Southern African Journal of Anaesthesia and Analgesia

An audit investigating the practice of preoperative fasting and the administration of medication to patients during the nil per mouth period in Metro East district hospitals

2025-01-06T09:45:02+00:00

Background: Fasting before anaesthesia is an important practice aimed at preventing the aspiration of gastric contents. However, extended fasting periods have been associated with adverse effects. Despite international guidelines, evidence suggests that patients often experience extended fasting times beyond these recommendations. This study evaluated preoperative fasting durations and medication administration practices within the Metro East Health District of Cape Town.

Methods: This descriptive study was conducted across four hospitals in the Cape Metro East Health District: Eerste River, Helderberg, Karl Bremer, and Khayelitsha. A total of 162 patients were enrolled. Eligible participants were aged 18 years or older, undergoing elective or urgent surgical procedures, and admitted more than six hours before surgery. Data on fasting duration, alignment with international fasting guidelines, and medication administration were collected using structured questionnaires. Statistical analysis included one-way ANOVA for fasting times and chi-square tests for categorical variables.

Results: The average fasting durations observed were 14.25 hours for solid foods and 13.10 hours for fluids, which significantly exceeded the recommended guidelines. There were no statistically significant differences in fasting durations between hospitals. Only 17.90% of patients’ fasting instructions conformed to the international guidelines. Correct fasting instructions correlated with a significant reduction in fasting time for solids. However, no decrease was observed for fluids. The reduced fasting time for solids still exceeded acceptable practice. Adherence to medication protocols during the nil per mouth (NPM) period was notably poor.

Conclusion: Metro East Health District patients experience prolonged fasting durations that exceed recommendations. Contributing factors include inaccurate fasting instructions by doctors and suboptimal medication administration by nursing staff during the NPM period. Research is needed to develop interventions to improve NPM fasting times and medication administration.

A prospective analysis of shift work and fatigue scores in anaesthesiology registrars at four Johannesburg hospitals

2025-02-24T11:11:40+00:00

Background: Fatigue among anaesthesiologists is a critical safety concern. The prevalence of fatigue is high among South African doctors, with an unknown prevalence among South African anaesthesiologists. This study aimed to determine the fatigue scores of anaesthesiology registrars at four academic hospitals in Johannesburg.

Methods: This was a prospective, cross-sectional study using selective sampling. Data were collected from shifts worked by 47 anaesthesiology registrars in the Department of Anaesthesiology at the University of the Witwatersrand across the four academic hospitals. Objective and subjective fatigue scores for each completed shift worked by each anaesthesiology registrar were obtained using the Fatigue Audit InterDyne (FAID^®) Quantum tool by InterDynamics (Brisbane, Australia) and the Karolinska Sleepiness Scale (KSS), respectively. Descriptive statistics, t-tests, ANOVA, chi-square tests, and correlation and agreement analyses (Pearson, Spearman, and Kappa tests) were used to analyse the data.

Results: A total of 1 321 shifts were analysed across 47 anaesthesiology registrars. There were 183 shifts (13.9%, 95% confidence interval [CI] 12.0 to 15.8) that scored a dangerous level of objective fatigue during a shift. Also, 446 shifts (33.8%, 95% CI 31.2 to 36.4) scored a dangerous level of subjective fatigue after a shift, indicating an elevated risk of fatigue-related errors (p < 0.001). A moderate positive correlation of 0.35 was observed between the two fatigue scores (p < 0.001).

Conclusion: Anaesthesiology registrars at the University of the Witwatersrand experience fatigue that can be considered dangerous based on objective and subjective scores. The implications of fatigue on clinical decision-making and burnout present important areas for future research.

To evaluate the changes in perfusion index in the lithotomy position during spinal anaesthesia

2025-04-22T09:58:17+00:00

Background: Spinal anaesthesia induces lumbosacral sympathetic blockade. The lithotomy position is an add-on to spinal anaesthesia vasodilation, which further compromises tissue perfusion. This study aimed to identify the changes in perfusion index (PI) in the upper and lower limbs in the lithotomy position following spinal anaesthesia. A comparison of PI changes in the upper and lower limbs was a secondary objective.

