Brachial plexus block (BPB) techniques provide significant benefits including better pain control, faster discharge and reduced adverse effects compared to general anaesthesia. Prior to 2005 BPBs were performed using landmark, paraesthesia or electrical nerve stimulation (PNS) methods and were associated with reasonable success (70-80%) but were still associated with risk of failure and complications. Use of ultrasound (US) to guide local anaesthetic injection was first reported in 1989 but until 2004 remained unexplored. From 2004 we aimed to explore the feasibility, success and safety of ultrasound-guided brachial plexus block (USBPB) compared to techniques guided by anatomical landmarks or peripheral nerve stimulation. We hypothesized that USBPB would be feasible, have greater success and safety compared to standard methods. In 2004 we identified the possibility of using US to place infraclavicular block (ICB) and identified a pattern of local anaesthetic spread that predicated successful block. A subsequent randomized trial found improved success of US compared to existing methods. We examined success of US-guided axillary brachial plexus block (ABPB) and found that performance time and success were improved. In a large retrospective review of ABPB techniques we identified that US techniques were faster to perform, had a higher success and were safer compared to standard methods. We also assessed existing nerve localization methods in an observational study and found that both have poor sensitivity and specificity possibly explaining some of the limitations of these techniques. A bench study examining local anaesthetic injection using ultrasound found that both novices and experts could accurately determine local anaesthetic spread. In practice this is a useful marker for safe injection and could explain findings of increased safety with ultrasound methods. we systematically reviewed the literature for studies examining USBPB and this demonstrated that US improved block success and performance time. Subsequent pilot work indicated that US, in addition to improves block success and performance time. Subsequent pilot work indicated that US, in addition to improving quality, could also reduce volume of local anaesthetic required for successful block and we hypothesized that for certain techniques such as interscalene block this may improve safely. we compared US-guided interscalene block (ISB) using traditional volumes (20ml) and compared with a low volume (5ml) of ropivacaine 0.5%. Results demonstrated no difference in efficacy or duration but significant reduction in respiratory (and other) complications with lower volumes. We then compared US-guide ISB to PNS using and Up and Down Sequential Allocation design to estimate the minimum effective anaesthetic volume (MEAV50) for ropivavaine 0.5% for major shoulder surgery. Our findings indicated that volumes of local anaesthetic could be dramatically reduced with US (0.9 vs 5.4ml) whilst still providing effective pain relief. In the last ten years the cases and studies described have demonstrated that US improves BPB success and safety. For ISB US reduces volumes of local anaesthetic required for success whilst also reducing respiratory and other complications.

No description available.

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 It is unknown whether the implementation of an information video on spinal anesthesia for caesarean section, narrated in a patient's first language, reduces anxiety, increases satisfaction, and improves doctor-patient communication if there is a language barrier. In South Africa most doctors speak English, and patients Xhosa, with educational and cultural disparities existing in many doctor-patient interactions. Methods One hundred and seventy-five Xhosa patients scheduled for elective cesarean section were enrolled in the study. The first 92 patients received “usual care” verbal explanations of the spinal anesthesia procedure (control group); the next 83 patients watched a spinal anesthesia information video (intervention group), narrated in Xhosa. Videos were displayed using smartphones. Maternal anxiety was assessed before and after spinal explanation, using a Numerical Visual Analog Anxiety Scale (NVAAS). A difference in post-explanation NVAAS score of 1.5 points between intervention and control groups was regarded as clinically significant. Patient satisfaction was assessed using the Maternal Satisfaction Scale for Cesarean Section (MSSCS). Results The mean (SD) age (31.5 (5.2) and 32.1 (5.4) years) and pre-explanation NVAAS score (4.2 (3.2) and 4.0 (3.0)) of the intervention and control groups respectively, showed no difference at baseline. The mean (SD) post-explanation decrease in NVAAS score was greater in the intervention- than in the control group (1.6 (3.5) versus .7 (2.3), P = .046, unadjusted mean difference .9 points (95% CI .02 to 1.8)). A linear regression model for the post-explanation NVAAS score showed that the intervention effect was significantly associated with the pre-explanation score (P = .002), adjusted for age and English fluency. Patients with pre-explanation NVAAS scores ³ 5 showed a statistically significant intervention effect. There was no significant difference in patient satisfaction between the intervention and control groups. The smartphone was an accessible and convenient display medium for the video. Ninety nine percent of patients exposed to the intervention would recommend watching the video prior to the procedure. Conclusion In this pilot study, lower NVAAS scores were observed in anxious patients, when a Xhosa information video was used to ameliorate challenges posed by a doctor-patient language barrier. It is easily implemented and demonstrates a novel use of mobile health technology. The study provides baseline data to inform sample size calculations for future studies. A high level of patient recommendation for the video suggests that this is an agreeable practice.

