Masters Degrees (Anaesthesiology)

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Open Access
Knowledge of relevant medical laws pertaining to informed consent, by doctors working at the Department of Anaesthesiology of the UFS in June 2015
(University of the Free State, 2015) Lourens, T.; Lamacraft, G.
Doctors follow an ethical code imprinted on them from the time of Hippocrates. Practicing medicine within these ethical codes, doctors also have to practice their craft within the legal boundaries of the country and institution they inhabit. The primary aim of this study was to investigate the current knowledge of relevant medical laws pertaining to informed consent, by doctors working at the Department of Anaesthesiology of the University of the Free State, UFS, in June 2015. The secondary aim of the study was to determine if doctors working at the Department of Anaesthesiology of the UFS complete their section of the standard surgical consent form available in the hospitals they practice in. The study was designed as a cross sectional observational study, using self-administered questionnaires after approval by the Ethics Committee of the Faculty of Health Sciences, UFS. Data analysis was performed by the Department of Biostatistics at the UFS. The results were summarised using frequencies and percentages. Results of the primary aim of the study indicated a poor level of understanding pertaining to the medical laws in which doctors' practice with various levels of confusion to details especially regarding the Children's Act of 2005 and the Choice on Termination of Pregnancy Act of 1996. This study demonstrated the poor understanding of biomedical ethical concepts and how they are incorporated in the various South African laws.This study indicated that the doctors that worked at the Department Anaesthesiology of the University of the Free State during June 2015 expose themselves to possible medical malpractice and future litigation due to lack of documentation on the informed consent form.
Open Access
The resuscitation knowledge and skills of intern doctors working in the Department of Anaesthesiology at the Bloemfontein Academic Hospital Complex
(University of the Free State, 2015) Geldenhuys, Jacques; Turton, E. W.
BACKGROUND: Intern doctors are often regarded as first responders to attend to patients in emergency situations. But the fact is that many Intern doctors are not equipped with the necessary knowledge and skills to carry out effective cardiopulmonary resuscitation. It was also noted that Intern doctors might not be aware of gaps in their resuscitation knowledge and skills. OBJECTIVES: The aim of the study is to determine the theoretical knowledge and practical skill on resuscitation of Intern doctors working in the Department of Anaesthesiology at the Bloemfontein Academic Hospital Complex. Their resuscitation knowledge will be tested based on the 2010 American Heart Association’s guidelines for Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and Paediatric Advance Life Support (PALS). We will determine the Intern doctors’ knowledge and skills on resuscitation during the first and again during the last week of their rotation in the Department of Anaesthesiology. METHOD: After approval from the Research Division of the Ethics Committee of the University of the Free State, 26 Intern doctors were enrolled in the study. They completed a demographic questionnaire, written a multiple choice test, and performed a skills evaluation in a simulation centre; to assess their adequacy of performing effective cardiopulmonary resuscitation. Follow-up evaluation was done at the end of their two-month rotation in the Department of Anaesthesia RESULTS: The average result for the pre-rotation written test was 58.4% (14.6/25), while they scored unsatisfactory in the practical skills assessment. The biggest problem areas identified were the quality of chest compressions, and the use of a defibrillator. There was no improvement with the follow-up evaluation at the end of their two-month rotation. The resuscitation knowledge and skills of the Intern doctors were rated as unsatisfactory. CONCLUSION: The following conclusions can be drawn from the study: 1. Intern doctors are not equipped to provide adequate cardiopulmonary resuscitation. 2. The undergraduate resuscitation training programs that are currently in place are not adequate to equip Intern doctor with the necessary knowledge and skills to provide adequate cardiopulmonary resuscitation; or the knowledge and skills obtained, are not retained.3. Active advanced life support training programs should be initiated to help provide Interns with the necessary knowledge and skills to provide adequate cardiopulmonary resuscitation. 4. Current resuscitation training programs need to be seriously re-evaluated, and aimed at improving Interns knowledge and skills.