Methods: A total of 100 patients, aged 18–60 years, with an American Society of Anesthesiologists (ASA) physical status of 1 and 2, and scheduled for surgery under spinal anaesthesia in the lithotomy position, were included. Baseline PI was measured using a specific pulse oximeter probe (Masimo Radical-7^® Pulse CO-Oximeter^®, Masimo Corp., Irvine, United States), one at the fingertip and another at the toe. The lithotomy position was made after 10 minutes of spinal anaesthesia. The PI was noted subsequently at different time periods at both sites. Mean arterial pressure (MAP), heart rate (HR), and SpO₂ were also recorded.

Results: The mean PI value measured in the toe increased immediately after spinal anaesthesia, and reached a peak at 10–15 minutes, then decreased progressively in the lithotomy position. In the postoperative period, PI increased immediately after positioning the patient supine, and subsequently decreased, reaching near-baseline values. These changes in PI in toe at all the time periods were clinically significant. Conversely, PI values measured in the fingertip at all the time periods were clinically insignificant.

Conclusion: PI can be used to estimate circulatory states. Therefore, its use is recommended to prevent circulatory compromise in the lower limbs following spinal anaesthesia and the lithotomy position.

Knowledge of essential regional ultrasound anatomy in an academic department of anaesthesiology and critical care

2025-06-11T12:40:48+00:00

Background: Regional anaesthesia offers significant benefits for pain management, patient satisfaction, and surgical outcomes. Ultrasound-guided regional anaesthesia (UGRA) enhances accuracy and reduces complications; however, it requires thorough knowledge of sonoanatomy to avoid serious injuries. International guidelines now emphasise the concept of “Plan A blocks”, promoting standardised UGRA training with set core competencies. This study aimed to assess anaesthetists’ knowledge of the regional sonoanatomy of these Plan A blocks.

Methods: After ethical approval, a descriptive, cross-sectional study was conducted at an academic meeting in the Department of Anaesthesiology and Critical Care at Tygerberg Hospital. The questionnaire was face-validated by experienced providers according to published standards and contained general questions and ultrasound images of the seven Plan A blocks. Participants were asked to identify the block and label essential anatomical structures as defined in the literature.

Results: The academic meeting was attended by 54 anaesthetists and all were enrolled. All practised UGRA. According to the assessment, only 25.9% of participants had sufficient knowledge of regional ultrasound anatomy (could identify ≥ 60% of the structures). Most could identify the blocks but were unable to label the structures correctly. A statistically significant relationship could not be shown between anaesthesia experience and overall score on the Plan A blocks section of the questionnaire (F = 2.07, p = 0.07). A statistically significant relationship was found between experience and participants’ self-knowledge rating (F = 3.49, p = 0.006). Nearly all the participants (98.1%) believed that a formal teaching programme would be beneficial. Barriers to performing UGRA included lack of time, pressure from surgeons and unavailability of equipment.

Conclusion: Core knowledge of ultrasound anatomy is essential for anaesthetists performing UGRA to ensure patient safety and optimal outcomes. This study found that anaesthesia providers at Tygerberg Hospital lack sufficient knowledge of essential regional sonoanatomy specific to Plan A blocks, and suggest implementation of a formal training programme.

Enhanced recovery after caesarean section - a call to action

2025-04-22T04:55:19+00:00

Caesarean section (CS) is the most common surgical procedure globally and represents a third of surgeries performed in resource-limited settings.^1,2 In South Africa (SA), the reported CS rate in the public sector was 24.1% in 2015 and continues to rise.³ A SA study found that pain assessment post-CS was poor, with less than a third of patients receiving analgesics as prescribed.⁴ Another SA study found that post-CS patients experienced the highest incidence of moderate to severe pain of all procedures (> 80%).⁵ Pain management post-CS remains particularly challenging in resource-limited settings, especially in the context of enhanced recovery programmes.^1,2

Beyond "nil per mouth": towards evidence-based fasting and medication practices

2025-09-30T10:04:42+00:00

Excessive preoperative fasting remains entrenched across South African hospitals despite clear international guidance that prolonged fasting confers no benefit and can be harmful. In this issue, Du Pisanie et al.¹ add new data from district hospitals to prior tertiary-level reports, confirming that patients continue to experience fasting durations far exceeding guideline recommendations. Prolonged fasting contributes to dehydration, hypoglycaemia, patient discomfort, and increased perioperative stress, all of which may impact perioperative outcomes.²

CPD Questionnaire (V31N05)

2025-10-13T07:23:55+00:00

CPD questionnaire