Towards the quantification of perioperative cardiovascular risk in the African context: A sub-analysis of the South African Surgical Outcomes Study and the African Surgical Outcomes Study.

BACKGROUND: The burden of cardiovascular disease in patients requiring non-cardiac surgery in Africa is not known. These patients are at increased risk for postoperative cardiovascular complications. OBJECTIVES: In this sub-study, to use data on comorbidities and surgical outcomes from two large observational studies, the South African Surgical Outcomes Study (SASOS) and the African Surgical Outcomes Study (ASOS), to investigate the prevalence of cardiovascular disease in elective surgical patients and the risk of postoperative cardiovascular complications in this population. METHODS: SASOS and ASOS were both prospective, observational cohort studies that collected data over 1 week in each participating centre. The primary outcome was in-hospital postoperative complications, which included prespecified and defined cardiovascular complications. We defined the cardiovascular disease burden of patients aged ≥45 years presenting for surgery (main objective), determined the relative risk of developing postoperative cardiovascular complications (secondary objective) and assessed the utility of the Revised Cardiac Risk Index (RCRI) for preoperative cardiovascular risk stratification of elective, non-cardiac surgical patients in Africa (third objective). RESULTS: The primary outcome analysis of 3 045 patients showed that patients with major cardiac complications were significantly older, with a higher prevalence of hypertension, coronary artery disease or congestive cardiac failure, and had undergone major surgery. In-hospital mortality for the cohort was 1.2%. CONCLUSIONS: The substantial burden of cardiovascular disease in patients presenting for non-cardiac surgery in Africa is shown in the principal findings of this study. The RCRI has moderate discrimination for major cardiac complications and major adverse cardiac events in African patients undergoing non-cardiac surgery.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications.

BACKGROUND: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. METHODS: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. RESULTS: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. CONCLUSIONS: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. CLINICAL TRIAL REGISTRATION: NCT03044899.

A National Survey of Oxytocin Use during Caesarean Section in Zimbabwe

Background: Post-partum haemorrhage is the leading cause of mortality for labouring women in Zimbabwe. Current literature supports the use of low dose oxytocin to prevent bleeding during Caesarean section. Internationally; clinical practice has been slow to change and the use of potentially harmful; higher than recommended dose is common.Objective: To describe the current clinical practice in Zimbabwe.Design: A self-administered questionnaire survey. Descriptive statistics were used to report the study results.Setting: In 2013 a national survey was conducted on the use of oxytocin by different types of clinicians; who provide either anaesthesia or surgery for Caesarean section.Results: Of a total of 221 (61%) questionnaires returned; 170 (80%) were completed fully. Only 23% of respondents would give an intravenous dose of 5.0 IU or less of oxytocin for elective Caesarean section. The majority of clinicians (77%) would administer more than 5.0 IU of oxytocin at elective. A significant number of nurse anaesthetists 16/59 (27%); and a non-negligible number of specialist anaesthetists 3/48 (6%) would even give 20 IU of oxytocin in elective cases rising to 30% and 13% respectively for emergency cases. In case of persistent bleeding due to uterine atony; oxytocin was more likely to be repeated (45%); rather than using misoprostol (25%) or ergometrine (19%). Conclusion: Most clinicians in Zimbabwe use oxytocin doses well above current internationally recommended. This illustrates the urgent need for updated national guidelines for the prevention of post-partum haemorrhage during Caesarean section

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

Metabolic effects of Carbon Dioxide (CO2) insufflation during laparoscopic surgery: changes in pH, arterial partial Pressure of Carbon Dioxide (PaCo2) and End Tidal Carbon Dioxide (EtCO2).

