A simulation-based study evaluating the preparedness of interns' post-anaesthesia rotation in managing a failed obstetric intubation scenario: Is our training good enough?

BACKGROUND: Difficult or failed intubation of obstetric patients may be up to 8 times higher than in general surgical patients. A decline in obstetric intubation opportunities may be a contributing factor, resulting in reduced training opportunities for junior doctors, who therefore do not acquire airway management skills. OBJECTIVES: To assess post-anaesthesia rotation interns' preparedness to manage a difficult/failed obstetric airway scenario. METHODS: We recruited 49 interns, obtained informed consent and individually assessed them on a simulation-based scenario using a high-fidelity manikin. Two independent assessors scored participants using a checklist assessment and a global rating scale. After the simulation-based scenario, participants completed a questionnaire on their internship training, rated the simulation experience and received debriefing. The borderline regression method was used to determine the checklist pass mark. RESULTS: Analysis showed that 40% of interns passed. Correlation between assessors was strong for checklist scores and global ratings. The main reasons for failing were repeated attempts at intubation and failure to optimise the intubating position or conditions. There was concern regarding the infrequent use of a supraglottic airway device as a rescue. Twenty-eight interns had performed <5 general obstetric anaesthetic procedures. CONCLUSIONS: There are concerns regarding adequate anaesthetic preparation for interns to manage a difficult/failed intubation scenario in a full-term pregnancy. Despite the Essential Steps in Managing Obstetric Emergencies (ESMOE) airway module training, which all interns should receive, a high rate of success was not achieved in this study. Simulation-based training and assessment may be a valuable tool to improve intern training and preparedness.

An audit of operating theatre utilisation and day-of-surgery cancellations at a regional hospital in the Durban metropole.

BACKGROUND: Operating theatres account for a significant proportion of hospital costs. There is a paucity of data evaluating utilisation of South African (SA) state operating theatres. OBJECTIVES: To measure operating theatre utilisation and the rate of day-of-surgery cancellations (DOSCs) in a state hospital theatre complex. METHODS: A prospective audit of a state operating theatre complex at a Durban regional hospital was performed between 26 February and 26 April 2018. Times were collected for each theatre case from the entry of the patient into theatre to their departure to the post-anaesthetic care unit. This was done on weekdays between 08h00 and 16h00. The factors causing any delays and DOSCs were identified and recorded. RESULTS: Over the study period, 125 220 operative minutes were available for both elective and emergency operating theatres; 655 elective cases and 359 emergency cases were performed. Overall theatre utilisation was 55.2%, with actual operating time comprising only 36.9% of all available time. Non-operative time occupied 63.1% of all available time, split between late starts (9.3%), early list finishes (16.1%), changeover times (19.4%) and anaesthetic time (18.3%). The DOSC rate was 26.2%, with 232 cases cancelled on the day of surgery. Just under half of the DOSCs were avoidable. The most common reason for cancellation was lack of operative time. CONCLUSIONS: Measured theatre utilisation was higher than previously quoted figures for SA state hospitals, but below international benchmarks. A significant amount of time was wasted as a result of delayed first-case starts, prolonged changeovers and early terminations of lists, all of which contributed to a high DOSC rate. Before more theatre time can be made available, theatre users must first optimise use of currently available time. Further studies quantifying the effect of staff shortages in state operating theatres on inefficient use of time are required.

South African Paediatric Surgical Outcomes Study: a 14-day prospective, observational cohort study of paediatric surgical patients.

BACKGROUND: Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low- and middle-income countries (LMICs). METHODS: We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. RESULTS: We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4-11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2-8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6-1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. CONCLUSIONS: The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings should be used to develop strategies to improve paediatric surgical outcomes in LMICs, and support the need for larger prospective, observational paediatric surgical outcomes research in LMICs. CLINICAL TRIAL REGISTRATION: NCT03367832.

National Priorities for Perioperative Research in South Africa

BACKGROUND:Perioperative research is currently unco-ordinated in South Africa (SA); with no clear research agenda.OBJECTIVE:To determine the top ten national research priorities for perioperative research in SA.METHODS:A Delphi technique was used to establish consensus on the top ten research priorities.RESULTS:The top ten research priorities were as follows: (i) establishment of a national database of (a) critical care outcomes; and (b) critical care resources; (ii) a randomised controlled trial of preoperative B-type natriuretic peptide-guided medical therapy to decrease major adverse cardiac events following non-cardiac surgery; (iii) a national prospective observational study of the outcomes associated with paediatric surgical cases; (iv) a national observational study of maternal and fetal outcomes following operative delivery in SA; (v) a stepped-wedge trial of an enhanced recovery after surgery programme for (a) surgery; (b) obstetrics; (c) emergency surgery; and (d) trauma surgery; (vi) a stepped-wedge trial of a surgical safety checklist on patient outcomes in SA; (vii) a prospective observational study of perioperative outcomes after surgery in district general hospitals in SA; (viii) short-course interventions to improve anaesthetic skills in rural doctors; (ix) studies of the efficacy of simulation training to improve (a) patient outcomes; (b) team dynamics; and (c) leadership; and (x) development and validation of a risk stratification tool for SA surgery based on the South African Surgical Outcomes Study (SASOS) data.CONCLUSIONS:These research priorities provide the structure for an intermediate-term research agenda

A meta-analysis of the efficacy of preoperative surgical safety checklists to improve perioperative outcomes

