Global Capnography Project (GCAP): implementation of capnography in Malawi - an international anaesthesia quality improvement project

The Lancet Commission on Global Surgery emphasised the importance of access to safe anaesthesia care. Capnography is an essential monitor for safe anaesthesia, but is rarely available in low‐income countries. The aim of this study was twofold: to measure the prevalence of capnography in the operating theatres and in intensive care units; and to determine whether its introduction was feasible and could improve the early recognition of critical airway incidents in a low‐income country. This is the first project to do this. Forty capnographs were donated to eight hospitals in Malawi. Thirty‐two anaesthesia providers received a 1‐day capnography training course with pre‐ and post‐course knowledge testing. Providers kept logbooks of capnography use and recorded their responses to abnormal readings. On follow‐up at 6 months, providers completed questionnaires on any significant patient safety incidents identified using capnography. In January 2017, at the commencement of the project, only one operating theatre had a capnograph. Overall, 97% and 100% ‘capnography gaps’ were identified in the theatres and intensive care units, respectively. The mean (SD) scores of our capnography multiple choice questionnaires improved after training from 15.00 (3.16) to 18.70 (0.99), p = < 0.001. The capnography equipment was appropriately robust and performed well. Six months following implementation, 24 (77%) anaesthesia providers reported recognising 44 oesophageal intubations and 28 (90%) believed that capnography had saved lives. This study has shown it is feasible to introduce capnography in a low‐income country, resulting in early recognition of critical airway incidents and ultimately helping to save lives. Building on the experience of the first trial of pulse oximetry implementation in low‐income countries in 2007, we believe this is one of the most important projects in anaesthesia safety in the last decade.

Evening primrose oil (Epogam) in the treatment of chronic hand dermatitis: disappointing therapeutic results

BACKGROUND

Hand dermatitis is a common therapeutic challenge with limited and unsatisfactory therapy modules. A possible beneficial role of oral evening primrose oil needs to be investigated.

OBJECTIVE

Pharmacological doses of gamma-linolenic acid (GLA) could improve the water permeability barrier of the epidermis in chronic hand dermatitis. Clinical improvement, changes in the lipogram and epidermal lipid composition could define functional improvement of the skin. Electron-microscopic evaluation of the epidermal lipid bilayer could underline the efficacy of essential fatty acids in chronic hand dermatitis.

METHODS

Thirty-nine patients with chronic (> 1 year), stable hand dermatitis entered a 24-week double-blind placebo-controlled trial. Patch test with the European standard of allergens, haematogram and serum IgE values were determined before commencement of the study. Active therapy (600 mg/day of GLA) was administered to half the patient group. Medication was given for 16 weeks and observations continued for another 8 weeks. Patients were assessed clinically, using a visual analogue scale at 4-week intervals. Plasma and red blood cell lipograms, as well as skin biopsies, were taken before therapy, after the 16-week supplementation period and at week 24. Tissue was used for histological evaluation, electron-microscopic assessment and epidermal lipid analysis.

RESULTS

Improvement in clinical parameters was present in the Epogam and placebo groups, but no statistical difference could be confirmed between the groups. Haematogram, blood and epidermal biochemistry were normal at baseline. No change in the lipid composition of plasma red cells or epidermis could be detected during the trail. Ultrastructurally skin specimens showed no change during the study period.

CONCLUSION

The study indicates that the therapeutic value of orally administered GLA for chronic hand dermatitis is not superior to that of placebo.

Preliminary study of a pregnanolone emulsion (Kabi 2213) for i.v. induction of general anaesthesia

Pregnanolone emulsion was administered i.v. to 13 healthy male volunteers to assess its potential as an agent for i.v. induction of general anaesthesia and to establish a pharmacokinetic profile at two doses. Each subject received 0.5 mg kg-1, 0.75 mg kg-1 and 1.0 mg kg-1 on successive occasions, the rate of administration being constant for each dose. Pregnanolone emulsion was found to produce smooth and reliable induction of general anaesthesia with cardiorespiratory effects comparable to those of other i.v. induction agents.

An ultrastructural study of initial changes in epithelium damaged by surface freezing

The changes seen in frozen thawed epithelium have been compared with pathological changes occurring under other circumstances. The intact cell membranes, invaginated cells, and varying densities of cell cytoplasm are all compatible with osmotic changes occurring after alteration in cell membrane permeability as is the development of bullae under these conditions. It is suggested, therefore, that this constitutes the major mechanism of cryosurgical attack at these temperatures. The finding that ultrastructural damage was evident very shortly after thawing, implicates changes directly due to freezing and thawing but does not necessarily rule out later additional cell damage occurring in an ischaemic situation.