Background: Acid base alterations occur during laparoscopy with carbon dioxide insufflation. The purpose of this study was to investigate the effects of low tidal volume ventilation on acid base status during pneumoperitonium. Materials and Methods: 30 patients undergoing laparoscopic surgery under General Anaesthesia were ventilated with tidal volume of 6 ml/kg and respiratory rate of 12 breaths/minute. Arterial blood gas analysis was done before, during and after C02 pneumoperitoneum. Arterial haemoglobin oxygen saturation by pulse oximetry (SPO2) and EtC02 were monitored continuously throughout the laparoscopy. Respiratory adjustments were done for EtCO2 levels above 60mmHg or SPO2 below 92% or adverse haemodynamic changes. Results: low tidal volume ventilation during pneumoperitoneum resulted in a significant elevation in PaCO2 (p<0.001) and a fall of pH (p <0.001), ion bicarbonate (HCO3-) (p = 0.011), and base excess (ABE) (p <0.001). A correlation was found between the EtCO2 and PaCO2 during pneumoperitoneum. Oxygenation was well maintained during pneumoperitoneum. No ventilatory adjustments were instituted on any of the patients as they maintained EtCO2 below 60mmHg throughout pneumoperitoneum. Conclusion: Ventilation with low tidal volume during pneumoperitoneum causes a mixed respiratory and metabolic acidosis. EtCO2 is still a good non-invasive monitor for estimation of PaCO2 during low tidal volume ventilation during pneumoperitoneum.

Review of causes of maternal deaths in Botswana in 2010.

BACKGROUND: In Botswana the maternal mortality ratio in 2010 was 163 per 100 000 live births. It is a priority to reduce this ratio to meet Millennium Development Goal 5 target of 21 per 100 000 live births. OBJECTIVE: To investigate the underlying circumstances of maternal deaths in Botswana.Method. Fifty-six case notes from the 80 reported maternal deaths in 2010 were reviewed. Five clinicians reviewed each case independently and then together to achieve a consensus on diagnosis and underlying cause(s) of death. RESULTS: Sixty-six percent of deaths occurred in Botswana's two referral hospitals. Cases in which death had direct obstetric causes were fewer than cases in which cause of death was indirect. The main direct causes were haemorrhage (39%), hypertension (22%), and pregnancy-related sepsis (13%). Thirty-six (64%) deaths were in HIV-positive women, of whom 21 (58%) were receiving antiretroviral (ARV) therapy. Nineteen (34%) deaths were attributable to HIV, including 4 from complications of ARVs. Twenty-nine (52%) deaths were in the postnatal period, 19 (66%) of these in the first week. Case-note review revealed several opportunities for improved quality of care: better teamwork, communication and supportive supervision of health professionals; earlier recognition of the seriousness of complication(s) with more aggressive case-management; joint management between HIV and obstetric clinicians; screening for, and treatment of, opportunistic infections throughout the antenatal to postnatal periods; and better supply management of medications, fluids, blood for transfusion and laboratory tests. CONCLUSION: Integrating HIV management into maternal healthcare is essential to reduce maternal deaths in the region, alongside greater efforts to improve quality of care to avoid direct and indirect causes of death.

Assessment of the burden of critical illness in a rural Botswana hospital with the use of an early warning score.

Background: There is little data on prevalence of critical illness in Sub Saharan Africa, especially in rural areas, but it is needed to develop critical care services in district hospitals. Methods: We sought to determine the prevalence of patients 'at risk of' critical illness using an Early Warning Score (EWS) in a district hospital in Botswana. During two-month period patients daily vital signs were recorded and EWSs calculated on adult medical or surgical wards to identify patients who scored ≥3. Results: EWS on 826 patients were obtained. There were 180 patients with ≥3 [8 refused to give consent and were excluded] with mortality 63(37%) and 646 patients scored below 3, mortality of 3 (0.6%). Patients with scores ≥3 were medical (63%), surgical (27%) and orthopaedic (9%). Of patients that were transferred to a referral centre [6 (3%)], none were admitted to ICU. Patients who died lived for 6.5 (SD 7.0) days after first score of ≥3. HIV prevalence among patients that died was 37%. Other co-morbidities were rare, except hypertension (21%). Cause of death was not clear in 60% of patients. When cause of death could be inferred from clinical records, it was illness related in 75% of cases. Conclusions: Using the EWS we have identified the burden of critical illness in a rural district hospital in Botswana and the 'critical care gap' where patients do not get the intensive care they need.

