LBM does not increase at the same rate as the increase in fat. Thus, although we know that they need more drug than normal-weight patients, how much more is often uncertain.
Anaesthetic management of a three-month-old baby for cervical limited dorsal myeloschisis repair using propofol and alfentanil infusions guided by pharmacokinetic simulation software : case report
(Medpharm Publications, 2019) Coetzee, E.; Gray, R.; Hollmann, C.; Enslin, N. J. M.; Coetzee, J. F.
ENGLISH ABSTRACT: We present an uncommon case of limited dorsal myeloschisis in a 3-month-old infant requiring repair guided by intraoperative neuromonitoring (IONM) and therefore avoidance of volatile anaesthetic agents. The case presented challenges in positioning, airway management, a lack of age appropriate pharmacokinetic models in target-controlled infusion (TCI) syringe pumps and unavailability of remifentanil, considered to be an essential drug in this setting. We overcame these challenges using manually controlled infusions of propofol and alfentanil guided by pharmacokinetic simulation software (Stelsim).
Anaesthetic management of cerebral artery aneurysms at Tygerberg Hospital, 1980-1982
(Health and Medical Publishing Group -- HMPG, 1984-05) Erasmus, F. R.; Du Toit, H. J.; Rose-Innes, A. P.
Forty-seven patients were operated on for intracranial artery aneurysms at Tygerberg Hospital, Parowvallei, CP, between January 1980 and December 1982. Problems related to anaesthesia which are peculiar to this condition and the solution thereof are outlined. The importance of meticulous anaesthetic management in the successful recovery of these patients, the majority of whom are young and in the productive phase of their lives, is stressed. A plea is made for increased awareness, early diagnosis and surgical intervention to decrease the high mortality rate associated with this lethal condition.
The anaesthetic management of distal (thoracic) tracheal resection in a quadriplegic patient
(Health & Medical Publishing Group, 1980-06) De Roubaix, J. A. M.
ENGLISH ABSTRACT: The anaesthetic management of distal tracheal resection in a quadriplegic patient is described. Ketamine, halothane, fentanyl and Entonox (50% N2O, 50% O2) were successfully employed. The major problems discussed include airway maintenance, cardiovascular instability and autonomic hyperreflexia, the dangers of depolarizers, and the need for monitoring temperature, blood pressure and fluid balance. The importance of team work is mentioned.
An audit of the labour epidural analgesia service at a regional hospital in Gauteng Province, South Africa
(Health and Medical Publishing Group, 2018) Leonard, T. G. A.; Perrie, H.; Scribante, J.; Chetty, S.
Background. Neuraxial analgesia in the form of a labour epidural has been shown to be the most effective analgesic strategy for the labouring mother. In developed countries, data are readily available as to the number of women receiving labour epidural analgesia, as well as the complication rates of labour epidurals. However, data for South Africa (SA) on labour epidural analgesia services are limited, and there were no published data for Rahima Moosa Mother and Child Hospital (RMMCH), Johannesburg, SA. Objective. To describe the labour epidural analgesia service at RMMCH over the period of 1 year. Methods. A retrospective audit using consecutive convenience sampling was done reviewing all epidural records at RMMCH from 1 January to 31 December 2014. Results. During the study period, labour epidural analgesia was administered for 187 (1.6%) of 11 853 deliveries. Epidural records were collected for all administered labour epidurals. The most common indications documented were labour analgesia (41.7%) and primigravida (28.9%). Labour epidurals were not administered for specific medical conditions. The incidence of complications was 22.6%, and these were minor and self-limiting. Hypotension was the most common complication (12.3%). Patient satisfaction with labour epidural analgesia, where documented, was high (98.4%). Conclusion. This audit revealed a low incidence of labour epidural analgesia at RMMCH during the study period. The incidence of complications was in keeping with that seen in developed countries. Poor documentation was noted to be a problem.
Blood oxygen saturation levels during conscious sedation with midazolam. A report of 16 cases
(Health & Medical Publishing Group, 1986) Roelofse, J. A.; Van der Bijl, P.; Joubert, J. J.; Breytenbach, H. S.
In a double-blind randomized study on 16 healthy individuals, two groups of subjects (8 in each group) received either midazolam (Dormicum; Roche) 0,1 mg/kg or placebo intravenously for conscious sedation during oral surgical procedures. Oxygen saturation of the blood was measured at different stages. Ten minutes after administration of the drug, the percentage oxygen saturation was significantly lower (P<0.05) in the midazolam group than in the placebo group.
Blood pressure measurement in obese patients : non-invasive proximal forearm versus direct intra-arterial measurements
(Taylor & Francis Group, 2018) Verkhovsky, A.; Smit, M.; Levin, A.; Coetzee, J. F.
