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Background: Myocardial injury affects up to one in three patients undergoing non-cardiac surgery. However, very little is known about the underlying pathophysiology. In the general population, patients with elevated resting heart rate are at increased risk of cardiac events, mortality, heart failure and autonomic dysfunction, while hypertension is a well described risk factor for cardiovascular disease. I hypothesised that common abnormalities of heart rate or blood pressure were associated with myocardial injury after non-cardiac surgery. Methods: This thesis comprises a series of secondary analyses of data from five prospective multi-centre epidemiological studies of surgical patients. The main outcome of interest was myocardial injury, defined using objective measurement of cardiac troponin. I used logistic regression analysis to test for association between exposures and outcomes. Results: In a large international cohort, patients with high preoperative heart rate had increased risk of myocardial injury and patients with very low preoperative heart rate had reduced risk of myocardial injury. Patients with elevated preoperative pulse pressure had increased risk of myocardial injury, independent of existing hypertension or systolic blood pressure. High heart rate, or high or low systolic blood pressure during surgery, was associated with increased risk of myocardial injury. In a separate study, elevated preoperative heart rate was associated with cardiopulmonary and autonomic dysfunction, and reduced left ventricular stroke volume, suggestive of heart failure. Finally, autonomic dysfunction, identified using cardiopulmonary exercise testing, was associated with elevated preoperative heart rate, elevated plasma NT-Pro-BNP (indicative of heart failure) and postoperative myocardial injury. Conclusions: Elevated preoperative heart rate, autonomic dysfunction and subclinical heart failure may be part of a common phenotype associated with perioperative myocardial injury. Further research is needed to characterise the pathological processes responsible for myocardial injury, and to identify potential therapeutic targets.

Knowledge of surgical procedures, instruments, and supplies is essential to the perioperative nurse working in the operating room (OR). Nursing school curricula do not specifically educate surgical nurses; therefore, it is difficult to fill open OR positions with experienced perioperative nurses. The purpose of this doctoral project was to develop a perioperative educational program for RNs newly hired in the OR. The practice-focused question asked whether an evidence-based staff education program for the novice perioperative nurse would increase the nurse's knowledge of OR procedures and protocols for patient management. The novice-to-expert framework was used to explore how adult learners acquire knowledge. Five experts were asked to review the educational program for its content, readability, length, and learner objectives using a 5-point Likert scale questionnaire consisting of 8 questions. Experts strongly agreed that the program content met learner objectives. The program was then presented to 4 novice nurses with a pretest/posttest consisting of 5 fill-in-the-blank questions. Pretest results showed 1 of 5 questions were answered correctly by all participants. Posttest results showed all questions were answered correctly by all participants. The educational program has the potential to create a positive social change through increased nurses' knowledge of OR procedures, which might promote improved surgical care and outcomes for patients.

Många patienter blir hypoterma under den perioperativa vården. Det finns en mängd åtgärder som kan vidtas för att minska oönskad hypotermi. Pre- och intraoperativ uppvärmning med värmetäcke, varmt på operationssalen, cirkelsystem och användning av varma infusioner kan vara en bra kombination. Oavsett vilken terapi som används är normotermi alltid högt prioriterat.  Det handlar om patientsäkerhet. Genom att effektivt motverka hypotermi skulle möjligheten öka till snabbare återhämtning, färre postoperativa infektioner, mindre kostnader för sjukhuset och minskat lidande för patienter. Syftet med studien var att undersöka anestesisjuksköterskans upplevelser av att förebygga perioperativ hypotermi hos vuxna elektiva patienter. En kvalitativ intervjustudie med induktiv ansats gjordes inom problemområdet. Insamlingen av data gjordes genom intervjuer som spelades in. Intervjuerna transkriberades och analyserades med kvalitativ innehållsanalys. I resultatet framkommer att, även om normotermi är målet och ambitionen finns, är det många faktorer som spelar in hur vida de hypotermiförebyggande åtgärderna når framgång. Det krävs en god planering samt erfarenhet av förebyggande arbete. Att mätmetoderna är ifrågasatta kan bidra till att mätning inte alltid utförs. Avsaknad av riktlinjer kring hypotermiförebyggande åtgärder bidrar till oklarheter för vårdpersonalen. Alla de olika personalkategorierna kring en operation tenderar att fokusera på sina egna uppgifter. En stor ansvarskänsla samt till viss del ensamhetskänsla i besluten, om vilka åtgärder som skall vidtas samt när finns hos anestesisjuksköterskan. När patienten blir kall trots att anestesisjuksköterskan har gjort allt kan det upplevas som ett misslyckande att inte räcka till. När patienten anländer kall till uppvaket kan anestesisjuksköterskan känna skuld till patientens tillstånd samt lidandet det medför. Strävan är att patienten ska må bra även postoperativt. Genom att informera patienten om varför det är nödvändigt att det tillförs extra värme gör att patienten blir delaktig i omvårdnaden. Anestesisjuksköterskan upplever att värmda täcken, strumpor samt mössa gör patienten mindre spänd samt stressad. På så vis ökar man patientens upplevs av välbefinnandet.

