The development of a nurse-led preoperative anaesthesia screening tool by Delphi consensus.

BACKGROUND: Low- and middle-income countries have a critical shortage of specialist anaesthetists. Most patients arriving for surgery are of low perioperative risk. Without immediate access to preoperative specialist care, an appropriate interim strategy may be to ensure that only high-risk patients are seen preoperatively by a specialist. Matching human resources to the burden of disease with a nurse-administered pre-operative screening tool to identify high-risk patients who might benefit from specialist review prior to the day of surgery may be an effective strategy. OBJECTIVE: To develop a nurse-administered preoperative anaesthesia screening tool to identify patients who would most likely benefit from a specialist review before the day of surgery, and those patients who could safely be seen by the anaesthetist on the day of surgery. This would ensure adequate time for optimisation of high-risk patients preoperatively and limit avoidable day-of-surgery cancellations. METHODS: A systematic review was conducted to identify preoperative screening questions for use in a three-round Delphi consensus process. A panel of 16 experienced full-time clinical anaesthetists representing all university-affiliated anaesthesia departments in South Africa participated to define a nurses' screening tool for preoperative assessment. RESULTS: Ninety-eight studies were identified, which generated 79 questions. An additional 14 items identified by the facilitators were added to create a list of 93 questions for the first round. The final screening tool consisted of 81 questions, of which 37 were deemed critical to identify patients who should be seen by a specialist prior to the day of surgery. CONCLUSION: A structured nurse-administered preoperative screening tool is proposed to identify high-risk patients who are likely to benefit from a timely preoperative specialist anaesthetist review to avoid cancellation on the day of surgery.

Mediastinal goitre - a South African case series.

BACKGROUND: Mediastinal goitres are rare and may be diagnosed late since they are likely to manifest with non-specific cardiorespiratory symptoms especially when there is no visible cervical component. The imaging modality of choice is a contrast-enhanced computed tomography (CT) scan of the neck and chest after incidental finding of goitre on chest X-ray indicated for a condition unrelated to goitre. METHODS: This case series aims to highlight the peculiarity of mediastinal goitre in terms of clinical presentation, surgical approach, airway challenges at anaesthesia, specific complications and final histopathological report. RESULTS: Over a nine-year period, four cases of euthyroid mediastinal goitre underwent sternotomy. The mean age was 57.5 years (45-71) and all patients were female. Most patients presented with non-specific cardiorespiratory symptoms. The difficult airway set was used in all cases and there were two instances of damage to the recurrent laryngeal nerve (RLN). All histopathological reports were benign. CONCLUSION: The presentation of the mediastinal goitres was atypical. Cervical incision and sternotomy were performed in all cases. There were two instances of RLN injury and no malignant histopathology. Despite the potential threat to the airway, all intubations were uneventful.

Risk factors associated with unplanned ICU admissions following paediatric surgery: A systematic review.

Background: Unplanned admissions to the intensive care unit (ICU) have important implications in the general management of patients. Research in this area has been conducted in the adult and non-surgical population. To date, there is no systematic review addressing risk factors in the paediatric surgical population. Objectives: To synthesise the information from studies that explore the risk factors associated with unplanned ICU admissions following surgery in children through a systematic review process. Methods: We conducted a systematic review of published literature (PROSPERO registration CRD42020163766), adhering to the Preferred Reporting of Observational Studies and Meta-Analysis (PRISMA) statement. The Population, Exposure, Comparator, Outcome (PECO) strategy used was based on: population - paediatric population, exposure - risk factors, comparator - other, and outcome - unplanned ICU admission. Data that reported on unplanned ICU admissions following paediatric surgery were extracted and analysed. Quality of the studies was assessed using the Newcastle-Ottawa Scale. Results: Seven studies were included in the data synthesis. Four studies were of good quality with the Newcastle-Ottawa Scale score ≥7 points. The pooled prevalence (95% confidence interval) estimate of unplanned ICU stay was 2.69% (0.05 - 8.6%) and ranged between 0.06% and 8.3%. Significant risk factors included abnormal sleep studies and the presence of comorbidities in adenotonsillectomy surgery. In the general surgical population, younger age, comorbidities and general anaesthesia were significant. Abdominal surgery and ear, nose and throat (ENT) surgery resulted in a higher risk of unplanned ICU admission. Owing to the heterogeneity of the data, a meta-analysis with risk prediction could not be performed. Conclusion: Significant patient, surgical and anaesthetic risk factors associated with unplanned ICU admission in children following surgery are described in this systematic review. A combination of these factors may direct planning toward anticipation of the need for a higher level of postoperative care. Further work to develop a predictive score for unplanned ICU stay is desirable. Contributions of the study: Unplanned admissions to the intensive care unit (ICU) have been acknowledged as an overall marker of safety.[1] Awareness of this concept has encouraged research to determine the incidence and risk factors of these occurrences. This research has been interrogated in a systematic review process with beneficial conclusions drawn; however, these studies included adults and non-surgical patients.[2-4] To date, we have not been able to find a systematic review addressing the risk factors associated with unplanned ICU admissions in paediatric surgical patients.

Audit of perioperative pain management in paediatric patients following tonsillectomy at a tertiary hospital in Johannesburg

Background: Adenotonsillectomy remains one of the most frequently performed surgical procedures in children. Despite improvements in anaesthetic and surgical techniques, severe pain is reported in as many as 25­50% of children. Pain assessment and knowledge of drug pharmacodynamics and pharmacokinetics in the paediatric patient, is a prerequisite for optimal care. Much has been written on perioperative pain management following tonsillectomy. However, no consensus has been reached on what the ideal analgesic regimen should be. This audit is a review of current practice at Chris Hani Baragwanath Academic Hospital. It aims to identify problems and develop possible solutions to improve anaesthetic practice. Methods: A prospective, contextual, descriptive study design using a data collection sheet was used on paediatric patients presenting for tonsillectomy. Results: Eighty-five patients aged three to 12 years of age, with ASA grading I or II, were enrolled in the study. The choice of anaesthetic was variable with a combination of simple analgesics, opioids and adjuvants. This affected postoperative pain scores. Snare dissection and monopolar cautery haemostasis, was the standard surgical technique. Surgical seniority influenced the duration of tonsillectomy, with an effect on postoperative pain scores. Conclusions: Audits are necessary to evaluate what resources are needed to optimise care. The occurrence of pain after tonsillectomy continues to be poorly managed. Appropriate premedication and fasting of clear fluids for no more than two hours, needs to be introduced. Where possible surgical technique should involve bipolar cautery and be limited to less than 45 minutes. A preemptive, multimodal, opioid-sparing anaesthetic should be routinely practised