Background: There is no established costing model for operating theatres in South Africa, yet both sectors have existing charges for operating theatre (OT) time: in the state sector, Uniform Patient Fee Schedule (UPFS) rates, and in the private sector, Rands/minute (R/min) rates for OT time. Understanding the cost of providing the separate components of a health service is important for planning and funding purposes. Objective: The primary objective of this study was to develop a costing model that would allow the calculation of the R/min cost of OT time. The secondary objective was to determine the actual costs, in order to establish the comparable costs that would be included in the R/min charges for OTs in the private health sector. Method: The OTs in a secondary level, state sector hospital in Cape Town were used in this quantitative observational study to develop a top-down costing model for OTs in South Africa. The inclusive costing model was developed in a consultative process with professionals, managers and experts from the state and private sector. The model was then populated with utility measurements (water and electricity) for the month of August 2018, staff salaries, excluding surgeons and anaesthetists, and other costs for the 2018/19 financial year. Results: Costs were considered in the categories of full costs, shared costs and capital or annualised costs. Due to uncertainty in costing of OTs, two models - with different annualisation times assigned to the capital costs - were developed to demonstrate the difference. For shared costs, correction factors were determined using either an activity based (work-load) factor, or a more generic estimation of workload using theatre nursing staff as a percentage of total hospital nursing staff. To determine a R/min cost of creating a minute of available theatre time, all the annual costs were divided by minutes that the OTs are explicitly available, each year, to provide patient care. The model was then populated with costs using the appropriate correction factors. The longer annualisation model costed OT time at R31,46 per minute, and the shorter annualisation model at R33,77 per minute. In both the longer and shorter capital annualisation models, nursing was the largest contributor to costs at 36% and 33% respectively, followed by construction costs at 9% and 11%, and then OT equipment at 8% and 11%. Conclusion: An inclusive, top-down costing model for OTs in South Africa was developed. This costing model will support work to develop costing for individual procedures, the appropriate charge for planned and emergency OT time, and to better determine budgeting for OT services. Meaningful critique of the model will improve its fidelity, and likely increase its utility, especially as SA moves towards universal health coverage.

Introduction Chronic pain affects 10- 25% of the population worldwide. However, studies of people with chronic pain have primarily been conducted in WEIRD (Western, Educated, Industrialised, Rich and Democratic) countries. There is a paucity of data from developing countries with the existing biased data being used to guide treatment of patients in developing countries. To address this knowledge gap, we have analysed the data of 623 patients attending the Chronic Pain Management Clinic (CPMC), at a tertiary facility in Cape Town, South Africa. The profile of the patients was compared to the global data. Methods A cross-sectional study of patients who attended the CPMC was conducted to describe their profile according to age, sociodemographic characteristics, health, gender and use of illicit drugs. Results The typical patient attending the CPMC was of middle age, female gender, of low educational level and less advantageous socio-economic status. They were also more likely to be on a disability grant and suffer from anxiety and depression. Conclusion The profile of the patients attending the CPMC was found to be similar to those from WEIRD countries. These results suggest that we can apply global data of people with chronic pain to patients attending this clinic.

Objective: In this study of patients presenting for non-cardiac, emergency surgery in a resource limited setting, we aimed to evaluate the impact of routine preoperative transthoracic echocardiography on perioperative management. Design: A prospective before- and after-study of adult patients presenting for emergency, non-cardiac, non-obstetric surgery. Setting: The study was performed at an academic hospital in Cape Town, South Africa. Participants: Consenting patients over 18 years of age presenting for emergency surgery enrolled via convenience sampling during working hours over a 10 day period. Interventions: Basic and advanced Focused Assessment Transthoracic Echocardiography (FATE) was performed to evaluate ventricular function, valvular pathology and fluid status. After completing an assessment and treatment plan, the FATE findings were disclosed to the treating anesthetist. A post FATE plan was subsequently completed. Measurements and Main Results: A total of 67 patients were scanned with a change in management detected in 55% of cases. Thirty-nine percent of these alterations were in response to fluid management strategies with 31% of patients scanned being assessed as hypovolemic. There was a statistically significant link between patient volume status and change in perioperative management (p=0.0003). The presence or absence of valvular pathology also led to a significant association with change in management (p=0.020), most commonly in relation to the decision to proceed with surgery or the use of additional monitoring. Conclusion: This observational study of adult patients presenting for emergency surgery in an upper middle-income country demonstrates that routine preoperative transthoracic echocardiography has an impact on perioperative anesthetic management.