A discrete event simulation was applied to model the perioperative process in the general surgery service at Toronto General Hospital, aiming at reducing the number of surgical cancellations and improving the perioperative process. This model includes emergency case interruptions with two types of emergency cases with different levels of urgency, and takes into account the availability of three types of post-surgical beds: medical surgical intensive care unit, step-down unit and ward beds in decision making level. The effect of three types of scenarios on the number of surgical cancellations was explored: 1) applying effective scheduling rules based on the utilization of post-surgical beds, 2) sequencing the surgical operations based on the length of surgeries and the variance of surgery durations, 3) increasing the number of post-surgical beds.

A discrete event simulation was applied to model the perioperative process in the general surgery service at Toronto General Hospital, aiming at reducing the number of surgical cancellations and improving the perioperative process. This model includes emergency case interruptions with two types of emergency cases with different levels of urgency, and takes into account the availability of three types of post-surgical beds: medical surgical intensive care unit, step-down unit and ward beds in decision making level. The effect of three types of scenarios on the number of surgical cancellations was explored: 1) applying effective scheduling rules based on the utilization of post-surgical beds, 2) sequencing the surgical operations based on the length of surgeries and the variance of surgery durations, 3) increasing the number of post-surgical beds.

Background Worldwide, the number of patients suffering from surgical complications account for a significant burden on healthcare systems. Myocardial injury after non-cardiac surgery (MINS) is a new entity that has recently been identified as an independent risk factor associated with 30-day all-cause mortality. The risk of death increases approximately 10 fold following MINS in the perioperative period. Diagnosing myocardial injury in nonsurgical patients often relies on specific symptomatology and clinical findings combined with special investigations. However, in surgical patients, more than 80% of patients with postoperative myocardial injury will be asymptomatic, and hence the majority of diagnoses will be missed. Studies identifying the prevalence and risk factors for MINS have been conducted in countries with a different surgical population to South Africa. The primary outcome of this study was to investigate the prevalence of MINS after non-cardiac, elective, elevated risk surgery in South Africa. Methods Patients undergoing elevated risk, elective, non-cardiac surgery ≥ 45 years of age were enrolled via convenience sampling. The new 5th generation, high sensitivity cardiac troponin T (hscTnT) blood test was used to identify MINS. Blood samples were taken between 24 to 72 hours after surgery. Exclusion criteria included patients with known renal disease, a recent cardiac event, pulmonary embolism or sepsis. Results A total of 244 patients were included in the study. The prevalence of MINS was 4.9% (95% CI 2.2-7.6) which was not significantly different (p=0.078) to reports from international prospective observational studies. Conclusion Elective, elevated risk surgical patients in South Africa have a similar incidence of MINS when compared to patients from international studies. As the risk profile of South African patients is significantly lower than other similar international observational studies, it is possible that the prevalence of MINS is more common in South Africa, when patients are adjusted for cardiovascular risk profile. The burden of MINS on public health morbidity is therefore likely to be proportionally more in South Africa when compared to international reports. This may suggest that the calibration of international cardiovascular risk prediction models is incorrect for South African patients, or there are confounding comorbidities which should be included in South African cardiovascular risk prediction models. Larger studies are required to confirm this hypothesis however, and should also aim to address the need for appropriate cardiovascular risk predicting models in South Africa, to ensure timeous identification of patients at risk of MINS.

