Anaesthetic agent usage and wastage during caesarean deliveries done with spinal anaesthesia in a labour ward theatre: a concern for the financial implication

Background: Local anaesthesia usage and wastage are common in the operation rooms. The wastage is often not given due considerations. Budgetary allocation for drugs is an identifiable area for cost-cutting and savings. Hence, the need to minimize wastage Objectives: To assess and estimate the amount of local anaesthesia usage and wastage in the labour ward theatre. Also, to analyze the financial implications of the wastages and suggest appropriate steps to reduce the wastages. Methodology: A prospective observational study conducted in the labour ward theatre of a tertiary care hospital. The amount of local anaesthesia administered to the patient during spinal anaesthesia prior to caesarean section was considered the dose used. The wastage was considered as the amount of local anaesthetic agents left unutilized in the syringes, ampules or vials after completion of each caesarean delivery. An estimation of the cost of wasted local anaesthetic agents was made. Result: The local anaesthetic agents being used in significant quantities were hyperbaric bupivacaine, plain lidocaine and lidocaine with adrenaline. The wastage was found more during the use of hyperbaric bupivacaine as the cost of its wastage formed the bulk (N75,000.00/ $210.10) of the estimated total cost of wasted local anaesthetic agents during the study period which was N88, 100.00 ($246.77). Conclusion: There were appropriate uses of the local anaesthesia with respect to the choice and doses for caesarean deliveries but there were wastages often ignored as infinitesimal. In the long run, the wastages become significant and the financial implication scale up the burden of health bills. Effective waste reduction strategies have input in the overall reduction of financial burden associated with health care. Emphasis should be t ailored towards awareness of these wastages among resident doctors and their prudent use of local anaesthesia

Anaesthetic method and short-term outcomes of preterm infants delivered by caesarean section at a tertiary hospital in South Africa

Background. There are inconsistent published data describing the influence of maternal anaesthetic type during caesarean section (CS) on outcomes of preterm neonates. Objectives. To describe indications and type of anaesthesia in preterm neonates, and their short-term outcomes, comparing spinal anaesthesia (SA) to general anaesthesia (GA). Methods. Data were collected retrospectively on preterm babies born at 28 - 35 weeks' gestation by CS between 1 January and 30 September 2014 at Groote Schuur Hospital, Cape Town, South Africa. Babies with missing data were excluded. The largest group of babies with similar indications for delivery were identified from the theatre register. Baseline characteristics and short-term outcomes for this group were extracted from an existing prospective data base, and compared between those delivered under SA and GA. Results. Data were available for 226 deliveries, having excluded 23 with incomplete data. Most babies (75%) were delivered under SA. The most common indication for CS was 'cardiotocograph abnormalities', in 139 deliveries. Within this group, SA was the more frequent (81.7% v. 12.9%), while GA was associated with lower Apgar scores (p<0.001) and more intubation at birth (p=0.004). There was no difference in mortality when comparing SA with GA. Conclusion. Our data suggest a sedative effect of maternal GA on preterm babies delivered by CS, and the need for staff with advanced resuscitation skills. This study provides novel baseline data in our setting, but these data need to be validated in a prospective study

Anaesthetic outcomes in neonatal surgical care in a tertiary health facility in Nigeria

ABSTRACT: There is always a concern about the survival of new-borns undergoing corrective surgical procedure early in life. Perioperative care, especially in sick babies, is challenging, and this makes ascribing outcomes to care given difficult. This study was aimed at determining and evaluating factors associated with poor outcomes in new-borns undergoing surgery and anaesthesia. This was a retrospective case notes review of 37 neonates who received general anaesthesia during surgical care over a three-year period. After ethical approval for the study, the demographic data, indications for surgery, American Society of Anesthesiologists' (ASA) classifications, preoperative, intraoperative and postoperative challenges present in these neonates as well as their outcome were extracted. A total of 48 neonates were operated over a three-year period, and only 37(77.1%) case files were available for review. Male: Female ratio was about 2:1, the two most common procedures performed were bowel resection and anastomosis in 7(18.9%) and colostomy 7(18.9%). Overall mortality was 29.7%. Neonatal mortality was significantly higher in patients with postoperative sepsis (p=0.006) and respiratory challenge (p=0.035). The median time to death was 9 days. Only one (9.1%) patient died within 24hours postoperative. Mortality in neonates undergoing surgical procedure early in life is very high in this study. However, it is difficult to implicate anaesthesia in our study as the cause of mortality as most occurred very late after many days of surgery. Availability of postoperative elective ventilation for selected patients may improve outcome

Topical Anaesthesia for Pain Relief during High Dose Rate Brachytherapy for Carcinoma of the Cervix

