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1.
S Afr Med J ; 113(2): 57-60, 2023 02 01.
Article in English | MEDLINE | ID: mdl-36757073

ABSTRACT

The illegal practice of combining organophosphates (OPs) with other compounds such as carbamates and pyrethroids, creating 'streetpesticides', is common in South Africa. These agents contain mostly unknown quantities of unregulated toxins and contribute to atypicaland unpredictable clinical presentations following human ingestion. We present such a case in a patient with intentional rodenticideingestion. The initial presentation in the emergency department was a classic cholinergic toxidrome, and clinical resolution was achievedafter provision of atropine. This was followed 12 hours later by an acute decompensation resulting from an apparent sympatheticallydriven episode of autonomic instability and acute pulmonary oedema requiring immediate respiratory and haemodynamic support. In ourdiscussion, we explore this secondary decompensation and suggest various pathophysiological explanations for this atypical clinical coursefollowing what had appeared to be OP poisoning. The patient was discharged home after a total of 6 days in hospital.


Subject(s)
Atropine , Pyrethrins , Humans , South Africa , Atropine/therapeutic use , Carbamates , Organophosphates
2.
S Afr Med J ; 0(0): 13182, 2020 12 14.
Article in English | MEDLINE | ID: mdl-33334391

ABSTRACT

BACKGROUND: The COVID-19 pandemic has led to the implementation of restrictive policies on theatre procedures, with profound impacts on service delivery and theatre output. OBJECTIVES: To quantify these effects at a tertiary hospital in KwaZulu-Natal Province, South Africa. METHODS: A retrospective review of morbidity and mortality data was conducted. The effects on emergency and elective caseload, intensive care unit (ICU) admissions from theatre, theatre cancellations and regional techniques were noted. RESULTS: Theatre caseload decreased by 30% from January to April 2020 (p=0.02), ICU admissions remained constant, and theatre cancellations were proportionally reduced, as were the absolute number of regional techniques. CONCLUSIONS: The resulting theatre case deficit was 1 260 cases. It will take 315 days to clear this deficit if four additional surgeries are performed per day.


Subject(s)
COVID-19 , Elective Surgical Procedures/statistics & numerical data , Infection Control , Surgery Department, Hospital , Tertiary Healthcare , Adult , COVID-19/epidemiology , COVID-19/prevention & control , Emergency Service, Hospital/organization & administration , Emergency Service, Hospital/statistics & numerical data , Female , Health Policy , Humans , Infection Control/methods , Infection Control/organization & administration , Male , Mortality , Needs Assessment , Organizational Innovation , Safety Management/trends , South Africa/epidemiology , Surgery Department, Hospital/organization & administration , Surgery Department, Hospital/statistics & numerical data , Tertiary Healthcare/organization & administration , Tertiary Healthcare/trends
3.
S Afr Med J ; 111(2): 120-123, 2020 12 14.
Article in English | MEDLINE | ID: mdl-33944721

ABSTRACT

BACKGROUND: The COVID-19 pandemic has led to the implementation of restrictive policies on theatre procedures, with profound impacts on service delivery and theatre output. OBJECTIVES: To quantify these effects at a tertiary hospital in KwaZulu-Natal Province, South Africa. METHODS: A retrospective review of morbidity and mortality data was conducted. The effects on emergency and elective caseload, intensive care unit (ICU) admissions from theatre, theatre cancellations and regional techniques were noted. RESULTS: Theatre caseload decreased by 30% from January to April 2020 (p=0.02), ICU admissions remained constant, and theatre cancellations were proportionally reduced, as were the absolute number of regional techniques. CONCLUSIONS: The resulting theatre case deficit was 1 260 cases. It will take 315 days to clear this deficit if four additional surgeries are performed per day.


Subject(s)
COVID-19/epidemiology , Decision Making, Organizational , Pneumonia, Viral/epidemiology , Surgical Procedures, Operative/statistics & numerical data , Tertiary Care Centers/organization & administration , Workload/statistics & numerical data , Humans , Pandemics , Pneumonia, Viral/virology , Retrospective Studies , SARS-CoV-2 , South Africa/epidemiology
4.
BMC Musculoskelet Disord ; 19(1): 140, 2018 May 09.
Article in English | MEDLINE | ID: mdl-29743063

ABSTRACT

BACKGROUND: A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs. METHODS: Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty. RESULTS: Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category. CONCLUSION: The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.


