Background: Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low-and middle-income countries (LMICs). Methods: We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. Results: We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4e11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2e8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6e1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. Conclusions: The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings

Background The prevalence of anemia in the South African pediatric surgical population is unknown. Anemia may be associated with increased postoperative complications. We are unaware of studies documenting these findings in patients in low‐ and middle‐income countries (LMICs). Aim The primary aim of this study was to describe the association between preoperative anemia and 26 defined postoperative complications, in noncardiac pediatric surgical patients. Secondary aims included describing the prevalence of anemia and risk factors for intraoperative blood transfusion. Method This was a secondary analysis of the South African Paediatric Surgical Outcomes Study, a prospective, observational surgical outcomes study. Inclusion criteria were all consecutive patients aged between 6 months and <16 years, presenting to participating centers during the study period who underwent elective and nonelective noncardiac surgery and had a preoperative hemoglobin recorded. Exclusion criteria were patients aged <6 months, undergoing cardiac surgery, or without a preoperative Hb recorded. To determine whether an independent association existed between preoperative anemia and postoperative complications, a hierarchical stepwise logistic regression was conducted. Results There were 1094 eligible patients. In children in whom a preoperative Hb was recorded 46.2% had preoperative anemia. Preoperative anemia was independently associated with an increased risk of any postoperative complication (odds ratio 2.0, 95% confidence interval: 1.3‐3.1, P = .002). Preoperative anemia (odds ratio 3.6, 95% confidence interval: 1.8‐7.1, P < .001) was an independent predictor of intraoperative blood transfusion. Conclusion Preoperative anemia had a high prevalence in a LMIC and was associated with increased postoperative complications. The main limitation of our study is the ability to generalize the results to the wider pediatric surgical population, as these findings only relate to children in whom a preoperative Hb was recorded. Prospective studies are required to determine whether correction of preoperative anemia reduces morbidity and mortality in children undergoing noncardiac surgery.

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],). 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.

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.

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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 1 st January to 31 st 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.

Background: Adenotonsillectomy remains one of the most frequently performed surgical procedures in children. Despite improvements in anaesthetic and surgical techniques, severe pain is reported in as many as 25–50% of children. Pain assessment and knowledge of drug pharmacodynamics and pharmacokinetics in the paediatric patient, is a prerequisite for optimal care. Much has been written on perioperative pain management following tonsillectomy. However, no consensus has been reached on what the ideal analgesic regimen should be. This audit is a review of current practice at Chris Hani Baragwanath Academic Hospital. It aims to identify problems and develop possible solutions to improve anaesthetic practice. Methods: A prospective, contextual, descriptive study design using a data collection sheet was used on paediatric patients presenting for tonsillectomy. Results: Eighty-five patients aged three to 12 years of age, with ASA grading I or II, were enrolled in the study. The choice of anaesthetic was variable with a combination of simple analgesics, opioids and adjuvants. This affected postoperative pain scores. Snare dissection and monopolar cautery haemostasis, was the standard surgical technique. Surgical seniority influenced the duration of tonsillectomy, with an effect on postoperative pain scores. Conclusions: Audits are necessary to evaluate what resources are needed to optimise care. The occurrence of pain after tonsillectomy continues to be poorly managed. Appropriate premedication and fasting of clear fluids for no more than two hours, needs to be introduced. Where possible surgical technique should involve bipolar cautery and be limited to less than 45 minutes. A preemptive, multimodal, opioid-sparing anaesthetic should be routinely practised.

Children presenting for liver resection form a challenging population with co-morbidities that require adequate preoperative assessment and planning to improve postoperative outcomes. With the development of new surgical equipment and techniques, the anaesthestist is in a precarious position in which a delicate balance is needed between delivering organprotective anaesthesia and providing haemodynamic stability that will allow for optimal surgical results. This review will highlight some of these aspects.