Purpose: To determine the clinical efficacy of a local anaesthetic spray of 10 xylocaine in reducing pain and discomfort in patients undergoing high dose rate (HDR) brachytherapy. Patients and Method: Ninety two consenting patients diagnosed with cervical cancer and planned for HDR as part of their treatment were enrolled for the study. Each patient had three sessions of brachytherapy following the standard procedures. In the first session all the patients had brachytherapy in the usual manner with conscious Sedation with parenteral diazepam and pentazocine. For the second and third sessions; they had treatment sessions using conscious sedation and 10 xylocaine spray and a control session using conscious sedation and a placebo spray with 0.9 normal saline (NS) respectively. Visual Analogue Scale (VAS) was used in assessing pain during each of the procedure. Results: Only 80 patients completed the study. Their age ranged from 28-70 years with a median age of 54 years. The pre-treatment VAS median scores in the treatment and the control sessions were similar at 0.275 and 0.200. However; the post-procedure median VAS scores were increased to 6.3 in the control group and 3.2 in the xylocaine-treated group (P 0.0001). The haemodynamic status including the blood pressure (BP) and pulse rates (PR) were similar pre and post procedure in both groups. Conclusion: Topical xylocaine spray is efficacious in reducing pain and discomfort in HDR Brachytherapy without any appreciable adverse effect

Description of Surgical and Anaesthetic Services Provided at Two District Hospitals in KwaZulu-Natal in Relation to the Surgical Norms and Standards Outlined in the Service Package for District Hospitals

Provision of surgical services at district hospitals (DHS) is cost effective and important. The District Hospital Service Package for South Africa (package of services) specifies the services that a district hospital should provide. The aim of this study was to document the surgical services provided at two DHS in KwaZulu-Natal and to compare this with the recommendations in the package of services. Methods: In a retrospective quantitative study; data from 2008 were collected from the theatre register at two DHS. Data were analysed and results compared with the norms and standards in the package of services. Results were presented to staff at the hospitals; who then commented on the challenges of providing surgical services at DHS. Results: Only 60 and 30 respectively of procedures listed in the package of services were being carried out at the two hospitals. In total; 3 900 procedures were carried out over the year. Dundee Hospital offered a broader range of surgical procedures and anaesthetics than the Church of Scotland Hospital (COSH). COSH has a large obstetric burden; with 3 666 deliveries each year. A large number of procedures were being carried out by a single operator. Conclusions: Many surgical procedures are being carried out even though neither hospital provides the full complement of surgical services as specified in the package of services. The wide variation between the surgical services offered reflects the surgical and anaesthetic skills at the respective hospitals. Potential medico-legal hazards that require urgent attention were identified. A review of the package of services is essential to identify core procedures that must be provided at DHS

Circumcision Weeks: Making Circumcision Part of Routine Training and Service Delivery at District-level Hospitals in South Africa

"Background: Medically safe; elective male circumcision supports traditional and cultural rites of passage by reducing the risk of adverse events and death among men undergoing initiation. It is a way of preventing penile conditions that arise from being uncircumcised. It also protects against various sexually transmitted infections; playing a particularly important role in human immunodeficiency virus (HIV) prevention; as it protects against HIV infection in men by up to 60. It also helps reduce herpes simplex virus type 2; a key biological co-factor thought to account for some human susceptibility to HIV infection and human papillomavirus. To address these needs and to meet the World Health Organization's call to upscale male circumcision to 80 in HIV/AIDS epidemic-gripped sub-Saharan Africa; there is a need to provide male circumcision as standard care in district health. Method: A retrospective review of three years of circumcision services; using the sleeve method; and not the high-volume; forceps-guided method; and training at a Level 1 district hospital in South Africa. Results: Two hundred and twenty-one medical circumcisions were performed; increasing significantly in each successive year. Mostly; they were carried out under local anaesthetic; and there were only four complications; all of which were successfully resolved. The average age of the patients was 20; and generally; they elected to have medical circumcision carried out for cultural reasons. Some 60 students and clinicians were trained in safe medical male circumcision. Conclusion: To meet the growing demand for male medical circumcision; especially among teenagers and young adult men at district-level hospitals; there is a need to significantly expand the surgical competency of clinicians in this field. ""Circumcision weeks"" are one way of routinely upscaling surgical skill levels; while simultaneously responding to increased patient demand for safe medical circumcision."