Open Access
The use of lung‐ultrasound to confirm correct placement of left sided double lumen tubes
(University of the Free State, 2016) Bernard, N. J.; Turton, E. W.
Study objective: To assess the accuracy of the ultrasonographic lung sliding sign in detecting correct positioning of the endotracheal double‐lumen tube after intubation, compared to flexible bronchoscopy, in adult patients who present for thoracic surgery requiring one lung ventilation. Design: Prospective clinical study. Setting: Cardiothoracic theatre, Universitas Hospital, Bloemfontein. Patients: 30 adult patients, 18 years of age or older, who present for elective thoracic surgery, and require endotracheal left sided double‐lumen tube intubation after induction of anaesthesia for lung isolation. Intervention and measurement: The presence of the lung sliding sign was determined with an ultrasound on all 30 patients before induction of anaesthesia and after intubation, as well as post lung isolation. All patients were intubated with a left sided double‐lumen tube. The Anaesthetic consultant or registrar then performed a flexible bronchoscopy on all patients to verify the position of the double‐lumen tube. Results: A total of 17 patients were enrolled in the study. 1 Patient was excluded who was less than 18 years of age. In 1 case no bronchoscope was available to confirm correct position of the double‐lumen tube. In 11 cases the presence of the lung sliding sign pre‐intubation on the affected side was absent, and thus could not be used in comparing ultrasound findings with bronchoscopy. The overall sensitivity of the ultrasonographic lung‐sliding to confirm correct placement was 94.1% (confidence interval 73.0 to 99.0%). The positive predictive value was 100%. Conclusion: The presence of the lung‐sliding sign before induction of anaesthesia was absent in a high number of patients (37.9%). Our study suggests that, for patients with the presence of the lung‐sliding sign pre‐induction of anaesthesia, the ultrasonographic lung‐sliding sign can accurately detect correct positioning of the double‐lumen tube as compared to the gold standard which is a flexible bronchoscope. We therefore recommend that patients should first be assessed for the presence of lung‐sliding pre‐intubation before deciding on ultrasound as the means to confirm correct double‐lumen tube placement. Ultrasound will therefore not be able to replace bronchoscopy in thoracic surgery.
Open Access
The prevalence of skin scars on patients previously given intramuscular diclofenac injections, attending Universitas Academic Hospital Pain Clinic: a descriptive study
(University of the Free State, 2016) Tarloff, D.; Lamacraft, G.
INTRODUCTION: An incidental finding of scarring after intramuscular Diclofenac was made at the Pain Clinic, Universitas Academic Hospital, Bloemfontein. The primary objective of our study was to document the prevalence of scars caused by these injections and to determine how patients obtained intramuscular diclofenac and who administered it to them. METHODS: A descriptive study was performed at the Pain Clinic. Informed consent was obtained and all patients attending (1st December 2013 – 31st August 2014) were included. Patients completed a questionnaire and the attending doctor examined the injection site. Data captured at examination included: site of injection(s) and skin changes. RESULTS: 131 patients were enrolled and data analysis was performed on 118 patients (these patients were completely sure injection they had received was diclofenac). Scarring was identified in 8.5% of the study population. The majority of patients received the IM diclofenac from general practitioners (41.5%), private pharmacists (30.6%) and hospital pharmacies (15%). Only 17.5% of the patients always had a prescription and 78.8% had not been warned against skin scars. Associated complications included pain, pruritus, erythema at the injection site, ulceration or skin damage, scarring and nausea. Four patients required medical treatment for a skin ulcer or abscess and 2 of these patients required surgical treatment. DISCUSSION: This study shows that the prevalence of scarring after intramuscular diclofenac injections in our study population is 8.5%. In the population studied, 28.2% of patients had the drug administered by an unqualified person, and only 17.5% always had a prescription. This study shows that 78.8% of the study population had never been warned about skin scars as a potential side effect.