Background: In obesity, accurate perioperative blood pressure measurement using upper arm, non-invasive blood pressure (NIBP) is technically challenging. Proximal forearm NIBP may be an acceptable substitute. Mean arterial blood pressures (MAP) estimated by proximal forearm NIBP were compared with direct intra-arterial measurements. It was hypothesised that the measurement techniques would be interchangeable if between-technique MAP differed ≤ 20% and MAP ratios were < 1.2 and > 0.8. Method: A total of 30 adults with body mass index ≥ 30 kg/m2 in whom perioperative intra-arterial blood pressure measurement was considered mandatory were enrolled. MAP measurements using the two techniques were obtained at three random intervals in each patient. Bland–Altman analyses were employed. Results: Forearm mean NIBP MAP overestimated mean intra-arterial MAP by 2.2 (SD 8.1; range from 23.8 to –19.4 mmHg; p = 0.011, 95% CI 3.9 to 0.5). However, Bland–Altman analyses revealed a wide dispersion with several MAP differences and MAP ratios exceeding the pre-specified bounds for interchangeability. Conclusion: Forearm NIBP could not be considered interchangeable with direct intra-arterial MAP measurements in obese patients.
Caudal block for analgesia after paediatric inguinal surgery
(Health & Medical Publishing Group, 1987) Payne, K.; Heydenrych, J. J.; Martins, M.; Samuels, G.
Two hundred and eleven children aged 1 - 5 years were studied after undergoing herniorrhaphy or orchiopexy. In 111 cases a caudal block was used for postoperative analgesia. This was administered immediately after induction of anaesthesia, using bupivacaine 0,25% plain (0,7 ml/kg lean body mass), and was successful in 100 patients. A mean analgesic level (± SE) of T9,9 ± 0,47 was achieved (range L2-T6). In 5 cases no block occurred and in 6 the level was below T12. The other 100 children acted as controls. Behaviour patterns were more restful in the caudal block group on awakening and less opiate was required during the first 5 postoperative hours. No complications resulted.
'Closed circuit' anaesthesia
(Health & Medical Publishing Group, 1974) Foster, P. A.
[No abstract available]
Comparison of hemoglobin measurements by 3 point-of-care devices with standard laboratory values and reliability regarding decisions for blood transfusion
(Lippincott, Williams & Wilkins, 2020-08) Johnson, Marianne; Marwick, Peter C.; Coetzee, Johan F.
BACKGROUND: We compared the accuracy of 3 point-of-care testing (POCT) devices with central laboratory measurements and the extent to which between-method disagreements could influence decisions to transfuse blood. METHODS: Hemoglobin concentrations [Hb] were measured in 58 adult patients undergoing cardiothoracic surgery using 2 Ilex GEM Premier 3500 blood gas analyzers (BG_A and BG_B) and a HemoCue Hb-201+ device (HemoCue). Measurements were compared with our central laboratory’s Siemens Advia 2120 flow cytometry system (laboratory [Hb] [Lab[Hb]]), regarded as the gold standard. We considered that between-method [Hb] differences exceeding 10% in the [Hb] range 6–10 g/dL would likely erroneously influence erythrocyte transfusion decisions. RESULTS: The 70 Lab[Hb] measurements ranged from 5.8 to 16.7 g/dL, of which 25 (36%) were <10.0 g/dL. Measurements by all 4 devices numbered 57. Mean POCT measurements did not differ significantly (P > .99). Results of the Bland–Altman analyses revealed statistically significant bias, with predominant underestimations by all 3 POCTs predominating. HemoCue upper and lower limits of agreement (LOA) were narrower, and the 95% confidence intervals (95% CIs) of the LOAs did not overlap with those of BG_A and BG_B. Similarly, a narrow mountain plot demonstrated greater precision for the HemoCue. Comparing BG_A with BG_B revealed no bias and narrow LOA. Error grid analysis within the [Hb] range 6–10 g/dL revealed that 5.3% of HemoCue measurements were beyond the permissible 10.0% error zone in contrast to 19.0% and 16.0% of the blood gas measurements. Possible inappropriate transfusion decisions based on POCT values generally erred toward unnecessary transfusions. Calculations of Cohen κ statistic indicated better chance-corrected agreement between HemoCue and Lab[Hb] regarding erythrocyte transfusions than the blood gas analyzers. CONCLUSIONS: All 3 POCT devices underestimated the Lab[Hb] and cannot be used interchangeably with standard laboratory measurements. BG_A and BG_B can be considered to be acceptably interchangeable with each other. Whereas the HemoCue had little bias and good precision, the blood gas analyzers revealed large bias and poor precision. We conclude that the tested HemoCue provides more reliable measurements, especially within the critical 6–10 g/dL range, with reduced potential for transfusion errors. Decisions regarding erythrocyte transfusions should also be considered in the light of clinical findings.
The Critical Care Society of Southern Africa Consensus Guideline on ICU triage and rationing (ConICTri)
(Health and Medical Publishing Group (HMPG), 2019-08) Joynt, G. M.; Gopalan, D. P.; Argent, A. A.; Chetty, S.; Wise, R.; Lai, V. K. W.; Hodgson, E.; Lee, A.; Joubert, I.; Mokgokong, S.; Tshukutsoane, S.; Richards, G. A.; Menezes, C.; Mathivha, R. L.; Espen, B.; Levy, B.; Asante, K.; Paruk, F.
Background: In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector. Purpose: The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources. Recommendations: An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years. Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.
Drukomsetters in die kliniese en navorsingspraktyk : 'n kort kritiese beskouing
(Health & Medical Publishing Group, 1987) Fourie, P. R.; Badenhorst, E.; Coetzee, A. R.
The correct measurement of various blood pressures in clinical practice is of obvious importance. A method by which the frequency response and damping of various transducers and catheters can be determined is discussed and reference is made to values obtained in the validation of certain catheters.

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