Department of 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.
The ability of the thromboelastogram (TEG® R-time difference between kaolin and heparinase) as a point of care test to predict residual heparin activity after in vitro protamine titration
(Stellenbosch : Stellenbosch University, 2017-12) Joseph, Lauren Ann; Levin, Andrew I.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Anaesthesiology and Critical Care.
ENGLISH ABSTRACT: Background: Differentiation between surgical bleeding and coagulopathy is critical as re-exploration is associated with increases in mortality and morbidity. Adequate reversal of heparin with protamine at the end of cardiopulmonary bypass (CPB) is critical to prevent postoperative bleeding. Meticulous dosing of protamine is required as excessive dosages has deleterious side effects on clotting. Traditional methods make use of an activated clotting time (ACT) for evaluation of adequate heparin reversal. However, recent use of other point of care (POC) tests, the thromboelastogram (TEG®) has started challenging the utility and exclusive use of ACT to evaluate effective reversal. Differences between thromboelastographic Rkaolin and R-heparinase times is an indicator of residual heparin. However, the exact relationship between these parameters and the exact amount of residual heparin is unknown. The rationale for this study was to accurately determine the relationship between the magnitude of the R-kaolin and R-heparinase time difference and blood heparin concentrations. Aims: This study was performed to define the in-vitro relationship between the difference between the thromboelastographic R-kaolin and R-heparinase time difference (TEG® Delta-kh R-time) and plasma heparin concentrations. The primary outcome was to determined the relationship between the TEG® Delta-kh R-time difference and heparin concentrations. The secondary outcome was to determine the concentration of heparin at or below which R-kaolin times become measureable. Methods: This was a single centre, prospective, randomized laboratory study. Following institutional ethics approval and informed consent, sixty-two samples were taken during CPB from 20 patients meeting inclusion criteria. Samples were randomized to one of three groups which would dictate the protamine dose. The three groups were based on a protamine to heparin ratio (expressed as milligram protamine per milligram heparin administered to the patient) approximating 0.25, 0.5, and 0.75 mg/mg respectively. Each sample of blood was then administered a dose of protamine. The TEG® analysis entailed measuring the R-kaolin and R-heparinase time and noting the difference. Thereafter, each blood sample was sent for heparin concentration determination using an anti-Xa activity assay. Results: No relationship between the measurable R-kaolin time and heparin concentration could be demonstrated (p=0.80), as well as no relationship between measurable TEG® Delta-kh R- time difference and heparin activity (p=0.42). However, we did identify a high probability to be able to predict a measurable R-kaolin time (negative predictive value 90%, 95% CI 74% to 98%) when heparin concentration is less than 1.24IU/ml. Conclusions: We were unable to predict heparin concentration using TEG® in this study. It is likely that this was related to methodological problems. The protamine dose was a complex calculation and there is uncertainty with regard to the actual amounts used. There were also multiple laboratory technicians, with a possible loss of standardization. However, R-kaolin time will likely be measurable at heparin concentrations below 1.24 IU/ml, and not measurable above that value. This observation is immensely valuable for clinicians and researchers. Future studies should take this into account and attempt to determine the relationship between TEG® Delta-kh R- time differences and heparin activity only when heparin concentration are less than 1.24IU/ml.
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.
Airway management of a massive neonatal cervical teratoma : case report and review
(Stellenbosch : Stellenbosch University, 2016-12) Von Steiger, Ilonka; Levin, A. I.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Anaesthesiology and Critical Care.
ENGLISH ABSTRACT: Congenital cervical teratomas are rare tumours notorious for causing neonatal airway embarrassment. We report the multidisciplinary management of a foetus with an antenatally diagnosed massive cervical teratoma. Initial management with an ex-utero intrapartum treatment (EXIT) procedure failed. The neonate was delivered and airway control was then achieved using a supraglottic airway device. Tracheal intubation was eventually accomplished using fibreoptic bronchoscopy via the supraglottic airway. The discussion addresses perinatal cervical teratoma with the emphasis on airway management and the use of supraglottic airway devices.
Akute postoperatiewe pyn opname in Tygerberg Hospitaal
(Stellenbosch : Stellenbosch University, 2013-12) Murray, Albertus Adriaan; Retief, Francois Wilhelm; Stellenbosch University. Faculty of Medical and Health Sciences. Dept. of Anaesthesiology & Critical Care.
AFRIKAANSE OPSOMMING: Doelwit: Om die voorkoms en erns van postoperatiewe pyn te bepaal gedurende die eerste 24 uur periode in 'n tersiëre hospitaal met beperkte hulpbronne. Om spesifieke groepe en risiko faktore wat verband hou met 'n hoër voorkoms van pyn te identifiseer. Ontwerp: Opname met behulp van 'n vraelys. Opset: Ontwikkelende land tersiëre staatshospitaal met alle chirurgiese dissiplines. Populasie: Pasiënte van alle chirurgiese dissilpines bo 12 jaar oud en toegelaat vir 'n minimum van 24 uur postoperatief. Metodiek: Opname 24 uur na die operasie met behulp van 'n vraelys met 3 visuele analoog pyn skale (VAS) en 'n vraag. Verdere data is ingesamel vanaf die narkose en voorskrif kaarte. Resultate: Postoperatiewe pyn is gerapporteer as matig in 25% en erg in 37% van pasiënte. Onafhanklike risikofaktore vir matige of erge postoperatiewe pyn was ‘n jonger ouderdom, vroulike geslag, nood en abdominale chirurgie. Prosedures met die hoogste voorkoms van matige of erge pyn was keisersnitte (87%) en ortopediese chirurgie van die onderste ledemate (80% - 85%). Morfien toediening was baie minder gereeld as voorgeskryf. Gevolgtrekking: Voorkoms van postoperatiewe pyn in hierdie hulpbron beperkte omgewing is hoog, maar vergelyk met ander instansies. Spesiale sorg moet geneem word in die geïdentifiseerde groepe wat verband hou met 'n hoër voorkoms van pyn. Roetine sistemiese analgesie moet meer tydig toegedien word, veral wanneer die effek van regionale narkose termineer.
