A Retrospective Review of Decision to Delivery Time Interval for Foetal Distress at a Central Hospital.

Purpose: The aim of this study was to describe the trajectory of emergency caesarean deliveries for foetal distress at Chris Hani Baragwanath Academic Hospital (CHBAH). Patients and Methods: A retrospective, contextual, descriptive study, using consecutive convenience sampling was done reviewing all the records of emergency caesarean deliveries for foetal distress at CHBAH in February 2019 until a minimum sample size of 385 was reached. Results: During the study period, a total of 617 caesarean deliveries were done, of which 572 (92.7%) were emergencies. Foetal distress accounted for 395 (69.1%) of the emergency caesarean deliveries. No emergency caesarean delivery for foetal distress conformed to the 30-minute DDI and the mean (SD) DDI was 411 (291) minutes. The mean (SD) 5-minute and 10-minute Apgar scores were 8.4 (1.6) and 9.6 (1.3), respectively. There was a significant difference between the type of anaesthetic (general or neuraxial), with those receiving general anaesthesia having shorter anaesthetic start to cut time (p=0.0110). However, those delivered following neuraxial anaesthesia had better 5-minute (p=0.0002) and 10-minute (p=0.0175) Apgar scores. Conclusion: This study showed that a DDI of 30-minutes, was not achieved at CHBAH during the study period. Most babies diagnosed with foetal distress pre-delivery had 5-minute and 10-minute Apgar scores inconsistent with this diagnosis. This over-diagnosis of foetal distress in some cases could have led to delays in delivery of babies who had actual foetal distress and where a 30-minute DDI could have improved outcome.

Erratum: Anaesthetists' knowledge of airborne infections.

[This corrects the article DOI: 10.4102/sajid.v37i1.351.].

Quality of recovery in the perioperative setting: A narrative review.

Quality of recovery (QoR) is an important concept in the perioperative care of a patient. Assessment of QoR has prognostic and economic importance, with clinical and research applications and improves patient satisfaction in the perioperative period. It, therefore, behooves the perioperative clinician to have a good understanding of the concept of QoR to better manage the perioperative patient. This literature review will discuss the concept of QoR, the development thereof, and explore the different assessments of QoR. Special attention is paid to the Quality of Recovery 40 (QoR-40) and the Quality of Recovery 15 (QoR-15) assessment tools, with further attention to development, composition, validation, and subsequent usage of the QoR-15. Furthermore, factors that have been found to influence QoR and the importance of measuring QoR will be discussed.

Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital.

Background: The aim of this study was to determine the anti-factor Xa levels in patients receiving enoxaparin sodium for venous thromboembolism prophylaxis in the intensive care unit (ICU). Patients and methods: Using a cross-sectional study methodology, 73 ICU patients receiving 40 mg enoxaparin sodium daily were enrolled in this study. Anti-factor Xa levels were measured following the second dose. Prophylactic and subprophylactic groups of patients were compared for age, sex, weight, body mass index, total bilirubin, serum albumin, and APACHE II score. Results: Anti-factor Xa levels were prophylactic (0.2-0.6 IU/mL) in 44 (60.3%) patients and subprophylactic (<0.2 IU/mL) in 29 (39.7%) patients. The mean (SD) actual delivered dose of enoxaparin per kilogram body weight was significantly higher, at 0.59 (0.11) mg/kg in the prophylactic group compared to 0.53 (0.13) mg/kg in the subprophylactic group (p = 0.043). The subprophylactic group had significantly lower serum albumin levels compared to the prophylactic group. The total bilirubin levels were not found to be significantly different between the two groups (p = 0.110). Conclusion: A fixed prophylactic 40 mg dose of enoxaparin was associated with a high proportion of subprophylactic anti-factor Xa levels. Weight-based dose and serum albumin level were independent predictors of achieving the prophylactic target range. How to cite this article: Baloo MM, Scribante J, Perrie H, Calleemalay D, Omar S. Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital. Indian J Crit Care Med 2021;25(8):917-919.

Microbial contamination of the hands of healthcare providers in the operating theatre of a central hospital.

