Masters Degrees (Anaesthesiology)

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Browsing Masters Degrees (Anaesthesiology) by Author "Lamacraft, Gillian"

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    The amount of morphine administered per patient, for postoperative pain, using a Patient-Controlled Analgesia (PCA) device: at Universitas Academic Hospital, Bloemfontein, from January 2015 to December 2017
    (University of the Free State, 2020-12) Kotze, George Petrus Johannes; Lamacraft, Gillian
    Background: Intravenous morphine patient-controlled analgesia (PCA) is one of the modalities used by anaesthesiologists to treat patients after operation for acute postoperative pain. About 50% of patients experience inadequate pain control post-surgery when treated with traditional intramuscular (IM) opioids prescribed pro re nata (PRN). Patient-controlled analgesia can also be used to treat patients with chronic pain conditions, advanced metastatic cancer, and in pregnant patients during normal vaginal delivery. The development of intravenous morphine patient-controlled analgesia has led to more effective management of acute postoperative pain, especially in older patients with more comorbid conditions, where a more controlled administration of opioid analgesia is preferred. Other modalities of pain management, like neuraxial and regional analgesia techniques also provide efficacious control of post-surgical pain versus morphine PCA. These techniques are sometimes difficult to perform and contraindicated in patients taking anticoagulation therapy or patients with pre-existing neurological deficits. Intravenous morphine patient-controlled analgesia remains the gold standard for treating pain in these patients. Objectives: The aim and primary objective of the study was to determine how many intravenous (IV) morphine is being used via intravenous morphine patient-controlled analgesia at Universitas Academic Hospital per patient over a 24-hour period and to determine the amount of morphine unused and discarded as wastage. Methods: A retrospective study was conducted including all adult patients that underwent surgery and received intravenous morphine patient-controlled analgesia at Universitas Academic Hospital in Bloemfontein from 2015 to 2017. Data related to morphine PCA usage and presence of side-effects were collected from the PCA record form which is kept in the patient’s file after discharge. Results: A total of 155 patients who received intravenous morphine patient-controlled analgesia after surgery were included in the study. The median age were 55 years with 48.6% female patients and 51.4% male. The median total dosage of morphine received per patient was 22.75 mg over 24 hours. The median volume of morphine solution discarded per patient was 60 ml. Morphine PCA was mostly used for neurosurgical procedures (28.2%), followed by general surgery (20.8%), and orthopaedic surgery (16.1%). 86.9% of patients reported sufficient analgesia with intravenous morphine patient-controlled analgesia and 77.8% of patients did not require breakthrough pain medication. The intravenous morphine PCA device was used with insight by 76.5% of patients. Only 53.6% of the PCA record forms were assessed as correct and completely documented. Conclusion: This study found that the average total dosage of morphine being used per patient receiving intravenous morphine patient-controlled analgesia was 22.75 mg over a 24-hour period. This is much less than the 90 mg morphine solution being used in the morphine PCA pump. A large volume of morphine gets discarded as wastage. We recommend reviewing the intravenous morphine PCA protocol of Universitas Academic Hospital to decrease unnecessary morphine wastage. Further research opportunities include a cost analysis study of intravenous morphine PCA usage per patient at Universitas Academic Hospital.
