Southern African Journal of Anaesthesia and Analgesia The Journal's primary aim is the publication of review and CME papers, aimed at both specialist professionals and general practitioners. Original research will be accepted for review; as will Case Reports and letters to the Editor. All material will be sent for peer review. <p>Other websites related to this journal: <a title="" href="" target="_blank"></a></p> Medpharm Publications (Pty) en-US Southern African Journal of Anaesthesia and Analgesia 2220-1181 <p>By submitting manuscripts to SAJAA, authors of original articles are assigning copyright to the SA Society of Anaesthesiologists. Authors may use their own work after publication without written permission, provided they acknowledge the original source. Individuals and academic institutions may freely copy and distribute articles published in SAJAA for educational and research purposes without obtaining permission.</p> Editorial: Fools rush in where angels fear to tread No Abstract R.M. Pearse Copyright (c) 2019-03-08 2019-03-08 25 1 Editorial: Anaesthetic induction with propofol: How much? How fast? How slow? No Abstract J.F. Coetzee Copyright (c) 2019-03-08 2019-03-08 25 1 Editorial: Obesity, lean body mass, and sugammadex dosing No Abstract Carl Lynch III Copyright (c) 2019-03-08 2019-03-08 25 1 The African Surgical OutcomeS-2 (ASOS-2) Pilot Trial, a mixed-methods implementation study <p><strong>Background:</strong> The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. The working hypothesis is that patients die as a result of failure to rescue following complications in the postoperative period. The African Surgical OutcomeS-2 (ASOS-2) Trial plans to test the efficacy of increased postoperative surveillance in high risk patients for decreasing perioperative morbidity and mortality. This pilot trial aimed <em>i</em>) to evaluate the adequacy of data produced by the data collection strategies of the ASOS-2 Trial, <em>ii</em>) to evaluate the fidelity of implementation of the increased postoperative surveillance intervention, and <em>iii</em>) to understand the acceptability, appropriateness and feasibility of the intervention and the trial processes.</p><p><strong>Methods:</strong> The ASOS-2 Pilot Trial was a mixed-methods (quantitative-qualitative) implementation study focusing on the intervention arm of the proposed ASOS-2 Trial. The intervention is increased postoperative surveillance for high-risk surgical patients. The intervention protocol was implemented at all sites for a seven-day period. A post pilot trial survey was used to collect data on the implementation outcomes.</p><p><strong>Results:</strong> 803 patients were recruited from 16 hospitals in eight African countries. The sampling and data collection strategies provided 98% complete data collection. Seventy-three percent of respondents believed that they truly provided increased postoperative surveillance to high risk patients. In reality 83/125 (66%) of high-risk patients received some form of increased postoperative surveillance. However, the individual components of the increased postoperative surveillance intervention were implemented in less than 50% of high-risk patients (excepting increasing nursing observations). The components most frequently unavailable were the ability to provide care in a higher care ward (32.1%) and assigning the patient to a bed in view of the nurses’ station (28.4%). Failure to comply with available components of the intervention ranged from 27.5% to 54.3%. The post pilot survey had a response rate of 30/40 (75%). In Likert scale questions about acceptability, appropriateness, and feasibility of the ASOS-2 intervention, 63% to 87% of respondents indicated agreement. Respondents reported barriers related to resources, trial processes, teamwork and communication as reasons for disagreement.</p><p><strong>Conclusions:</strong> The proposed ASOS-2 Trial appears to be appropriate, acceptable and feasible in Africa. This pilot trial provides support for the proposed ASOS-2 Trial. It emphasises the need for establishing trial site teams which address the needs of all stakeholders during the trial. A concerted effort must be made to help participating hospitals to increase compliance with all the components of the proposed intervention of ‘increased postoperative surveillance’ during the ASOS-2 Trial.</p><p><strong>Keywords:</strong> Trial, cluster randomised, Trial, pilot, Implementation science, Mixed methods, Mortality, Surgery</p> L du Toit H.L. Kluyts V Gobin C.M. Sani E Zoumenou A.O. Omigbodun S.D. Amanor-Boadu S Zimogo A Ndonga Z Ngumi D.M. Munlemvo C Copley D van Straaten P Forget R.M. Pearse B.M. Biccard Copyright (c) 2019-03-08 2019-03-08 25 1 Induction of anaesthesia with propofol according to the adjusted ideal body mass in obese and non-obese patients: an observational study <p><strong>Background:</strong> Obesity changes body composition including fat free mass (FFM), regarded as the “pharmacologically active mass”. Scaling drug doses to obese patients by total body mass (TBM) results in overdose. We aimed to determine the success rate of inducing anaesthesia in normal, overweight and obese patients with propofol, using an adjusted body mass scalar (ABM), which embodies the increased FFM of obese patients.