The development of a nurse-led preoperative anaesthesia screening tool by Delphi consensus

BACKGROUND

Low- and middle-income countries have a critical shortage of specialist anaesthetists. Most patients arriving for surgery are of low perioperative risk. Without immediate access to preoperative specialist care, an appropriate interim strategy may be to ensure that only high-risk patients are seen preoperatively by a specialist. Matching human resources to the burden of disease with a nurse-administered pre-operative screening tool to identify high-risk patients who might benefit from specialist review prior to the day of surgery may be an effective strategy.

OBJECTIVE

To develop a nurse-administered preoperative anaesthesia screening tool to identify patients who would most likely benefit from a specialist review before the day of surgery, and those patients who could safely be seen by the anaesthetist on the day of surgery. This would ensure adequate time for optimisation of high-risk patients preoperatively and limit avoidable day-of-surgery cancellations.

METHODS

A systematic review was conducted to identify preoperative screening questions for use in a three-round Delphi consensus process. A panel of 16 experienced full-time clinical anaesthetists representing all university-affiliated anaesthesia departments in South Africa participated to define a nurses' screening tool for preoperative assessment.

RESULTS

Ninety-eight studies were identified, which generated 79 questions. An additional 14 items identified by the facilitators were added to create a list of 93 questions for the first round. The final screening tool consisted of 81 questions, of which 37 were deemed critical to identify patients who should be seen by a specialist prior to the day of surgery.

CONCLUSION

A structured nurse-administered preoperative screening tool is proposed to identify high-risk patients who are likely to benefit from a timely preoperative specialist anaesthetist review to avoid cancellation on the day of surgery.

Consensus statement on measures to promote equitable authorship in the publication of research from international partnerships

Despite the acknowledged injustice and widespread existence of parachute research studies conducted in low‐ or middle‐income countries by researchers from institutions in high‐income countries, there is currently no pragmatic guidance for how academic journals should evaluate manuscript submissions and challenge this practice. We assembled a multidisciplinary group of editors and researchers with expertise in international health research to develop this consensus statement. We reviewed relevant existing literature and held three workshops to present research data and holistically discuss the concept of equitable authorship and the role of academic journals in the context of international health research partnerships. We subsequently developed statements to guide prospective authors and journal editors as to how they should address this issue. We recommend that for manuscripts that report research conducted in low‐ or middle‐income countries by collaborations including partners from one or more high‐income countries, authors should submit accompanying structured reflexivity statements. We provide specific questions that these statements should address and suggest that journals should transparently publish reflexivity statements with accepted manuscripts. We also provide guidance to journal editors about how they should assess the structured statements when making decisions on whether to accept or reject submitted manuscripts. We urge journals across disciplines to adopt these recommendations to accelerate the changes needed to halt the practice of parachute research.

Variation in global uptake of the Surgical Safety Checklist

Background

The Surgical Safety Checklist (SSC) is a patient safety tool shown to reduce mortality and to improve teamwork and adherence with perioperative safety practices. The results of the original pilot work were published 10 years ago. This study aimed to determine the contemporary prevalence and predictors of SSC use globally.

Methods

Pooled data from the GlobalSurg and Surgical Outcomes studies were analysed to describe SSC use in 2014–2016. The primary exposure was the Human Development Index (HDI) of the reporting country, and the primary outcome was reported SSC use. A generalized estimating equation, clustering by facility, was used to determine differences in SSC use by patient, facility and national characteristics.

Results

A total of 85 957 patients from 1464 facilities in 94 countries were included. On average, facilities used the SSC in 75·4 per cent of operations. Compared with very high HDI, SSC use was less in low HDI countries (odds ratio (OR) 0·08, 95 per cent c.i. 0·05 to 0·12). The SSC was used less in urgent compared with elective operations in low HDI countries (OR 0·68, 0·53 to 0·86), but used equally for urgent and elective operations in very high HDI countries (OR 0·96, 0·87 to 1·06). SSC use was lower for obstetrics and gynaecology versus abdominal surgery (OR 0·91, 0·85 to 0·98) and where the common or official language was not one of the WHO official languages (OR 0·30, 0·23 to 0·39).

Conclusion

Worldwide, SSC use is generally high, but significant variability exists. Implementation and dissemination strategies must be developed to address this variability.