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    The association of duration of mechanical ventilation and ICU stay with the use of dexmedetomidine as a single or adjuvant sedative versus other sedatives in critically ill patients in the multidisciplinary intensive care unit at the Universitas Academic Hospital in Bloemfontein, 2015 versus 2017, a retrospective cohort analysis
    (University of the Free State, 2019-11) Swart, Reinier; Maasdorp, Shaun D.; Lamacraft, Gillian; maasdorp
    Background: Sedation is often used in the intensive care unit (ICU), but can be harmful if used inappropriately or excessively. Dexmedetomidine offers a favourable, co-operative sedation profile, despite a higher relative cost compared to other commonly used sedatives. Dexmedetomidine also has analgesic and opioid-sparing properties. It is, however, highly protein-bound with known haemodynamic side effects, such as bradycardia and hypertension. The multidisciplinary ICU at our central South African hospital adopted the use of dexmedetomidine over the period of 2016. This study was done to see whether this change in practice affected the ICU length of stay and duration of mechanical ventilation at this unit. Methods: This study was done as a retrospective cohort analysis and the files of patients who were sedated with midazolam and propofol in 2015 and those who were sedated with dexmedetomidine in 2017, were used to note the sedatives, demographic data, vital data and treatment. Institutional Ethics (UFS-HSD2018/0542/2808) and Free State Department of Health approval was obtained. Funding was obtained from the Research Committee of the Three Schools of Medicine, UFS to secure a research assistant who helped with collecting file numbers and files. Group 2015 and Group 2017 were also analysed for possible confounders, where appropriate, and these confounders were excluded for a re-analysis to assess for contribution to the primary or secondary outcomes. Results: There were 52 patients in Group 2015 and 60 patients in Group 2017. No difference was found in the duration of ICU length of stay (LOS) (median 5 vs 8.5 days, p = 0.1) or mechanical ventilation (median 91 vs 129 hours, p = 0.44). Those who were sedated with dexmedetomidine had better initial prognoses (median APACHE II 13 vs 18), were sedated for greater fractions of their total ICU admission times (median 46% vs 25%) and had a higher incidence of hypotension and bradycardia (36.7% vs 11.4%, p < 0.01); which did not relate to a higher mortality. The findings of more incidences of hypotension may relate to the bradycardia experienced with the use of dexmedetomidine. Spearman rank correlation coefficients also showed a weak to moderate association with longer ICU stay and ventilation duration when the duration of sedation with midazolam or propofol was shorter. Conclusion: This study did not show a reduction in ICU LOS or mechanical ventilation with the advent of dexmedetomidine in our unit. The absence of regular documentation of sedation levels and scheduled sedation breaks may have contributed to these results. Dexmedetomidine has a role to play in the ICU setting, but it should only be used when clearly indicated, with a clear protocol for its use, in order to warrant its higher cost. Vigilance for hypotension and bradycardia is required when using dexmedetomidine. More prospective research is required to validate these findings in a resource-constrained environment, but evidence from high income countries supports these findings.
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    The prevalence of burnout among anaesthesiology registrars in the University of the Free State
    (University of the Free State, 2020-01) Adeleke, Durotolu Motunrayo; Lamacraft, Gillian
    Introduction: In January 2019 the leading health care organizations in the United States declared burnout as a “public health crisis” with an alarming figure of 78% among the nation’s physicians. Burnout is an “individual experience that is specific to the work context” which is associated with poor outcomes in job performance and health. Studies have revealed burnout ranging from 18-84% during postgraduate medical education (residency). The aim of the study was to quantify the prevalence of burnout among anaesthesiology registrars and to identify protective and aggravating factors. Method: A descriptive, prospective cross-sectional study was done in November 2018 among 23 anaesthesiology registrars using the Maslach Burnout Inventory (MBI), which is the instrument that has been validated globally to assess the dimensions of burnout: emotional exhaustion, depersonalization and a reduced sense of personal accomplishment. A self-developed questionnaire that assessed demographics, factors that contributed to and protected from burnout was also administered. Results: A prevalence of 17.4% of burnout was found with an equal distribution between males and females. The analysis of the data showed that all the participants who reported burnout were married. Difficulty in maintaining a balance between work, family and a social life was the greatest factor for reconsidering anaesthesia as a career. This was exacerbated by not having fixed working hours. The protective factors identified were: spending time with loved ones, praying, taking a break or spending time in solitude and exercise. About half (47.8 %) of the participants reported themselves as being prone to errors particularly when sleep deprived. Conclusion: The registrars in the department of anaesthesiology showed less burnout in comparison with counterparts in anaesthesiology residency training programmes within South Africa and internationally. This reinforces the findings in other studies that physicians in small urban settings show less burnout when compared with national averages. The protective factors identified in Bloemfontein can be further adopted as preventive action to further improve the wellbeing of the registrar vis-à-vis patient outcomes.