Subject(s)
Arthroplasty, Replacement, Hip/standards , Arthroplasty, Replacement, Knee/standards , Consensus , Delphi Technique , Health Personnel/standards , Perioperative Care/standards , Arthroplasty, Replacement, Hip/methods , Arthroplasty, Replacement, Knee/methods , Humans , Perioperative Care/methods , South Africa/epidemiology
5.
S. Afr. med. j. (Online) ; 106(6): 592-597, 2016.
Article in English | AIM (Africa) | ID: biblio-1271107

ABSTRACT

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


Subject(s)
Checklist , Preoperative Care , Surgical Procedures, Operative
6.
S Afr Med J ; 105(4): 271-4, 2015 Apr.
Article in English | MEDLINE | ID: mdl-26294865

ABSTRACT

Maternal deaths due to haemorrhage continue to increase in South Africa (SA). It appears that oxytocin and other uterotonics are not being used optimally, even though they are an essential part of managing maternal haemorrhage. Oxytocin should be administered to every mother delivering in SA. Awareness is required of the side-effects that can occur and the appropriate measures to avoid harm from these. Second-line uterotonics should also be available and utilised in conjunction with mechanical and surgical means to arrest haemorrhage in women who continue to bleed after the appropriate administration of oxytocin.


Subject(s)
Mothers/statistics & numerical data , Oxytocin/pharmacology , Postpartum Hemorrhage/prevention & control , Female , Humans , Maternal Death/trends , Oxytocics/pharmacology , Postpartum Hemorrhage/epidemiology , Pregnancy , Safety , South Africa/epidemiology
7.
S Afr Med J ; 105(4): 287-91, 2015 Apr.
Article in English | MEDLINE | ID: mdl-26294872

ABSTRACT

BACKGROUND: In the latest (2011-2013) Saving Mothers report, the National Committee for Confidential Enquiries into Maternal Deaths in South Africa (SA) (NCCEMD) highlights the large number of maternal deaths associated with caesarean section (CS). The risk of a woman dying as a result of CS during the past triennium was almost three times that for vaginal delivery. Of all the mothers who died during or after a CS, 3.4% died during the procedure and 14.5% from haemorrhage afterwards. Including all cases of death from obstetric haemorrhage where a CS was done, there were 5.5 deaths from haemorrhage for every 10,000 CSs performed. OBJECTIVE: To scrutinise the contribution or effect of the surgical procedure on the ultimate cause of death by a cross-cutting analysis of the 2011-2013 national data. METHODS: Data from the 2011-2013 triennial review were entered into an Excel database and analysed on a national and provincial basis. RESULTS: There were 1,243 maternal deaths where a CS was the mode of delivery and 1 471 deaths after vaginal delivery. More mothers died as a result of CS in the provinces where there is a low overall CS rate. The following CS categories were identified as specific problems: bleeding during or after CS, pre-eclampsia and eclampsia, anaesthesia-related deaths, pregnancy-related sepsis and acute collapse and embolism. CONCLUSION: This is an area of concern, and a concentrated effort should be done to make CS in SA safer. Several recommendations are


Subject(s)
Cesarean Section/mortality , Delivery, Obstetric/mortality , Maternal Death/statistics & numerical data , Mothers/statistics & numerical data , Female , Humans , Maternal Mortality/trends , Pregnancy , Retrospective Studies , South Africa/epidemiology
8.
S Afr Med J ; 103(2): 81-2, 2012 Oct 08.
Article in English | MEDLINE | ID: mdl-23374300

ABSTRACT

The number of women dying as a result of spinal anaesthesia during caesarean section in South Africa is steadily increasing in the triennial reports of the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD). This article postulates some of the reasons behind this phenomenon. The concern is raised that spinal anaesthesia is being undertaken inappropriately by poorly trained practitioners. A case is made for the rigorous application of known safety standards and for doctors to be appropriately trained in anaesthesia and to be solely responsible for the care of the mother during caesarean section. The need for doctors to be trained and prepared to administer general anaesthesia when required is noted.


