Parents/Caregivers' perceptions towards use of analgesic suppositories in paediatric elective surgery.

Introduction: Despite the benefits of analgesic suppositories, there remains controversy around their administration. The perceptions of the parents and caregivers regarding this are unknown in our population. We investigated the perceptions of parents/caregivers towards the use of analgesic suppositories in elective paediatric surgery. We also explored whether parents/caregivers perceived a need for additional consent for the administration of suppositories. Materials and Methods: This was a prospective cross-sectional study conducted at Charlotte Maxeke Johannesburg Academic Hospital, South Africa. The primary outcome was to describe perceptions of parents/caregivers towards analgesic suppositories. Questionnaire-guided interviews were conducted with parents/caregivers of children presenting for elective paediatric surgery. Results: Three hundred and one parents/caregivers were enrolled in the study. Two hundred and sixty-two (87%) were female and 174 (13%) were male. Two hundred and seventy-six (92%) were parents and 24 (9%) were caregivers. There was a high level of acceptability of suppository use in 243 (81%) parents/caregivers. Majority (235, 78%) felt that they should be asked for permission before their child was given a suppository, and more than half (134, 57%) expressed that it should be in a written consent format. The parents/caregivers did not believe that suppositories would cause pain (unadjusted odds ratio [uOR]: 2.49; 95% confidence interval [CI]: 1.29-4.79; P = 0.006) but were unsure whether they would relieve post-operative pain (uOR: 0.25; 95% CI: 0.11-0.57; P = 0.001). Those who had previously used a suppository themselves were significantly more likely to accept the use of suppositories in children (uOR: 4.34; 95% CI: 1.56-12.07; P = 0.005). Conclusion: There was a high level of acceptability of the use of analgesic suppositories. Our population showed a unique preference for written consent over verbal consent. There was a strong positive association between previous use of suppositories by parents/caregivers and acceptance for use in children.

An audit of cancellation of elective surgery in paediatric patients at Chris Hani Baragwanath Academic Hospital.

Background: Cancellation of elective surgery is one of the quality indicators of theatre operation worldwide. The cancellation of elective surgery in paediatric patients is a worldwide problem with the rates ranging from 0.21% to 44%. This study aimed to determine the rates and describe the reasons for cancellation of elective surgeries in paediatric patients at Chris Hani Baragwanath Academic Hospital (CHBAH). Materials and Methods: A retrospective study was conducted using theatre records from 1st January to 31st December 2019. The numbers and reasons for elective paediatric surgeries were reviewed. Data were collected using the structured collection sheet and entered into Microsoft Excel. Statistical Package for the Social Sciences was also used to further analyse the data. Results were expressed as percentages in a graph and table forms. Results: In the year 2019, a total of 3399 elective paediatric procedures were scheduled in 14 specialities at CHBAH. Of these, 634 (19%) were cancelled due to various reasons. The highest number of cases cancelled were from paediatric surgery and neonates (n = 204, 31%), followed by ear nose and throat (n = 99, 24%), burns (n = 80, 20%) and paediatric orthopaedics (n = 79, 16%). The most common reason for cancellation of elective surgery in paediatric patients at CHBAH was found to be time constraint (34%). The reasons for cancellation in our study were mostly due to avoidable factors at 68% and non-avoidable at 32%. Conclusion: The rate of cancellation in our study was high. Majority of the causes for cancellation were avoidable.

A Survey of Paediatric Rapid Sequence Induction in a Department of Anaesthesia.