The Khayelitsha District Hospital (KDH) faces the difficult challenge of managing patients with high acuity penetrating cardiothoracic injuries, but without the full complement of resources to provide optimal care. At the time of this dissertation, we were unaware of the outcome of patients cared for at KDH, and of any potential modifiable risk factors that could improve their outcome. We therefore undertook a retrospective case audit to determine the outcome of patients presenting alive at our emergency unit with penetrating chest injuries (PCI). Objective: The objective of this study is to audit the KDH experience with penetrating chest injuries and to identify potential risk factors that predict outcomes in patients who sustain these injuries and require surgery at this district level hospital. The total study duration was 34 months. Methods: A retrospective review of all medical records of patients with PCI who were alive on presentation and had undergone surgery at KDH between 1st February 2012 and 31st December 2014 was undertaken .An audit was conducted on these files. During the audit, affected patient's clinical and physiological variables on admission, intra- and post-operative were collected and evaluated as potential predictors of outcome. This study also assessed a possible relationship between physiological parameters together with arterial blood gases (ABG) on presentation with immediate 48-hour mortality. The selected variables were: SBP (systolic blood pressure) <90 mmHg or >90 mmHg, palpable pulse, presence of a precordial stab wound, vascular injury, base deficit (BD) and lactate. A logistic regression analysis was performed to investigate the relationship between the selected variables and the 48-hour mortality. The relationship between fluid, BD and lactate was compared using Pearson correlation. Continuous data is presented as means ± standard deviations. Estimates for predictor variables are presented with odd's ratios (OR) and 95% confidence intervals (95% CI). Permission of this study was gained from human research ethics committee of University of Cape town. Results: Over the 34-month study period, a total of 646 patients were admitted to KDH with penetrating cardiothoracic trauma. Fifty-six patients required surgery at KDH. These results show that KDH had a PCI incidence of 5.1%, and that this was predominantly amongst males in the 15 - 24 year age group. Fifty-five patients were male and only one female. Of the 56 operated patients, 37 (66%) presented in hemorrhagic shock with SBP < 90mmHg. The mean amount of resuscitation fluid, which included both crystalloid and colloid, administered in the Emergency Room (ER) was 2481 ml per patient. Ten (17.8%) patients had a front room thoracotomy (FRT), with a mortality rate of 6 (60%). The overall mortality rate amongst operated patients was 16 (31.3%). Thirty-three patients (58.9%) had an isolated cardiac chamber injury and 23 (41.1%) had a vascular injury. Mortality amongst patients with isolated cardiac chamber injury was 5 (31.2%) and mortality among patients with isolated vascular injury was 7 (43.7%). Two patients sustained a combined cardiac and vascular injury with a mortality of 12.5%. The results of the logistic regression analysis revealed no statistically significant correlation between the selected predictors and 48-hour mortality (p-values: BP<90mmH p=0.27, palpable pulse p=0.181, precordial stab p=1.17, vascular injury p=0.38, BE p=0.98, Lactate p=0.06). Additionally, there was no statistically significant relationship between administered EC fluids and the acid base severity (Pearson correlation coefficient: BD r =0.091, Lactate r = -0.13). Conclusion: Physiological (blood pressure, pulse) and ABG parameters (lactate and base deficit) were not identified as significant risk factors for survival in the sample studied. The risk factor of isolated cardiac injury carried a better prognosis. Logistic regression analysis did not support the initial observation of higher mortality in patients with vascular injury. Additionally, there was no correlation between the severity of the acid base disturbance and the volume of fluid administered during resuscitation in ER. The outcomes of patients with PCIs presenting at KDH was within those published in the literature (range of published mortality: 17%-80%, survival 3-84%). The ideal predictor for PCI outcome in our cohort was indeterminate. Limitations of this study that include a small sample size and incomplete medical records, may have led to a type 2 error. A more comprehensive prospective study with meticulous record keeping is required to identify the factors that can influence the outcome of patients with PCI.

No description available.