BACKGROUND: Effort is invested in maintaining the sterility of the operating field, but less attention is paid to potential healthcare associated infection (HAI) sources through patient contact with non-scrubbed healthcare providers (HCPs). A single microbiological assessment of hands can provide a good assessment of the potential dynamic transmission of microorganisms. The aim of this study was to identify and quantify the microbial growth on the hands of HCPs in the operating theatres of Chris Hani Baragwanath Academic Hospital. METHODS: A prospective, contextual and descriptive study design was followed. Seventy-five samples were collected using convenience sampling from an equal number of surgeons, anaesthetists and nurses. Specimens were taken using agar plates and underwent semi-quantitative analysis. RESULTS: All the hands of the HCPs displayed growth; 95% grew commensals and 64% grew pathogens. Eighteen commensal microorganisms and 21 pathological microorganisms were noted. Comparisons of commensal, pathological and combined levels of contamination among the three groups were not statistically significant (p = 0.061, p = 0.481, p = 0.236). No significant difference between the growth of combined microorganisms (p = 0.634) and pathological microorganisms (p = 0.499) among the groups. Surgeons had significantly more commensal growth (p = 0.041). There was no statistically significant difference between sexes (p = 0.290). CONCLUSION: It was concerning that 100% of the hands of HCPs who were about to commence with the surgical list had microbial growth. These HCPs could have already been in contact with patients and equipment in the theatre environment.

Quality of Recovery Following Orthopedic Surgery in Patients at an Academic Hospital in South Africa.

BACKGROUND: Measurement of perioperative quality of recovery (QoR) is an important tool in improving the patient's perioperative experience. By making use of the Quality of Recovery-15 (QoR-15) questionnaire, this study aimed to measure the QoR on day 1 in patients following elective and semiurgent orthopedic surgery at an academic hospital. A secondary aim was to determine factors that may influence the QoR. METHODS: A cross-sectional research study was performed in 122 patients presenting for elective and semiurgent orthopedic surgery during core working hours between July and November 2019 at Helen Joseph Hospital, Johannesburg, South Africa. Patients completed a baseline QoR-15 assessment preoperatively and a day 1 QoR-15 assessment between 12 and 24 hours postoperatively. Additional information on various anesthetic, surgical, and patient factors was collected. RESULTS: Nineteen patients (15.6%) had a poor QoR on day 1 and were found to have started with a significantly worse baseline QoR-15 score than those with no poor QoR (98.5 vs 128.5; P < .001). A significant worsening from the overall mean baseline QoR-15 to the overall mean day 1 QoR-15 score was found (123.8 vs 113.1; P = .001). This worsening score was more pronounced in patients with a poor day 1 QoR-15 score than no poor day 1 score (25.3 vs 8; P = .002). Surgical site was found to have a significant effect on day 1 score (P = .026). A significantly worse severe pain score was found in patients with foot/ankle and knee surgery compared to hand/arm surgery (P = .012 and P = .032, respectively) and is thought to be due to the decreased use of peripheral nerve blocks in lower limb surgery. Sex, American Society of Anesthesiologists (ASA) physical status, type of anesthesia, postoperative analgesia, and antiemetic given (only applicable in general anesthetic cases) were not found to have a significant effect on the day 1 QoR-15 scores. CONCLUSIONS: Patients who had a poor QoR on day 1 started with a significantly worse baseline QoR-15 score and experienced a significantly greater negative change in the mean difference. Preoperative identification of patients who are at risk of a poor postoperative QoR may aid in preemptive targeting of limited resources to those who need them most. Postoperative pain, particularly in patients after foot/ankle and knee surgery, is a significant modifiable factor to improve postoperative QoR at our institution.

Preoperative cognitive dysfunction in older elective noncardiac surgical patients in South Africa.