BACKGROUND:Meta-analyses of the implementation of a surgical safety checklist (SSC) in observational studies have shown a significant decrease in mortality and surgical complications.OBJECTIVE:To determine the efficacy of the SSC using data from randomised controlled trials (RCTs). METHODS:This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (CRD42015017546). A comprehensive search of six databases was conducted using the OvidSP search engine.RESULTS:Four hundred and sixty-four citations revealed three eligible trials conducted in tertiary hospitals and a community hospital; with a total of 6 060 patients. All trials had allocation concealment bias and a lack of blinding of participants and personnel. A single trial that contributed 5 295 of the 6 060 patients to the meta-analysis had no detection; attrition or reporting biases. The SSC was associated with significantly decreased mortality (risk ratio (RR) 0.59; 95% confidence interval (CI) 0.42 - 0.85; p=0.0004; I2=0%) and surgical complications (RR 0.64; 95% CI 0.57 - 0.71; petlt;0.00001; I2=0%). The efficacy of the SSC on specific surgical complications was as follows: respiratory complications RR 0.59; 95% CI 0.21 - 1.70; p=0.33; cardiac complications RR 0.74; 95% CI 0.28 - 1.95; p=0.54; infectious complications RR 0.61; 95% CI 0.29 - 1.27; p=0.18; and perioperative bleeding RR 0.36; 95% CI 0.23 - 0.56; petlt;0.00001.CONCLUSIONS:There is sufficient RCT evidence to suggest that SSCs decrease hospital mortality and surgical outcomes in tertiary and community hospitals. However; randomised evidence of the efficacy of the SSC at rural hospital level is absent

Hereditary Non-Polyposis Colorectal Cancer is Predicted to Contribute towards Colorectal Cancer in Young South African Blacks

A disproportionately large number of young (50 years); those from young black patients presented more often with a low methylation phenotype (CIMP-L) and high levels of microsatellite instability (MSI-H). Furthermore; as determined by real-time PCR using probe technology; the tissues from35of young blacks showed mutations within exon 1 of the KRAS gene. The BRAF-V600E mutation was only evident in the case of a single young black patient. Based on these results it seems likely that a proportion of CRC cases in young black patients from South Africa develop through the accumulation of mutations resulting in a mismatch repair deficiency linked to MSI-H and; possibly; germline mutations in the mismatch repair genes. The features in these patients are consistent with a diagnosis of the Hereditary Non-Polyposis Colorectal Cancer (HNPCC) syndrome. This finding has important implications for patient management and suggests that family members may be at high risk for CRC

Colorectal cancer in South Africa: a heritable cause suspected in many young black patients.

BACKGROUND: Colorectal carcinoma (CRC) has a low incidence among the black African population. Largely unrecognised in the scientific literature is the fact that a disproportionately large number of young black patients (<50 years old) present with CRC. OBJECTIVES: To analyse those tumours, which we propose may link them to morphological features associated with known genetic pathways. METHODS: A retrospective review of South African patients histologically diagnosed as having CRC by the Division of Anatomical Pathology, National Health Laboratory Service (NHLS) and the University of the Witwatersrand (1732 patients from 1990 to 2003). The histology was fully reviewed in 609 patients (1997-2002), and all specimens from patients <50 years of age were subjected to immunohistochemistry tests for mismatch repair proteins, as well as APC and p53 proteins. RESULTS: Most young patients (<50 years) were black (41% v. 10% white; p < or = 0.001). Blacks had predominantly proximal tumours and significantly more poorly differentiated and/or mucinous tumours (p = 0.006), and loss of mismatch repair protein expression was more evident than in whites. CONCLUSIONS: It seems likely that CRC in young blacks develops through the accumulation of mutations, most probably via mismatch repair deficiency or promoter methylation, which in turn is linked to poor differentiation and a mucinous architecture.

Colorectal Cancer in South Africa: a Heritable Cause Suspected in many Young Black Patients

Background. Colorectal carcinoma (CRC) has a low incidence among the black African population. Largely unrecognised in the scientific literature is the fact that a disproportionately large number of young black patients (50 years old) present with CRC. Objectives. To analyse those tumours; which we propose may link them to morphological features associated with known genetic pathways. Methods. A retrospective review of South African patients histologically diagnosed as having CRC by the Division of Anatomical Pathology; National Health Laboratory Service (NHLS) and the University of the Witwatersrand (1 732 patients from 1990 to 2003). The histology was fully reviewed in 609 patients (1997 - 2002); and all specimens from patients 50 years of age were subjected to immunohistochemistry tests for mismatch repair proteins; as well as APC and p53 proteins. Results. Most young patients (50 years) were black (41v. 10white; p=0.001). Blacks had predominantly proximal tumours and significantly more poorly differentiated and/or mucinous tumours (p=0.006); and loss of mismatch repair protein expression was more evident than in whites. Conclusions. It seems likely that CRC in young blacks develops through the accumulation of mutations; most probably via mis- match repair deficiency or promoter methylation; which in turn is linked to poor differentia- tion and a mucinous architecture

Iron overload and tuberculosis: a case for iron chelation therapy.

Elevated levels of iron impair immune defence mechanisms, and specifically the macrophage function of innate immunity. Iron enhances Mycobacterium tuberculosis infection, M. tuberculosis replication, progression to clinical disease and death from tuberculosis (TB). Chelation of iron in individuals with an excessive iron burden may reduce M. tuberculosis viability and replication, restore host defence mechanisms and could find application in the prevention and treatment strategies in settings where both iron overload and TB are prevalent. The objective of this paper was to summarise recent literature on the role of iron in TB pathogenesis and to examine the potential of iron chelation therapy. The literature confirms a key role for iron in mycobacterial virulence. The ability of chelation to enhance host effector mechanisms and to inhibit replication of various pathogens justifies further studies into iron chelation as a potential additive therapy for TB.