Practical Regional Anaesthesia

Regional anaesthesia; from plexus blocks to skin infiltration; can be used to provide analgesia for most surgery. Cognisance must be taken of the following when choosing the dose of local anaesthetic agent : potency and toxicity of the drugs the site of injection the volume needed for the block the desired characteristics of the block (motor or sensory block) the patient's physiology

Lavage Drain Extension for Local Anaesthetic Instillation into Abdominal Wounds

BACKGROUND. A new device made by ThebeMedicare allows efficient local anaesthetic washout of wound areas; by utilising an attachment to an existing drain. The aim of this trial was to explore 'proof of concept' in patients undergoing abdominoplasty procedures. PATIENTS AND METHODS. Thirty-one patients who had undergone abdominoplasty procedures were selected for instillation of a local anaesthetic preparation; ropivacaine (Naropin; AstraZeneca) into the wound site on day 1 and 2 after surgery; followed by early mobilisation. Efficacy of the system; patient comfort and mobilisation were documented. RESULTS. The abdominoplasty patients experienced no discomfort from the procedure and claimed effective relief of pain for an average of 12 hours following instillation of local anaesthetic. All mobilised effectively. The device worked well; with no technical problems. CONCLUSION. The lavage drain extension has proved to be a cost-effective and efficient way of providing postoperative pain control and promoting early mobilisation in this patient group

Anaesthetic management of mentosternal contractures where resources are limited

Objective: Perioperative airway management in postburn mentosternal contractures often pose great challenges to the anaesthetist as well as the plastic surgeon. This is more so where resources are limited. Method: Patients with postburn mentosternal contracture who had surgery between January 2000 and December 2006 at the Jos University Teaching Hospital, Jos Nigeria were retrospectively reviewed. The information obtained from the anaesthetic chart as well as the patients' case notes included demographic data, type of anaesthetic induction and maintenance as well as the type of airway management. Results: There were 15 patients (12 males and 3 females), aged between 6 and 65 years. A total of 17 procedures were performed on the patients. Five of the patients were induced with ketamine and maintained with the same drug until adequate release was achieved. In five others the release were done under inhalational anaesthesia using a facemask after induction with ketamine. Six of the cases had laryngeal mask airway (LMA) inserted while one patient had a tracheostomy under local anaesthesia. After adequate release endotracheal tubes were inserted except in those who had LMA which were maintained to the end of the surgery. The rest of the procedure was then continued under general inhalational anaesthesia. Conclusion: Fixed flexion deformities in postburn mentosternal contractures could present serious airway challenges to the attending anaesthetist during contracture release and skin cover. This could be overcome by the use of ketamine, inhalational anaesthesia as well as the use of LMA before contracture release

An Audit of Anaesthetic Record Charts in the Orthopaedic Theatre of a Nigerian Teaching Hospital

Objective: The anaesthetic record is an essential part of a patient's record; providing useful information for the management of the patient. It is of medico-legal importance and can be used for quality assurance and researchpurposes. An analysis of anaesthetic record charts from a satellite operating theatre of the University of Port-Harcourt Teaching Hospital (UPTH) was undertaken to determine their legibility; correctness and completeness. Method: A retrospective analysis of the anaesthetic record charts from March 2003 to February 2004 of the orthopaedic theatre of the UPTH was undertaken. Results : A total of 232 anaesthetic record charts were analyzed. All entries were manually-written. Of these; 141 (60.9) were filled by anaesthetic registrars; the rest were filled by senior registrars 85 (36.5) and consultants 6 (2.6). One hundred and twenty-one charts (52.2) were legible; completely and correctly filled; but 47.8were incompletely filled; and 47.7had at least an illegible parameter. Conclusion: It is concluded from this analysis that the standard of anaesthetic record-keeping needs to be improved and consideration given to the use of computer-generated records which will eliminate the problems of illegible records

Standardization of anaesthetic equipment in Malawi: report for the period April 1st 1987 - April 1st 1988

Reviews implementation of the Danish International Development Agency [DANIDA] plan to modernized anesthetic equipment in Malawi for the 1987 financial year which show a reduction in expenditure on oxygen and transportation for cylinders and patients to central hospitals

Open heart surgery in a developing country : a report of the experience in Zimbabwe

Zimbabwe; a developing country; to date enjoys one of the highest standards of health services in Sub-Saharan Africa and among other developing countries. The infrastructure for the health services which gained a good background from the colonial era continues to progress both in the maintenance and erection of new medical centres. This has greatly contributed to the establishement of the open heart surgery centre in Zimbabwe which has so far stood the test of time. The participation of the external agencies; the Loma Linda team; is highly commendable for the initial establishement of the open heart centre. Earlier efforts in heart surgery had not yielded a presentable structure. The present programme started in the mid 80's and despite some unavoidale problems it is persistently running with an aim of establishing a fully flagged centre in this part of Africa. Although expensive to maintain; it is hoped that this centre will continue to prosper and serve tha needs of Zimbabwe and neighbouring countries which can not afford the expenses of sending patients overseas. Research and man power training are part of the intentions of this centre. The historical background and progress of cardiac surgery in Zimbabwe is studied and presented in this dissertation. Descriptive statistics of the first fifty partients who underwent Open Heart Surgery are also presented; with special consideration given to anaesthetic management and outcome