</p><p><strong>Methods:</strong> Ninety-six patients were divided into three groups according to body mass index (BMI): normal, overweight and obese. Propofol 2 mg/kg ABM was administered according to the equation: ABM = IBM + 0.4(TBM – IBM), where IBM = ideal body mass. Induction success was assessed clinically and by electroencephalographic spectral entropy.</p><p><strong>Results:</strong> The groups were similar regarding gender, age, height and IBM. One patient was morbidly obese (BMI = 44). State entropy (SE) decreased to &lt; 60 in 33/33, 28/29 and 33/34 patients in the normal-weight, overweight and obese groups respectively, an overall success rate of 97.5% (95% confidence interval 92.7% to 99.4%). Median lowest achieved SE values and median times that SE remained &lt; 60 did not differ between groups, however the individual values ranged widely in all three groups. Induction failed in the two patients whose SE did not decrease to &lt; 60 (one overweight and one obese).</p><p><strong>Conclusions:</strong> The ABM-based propofol induction dose has a high success rate in normal, overweight and obese patients. Further studies are required to determine the feasibility among morbidly obese patients.</p><p><strong>Keywords:</strong> administration and dosage, body mass index, body compositions, propofol</p> F.J. Smith F.X. Jurgens J.F. Coetzee P.J. Becker Copyright (c) 2019-03-08 2019-03-08 25 1 Dosage of sugammadex according to the calculated lean body mass in obese female patients: time to reverse moderate neuromuscular blockade induced by rocuronium <p><strong>Background:</strong> Sugammadex is a selective relaxant binding agent for antagonism of prolonged rocuronium-induced neuromuscular blockade. The recommended dose is 2 mg/kg. Based on the pharmacological characteristics of sugammadex in obese patients, the calculated lean body mass (CLBM) should be used to determine the dose to reverse moderate neuromuscular blockade induced by rocuronium.</p><p><strong>Objective:</strong> A study was undertaken to prove that sugammadex can be used according to CLBM to reverse moderate neuromuscular blockade in obese female patients.</p><p><strong>Methods:</strong> This is a prospective, non-randomised, observational study. Sugammadex was used at the end of bariatric surgery on obese patients with a body mass index &gt; 32 kg/m<sup>2</sup>. The dose was calculated according to the lean body mass. Muscle blockade was assessed using train-of-four monitoring.</p><p><strong>Results:</strong> Twenty women were included in this study. All patients were female and ASA 2. The age of patients ranged between 20 and 50 years with a mean age of 35.74 (±10) years. The mean CLBM was 50 kg. The mean time from administration of sugammadex to reverse neuromuscular blockade from two responses of TOF to T4/T1 &gt; 90% was 167.25 seconds (2.8 minutes) (60–285 seconds).</p><p><strong>Conclusion:</strong> It is concluded that the calculated lean body mass can be used to calculate the dose of sugammadex for obese female patients to reverse moderate neuromuscular blockade induced by rocuronium.</p><p><strong>Keywords:</strong> calculated lean body mass, neuromuscular blockade, rocuronium, sugammadex</p> Cheik Tidiane Hafid Wind-Pouiré Bougouma Jean-Luc R.J. Demeere Copyright (c) 2019-03-08 2019-03-08 25 1 Hypotension during spinal anaesthesia for Caesarean section in a resourcelimited setting: towards a consensus definition <p><strong>Background:</strong> Intraoperative hypotension following spinal anaesthesia for Caesarean section is associated with maternal morbidity and mortality. Because of inconsistent definitions the reported incidence of hypotension varies between 7% and 74%, making it almost impossible to set standard targets. Developing and adopting a clinically significant threshold for intraoperative hypotension will allow for benchmarking, comparison between studies, and consistency in guidelines and recommendations.</p><p><strong>Methods:</strong> Common definitions for spinal hypotension were first identified from a recent systematic review of the literature and a consensus statement on spinal hypotension. These definitions were applied to haemodynamic data taken from a prospective interventional obstetric spinal hypotension study conducted at Edendale Hospital, to determine the incidence of hypotension when applying these different thresholds. Finally, a definition was proposed based on these incidences and a review of the relevant literature.</p><p><strong>Results: </strong>Fifteen different definitions were identified. These were then applied to the study population with a resultant incidence of hypotension ranging from 15.8% to 91.4%. Based on a literature review of obstetric and other relevant perioperative and critical care medicine, targeting a mean arterial pressure &gt; 70 mmHg and systolic blood pressure &gt; 100 mmHg is recommended, and it is proposed that the lowest absolute values at which vasopressor therapy should be initiated are a mean arterial blood pressure &lt; 65 mmHg or systolic blood pressure &lt; 90 mmHg. Optimally, practitioners should maintain systolic blood pressure at greater than 90% of the baseline pre-spinal anaesthesia value.