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.
An audit of the time spent by patients in the post anesthetic care unit before and after the introduction of a discharge criteria scoring system at Tygerberg Academic Hospital
(Stellenbosch : Stellenbosch University, 2014-04) Dwyer, Sean; De Kock, M.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Anaesthesiology and Critical Care.
ENGLISH ABSTRACT: BACKGROUND Post anesthesia discharge criteria scoring systems have been used successfully to aid discharge from the post anesthetic care unit (PACU) for over 40 years. They do not replace, but rather act in conjunction with good clinical judgment, and provide concise, standardized documentation of a patient’s readiness for discharge. 1,2,3,4,5 In order to improve patient safety, provide clear documentation and to aid future audit, a discharge criteria scoring system was developed for use in our PACU (Addendum A). It is a modification of the Aldrete Scoring System and the modified Post Anesthetic Discharge Scoring System (PADSS) proposed by Chung.1 There is a steadily increasing patient burden on the existing medical infrastructure in South Africa. Tygerberg Academic Hospital is no exception, and because of the high demand on our theatre services, optimal efficiency is essential. We speculated that our discharge criteria scoring system might increase the efficiency of our PACU when compared to the traditional time based system. The more healthy patients, undergoing minor procedures, could potentially spend less time in PACU, allowing the nurses to focus on problem cases. Increasing the speed of transit might also help prevent delays in theatre due to lack of bed space in PACU. Our primary endpoint was to compare the duration of time spent by patients in the PACU at Tygerberg Academic Hospital, from the moment they are admitted, to the time they are discharged to the ward, before and after the introduction of a discharge criteria scoring system. While planning the audit, one of the factors that staff identified as contributing to delayed discharge from PACU, was the time it took for the wards to collect their patients. A secondary objective, therefore, was to assess the amount of time that elapsed between calling the ward to collect the patient, and the patient leaving PACU. METHODS AND MATERIALS Prior to commencing the audit, approval was obtained from the Human Research Ethics Committee of the Faculty of Health Sciences of the University of Stellenbosch and Tygerberg Academic Hospital. The Audit, its purpose and possible benefits, was discussed with representatives of the nurses working in PACU, and written consent was obtained from those who would be involved in the data collection (Addendum B). Audit forms (Addendum C), collection boxes, and posters reminding staff to participate in the audit were prepared. Our first audit was performed over approximately a week in August 2012. During this period, the traditional time-based discharge system was still in operation. Data was captured from 327 patients. Audit forms were placed in a collection box, which was cleared daily by the primary investigator. The discharge criteria scoring system was introduced to the PACU staff in January 2013. The nurses were trained in its use, and a one month period was allowed for all involved to become accustomed to the new system. A second audit was performed in February 2013, again over a week, during which we gathered data from 313 patients. RESULTS The median value of the time spent by patients in the PACU decreased from 1 hour 25 minutes, to 1 hour 15 minutes, after introduction of the discharge criteria scoring system. This was statistically significant (p-value = 0.003). The median time between calling the ward to collect a patient, and the patient leaving recovery, was 15 minutes. CONCLUSION The main finding of the study was that the introduction of a discharge criteria scoring system decreased the median duration of time spent by patients in the post anesthetic care unit at Tygerberg Academic Hospital.
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.
Blood pressure measurement in the obese patient: a comparison between non-invasive proximal forearm and radial arterial blood pressure measurement
(Stellenbosch : Stellenbosch University, 2017-12) Verkhovsky, Anna; Smit, Marli; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Anesthesiology and Critical Care.
ENGLISH ABSTRACT: ABSTRACT Background: South Africa has a high prevalence of obese adults. When these (obese) individuals present to a health care facility, blood pressure measurement will play an important role during routine medical evaluation. Accurate non-invasive blood pressure monitoring is a challenge in obese individuals secondary to inaccurate readings associated with inappropriate cuff size, structural differences of the upper arm as well as short upper arm length. Our aim was to identify an accurate, affordable, minimally invasive and low-risk blood pressure measurement modality in obese patients. Methods: This study included 30 patients with a body mass index of greater or equal to 30 kg/m2 presenting for surgery or staying in a High Care Unit at Tygerberg Hospital. In all of these patients, an intra-arterial line was included as part of their routine care. We compared the non-invasive (mean, systolic and diastolic) blood pressures readings from the proximal forearm, with the gold standard, being intra-arterial blood pressure readings. Results: There was poor agreement between the mean intra-arterial blood pressure measurement and the noninvasive blood pressure (NIBP) measured at the forearm. The mean NIBP measured at the forearm overestimated the intra-arterial blood pressure reading by 2% (±8.1 %. P 0.031). The computed upper and lower levels of agreement between the 2 methods ranged from -19.3 to 15.2%. Systolic NIBP measurements at the forearm over-estimated the IABP measurements by 0.9% (P 0.295). Upper and lower levels of agreement between the 2 methods ranged from -16.4 to 14.7%. Larger discrepancies between the two methods were observed for diastolic blood pressure measurements with a mean difference of -5.8% (P <0.0001). Conclusion: We cannot recommend that the forearm NIBP reading be used as an accurate, non-invasive and cost effective substitute to measure blood pressure in obese patients.

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