Anaesthesia associated mortality in a district hospital in Zimbabwe: 1994 to 2001.

OBJECTIVE: To describe anaesthetic associated mortality in a district hospital in Zimbabwe. DESIGN: A retrospective descriptive study of anaesthesia associated mortality over an eight year period. SETTING: Murambinda Mission Hospital: a 120 bed rural district hospital in Zimbabwe. SUBJECTS: All patients who died within 24 hours of receiving an anaesthetic. MAIN OUTCOME MEASURES: The overall mortality rate (OMR), being all deaths up to 24 hours after an anaesthetic. Avoidable anaesthetic mortality rate (AMR), are deaths in which correctable anaesthetic factors played a major role. RESULTS: An overall mortality rate (OMR) of 1:344 (2.9 deaths/1 000 anaesthetics) and avoidable mortality rate (AMR) for anaesthesia of 1:482 (2.1 deaths/1 000 anaesthetics) are reported. Factors under the control of the anaesthetist accounted for 72% of mortalities (AMR:OMR). All were emergency obstetric patients and had emergency surgery. The hospital maternal mortality rate of 360 per 100 000 and an operative obstetric mortality of 1:293 (3.4 deaths/1 000) are reported. CONCLUSIONS: Most of the anaesthetic factors are preventable. These results, although very poor, are consistent with reports from hospitals in the region. By comparison, developed countries are at least 10 times better. Improving the provision, skills, support and profile of anaesthesia providers in the care of peri operative patients, would reduce anaesthesia-associated factors in peri operative mortality. A system of national audit data collection comparable to the CEPOD or Confidential Enquiry into Maternal Deaths is overdue in Zimbabwe.

A hospital response to a soccer stadium stampede in Zimbabwe.

OBJECTIVES: When a soccer stadium stampede occurred in Zimbabwe on 9 July 2000, the hospital disaster (medical emergency) plan failed. This report describes the use of the audit technique to change the hospital's disaster preparedness. METHOD: A literature review was done to establish international standards of best practice in major medical incident response. The hospital disaster plan (major medical incident plan) was reviewed and used as local standard. Written submissions and unstructured interviews technique were used to collect information from staff present on the day and involved in the care of the stampede victims and from staff specified in the hospital disaster plan. This was presented as a report to the Hospital Clinical Audit and Quality Assurance Committee (CAQAC), with recommendations. RESULTS: The hospital's response to the disaster was suboptimal. The initial recommendations were accepted. Implementation is ongoing while discussion is drawing in other people and agencies. An integrated prehospital care system is required. The casualty department needs to develop into a modern accident and emergency department. Individual departments need to develop their own disaster plans that link into the hospital plan. A system for future audits of the hospital's performance after a disaster need to be put in place. Implementation of these recommendations is changing disaster preparedness in and out of the hospital. CONCLUSIONS: The exercise was very useful in raising awareness and the value of audit and specific issues were defined for improvement. Long term and short term goals were set. Despite the shortage of resources, change was felt to be necessary and possible.

A critical incident reporting system in anaesthesia.

OBJECTIVE: To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department. DESIGN: Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. SETTING: The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. SUBJECTS: Between May and October 2000, 62 completed critical incident forms were collected. MAIN OUTCOME MEASURES: The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. RESULTS: A total of 14,165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14,165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57%, oxymetry 90% and ECG 100%. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15% died, 23% were unplanned admissions to HDU while 62% were discharged to the ward with little or no adverse outcome. CONCLUSION: Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change of practice and improvement in the safety features of the service provided by the hospital and staff.