It is widely assumed in the literature that large thyroid goitres pose a significant risk to the airway perioperatively. They are of concern to anaesthetists because of anticipated difficulty relating to intubation, ventilation and post-thyroidectomy tracheomalacia. They are of concern to surgeons because of the anticipated risk of difficult dissection and increased risk of surgical complications including haemorrhage, laryngeal nerve injury and tracheomalacia. Objectives: To analyse the folders of patients who have undergone anaesthesia and surgery for large, nonmalignant goitre, to assess the impact of large goiters on perioperative and postoperative management. An attempt will also be made to identify possible predictive markers/ patient characteristics associated with difficult intubation. Design: A retrospective folder review Setting: Groote Schuur Hospital Participants: All patients who had thyroidectomies performed at Groote Schuur Hospital between Jan 2010 and June 2016 for large, non-malignant goitres. Measurements and main results: Of the patients who underwent a thyroidectomy procedure at Groote Schuur Hospital between Jan 2010 and June 2016, 196 were identified as having non-malignant goitre and size in one dimension of greater than fifty millimeters. There were seven documented difficult intubations and only one case of failed intubation. This case was subsequently put onto cardiopulmonary bypass and intubated successfully using a rigid fibreoptic bronchoscope. Of the one hundred and nighty-six cases, four were intubated using a fibreoptic bronchoscope, eight with a videolaryngoscope, and six cases, a bougie. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed via a collar incision with no requirement to proceed to sternotomy. There was only one patient requiring blood intraoperatively and only four reported cases of postoperative haematomas. There were no instances of tracheomalacia. Two patients suffered long term recurrent laryngeal nerve injury with voice changes. Conclusion: The data shows that, in patients with large, benign goitre undergoing thyroidectomy, airway difficulties at intubation and surgical and anaesthetic complications postextubation are rare. Intravenous induction and direct laryngoscopy is a safe technique in appropriately experienced hands.

Background: The ability to correctly measure the partial pressure of Oxygen is one of the fundamental test that influence clinical decision making in a septic ICU patient. The study examined the extent of error over time, from collection to processing, when measuring blood gas samples for PO₂, PCO₂, pH, in critically-ill patients with sepsis and metabolically active leucocytosis > 12 000/mm³ and compares it with a control, where immersing it in ice has stopped metabolism. Methods: Thirty septic ICU patients with confirmed leucocytosis > 12 000/mm³, who had routine arterial blood analysed was included in the study. Blood form the standard PICO50 radiometer arterial blood sampler (2ml) syringe was decanted into two 1ml Glass syringes that was pre-heparinised with 1ml Heparin 1000U - all excess Heparin removed. One syringe was cooled with ice slurry and tested as a control at 60 minutes The other syringe was used to repeatedly analyse the sample at 0,10, 30 and 60 minutes. The syringes were sealed with plastecine and a glass capillary tube was use to decant the sample just prior to analysis to fit the analyser. Samples were processed using an ABL 800 blood gas analyser. Results: The mean absolute difference in PO₂ at 10 minutes was -0.94 kPa (95% CI: -1.48 to -0.4 kPa), at 30 minutes -2.42 kPa (95% CI: -3.10 to -1.75 kPa) and at 60 minutes -4.44 kPa (95% CI: -5.54 to -3.34 kPa). The relative difference in pO₂ at 10 minutes was -4.98% (95% CI: -8.12 to -1.84%), at 30 minutes -13.79% (95% CI: -17.40 to -10.17%) and 60 minutes -25.46% (95% CI: -30.97 to -19.95%). The absolute difference in PO₂ at 60 minutes on Ice was - 0.31 kPa. Conclusion: Delayed blood gas analysis in Septic ICU patients with a raised WCC > 12 000/mm³, results in statistical and possible clinical significant abnormality in the pO₂, that progressively worsens with time. After 10 minutes there was a 5% change, at 30 minutes a 14% change and there was a 25% change from baseline PO₂ at 60 minutes. The magnitude of change with statistical mixed linear models shows the rate of decline to be of the magnitude of 1% per minute. So at 60 minutes, the ratio change is 0.7313859 (0.9948 to the power of 60).This deviation may alter clinical decision making.