Open Access
The use of lung ultrasound to assess the prevalence of lung interstitial syndrome in paediatric cardiac surgery patients and the measurement of postoperative length of hospital stay
(University of the Free State, 2016) Larson, Ilke; Diedericks, Johan
Background: In recent years, ultrasound has gained popularity in the assessment of pulmonary pathology, especially in the critical care setting. However, limited data are available for the use of lung ultrasound (LUS) for the diagnosis of lung interstitial syndrome (LIS) in the paediatric cardiac surgery population. Methods: The aim of this observational cross-sectional study primarily was to assess the prevalence of LIS due to extravascular lung water (EVLW) in paediatric patients with high pulmonary-flow congenital cardiac lesions. Patients who underwent corrective open heart surgery were scanned immediately post-operatively and B-lines in each of eight thoracic areas were counted. LIS was diagnosed or ruled out based on this result. Secondary outcomes were postoperative length of stay (LOS) in Cardiothoracic Unit (CTU) and in hospital and whether LIS is associated with prolonged LOS. Results: Twenty children aged between 6 months and 9 years were included in this study. The prevalence of LIS was found to be 25%. The median LOS in the CTU for children diagnosed with LIS was 4.0 days (range 3.0 to 6.0) and median length of hospital stay was 7.5 days (range 6.0 to 20.0). There was no statistical difference in CTU LOS (p = 0.601) or hospital LOS (p = 0.544) between the groups with or without LIS. Conclusion: Pulmonary complications are common after surgery for congenital heart disease. This study showed a prevalence of LIS of 25%. This can potentially result in increased morbidity and mortality, but the study sample was too small to prove this. LUS can be used for early identification and management of complications.
Open Access
The emotional impact of a death on the theatre table on the anaesthetist in South Africa
(University of the Free State, 2019-05) Van Niekerk, J. J. S.; Lemmer-Malherbe, J.
Introduction: Perioperative deaths in developing countries are a common occurrence, thus an anaesthetist in South Africa is likely to experience at least one death on the table during his career. It affects the anaesthetist emotionally and can lead to a variety of disorders like anxiety, depression, substance abuse and most commonly post-traumatic stress disorder (PTSD). Certain interventions, like debriefings, have been proposed in order to mitigate the impact of a death on the table, but are not done regularly. The aim of this study was to determine the emotional impact that a death on the theatre table has on anaesthetists. We determined whether the anaesthetist was debriefed, had time off after the death and measured the prevalence of subsequent PTSD. Methods: The study followed a quantitative observational, cross-sectional design with convenient sampling using an online questionnaire. The Impact of Events Scale- Revised was used to measure the likelihood of PTSD. The study population was anaesthetists (consultants and registrars) registered with SASA who has experienced a death on the table. Results: A total of 1859 potential participants were contacted of which 453 responded, yielding a 24% response rate. The final analysis included 375 completed questionnaires. A total of 28.8% (CI 24.4%- 33.6%) had a probable diagnosis of PTSD. Age, years of experience and level of qualification did not affect the likelihood of developing PTSD. Only 15.5% of respondents were debriefed although 82.7% would have wanted a debriefing. Of the respondents with probable PTSD, 93% would have wanted debriefing, 85% would have liked time off and 82% felt the event influenced their work decisions. Correlating figures in those without PTSD was lower (78%, 61% and 67% respectively). Conclusion: The prevalence of PTSD following a death on the table was high and debriefings were not done in most cases. The authors recommend the development of workplace protocols to help an anaesthetist deal with a death on the table.