Objectives: To establish the median and interquartile range or the mean and standard deviation for closure times , with the CADP and CEPI cartridges for children with CCHD and to compare this to normal children. Design: Prospective observational pilot study Setting: Red Cross War Memorial Children's Hospital (RCWMCH) in association with the University of Cape Town Participants: Children between birth and 16 years old diagnosed with CCHD presenting for corrective or palliative cardiothoracic surgical procedures Interventions: 0.8ml of whole blood obtained from the participants was pipetted into both the CEPI and CADP cartridges and analyzed by the PFA machine. Closure times for both cartridges were obtained and recorded on the data collection form. Results: 40 successful CADP samples and 39 successful CEPI cartridges were analysed. Of the total 40 valid CADP samples there was left skewed distribution , the median was 114.50 seconds with an interquartile range from 87.25 seconds to 153.75 seconds. Of the total 39 valid CEPI samples the data was normally distributed to give a mean of 175.38 and a standard deviation of 74.998. Both of which are not significantly different from the typical normal ranges obtained with 3.2% trisodium citrate ; 55–112 s for CADP and 79–164 s for CEPI (Harrison 2005). However, when compared to the normal ranges quoted by Carcao et al for neonates and children, there was a significant prolongation for both the CEPI and CADP samples in the neonates and children with CCHD Conclusion: This is a pilot study and limited by small sample sizes obtained due to time limitation. Further research would be needed to further assess whether the PFA could be used to guide platelet replacement in this population.

Background Rapid growth in optical and video devices for indirect visualisation of the airway has expanded the options for emergency and elective endotracheal intubation in patients with unstable fractures of the cervical spine. Aiming to ascertain whether video laryngoscopy (VL) has replaced awake flexible intubation (AFI) as the preferred technique for airway management, we conducted a global survey to evaluate current clinical practice. Methods After ethics approval, we created a questionnaire featuring one emergency and one urgent elective hypothetical patient with unstable injuries of the cervical spine. Target sample sizes per country were estimated using data from the World Federation of Societies of Anaesthesiologists' (WFSA) Global Anaesthesia Workforce Survey. Respondents were asked about their training, experience, airway skills, current clinical setting, and availability of airway equipment, as well as their preferred airway strategy in each case. The questionnaire was actively distributed for one year through the WFSA member societies and via social networks to physician anaesthesia providers (PAPs). Global and regional trends were assessed using descriptive statistics. Results Of a total of 1904 responses, 1153 (101 countries) were included in the final analysis. In the emergency case, 46.9% (95% confidence interval [CI]: 44.0–49.8%) of participants preferred VL and 39.8% (95% CI: 38.0-42.6%) chose AFI. In the urgent elective case, 51.3% (95% CI: 48.3-54.3%) selected VL as their preferred method, while 37.3% (95% CI: 34.4-40.2%) indicated AFI. Significant regional variations in preference were found. Conclusion The results suggest that practice in airway management of unstable cervical spine fractures is changing, and currently tends to favour VL over AFI. There is a statistically significant preference for VL in elective cases, traditionally considered to be a stronghold of AFI.

Background: This tertiary referral centre is one the largest paediatric hospitals in Africa. Despite an increasing number of surgical and diagnostic procedures being performed annually, a formal out-of-theatre sedation service does not exist. Procedural sedation and analgesia (PSA) is an important adjunct in behavioural management for invasive procedures in children. Objective: A prospective, observational study was performed at RCWMCH, aimed primarily at defining the number of cases of PSA performed outside the operating theatre. Methods: Data was collected from all procedural out-of-theatre sedations performed over a period of three months, including ward patients and out-patient departments. All children < 13 years of age were included. Results: A total of 639 sedations were performed. Of these sedations, 288 (45.0%) paper responses were captured and analysed. The reported incidence of desaturation was 4.2% (12/288), laryngospasm 0.3% (1/288) and nausea and vomiting 2.4% (6/288). Three cases required conversion to general anaesthetic, and three cases were abandoned due to inadequate sedation. In 16.3% (47/288) of cases the clinician was an operator sedationist (the same person performing the sedation and the procedure). In 90.6% of cases the intravenous route was utilized, with dexmedetomidine, ketamine and propofol being the three most commonly used agents. Conclusion: 639 PSA events were recorded in 3 months. The 288 events analysed were safely performed with minimal serious reported events. These results compare favourably with international studies and provide quantitative evidence as a prelude to setting up a dedicated sedation service at our facility.