Subject(s)
Anesthesia, Obstetrical/methods , Anesthesia, Spinal/adverse effects , Cesarean Section/mortality , Anesthesia, Obstetrical/adverse effects , Cesarean Section/methods , Female , Humans , Maternal Mortality/trends , Pregnancy , Retrospective Studies , South Africa/epidemiology
9.
S Afr J Surg ; 49(4): 194-8, 2011 Nov 30.
Article in English | MEDLINE | ID: mdl-22353271

ABSTRACT

INTRODUCTION: Caring for trauma patients is a dynamic process, and it is often necessary to move the trauma patient around the hospital to different locations. This study attempted to document the quality of observations performed on acute trauma patients as they moved through the hospital during the first 24 hours of care. METHODOLOGY: This study was a student elective and was undertaken at Grey's Hospital, Pietermaritzburg. A third-year medical student was assigned to follow acute trauma patients throughout the hospital during the first 24 hours after admission. This single independent observer recorded the frequency with which vital signs were recorded at each geographical location in the hospital for each patient. A scoring system was devised to classify the quality of the observations that each patient received in the different departments. The observer recorded all the geographical movements each patient made during the first 24 hours after admission. RESULTS: Fifteen patients were recruited into this study over a 4-week period. There were 14 adult males (average age 28 years, range 18 - 56 years) and a 7-year-old girl in the cohort. There were significant differences in the quality of the observations, depending on the geographical location in the hospital. These variations and differences were consistent in certain locations and highly variable in others. Observations in the intensive care unit (ICU) and operating theatre were uniformly excellent. In the radiology suite the level of observations was universally poor. In casualty and the wards there was great variability in the level of observation. A total of 45 distinct geographical visits were made by the study cohort. Each patient made an average of 3 (range 2 - 5) visits during their first 24 hours after admission. All patients attended casualty, and there were 11 patient visits to the ward, 10 to radiology, 4 to ICU and 5 to theatre. CONCLUSION: Significant variations exist in the level of observations of vital signs between different geographical locations within the hospital. This is problematic, as acute trauma patients need to be moved around the hospital as part of their routine care. If observations are not done and acted upon, subtle clinical deterioration may be overlooked and overt deterioration may be heralded by a catastrophic event.


Subject(s)
Hospitals/standards , Quality of Health Care , Wounds and Injuries/therapy , Adolescent , Adult , Child , Female , Humans , Male , Middle Aged , South Africa , Trauma Severity Indices
10.
Anaesth Intensive Care ; 32(3): 351-7, 2004 Jun.
Article in English | MEDLINE | ID: mdl-15264729

ABSTRACT

Current methods of crystalloid preload administration prior to spinal anaesthesia for elective caesarean section are relatively ineffective in preventing hypotension. This study examined the relevance of the timing of the fluid administered. Fifty women were randomly allocated to receive either 20 ml x kg(-1) of crystalloid solution during 20 minutes prior to induction of spinal anaesthesia (preload), or an equivalent volume by rapid infusion immediately after induction (coload). Significantly more patients in the coload group did not require vasopressor therapy pre-delivery (P=0.047). The coload group required a lower median dose (P=0.03) and a lower median number (P=0.04) of ephedrine doses for the treatment of maternal hypotension pre-delivery. There was no between-group difference in either the total cumulative dose, or in the total number of doses of ephedrine. Neonatal outcomes among the two groups were similar. Rapid crystalloid administration after, rather than over 20 minutes before the induction of spinal anaesthesia for elective caesarean section, may be advantageous in terms of managing maternal blood pressure prior to delivery.


Subject(s)
Anesthesia, Obstetrical , Anesthesia, Spinal , Cesarean Section , Plasma Substitutes/administration & dosage , Blood Pressure , Crystalloid Solutions , Elective Surgical Procedures , Ephedrine/therapeutic use , Female , Humans , Hypotension/drug therapy , Hypotension/prevention & control , Infusions, Intravenous , Isotonic Solutions , Postoperative Care , Postoperative Complications/prevention & control , Pregnancy , Preoperative Care , Vasoconstrictor Agents/therapeutic use
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