Summary Background Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality. Methods We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov , NCT03853824 . Findings Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported. Interpretation This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa. Funding Bill & Melinda Gates Foundation and the World Federati...

Background All the published Saving Mothers Reports generated by the National Committee of the Confidential Enquiries into Maternal Deaths in South Africa have associated anaesthesia-related maternal deaths with the lack of skills of the doctors administering the anaesthesia. The Reports have shown the Free State to be one of the provinces in South Africa with the highest rate of obstetric anaesthesia deaths. Therefore, the current study was performed to determine whether a deficiency exists in the training and experience of doctors administering obstetric anaesthesia. The identifying of such a deficiency would call for the implementation of remedial measures. Methods The study was performed in 2005 using questionnaires designed by the first two authors of this paper. All Level 1 and 2 hospitals in the Free State performing Caesarean sections (CSs) were visited. The doctors administering obstetric anaesthesia were each asked to respond to a questionnaire. The questionnaires enquired about previous training and experience in anaesthesia and, more specifically, obstetric anaesthesia, as well as anaesthesia and nonanaesthesia qualifications. In addition, questions were asked regarding supervision, and whether other duties were performed while administering anaesthesia. Results The response rate was 69% (105/148 doctors). Of the respondents, 9.5% were interns, 24.7% community service doctors, 47.6% medical officers, 15.2% general practitioners (GPs) and 2.9% specialists. Twenty-three per cent of respondents had been in their present post for five years or more. Most doctors had received 4 weeks or less training in anaesthesia as an Intern, not including obstetric anaesthesia in 13 cases. Six doctors (GPs or medical officers) had been appointed in posts in which obstetric anaesthesia was required, without previously having administered obstetric anaesthesia. At the time of the survey, two doctors had never performed spinal anaesthesia and five had never administered general anaesthesia for CS, although all were regularly administering obstetric anaesthesia. Apart from the specialists, the Diploma in Anaesthesia was held by only one doctor, a medical officer. Half of the interns were not directly supervised while administering obstetric anaesthesia, while more than half the community service doctors were employed in hospitals where no senior support was available. The doctors frequently had both to administer the anaesthetic and to perform neonatal resuscitation. Twelve of the doctors concerned had often also to perform the surgery itself. Most of the doctors requested further training in obstetric anaesthesia and improved senior anaesthetic assistance. Conclusions There is a lack of experience, training and supervision amongst doctors administering obstetric anaesthesia in the Free State. Doctors regularly have to perform other duties, whilst administering obstetric anaesthesia, which may put the mother at risk from inadequate observation. These may be contributory factors to the high rate of maternal deaths from anae...

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Background. Guidelines recommend a preoperative fasting period of 6 hours for solid food and 2 hours for clear fluids. Because of fixed meal times and imprecise operation starting times, patients often fast for an extended period of time.Objective. To investigate the prescribed preoperative fasting times, and the actual duration of fasting, compared with the internationally accepted fasting times for solid food and clear fluids.Methods. Patients (N=105) aged 14 -60 years, who were scheduled for elective surgery in the morning session (list starting time 07h00), were included in this prospective study. On arrival in theatre, all patients were asked when they last ate and drank. Anaesthetic records were used to determine the prescribed fasting times and operation starting times. Results. For solids, patients were most frequently prescribed to start fasting from 22h00 to 00h00 (53.3% and 39.1%, respectively). No patient fasted <8 hours. The median duration of fasting was 14 hours and 45 minutes (range 9 hours and 45 minutes -19 hours and 5 minutes). For fluids, patients were most frequently prescribed to start fasting from 05h00 (46.7%), 00h00 (27.6%) and 22h00 (7.6%). In practice, no patient ingested fluids after 22h30 or <9 hours preoperatively. The median fasting time for oral fluids was 13 hours and 25 minutes (range 9 hours and 37 minutes -19 hours and 5 minutes). Conclusion. Most patients started fasting too early preoperatively, consequently withholding food and oral fluids for longer than recommended. An increased awareness regarding complications of unnecessarily long fasting times, and interventions to correct this problem, is required.S Afr Med J 2017;107(10):910-914.

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Indwelling subcutaneous cannula for the administration of intermittent morphine boluses postoperatively have been used in several centers as an alternative to intramuscular (IM) injections. We introduced this technique to our hospital, assessed it for complications in 220 children, and conducted a survey to see if nursing staff preferred it to IM injections. The injections through the subcutaneous cannulae caused minimal distress to the children. There were no major complications, 95% of the nursing staff preferred this technique, and 74% would give morphine more readily to a child with a subcutaneous cannula in situ.

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