Introduction: Traumatic brain injury (TBI) is an important cause of morbidity and mortality in the developing world, and remains the leading cause of death and long-term disability in young adults. Hypocoagulopathy is a well described sequela of severe TBI and is associated with prolonged intensive care unit stays and poor outcomes. This study was conducted to determine the prevalence of coagulopathies in patients with severe, isolated TBI. The secondary outcome was to note any difference in the prevalence of detected coagulopathy between blunt and penetrating TBI. Methods: This is a prospective observational study of fifty patients with severe, isolated TBI (AIS head >3, AIS body <3), presenting to, or were referred to Groote Schuur Hospital. We drew blood for International Normalised Ratio (INR), activated partial thromboplastin time (aPTT), platelets count, sodium, potassium, urea and thromboelastography (TEG) on all patients at 12 hours (±3 hours), 36 hours (±3 hours) and eligible patients at 60 hours (±3 hours) post injury. Coagulopathy was defined as any one of the following: platelet count<120 x 109/L, INR>1.2, PTT>37 seconds, R time<4 minutes or >8 minutes, K time>4 minutes, α angle<47˚ or >74˚, maximum amplitude<54 mm or >72mm, EPL>15%, LY30>8 %, coagulation index<-3 or >3. Results: The patients were mostly male (n=47), with a mean age of 31 years. Median AIS head and body were 5 and 1, respectively. Thirty-six patients sustained blunt, and the remaining 14 penetrating trauma. Sixteen of the fifty patients demised during the course of the study. The cumulative prevalence of coagulopathy, as diagnosed by TEG, was 84% as diagnosed by TEG. Of the total 109 TEGs, 59 samples were hypercoagulable, 10 were hypocoagulable and the remaining 40 normal. There was poor correlation between laboratory-based coagulation assessments and TEG. Conclusions: Contrary to what is reported in the literature, we found little evidence of a hypocoagulable state as defined by TEG (10 of the 109 samples). Many patients were significantly hypercoagulable (59 of the 109 samples) according to criteria specified by the TEG manufacturer. When considering the CBT results, we had a much higher number of hypocoagulable samples (72 of the 109 samples), with none showing a hypercoagulable state. Moreover, there was poor correlation between coagulation status as measured by TEG described and that found on conventional blood testing. No significant differences in the prevalences of coagulopathy amongst blunt and penetrating mechanisms of injury were noted. Some differences in fluid balance and presenting vitals in the hypocoagulable group when compared to the normal and hypercoagulable groups were noticed, but this does not attain any statistical significance due to the small numbers of hypocoagulable patients in our study.

Includes bibliographical references (leaves 76-79). / It is well-established that endotracheal intubation in the field is associated with a considerably greater degree of difficulty, and a much higher complication and failure rate than intubation undertaken in the operating-theatre environment. The reasons for this are many-fold, have been quantified and discussed in detail. This study assesses the difficulties encounteed by paramedics in the field, by identifying factors contributing to difficult and failed intubation, by quantifying the incidence of difficult and failed intubations, by assessing and describing the incidence of complications and adverse outcomes, and by assessing the impact of the procedure on patient care. This dissertation includes a comprehensive international literature review of studies related to prehospital endotracheal intubation, and discusses and compares these published findings to the results obtained from this study. Furthermore, this study provides feedback to paramedics, paramedic-educators and managers, by offering a comprehensive strategy for improvement in the procedure of field intubation, with a view to increased safety, ease of execution, and improved patient outcome.

Background: Anaesthetic nurses form a critical part of the team providing peri-operative care to patients, but no accredited training exists for them in South Africa. In this setting, without a formal training programme, short in-service training interventions are a pragmatic attempt at improving nurse performance and patient outcomes. Traditional didactic teaching formats have limitations, and mLearning (the use of mobile telephones to facilitate education) has proven equivalent or superior to traditional teaching methods in several settings. Despite very high levels of mobile phone ownership amongst healthcare workers in Africa, this form of educational delivery has not been tested in the hospital-based nursing population. Methods: A telephonic True/False Pre-Test was performed with 12 nurses of varying levels of training, to assess their pre-existing knowledge of anaesthesia. A pre-learning package was then delivered to them in the form of daily SMS’s for a month covering relevant anaesthesia content. A telephonic post-intervention test was performed to assess if anaesthesia theory knowledge had improved. Results: Median test scores were compared using a Wilcoxon Signed Rank test and were statistically higher in the post-intervention test: 83,3% (IQR 66,7-86,7) vs. 70% (IQR 66,7-71,7) (p=0,018). Conclusions: The results show that knowledge scores of hospital-based anaesthetic nurses can be improved using training by SMS, thus validating the use of the mobile phone as a cheap, widely accessible and effective educational vehicle.