Abstract Background: Hypoxaemia during tracheal intubation in obstetrics remains a lifethreatening complication. This study aimed to identify common clinical preinduction predictors of difficult intubation. Methods: A retrospective analysis was performed of data pertaining to tracheal intubation in patients requiring general anaesthesia for caesarean delivery, with a gestational age from 20 weeks, and until 7 days post-delivery, obtained from an obstetric airway management registry (ObAMR) at the University of Cape Town. Data was entered anonymously into a secure UCT REDCap database. Data categories were: patient and pregnancy characteristics, airway characteristics, details of management, and operator experience. The primary aim of the study was to identify anatomical and physiological risk factors for hypoxaemia. The primary outcome was defined as arterial desaturation to < 90% during obstetric airway management. For this purpose, multivariable binary logistic regression was performed. Hypoxaemia was thus used as a composite indicator of anatomical and physiological difficulty. Results: Data was collected for 1095 general anaesthetics in the ObAMR. Overall, 143/1091 of patients (13.1%, 95%CI 11.1 to 15.4%) experienced peripheral oxygen saturation below 90%. Univariate analysis showed that 91/142 (64.1%) of patients who desaturated were obese (body mass index [BMI]> 30 kg/m2 ), compared with 347/915 (37.9%) who were obese and did not experience desaturation (p< .001). A receiver operating curve (ROC) was constructed post hoc, which showed a cut-point for BMI of 29.76, and a sensitivity of 0.66, and specificity 0.62 for the prediction of hypoxaemia. Desaturation occurred in 17.0% of patients with hypertensive disorders of pregnancy, versus 11.0 % without (p=0.005). Increasing Mallampati class was associated with an increased incidence of hypoxaemia. The incidence of hypoxaemia was 25.8% for interns, compared with 8.0 % for consultant anaesthesiologists (p=0.005). In the multivariate analysis of factors associated with hypoxaemia, body mass index (p< 0.001), room air saturation prior to preoxygenation (p=0.008), and the presence of airway oedema (p=0.027), were independently associated with hypoxaemia. Conclusions: In this study, both anatomical and physiological predictors of hypoxaemia were identified. Using this concept, a predictive tool could be developed to aid in the identification of a difficult airway in obstetrics. Simple interventions such as face mask ventilation and the use of high flow nasal oxygenation, could be introduced to protect the parturient from the consequences of life-threatening hypoxaemia.

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The syndrome of Malignant Hyperpyrexia in man follows administration of certain general anaesthetic agents, and, although rare, is fatal in 70% of cases (EDITORIAL, 1968). Following exposure to the anaesthetic, there is, in most instances of susceptible individuals, a rapid rise in body temperature, usually within a period of 10 minutes, often accompanied by muscular rigidity of the limbs~ Sometimes hyperthermia has.been delayed for hours and muscular rigidity not pronounced. The temperature reached maybe 43°C (115°F) or even somewhat above this. Halothane, CF3CHBrCl, a ha../o/~nated hydrocarbon, is thought to be responsible for most cases(WILSON, NICHOLS, DENT and ALLEN, 1966). Succinyl choline lfH2COOCH2CH2*(cH3 )~ 201_~H2COOCH2CH2~(cH3 )3 a skeletal muscle relaxant employed during anaesthesia, has also been implicated (BRITT and KALOW, 1970; HARRISON, 1971).

Three clinical investigations together with a combined editorial and review of the cardiovascular physiology of spinal anaesthesia in normal and preeclamptic pregnancy form the basis of a thesis to be submitted for the degree of Doctor of Medicine at the University of St Andrews. First, the longstanding consensus that spinal anaesthesia could cause severe hypotension in severe preeclampsia was examined using three approaches. The doses of ephedrine required to maintain systolic blood pressure above predetermined limits were first compared in spinal versus epidural anaesthesia. The doses of ephedrine required were then similarly studied during spinal anaesthesia in preeclamptic versus normal control subjects. The principal outcome of these studies, that preeclamptic patients were resistant to hypotension after a spinal anaesthetic, was then further investigated by studying pulse transit time (PTT) changes in normal versus preeclamptic pregnancy. PTT was explored both as beat-to-beat monitor of cardiovascular function and also as an indicator of changes in arterial stiffness. The cardiovascular physiology of obstetric spinal anaesthesia was then reviewed in the light of the three clinical investigations, developments in reproductive vascular biology and the regulation of venous capacitance. It is argued that the theory of a role for vena caval compression as the single cause of spinal anaesthetic induced hypotension in obstetrics should be revised.