Background: Video laryngoscopy has directly impacted airway management, with numerous studies demonstrating its utility in clinical management of anatomically difficult airways. However, availability of video laryngoscopes in all clinical areas has been limited by cost. We used smartphone technology, miniature cameras and three-dimensional printing to design and create an innovative low-cost hyperangulated video laryngoscope. This has the potential to make the technique more widely available. Objectives: The aim of this study was to determine if time to intubation with the novel device was clinically equivalent to an existing gold-standard video laryngoscope (Storz CMAC with Dörges blade). Methods: We conducted a randomised, controlled, cross-over equivalence study with 100 skilled practitioners who had previous video laryngoscopy experience. Participants received instruction on the new device, and adequate opportunity to practice. Intubations were then performed in a randomised order on a mannikin simulating a difficult airway. Video recordings of each intubation were analysed by two independent investigators to determine time to intubation. A mean difference in intubation time of less than 10 seconds was determined a priori to denote clinical equivalence. Results: Mean difference in intubation time between the devices was 4.92 seconds, (two one-sided test 95%CI: 2.34 – 7.49 seconds). The innovative low-cost VL was thus clinically equivalent to the industry standard in a simulated difficult airway. Further testing in vivo in a clinical environment is needed. Conclusion: The results of this study show that a low-cost disposable hyperangulated video laryngoscope is clinically equivalent to the industry standard in a simulated difficult airway. In the context of the current global pandemic, video laryngoscopy has been advised in nearly all airway guidelines. Access to a low-cost VL which does not require reprocessing may be of great value.

Introduction: Phantom limb pain is a common complication in people who have undergone limb amputation, with prevalence estimates ranging between 29% and 85.6%. Current systematic-review evidence suggests that recommended treatments are no more effective than placebo for reducing Phantom Limb Pain (PLP). Moreover, there is evidence suggesting that people with amputations may not be getting the treatment they want at different time-points after amputation. In consideration of these points, a research project comprised of a series of interconnected studies aimed to develop an in-depth understanding of the global burden of PLP and patient care priorities after limb amputations, and generate expert recommendations on the best management of PLP in people with amputations. Methods: The research project is comprised of a series of four interconnected studies addressing the four primary aims of the project. A systematic review and meta-analysis were conducted to determine the pooled prevalence estimate and risk factors for PLP in people with amputations. A cross sectional study was conducted to determine the prevalence and risk factors for PLP in people who had undergone lower limb amputations at Groote Schuur Hospital. An expert Delphi study was conducted to reach expert consensus and make recommendations on the effective treatments for PLP in people with limb amputations. Lastly, a patient Delphi study was conducted to generate patient consensus on care priorities for people who have had lower limb amputation for a year or less and for those who have had lower limb amputations for more than a year. Results: The systematic review and meta-analysis of 39 studies revealed a pooled PLP prevalence estimate of 64% [95%CI: 60.01 – 68.05], with a significantly higher prevalence estimate in studies conducted in developed countries 66.55% [95% CI: 62.02 –71.64] than those conducted in developing countries 53.98% [95% CI: 44.79–63.05] (U = 57, p = 0.03). Risk factors that were consistently positively associated with PLP included having an amputation of a lower limb, stump pain, non-painful phantom sensations, persistent pre-amputation pain, proximal site of amputation, and diabetic cause of amputation. The cross-sectional study using a sample of African people with amputations showed a PLP prevalence of 50.78% [95% CI: 41.80 – 59.72] during the week preceding data collection. In this group of patients, persistent pre-operative pain was the only risk factor associated with PLP in the multivariate logistic regression analysis [OR 2.25 (1.03 – 5.05); P=0.04]. In the expert Delphi study, consensus was reached on one pharmacological (amitriptyline) and six nonpharmacological (Graded Motor Imagery, mirror therapy, Cognitive Behavioural Therapy, virtual reality training, sensory discrimination training, use of a functional prosthesis) treatments that were considered effective for managing PLP, and on two treatments [citalopram (60%) and Pulsed Radiofrequency Stimulation of the dorsal root ganglion (70%)] that were considered ineffective. In the patient Delphi study, consensus was reached on 24 short-term care priorities and 12 long-term care priorities. The general consensus among the participants was that pre-amputation, they wanted education support to help them manage their expectations and prepare for life after amputation. In the early stage after amputation, they wanted help with dealing with the psychological trauma of having lost a limb. In the long-term, however, the participants prioritised the need for living a functional and normal life, with respect and dignity like everyone else. Conclusion: The prevalence of PLP in people with limb amputations is high, and awareness of this condition needs to be raised among healthcare professionals to implement evidence-based strategies for alleviating PLP by targeting the relevant underlying mechanisms and modifiable risk factors. Evidence-based medicine indicates that PLP is best managed using non-pharmacological and noninterventional treatments addressing biopsychosocial contributors for PLP. Finally, preparing people for life after amputation and helping them deal with the psychological trauma of having lost a limb may contribute to improved clinical outcomes that may enable them to live a functional and normal life, with respect and dignity.