Abstract Background: Pilot studies applying point-of-care ultrasound (POCUS) in preeclampsia indicate the presence of pulmonary interstitial edema, cerebral edema, and cardiac dysfunction. Laboratory markers of oncotic pressure (albumin) and cardiac dysfunction (brain natriuretic peptide [BNP]) may be abnormal, but the clinical application remains unclear. We investigated the prevalence of pulmonary interstitial syndrome (PIS), cardiac dysfunction, and increased optic nerve sheath diameter (ONSD) in late onset preeclampsia with severe features. The primary aim was to examine the association between PIS or ONSD and maternal serum albumin level. The secondary aims were to explore the association between cardiac dysfunction and PIS, ONSD, BNP, and serum albumin level, and between POCUS-derived parameters and a suspicious or pathological cardiotocograph (CTG). Methods: Ninety-five women were enrolled in this prospective observational cohort study. A POCUS examination of lungs, heart and ONSD was performed. PIS was defined as a bilateral B-line pattern on lung US, and diastolic dysfunction according to an algorithm of the American Society of Echocardiography. ONSD > 5.8 mm was interpreted as compatible with raised intracranial pressure (> 20 mmHg). Serum BNP and albumin levels were also measured. Results: PIS, diastolic-, systolic dysfunction, and raised left ventricular end-diastolic pressure (LVEDP) were present in 23 (24%,) 31 (33%), 9 (10%), and 20 (25%) women respectively. ONSD was increased in 27 (28%) women. Concerning the primary outcome, there was no association between albumin level and PIS (p = 0.4) or ONSD (p=0.63). With respect to secondary outcomes, there was no association between albumin level and systolic dysfunction (p = 0.21) or raised LVEDP (p = 0.44). PIS was associated with diastolic dysfunction (p = 0.02), and raised LVEDP (p = 0.009, negative predictive value 85%). BNP level was associated with systolic (p < 0.001)- and diastolic dysfunction (p = 0.003) and LVEDP (p = 0.007). No association was found between POCUS abnormalities and a suspicious/pathological CTG (p = 0.07). Conclusion: PIS, diastolic dysfunction and increased ONSD were common in preeclampsia with severe features. Cardiac ultrasound abnormalities may be more useful than albumin levels in predicting PIS. The absence of PIS may exclude raised LVEDP. The further clinical relevance of PIS and raised ONSD remains to be established. BNP level was associated with cardiac ultrasound abnormalities. Although this study was not designed to directly influence clinical management, the findings suggest that POCUS may serve as a useful adjunct to clinical examination for the obstetric anesthesiologist managing these complex patients.

An audit cycle of post-operative pain scores and patient satisfaction of pain control in orthopaedic patients at a Level Two State Hospital in Cape Town. In addition as part of the information collected during the research process we will audit the following: Intraoperative anaesthetic techniques, post-operative analgesia consumption and analgesic methods as well as any side effects to analgesic medication used in orthopaedic patients peri-operatively at Victoria Hospital Wynberg (VHW) will also be noted. Postoperative pain control is an essential, yet often inadequately managed part of peri-operative patient care. Adequate analgesia is important not only for patient comfort but also for maintaining stable physiology, facilitating recovery from surgery, enabling rehabilitation and to potentially decrease length of hospital stay post-operatively. International audits have previously shown that pain is poorly managed post-operatively in surgical patients. At facilities in the Western Cape, pilot student audits have shown that management of post-operative pain is also potentially inadequate. This means that surgical patients potentially experience severe pain in the first 48 hours following surgery, increasing the risk of chronic pain development as well as post-operative complications thereby placing a greater burden on already limited health care resources. These proposed observational audits will look at a population of orthopaedic patients at a Level Two Hospital in Cape Town. The study will be performed at Victoria Hospital Wynberg (VHW). VHW performs a large number of orthopaedic cases each week, giving us access to a potentially large number of patients. The choice of orthopaedic patients is due to the fact that orthopaedic surgery has been shown in some studies to be associated with a greater degree of post-operative pain as rated by patients when compared to other surgical disciplines. The high levels of pain associated with orthopaedic surgery are thought to be due to the degree of tissue trauma and the nature of tissue involved in the surgery itself.

Introduction: Emergency medical systems have evolved from mostly providing patient transport to healthcare facilities to the provision of emergency care interventions on scene or en route to a healthcare facility. Endotracheal intubation is one of these interventions but despite being performed in the prehospital setting for nearly two decades, the practice of prehospital ETI has not yet been examined on a national level. Methods: This is a retrospective chart review of prehospital ETI performed by non-physician prehospital providers of a ground-based emergency medical service that operates on a national level over a 12 month period. Results: Of the 806 cases recorded in the study period, 683 met the criteria for analysis. Male patients accounted for 67% of the cases. The majority of patients (56%) intubated were trauma patients while the remaining 44% were intubated for medical reasons. The first pass success rate was 74% and the overall success rate was 98%. Rapid sequence intubation was the method used to intubate 34% of patients. Approximately 29% received drug facilitated intubation and 27% of patients were intubated whilst being treated for cardiac arrest. Approximately 65% of patients had documented risk factors for difficult intubation. Clinical adverse events were recorded in 14% of cases. Discussion: The first pass success and overall success rates compare favourably with those reported in similar contexts. Adverse events were thought to be under-reported.

The results of this study show that in intact rats magnesium produces a more rapid resolution of bupivacaine induced electrophysiological changes than placebo. The improvements are in rhythm and electrical conduction, although this is often at the expense of potentiating the bradycardic effects of bupivacaine toxicity. Whilst the bradycardia remains a problem it is potentially more amenable to therapy than the changes in rhythm and conduction which magnesium sulphate reversed. The opportunity therefore exists to explore the possibility of combining magnesium with a positive chronotrophic agent such as dobutamine.

Includes bibliographical references.