Reduced incidence of postoperative nausea and vomiting in black South Africans and its utility for a modified risk scoring system.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common occurrence with a reported incidence between 20% and 40%. In this prospective observational study, we sought to determine the incidence of PONV in a South African population, differentiating between black South African (African) and the remainder of the multiethnic South African population (non-African). We attempted to identify individual risk factors for PONV and to test the performance of the Apfel PONV predictive scoring system in our patient population. METHODS: The primary outcome for the study was nausea, vomiting or retching, or the combination of both events within 24 hours of surgery. We collected 800 patients, 400 Africans and 400 non-Africans in each group, over a 4-month period. RESULTS: There was a statistically significant difference in the incidence of PONV between African and non-African groups (27% vs 45%, P < 0.0001). Stepwise, backward logistic regression analysis identified female sex (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.6), non-African ethnicity (OR, 2.1; 95% CI, 1.5-2.82), PONV or motion sickness history (OR, 2.6; 95% CI, 1.8-3.7), and the use of postoperative opioids (OR, 1.4; 95% CI, 1-1.9) to be independent predictors of PONV. The area under the receiver operator curve for the Apfel score was 0.62. When modeling the independent risk factors in our population, the combination of non-African ethnicity, female sex, and a history of motion sickness or PONV resulted in a receiver operator curve area of 0.67. CONCLUSION: We were able to identify black South African ethnicity as an independent risk factor for decreasing the incidence of PONV. The reason for this observation remains speculative and further investigation is warranted. The inclusion of ethnicity as a risk factor into PONV scoring systems should be explored.

Critical care admission of South African (SA) surgical patients: Results of the SA Surgical Outcomes Study.

BACKGROUND: Appropriate critical care admissions are an important component of surgical care. However, there are few data describing postoperative critical care admission in resource-limited low- and middle-income countries. OBJECTIVE: To describe the demographics, organ failures, organ support and outcomes of non-cardiac surgical patients admitted to critical care units in South Africa (SA). METHODS: The SA Surgical Outcomes Study (SASOS) was a 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 government-funded hospitals. All patients admitted to critical care units during this study were included for analysis. RESULTS: Of the 3 927 SASOS patients, 255 (6.5%) were admitted to critical care units; of these admissions, 144 (56.5%) were planned, and 111 (43.5%) unplanned. The incidence of confirmed or strongly suspected infection at the time of admission was 35.4%, with a significantly higher incidence in unplanned admissions (49.1 v. 24.8%, p<0.001). Unplanned admission cases were more frequently hypovolaemic, had septic shock, and required significantly more inotropic, ventilatory and renal support in the first 48 hours after admission. Overall mortality was 22.4%, with unplanned admissions having a significantly longer critical care length of stay and overall mortality (33.3 v. 13.9%, p<0.001). CONCLUSION: The outcome of patients admitted to public sector critical care units in SA is strongly associated with unplanned admissions. Adequate 'high care-dependency units' for postoperative care of elective surgical patients could potentially decrease the burden on critical care resources in SA by 23%. This study was registered on ClinicalTrials.gov (NCT02141867).

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; p<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; p<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.

Critical care of the vascular surgery patient.

Providing effective critical care to vascular surgical patients is challenging to the intensivist. These patients often have multiple significant concurrent diseases that need to be adequately managed. A selective policy for identifying patients that need ICU is recommended. Early and smooth restoration to their preoperative physiological homeostasis is crucial. Optimal pain relief, return to normothermia, and adequate intravascular volume replacement are thus key interventions. Epidurals provide excellent analgesia. Vigilant monitoring and decisive therapy of the wide range of complications that may occur in the postoperative is of paramount importance. The level of monitoring should be an extension of that done intraoperatively. Hemorrhage and thrombosis are dreaded sequelae; cardiac morbidity and mortality is significant. Respiratory complications may necessitate prolonged postoperative mechanical ventilation. Careful clinical evaluation is necessary to detect the various neurological complications that may occur. Renal and gastrointestinal complications are potentially lethal. Graft sepsis may occur later. The development of new techniques, such as endovascular repairs of aneurysms, may minimize the need for ICU.