Open Access
Knowledge of respiratory dysfunction among nurses working in surgical wards at Universitas Academic Hospital
(University of the Free State, 2019-11) Kediegile, Gaone; Kachelhoffer, Anna M
Background: Clinical deterioration in ward patients leading to adverse events such as cardiac arrest, intensive care unit (ICU) admission and death is often preceded by respiratory dysfunction. Monitoring of ward patients is nurse-led; therefore, their knowledge and skill are crucial to identifying the deteriorating patient and to make decisions on escalating patient care. Although knowledge is a prerequisite for quality of nursing care, performing well on test is not an indicator of the quality of care. The design of a reliable knowledge test involves the structured development of the task to be carried out, and methods for each with their underlying theoretical basis which is often in psychology, psychometry and education. Objectives: This study assesses the performance of the surgical ward nurses on a single best answer knowledge test based on respiratory dysfunction. Method: Nurses working at an academic hospital surgical wards participated in this cross-sectional study from 20th to 26th April 2018. Data collection was done using a self-administered questionnaire with two sections: one section for demographic data and the second section consisted of nine (9) single best answer multiple-choice questions. Results: Out of 95 ward staff, 78 were eligible to take part in the study. Of these, 50/78 (64%) agreed to take part and responded to the questionnaire and test. A desirable score of no more than two incorrect answers was set (77%), and this was achieved by 16 % of study participants. The lowest mark achieved was one correct out of 9 (11%), and the highest score was 8 out of 9 (89%), with a median mark of 5.0 and interquartile range 4.0-6.0. Conclusion: There was a wide range of performance on the knowledge test by all grades of nurses, with only 16% scoring correctly on seven or more questions. Respiratory deterioration in surgical patients is poorly understood, and failure to diagnose it may be an important factor in the development of surgical complications leading to delayed intervention, morbidity and mortality. Although nurses are the first-line caregivers, the interventions are doctor-led, requiring a communication and action loop that involves a team and systems approach.
Open Access
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.
Open Access
A descriptive study of the temperature at which anaesthetic refrigerated drugs are stored in operating theatre suites at Universitas Academic Hospital
(University of the Free State, 2020-01) Cloete, Nadia Danielle; Van Zyl, P. M.
Background: Temperature sensitive anaesthetic drugs require storage within individual theatre suites in order to be easily accessible to the anaesthetist for immediate use. This easy accessibility of drugs poses a risk of drug degradation due to incorrect temperature storage range. The method of storing refrigerated anaesthetic drugs in theatre suites, within a cooler box with a frozen eutectic gel pack (referred to as a cold drug storage unit) is well recognised and practiced. Yet, this method is poorly supported by literature and ill-defined in practice guidelines. The aim of this study is to determine whether refrigerated drugs in the operating theatre suites at Universitas Academic Hospital (UAH), during working weekdays, are stored according to the manufacturer’s temperature storage recommendation. Method: A descriptive observational study was done on the cold drug storage units in nine theatres suites at Universitas Academic Hospital, at six fixed time slots from 07:30 to 17:00, on five consecutive weekdays. The cold drug storage unit temperatures were measured and was assessed for adequacy of storage of refrigerated anaesthetic drugs according to the manufacturer’s recommendation on the package leaflet. The factors that could influence the internal environment of the cooler box were investigated; theatre room temperature, storage method of drugs within the cold drug storage unit, number, size and placement of the gel packs, the number of ampoules/vials and the utilisation of the operating theatre. Results: Five hundred and forty five temperature measurements were taken of which 268 were theatre room temperature with an accompanying 267 cold drug storage unit temperature measurements and ten main storage refrigerator temperature measurements. The cold drug storage unit temperature, for all theatres for the five days, was in the range of 4,30C – 23,80C with a median of 14,80C. This method of drug storage was not conducive to store all temperature sensitive anaesthetic drugs (requiring storage at 20C – 80C) on 235 temperature measurement (88%with a 95% Confidence Interval of 83,6% to 91,4%). The statistically significant factor (p <0,001) determining the cold drug storage unit temperature to fulfil the manufacturers recommendation to maintain temperatures below 80C was the number, size and placement of the eutectic gel packs within the cold drug storage unit. With the use of two eutectic gel packs, placed above and below the drugs within a Styrofoam® cooler box, a desired temperature range of 20C – 80C can be maintained for an average of 4 hours and 30 minutes, to a maximum time frame of 9 hours and 30 minutes, in a theatre suite with a maximum room temperature of 25,70C. Conclusion: The current method of storing temperature sensitive drugs, in operating theatre suites at Universitas Academic Hospital does not fulfil the temperature storage requirements as set out by the drug manufacturer’s most of the time. This method of passive refrigeration should not be abandoned as this study highlights the potential to maintain temperature below 80C...This potential success demonstrated in the study can be utilised to further research in determining the optimal storage conditions to store temperature sensitive anaesthetic drugs in an operating theatre suite within a resource limited environment.
