Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study.

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.

Case Report.

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.

Variations in levels of care within a hospital provided to acute trauma patients.

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.

Effect of COVID-19 pandemic decisions on tertiary-level surgical services in Pietermaritzburg, KwaZulu-Natal Province, South Africa.

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.

Effect of COVID-19 pandemic decisions on tertiary-level surgical services in Pietermaritzburg, KwaZulu-Natal Province, South Africa.

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.

Oxytocin--ensuring appropriate use and balancing efficacy with safety.

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.

Maternal death and caesarean section in South Africa: Results from the 2011-2013 Saving Mothers Report of the National Committee for Confidential Enquiries into Maternal Deaths.

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

'But it's just a spinal': combating increasing rates of maternal death related to spinal anaesthesia.

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.

Crystalloid preload versus rapid crystalloid administration after induction of spinal anaesthesia (coload) for elective caesarean section.

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.