(1) Background: Rapid sequence induction (RSI) is carried out by anaesthetists to secure the airway promptly in patients who are at risk of aspirating gastric content during induction of anaesthesia. RSI requires variation in the paediatric population. We conducted a survey to investigate current practice of paediatric RSI by anaesthetists. (2) Methods: A descriptive, contextual, cross-sectional research design was followed. The study population consisted of all anaesthetists working in the Department of Anaesthesia at the University of the Witwatersrand. Data was collected in the form of a self-administered questionnaire. (3) Results: Of 138 questionnaires that were distributed, 126 were completed. Clinical indication for RSI was predominantly for appendicitis with peritonitis (115/124; 92.7%). Preoxygenation was performed by 95.1% of anaesthetists for children, 87% for infants and 89.4% for neonates. Cricoid pressure was used significantly more in children (56%) than in infants (20.8%) and neonates (10.3%) (p < 0.001). Rocuronium was the paralytic agent of choice in children (42.7%) and infants (38.2%), while cisatracurium was used most frequently in neonates (37.4%). Suxamethonium was used least in neonates. Cuffed ETTs were used most frequently for children (99.2%) and least for neonates (49.6%). Eighty-five percent of anaesthetists omitted cricoid pressure during RSI for pyloromyotomy, for which a controlled RSI was performed more by consultants and senior registrars (p < 0.01). A classic RSI was performed by 53.6% of anaesthetists for laparotomy for small bowel obstruction. Consultants and PMOs were more likely to intubate a child for forearm MUA who was starved for 6 h and received opioids (p < 0.05). Controlled RSI with cisatracurium was the technique of choice for Tenkhoff insertion in a child with renal failure. (4) Conclusions: RSI practice for paediatric patients varied widely among anaesthetists. This may be attributed to a combination of anaesthetic experience, training in paediatric anaesthesia, and patient specific factors, along with the individualised clinical scenario's aspiration risk. A controlled RSI technique appears to be implemented more frequently by anaesthetists with increased experience.

The Phenotypical Profile and Outcomes of Neonates with Congenital Tracheoesophageal Fistula Associated with Congenital Cardiac Anomalies Presenting for Surgery.

(1) Background: Neonates born with oesophageal atresia and/or tracheooesophageal fistula (OA/TOF) are usually born with a multitude of other congenital anomalies, which may affect their anaesthetic care and survival to hospital discharge. We reviewed the profile and outcome of neonates with OA/TOF and associated congenital cardiac anomalies presenting for surgery at an academic hospital in South Africa. (2) Methods: A retrospective, cross-sectional analysis of all medical records of neonates who had undergone surgical repair of OA/TOF was conducted at an academic hospital between January 2015 and December 2019. Descriptive statistics were used to report the data. Comparisons in perioperative events and outcomes between those with cardiac lesions and those without were done. (3) Results: Neonates presenting for OA/TOF repair with congenital cardiac defects had an incidence of 62 [95% CI 38.5-99.8] per 1000 days since birth. In total, 45.9% had associated cardiac anomalies, with PDA and ASD as the most prevalent lesions. There were statistically significant differences in intraoperative adverse events seen in neonates with congenital cardiac lesions as compared to those without. (4) Conclusion: Despite advances in neonatal critical care and anaesthetic and surgical techniques, OA/TOF associated with congenital cardiac anomalies is still associated with high mortality rates in developing countries.

An Evaluation of Severe Anesthetic-Related Critical Incidents and Risks From the South African Paediatric Surgical Outcomes Study: A 14-Day Prospective, Observational Cohort Study of Pediatric Surgical Patients.

BACKGROUND: Severe anesthetic-related critical incident (SARCI) monitoring is an essential component of safe, quality anesthetic care. Predominantly retrospective data from low- and middle-income countries (LMICs) report higher incidence but similar types of SARCI compared to high-income countries (HIC). The aim of our study was to describe the baseline incidence of SARCI in a middle-income country (MIC) and to identify associated risk for SARCI. We hypothesized a higher incidence but similar types of SARCI and risks compared to HICs. METHODS: We performed a 14-day, prospective multicenter observational cohort study of pediatric patients (aged <16 years) undergoing surgery in government-funded hospitals in South Africa, a MIC, to determine perioperative outcomes. This analysis described the incidence and types of SARCI and associated perioperative cardiac arrests (POCAs). We used multivariable logistic regression analysis to identify risk factors independently associated with SARCI, including 7 a priori variables and additional candidate variables based on their univariable performance. RESULTS: Two thousand and twenty-four patients were recruited from May 22 to August 22, 2017, at 43 hospitals. The mean age was 5.9 years (±standard deviation 4.2). A majority of patients during this 14-day period were American Society of Anesthesiologists (ASA) physical status I (66.4%) or presenting for minor surgery (54.9%). A specialist anesthesiologist managed 59% of cases. These patients were found to be significantly younger (P < .001) and had higher ASA physical status (P < .001). A total of 426 SARCI was documented in 322 of 2024 patients, an overall incidence of 15.9% (95% confidence interval [CI], 14.4-17.6). The most common event was respiratory (214 of 426; 50.2%) with an incidence of 8.5% (95% CI, 7.4-9.8). Six children (0.3%; 95% CI, 0.1-0.6) had a POCA, of whom 4 died in hospital. Risks independently associated with a SARCI were age (adjusted odds ratio [aOR] = 0.95; CI, 0.92-0.98; P = .004), increasing ASA physical status (aOR = 1.85, 1,74, and 2.73 for ASA II, ASA III, and ASA IV-V physical status, respectively), urgent/emergent surgery (aOR = 1.35, 95% CI, 1.02-1.78; P = .036), preoperative respiratory infection (aOR = 2.47, 95% CI, 1.64-3.73; P < .001), chronic respiratory comorbidity (aOR = 1.75, 95% CI, 1.10-2.79; P = .018), severity of surgery (intermediate surgery aOR = 1.84, 95% CI, 1.39-2.45; P < .001), and level of hospital (first-level hospitals aOR = 2.81, 95% CI, 1.60-4.93; P < .001). CONCLUSIONS: The incidence of SARCI in South Africa was 3 times greater than in HICs, and an associated POCA was 10 times more common. The risk factors associated with SARCI may assist with targeted interventions to improve safety and to triage children to the optimal level of care.

Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review.

Open-heart surgery is the leading cause of neuronal injury in the perioperative state, with some patients complicating with cerebrovascular accidents and delirium. Neurological fallout places an immense burden on the psychological well-being of the person affected, their family, and the healthcare system. Several randomised control trials (RCTs) have attempted to identify therapeutic and interventional strategies that reduce the morbidity and mortality rate in patients that experience perioperative neurological complications. However, there is still no consensus on the best strategy that yields improved patient outcomes, such that standardised neuroprotection protocols do not exist in a significant number of anaesthesia departments. This review aims to discuss contemporary evidence for preventing and managing risk factors for neuronal injury, mechanisms of injury, and neuroprotection interventions that lead to improved patient outcomes. Furthermore, a summary of existing RCTs and large observational studies are examined to determine which strategies are supported by science and which lack definitive evidence. We have established that the overall evidence for pharmacological neuroprotection is weak. Most neuroprotective strategies are based on animal studies, which cannot be fully extrapolated to the human population, and there is still no consensus on the optimal neuroprotective strategies for patients undergoing cardiac surgery. Large multicenter studies using universal standardised neurological fallout definitions are still required to evaluate the beneficial effects of the existing neuroprotective techniques.

Assessment of Nutritional Status and Dietary Intake of Pregnant Women in Rural Area of Vhembe District, Limpopo Province.

Poor consumption of balanced diet could result in poor weight gain during pregnancy increasing the risk of premature delivery, low birth weight, and birth defects. To assess the nutritional status and dietary intake of pregnant women in rural areas of Vhembe district. A cross-sectional descriptive study was carried out among 240pregnant women who were selected conveniently from 16 clinics in Vhembe District. An interviewer-administered questionnaire was used for data collection. Anthropometric measurements were measured following standard techniques. Data on dietary intake were collected using Food Frequency Questionnaire (FFQ). Permission and clearance were obtained and participant's rights were respected. Majority (78%) had secondary educational level while 19.5% had tertiary educational level. The mean energy and carbohydrate intake was 2248 Kcal and 372.1 g, respectively. Prevalence of underweight, overweight and obese using BMI was 16.3%, 24.2%, and 8.7% respectively. Dietary intake of the study participants showed that the intake of energy, fats, carbohydrates and vitamin C met the Recommended Dietary Allowance (RDA) values. The mean intake of protein was 30.2 ± 18.2 g. However, micronutrients like zinc, iron, magnesium, calcium including Vitamin A, B1 and B2 did not meet the RDA values in the current study. Despite government's programs to ensure adequate consumption of micronutrients and proper weight gain during pregnancy, malnutrition and insufficient consumption of micronutrients remains a major public health problem in South Africa. Improving nutritional status during pregnancy should follow an integrated approach tackling both malnutrition and micronutrient deficiencies at the same time considering the behavioral approach which will improve child survival and maternal health.