Open Access
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.
Open Access
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.
Open Access
The use of a thromboelastogram (TEG®) protocol to decrease the usage of blood products in adult patients undergoing cardiac surgery at Universitas Academic Hospital, Bloemfontein, Free State, South Africa
(University of the Free State, 2020-11) MogorosI, J. B.; Turton, E. W.
Background: Blood transfusion during cardiac surgery carries potential complications like transfusion reactions, increased length of hospital stays and financial costs1-4. Efforts through research of Point of Care (POC) strategies like the Thromboelastogram (TEG®) that provide health care practitioners with rapid, predictive and outcome based POC coagulation testing algorithms5,6 to guide perioperative blood transfusions are underway. Objectives: There is currently no POC protocol to guide blood product use at Universitas Academic Hospital in Bloemfontein, South Africa. Aim: The primary aim of the study was to establish whether the use of a TEG® protocol versus physician decision will reduce blood product usage in adult patients undergoing elective cardiac surgery at Universitas Academic Hospital in Bloemfontein, Free State, RSA. Methods: A comparative, descriptive study using: A. The physician decision group consisting of a retrospective file review of the usual clinical practice, using clinical notes from Meditech® (an integrated software system that provides solutions to healthcare organisations throughout Africa) and the National Health Laboratory System (NHLS) Lab Trak® (an inter-systems results portal), 25 June to 30 September 2019, and B. The TEG® protocol group consisting of a prospective cohort of patients using the usual clinical practice with the addition of TEG®-based protocol, 25 June to September 2020. Results: The COVID pandemic markedly reduced elective theatre lists owing to the small prospective study population. Average cell saver volume (276ml, p < 0.0001) and FFP (2 units, p = 0.05) were statistically significant. There was no statistical significance in the average volume of RCC (1 unit, p = 0.6679), Platelets (1 unit, p = 0.2329) or Cryoprecipitate (1 unit, p = 0.6382) saved between the two groups. Conclusion: Cell saved blood and FFP transfusion were statistically and clinically significantly reduced in the TEG® protocol group. While red blood cell, platelet, cryoprecipitate, and total blood product transfusion had reduced trends in the TEG® protocol group though not of statistical significance. We suggest that this preliminary report be considered for future MMed or PhD research because it was a first in our institution and there is great potential to improve patient outcomes and contribute to best practice regarding patient blood management in the perioperative period.
Open Access
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.
Open Access
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.