BACKGROUND: Cognitive dysfunction after surgery includes delirium and postoperative cognitive dysfunction. Important risk factors for these include increased age and pre-existing cognitive dysfunction. This study describes preoperative cognitive dysfunction and its associated factors in patients aged ≥60 yr awaiting elective noncardiac surgery in a developing country. METHODS: A prospective, contextual, descriptive study design with consecutive convenience sampling was used at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. Assessment of cognition was subjective (through casual conversation, henceforth referred to as observer assessment) and objective (using the Mini-Cog test). RESULTS: A total of 194 outpatients (median age: 65 yr) were assessed. A score ≤3 (indicating mild cognitive impairment) was obtained by 111 patients (57.2%). Subjective memory complaints were reported by 124 patients (63.9%). Univariate analyses demonstrated significant associations between low Mini-Cog scores and increasing age (rs=-0.1901; P=0.0079), unskilled occupation (P=0.0033), low functional status (rs=-0.1831; P=0.0106), low level of education (P=0.0005), and frailty (rs=-0.3010; P<0.0001). Logistic regression showed level of education and frailty to be significant. A score ≤3 is more likely in frail patients (odds ratio: 7.54; P=0.003) and those with only primary school education (odds ratio: 3.54; P=0.003). CONCLUSIONS: Undiagnosed pre-existing cognitive dysfunction was common in older patients awaiting surgery at a regional academic hospital in South Africa. Patients at risk for cognitive dysfunction should be identified through brief preoperative screening.

Emergence delirium in children undergoing dental surgery under general anesthesia.

BACKGROUND: Emergence delirium is a well-described complication in pediatric anesthesia, occurring more often following short surgical procedures using volatile anesthetics with a rapid recovery profile. Dental extractions and conservation dentistry are commonly performed in children and are not painful postoperatively. The use of nerve blocks and local anesthetic infiltration intraoperatively limits nociception and obviates the need for opioids, allowing for more objective assessment of emergence delirium. AIM: The purpose of this preliminary study was to describe the incidence of emergence delirium and the associated risk factors in children undergoing elective dental surgery under general anesthesia at a regional academic hospital in South Africa. METHODS: A prospective, descriptive study of healthy children aged 2-6 years was undertaken. Patients were anesthetized using standardized protocols. Assessments included demographics of the child and caregiver, child anxiety at induction using the modified Yale Preoperative Anxiety Scale, intraoperative events, and Paediatric Anaesthesia Emergence Delirium score in the recovery room. Data were assessed for associations and correlations. RESULTS: Ninety-one children with a mean age of 3.9 (SD = 0.9) years were included. Anxiety was present in 69.2% at induction and emergence delirium occurred in 51.6% of the patients. The mean (SD, range) Paediatric Anaesthesia Emergence Delirium score in the patients without emergence delirium was 7 (2.65, 0-9) and in patients with emergence delirium was 14 (2.52, 10-18). Children with emergence delirium required more interventions in the recovery room but few required pharmacological treatment. CONCLUSIONS: Emergence delirium occurs commonly after dental surgery, and the majority of the children presenting for dental surgery are anxious at induction. Children with emergence delirium require more interventions in the recovery room but few require pharmacological treatment.

Antibiotic prescription practices and their relationship to outcome in South Africa: findings of the prevalence of infection in South African intensive care units (PISA) study.

BACKGROUND: The emergence of multidrug-resistant, extensively resistant and pan-resistant pathogens and the widespread inappropriate use of antibiotics is a global catastrophe receiving increasing attention by health care authorities. The antibiotic prescription practices in public and private intensive care units (ICUs) in South Africa are unknown. OBJECTIVE: To document antibiotic prescription practices in public and private ICUs in South Africa and to determine their relationship to patient outcomes. METHODS: A national database of public and private ICUs in South Africa was prospectively studied using a proportional probability sampling technique. RESULTS: Two hundred and forty-eight patients were recruited. Therapeutic antibiotics were initiated in 182 (73.5%), and 54.9% received an inappropriate antibiotic initially. De-escalation was practised in 33.3% and 19.7% of the public and private sector patients, respectively. Antibiotic duration was inappropriate in most cases. An appropriate choice of antibiotic was associated with an 11% mortality, while an inappropriate choice was associated with a 27% mortality (p=0.01). The mortality associated with appropriate or inappropriate duration of antibiotics was 17.6% and 20.6%, respectively (p=0.42). CONCLUSION: Inappropriate antibiotic prescription practices in ICUs in the public and private sectors in South Africa are common and are also associated with poor patient outcomes.