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    Resuscitation outcomes for adult patients with in-hospital cardiac arrest: are we successful? an audit of resuscitation outcomes for the period January 2015 to December 2017 at Universitas Academic Hospital, Bloemfontein, using the Utstein Model
    (University of the Free State, 2020-12) Strydom, Catharina Maria; Lamacraft, Gillian
    Background: The Utstein Model consensus definitions and template allows for the reliable and reproducible recording of data during cardiopulmonary resuscitation (CPR). Enabling inter-institutional comparison of resuscitation outcomes to ensure comparable standards of care. Objectives: To assess resuscitation outcomes for adult patients with in-hospital cardiac arrest at Universitas Academic Hospital (UAH), Bloemfontein, using the Utstein Model and compare them to similar institutional outcomes in South Africa as well as internationally. Methods: This study is a retrospective audit of resuscitation reports of adult in-patients for the period January 2015 to December 2017. Results: 194 institutional resuscitation reports were collected for adult in-patients for this study period with 189 reports meeting inclusion criteria. 28,0% of patients survived the cardiac arrest event, 32,8% of patients displayed return of spontaneous circulation (ROSC) with a survival to hospital discharge rate of 12,3%. Of the shockable first rhythms, 2,9% were not defibrillated. Median time to defibrillation was 10 minutes (2-38min range), a large deviation from the acceptable norm at comparable institutions. Advanced airway management strategies made no impact on ROSC (p-value 0.77) or survival to hospital discharge (p-value 0.53). Mechanical ventilation was superior to a bag-mask ventilation strategy for ROSC (p-value <0,001) and survival to hospital discharge (p-value 0.0012). Adherence to ACLS protocols for inotropic support was associated with ROSC (p-value < 0.001) and survival to hospital discharge (p-value <0.001). Conclusion: Resuscitation outcomes at UAH are comparable to similar institutions. UAH should focus on improving defibrillation practice. Adherence to ACLS principles of adrenaline administration is paramount in the survival of cardiac arrest.
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    Training, knowledge, experience and perceptions regarding cardiopulmonary resuscitation of doctors at Universitas Academic Hospital
    (University of the Free State, 2020-10) Du Plessis, Nadia Sarah; Lamacraft, Gillian
    Introduction: High-quality CPR is proven to improve immediate survival and survival to hospital discharge in patients having a cardiac arrest in hospital. Evidence shows that without frequent retraining in CPR, health-care providers lose their skill and knowledge earlier than the current recommendation i.e. to attend CPR retraining every two years. The purpose of this study was to determine the current competencies of doctors at Universitas Academic Hospital regarding CPR training, knowledge, experience and perceptions. Methods: A questionnaire designed by the researcher and reviewed by CPR providers was distributed to interns, medical officers, registrars and consultants obtaining information regarding CPR training, CPR exposure and perceptions regarding CPR retraining and CPR knowledge. The knowledge aspect of the questionnaire consisted of questions on basic, advanced cardiac, paediatric, neonatal and obstetric life support. Results: Of the 245 participants only 22,5 % achieved competency (a mark ≥ 80%) for the knowledge aspect of the questionnaire. The majority of participants had not had retraining after two years although 96,7 % of participants felt that keeping up to date with CPR guidelines improved patient outcomes. The most common reasons given for not feeling confident in performing CPR was training related. Conclusion: Doctors at Universitas Academic Hospital are currently not adequately trained in CPR and it reflects in their lack of CPR knowledge. Lack of training seems to be the most common reason for not feeling confident and being too busy to attend these retraining courses was reported as the most common reason. From this study it also seems that very little of the departments have CPR training for their doctors. Implementing a regular CPR training program within the hospital is suggested to improve CPR knowledge of doctors.