</p><p><strong>Conclusion:</strong> This study confirmed a wide variation in the incidence of obstetric spinal hypotension in a South African setting, depending on the definition used. An absolute threshold for intervention with vasopressor and an optimal target relative to baseline blood pressure are suggested. Further work is required to establish the effect of the adherence to these recommendations on important maternal and foetal outcomes.</p><p><strong>Keywords:</strong> Caesarean section, hypotension, incidence, neuraxial anaesthesia, regional anaesthesia, spinal anaesthesia</p> S.F. Zwane D.G. Bishop R.N. Rodseth Copyright (c) 2019-03-08 2019-03-08 25 1 Validation of age-based body mass estimation methods in toddlers and pre-school children <p><strong>Background:</strong> Body mass is commonly used to determine medication dosages and equipment size. In emergency situations (including cases necessitating surgery) weighing paediatric patients can be impractical. Clinicians may use any of several body mass estimation techniques to surmount this obstacle. This study’s aim was to compare the actual body mass of children with estimated mass as predicted by several commonly used estimation methods.</p><p><strong>Methods:</strong> This diagnostic cross-sectional study recorded data from patients between one and five years of age in the Tshwane district. Measurement procedures were standardised to ensure consistency.</p><p><strong>Results:</strong> The relationship between anthropometric and demographic variables were determined and applied to different estimation models to assess the models’ applicability to the Tshwane district population. The APLS (Advanced Paediatric Life Support) formula (Body mass (kg) = (Age + 4) × 2) proved the most appropriate. This formula gave a mean underestimation of 0.51 kg. Age proved to be the variable with the strongest correlation to body mass. A formula was developed specifically for the selected population, adding mid upper arm circumference as a second variable. This formula is more complex and offers only a marginal improvement in accuracy of weight estimation.</p><p><strong>Conclusion:</strong> The APLS formula is a reasonable tool to use when estimating the body mass in children between one and five years old in the Tshwane district population. It is a well-known and simple formula, making it well suited to this purpose.</p><p><strong>Keywords:</strong> anaesthesia, anthropometric, bodyweight, children, mass, paediatric, South Africa</p> Karin Booysen Johannes Marthinus Dippenaar Francois Jacobus Smith Copyright (c) 2019-03-08 2019-03-08 25 1 Emergency Centre-based paediatric procedural sedation: current practice and challenges in Cape Town <p><strong>Background:</strong> The aims and objectives of this survey of the current practice of doctors working in Emergency Centres (ECs) in the Cape Town metropole was to assess clinical practice and attempt to identify obstacles to the practice of paediatric procedural sedation and analgesia (PPSA). This was considered essential to establish a baseline for quality assurance purposes and improvement.</p><p><strong>Methods:</strong> After institutional ethics approval, a cross-sectional descriptive study was performed in 25 ECs in both private and government sectors in Cape Town. Specific aspects of PPSA practice were analysed after the anonymous completion of a specifically designed questionnaire, by full-time doctors working at each EC. The doctors’ grade and training, practice preferences, medication and use of monitoring, and any perceived challenges to performing PPSA were assessed.</p><p><strong>Results:</strong> Sixteen ECs agreed to be part of the study and 62 questionnaires were completed (a 64% response rate). Procedural sedation and analgesia was performed at all the participating ECs, by medical practitioners of varying experience. Doctors’ awareness of unit protocols was inconsistent. Common indications were orthopaedic interventions, radiological investigations and surgical procedures. Medications used were similar in the responding units, but dosages varied. Monitoring was poor compared with local and international standards. The obstacles reported predominantly related to a lack of training and formal protocols.</p><p><strong>Conclusions:</strong> This study was the first to evaluate the practice of Emergency Centre paediatric procedural sedation and analgesia practice in a South African setting. The lack of a formal system of training and accreditation, for both doctors and facilities, and the need for institutional and nationwide PPSA guidelines were highlighted.</p><p><strong>Keywords:</strong> Cape Town, paediatric, procedural sedation analgesia</p> A Burger P.W. Hodkinson L.A. Wallis Copyright (c) 2019-03-08 2019-03-08 25 1 Anaesthetic considerations in a child with fibrodysplasia ossificans progressiva <p>Fibrodysplasia ossificans progressiva (FOP) is an extremely rare genetic disorder characterised by extraskeletal ossification of connective tissue. Affected individuals often become completely immobilised by their third decade of life. Amongst numerous anaesthetic concerns, the airway management of patients with FOP may prove to be the greatest challenge. This case report describes the anaesthetic management of a three-year-old girl with FOP and highlights the difficulties encountered during airway management.</p><p><strong>Keywords:</strong> airway management, fibreoptic intubation, fibrodysplasia ossificans progressiva, paediatric anaesthesia</p> Thomas Kleyenstüber Copyright (c) 2019-03-08 2019-03-08 25 1