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: Emergence delirium is a well-described complication in pediatric anesthesia, occurring more often following short surgical procedures using volatile anesthetics with a rapid recovery profile. Dental extractions and conservation dentistry are commonly performed in children and are not painful postoperatively. The use of nerve blocks and local anesthetic infiltration intraoperatively limits nociception and obviates the need for opioids, allowing for more objective assessment of emergence delirium. Aim: The purpose of this preliminary study was to describe the incidence of emergence delirium and the associated risk factors in children undergoing elective dental surgery under general anesthesia at a regional academic hospital in South Africa. Methods: A prospective, descriptive study of healthy children aged 2-6 years was undertaken. Patients were anesthetized using standardized protocols. Assessments included demographics of the child and caregiver, child anxiety at induction using the modified Yale Preoperative Anxiety Scale, intraoperative events, and Paediatric Anaesthesia Emergence Delirium score in the recovery room. Data were assessed for associations and correlations. Results: Ninety-one children with a mean age of 3.9 (SD = 0.9) years were included. Anxiety was present in 69.2% at induction and emergence delirium occurred in 51.6% of the patients. The mean (SD, range) Paediatric Anaesthesia Emergence Delirium score in the patients without emergence delirium was 7 (2.65, 0-9) and in patients with emergence delirium was 14 (2.52, 10-18). Children with emergence delirium required more interventions in the recovery room but few required pharmacological treatment. Conclusions: Emergence delirium occurs commonly after dental surgery, and the majority of the children presenting for dental surgery are anxious at induction. Children with emergence delirium require more interventions in the recovery room but few require pharmacological treatment.
Fibrodysplasia ossificans progressiva (FOP) is an extremely rare genetic disorder characterised by extraskeletal ossification of connective tissue. Affected individuals often become completely immobilised by their third decade of life. Amongst numerous anaesthetic concerns, the airway management of patients with FOP may prove to be the greatest challenge. This case report describes the anaesthetic management of a three-year-old girl with FOP and highlights the difficulties encountered during airway management.
Distribution and determinants of heart disease vary greatly between high-income countries and sub-Saharan Africa where rheumatic heart disease (RHD) is a major public health challenge. (1) RHD is the predominant cause of valve disease in Africa, (2) resulting in Africa having the highest prevalence of cardiac disease in children and young adults .(1) Cumulative effects of poverty, social instability and lack of infrastructure, resources and awareness contribute to the underestimated impact of RHD. (1,2) Studies from Africa confirm that RHD is the main cause of cardiac morbidity and mortality from heart surgery. (1)(2)(3) Mitral valve disease, in the form of mitral stenosis and mitral regurgitation, is the commonest form of valve disease and its treatment usually involves surgical repair or replacement. These surgical procedures are highly invasive and not without risk of complications. (3) In South Africa, data on the management and outcomes of mitral valve surgery are limited. (4) Operative mortality in mitral valve replacement surgery is 5% -6% and 1% -2% in mitral valve repair. (5) Complications associated with mitral valve surgery are commonly related to cardiopulmonary
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