Open Access
A comparative review of obstetric anaesthesia training, supervision and experience of public sector doctors in the Free State, 2005 vs. 2019
(University of the Free State, 2021) Machai, Seta Liteboho; Lemmer-Malherbe, J.; Lamacraft, Gilian
𝗜𝗻𝘁𝗿𝗼𝗱𝘂𝗰𝘁𝗶𝗼𝗻: Obstetric anaesthesia is ranked first as a contributor to “potentially preventable deaths per underlying cause” of maternal death in South Africa. Lack of training, experience and supervision has been cited as the cause of these deaths. This study aimed to evaluate those public sector doctors administering obstetric anaesthesia in the Free State and compare training, experience and supervision findings with those of 14 years ago in a similar study by G Lamacraft. 𝗠𝗲𝘁𝗵𝗼𝗱: This was a cross sectional analytical study carried out between the 11th and 19th December 2019. All caesarean section sites within the Free State were identified from a list obtained from the provincial government. Hospital CEOs and clinical managers were informed prior to the visit. On Arrival a list of doctors administering obstetric anaesthesia was obtained from the clinical manager. An audience with the doctors was requested and those that could not come were traced to their work areas and given the questionnaire. An implied consent was stated at the beginning of the questionnaire which was self-administered. The same questionnaire as by Lamacraft (with one added question) was handed over after a brief description of the study and collected into a box at the end of the session. The collected data was kept anonymous. 𝗥𝗲𝘀𝘂𝗹𝘁𝘀: A total of 124 medical doctors met the inclusion criteria with 103 of them completing the questionnaire, thus an overall response rate of 83%. Level 1 and level 2 hospital response rates were 78% and 91% respectively. This was an improvement from the 69% overall response rate of 2005. Exposure to obstetric anaesthesia during internship has improved: in 2005 12% of respondents lacked exposure but this dropped to 5% in 2019. The reported level of supervision also improved: In 2005 21% of supervision was by junior medical officers and only 25% by consultants compared to 2019 where junior medical officer’s supervision contributed 15% and consultants 44%. A lack of exposure and training post internship was observed with only 1 doctor having a Diploma in anaesthesia in 2005 compared to 5 in 2019. Employment of a senior anaesthetist improved: 54% and 47% reported to have no senior anaesthetist employed by their hospital in 2005 and 2019 respectively. Unfortunately the added responsibility of neonatal resuscitation while administrating anaesthesia to the mother increased slightly from 42% in 2005 to 47% in 2019. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻: Training, supervision and experience of doctors in level 1 and 2 hospitals in the Free State post internship has marginally improved in the last 14 years. Greater improvement has been noted during internship training.
Open Access
The prevalence of patients with undiagnosed pulmonary tuberculosis, undergoing surgery at Pelonomi Tertiary Hospital
(University of the Free State, 2021-06) Botha, Anna Margaretha; Steyn, D.; Lamacraft, G.
Introduction: Tuberculosis (is a significant cause of death in South Africa (resulting in a massive financial burden on the economy of the country. Delayed diagnosis is a problem in low and middle income countries and can unintentionally cause other patients and personnel exposure, especially in enclosed areas such as theatres. The short and long term consequences of occupational acquired TB affect the health care worker s physical, physiological, and financial health. This might put much strain on the health care workers themselves, their families and the health care system. Method: This was a retrospective descriptive study done in May 2020, investigating all patients over the age of thirteen years that underwent surgery at Pelonomi Tertiary Hospital for one month (from 1 November 2019 till 30 November 2019) to evaluate how many of these patients might have had active tuberculosis (known or unknown) on the day that they underwent surgery. All available laboratory TB test results of the patients were included from three months before the documented surgery date and up to three months post the surgery date. Any patient with a documented positive TB laboratory test result during this period and not on TB treatment for at least two weeks, was considered potentially infectious. Results: A total of 583 patients underwent surgery in November 2019. Of these 583 patients, 21 had a TB test done during the mentioned period, and results were captured on the Natio nal Health Laboratory Service database. Only one patient of the total 21 who was tested for tuberculosis had a positive TB test, which was done on the day of surgery. On admission, the patient presented with a lower respiratory tract infection before receiving his open L4 biopsy for possible infective spondylolysis surgery. The staff screened the patient for pulmonary TB (and an Xpert ® MTB/RIF Ultra (Xpert ® Ultra) test was done on 12/11/2019. The Xpert ® Ultra results reported on 13/11/2019 were positive and sensitive to Rifampicin, and the patient was subsequently started on treatment. On the day of surgery, the patient was assumed to only have a bacterial lower respiratory tract infection and was not managed a s a TB infected patient, and the necessary precautions were not taken, leading to exposure of the theatre staff and other patients to PTB. Conclusion: The proportion of undiagnosed TB infection under patients who were perioperatively tested was 4,8%. However, since only patients who were expected to be admitted to ICU after surgery or who had respiratory symptoms before surgery were tested for TB, this study could not determine the prevalence of TB in patients receiving surgery.

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