South African Paediatric Surgical Outcomes Study: a 14-day prospective, observational cohort study of paediatric surgical patients

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): 8.4-11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2-8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6-1.5), 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 should be used to develop strategies to improve paediatric surgical outcomes in LMICs, and support the need for larger prospective, observational paediatric surgical outcomes research in LMICs.

CLINICAL TRIAL REGISTRATION

NCT03367832.

The role of non-invasive ventilation in blunt chest trauma: systematic review and meta-analysis

PURPOSE

Respiratory support is the mainstay for the management of patients with pulmonary contusion following blunt chest trauma. In patients not requiring immediate intubation and ventilation, the optimal respiratory management strategy is not clear. This systematic review and meta-analysis aimed to determine the efficacy of non-invasive ventilation (NIV), as compared to traditional respiratory support strategies (i.e., high-flow facemask oxygen or pre-emptive intubation and ventilation), in adult patients with blunt chest trauma.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing NIV to traditional forms of respiratory support (i.e., facemask oxygen or intubation and ventilation) in an adult trauma population. For each eligible trial, we extracted the outcomes of all-cause mortality, length of intensive care unit (ICU) stay, length of hospital stay, and pneumonia.

RESULTS

We identified 643 citations, selected 17 for full-text evaluation, and identified three eligible RCTs. Patients receiving NIV had a non-significant reduction in the risk of death (OR 0.55; 95 % CI 0.18-1.70; I (2) = 0 %), but significant reductions in length of ICU stay (mean difference -2.45 days; 95 % CI -4.27 to -0.63; I (2) = 66 %), length of hospital stay (mean difference -4.60 days; 95 % CI -8.81 to -0.39; I (2) = 85 %), and risk of pneumonia (OR 0.20; 95 % CI 0.09-0.47; I (2) = 0 %).

CONCLUSION

This meta-analysis suggests that NIV is superior to both high-flow facemask oxygen or pre-emptive intubation and ventilation in patients with blunt chest trauma who have no contraindication to NIV.

Elevated salivary C-reactive protein predicted by low cardio-respiratory fitness and being overweight in African children

Introduction

C-reactive protein (CRP) is a sensitive marker of systemic inflammation and is an independent risk factor for cardiovascular disease. The aim of the study was to examine the relationship between salivary CRP, cardio-respiratory fitness and body composition in a paediatric population.

Methods

This was a cross-sectional study of 170 black South African children (age 9.41 ± 1.55 years, 100 females, 70 males) in grades 3 to 7. Unstimulated whole saliva samples were obtained for the analysis of CRP. Height, mass, skin-fold thickness, resting blood pressure, and waist and hip circumference measurements were obtained. Cardio-respiratory fitness was assessed using a 20-m multi-stage shuttle run. Children were classified as overweight/obese according to the Center for Disease Control and Prevention (CDC) body mass index (BMI) percentile ranking, and meeting percentage body fat recommendations, if percentage body fat was ≤ 25% in boys and ≤ 32% in girls. The cut-off point for low cardio-respiratory fitness was a predicted aerobic capacity value ≤ the 50th percentile for the group. Contributions of low cardio-respiratory fitness, overweight/obesity, and not meeting percentage body fat recommendations, to elevated salivary CRP (≥ 75th percentile) concentration and secretion rate were examined using binary logistic regression analysis with a backward stepwise selection technique based on likelihood ratios.

Results

Poor cardio-respiratory fitness was independently associated with elevated salivary CRP concentration (OR 3.9, 95% CI: 1.7–8.9, p = 0.001). Poor cardio-respiratory fitness (OR 2.7, 95% CI: 1.2–6.1, p = 0.02) and overweight/obesity (BMI ≥ 85th percentile) (OR 2.5, 95% CI: 1.1–5.9, p = 0.03) were independent predictors of elevated salivary CRP secretion rate.

Conclusion

The results suggest a strong association between poor cardio-respiratory fitness and/or overweight/obesity and inflammatory status in children, based on elevated salivary CRP levels.

Suxamethonium and critical illness polyneuropathy

Administration of suxamethonium to patients with critical illness polyneuropathy may produce life-threatening hyperkalaemia. A questionnaire to assess the awareness of this problem was sent to all UK intensive care units. A clinical scenario suggestive of critical illness polyneuropathy was accompanied by a list of possible drugs used to facilitate endotracheal intubation. Most respondents (68.7%) chose suxamethonium while 20.4% avoided any muscle relaxant. This result suggests a worrying lack of appreciation of the dangers of suxamethonium use in critical illness polyneuropathy.