Issuu on Google+

ANAESTHESIA

No 2 April 2009

MELISA NEWS It has been a busy month for us.

QUOTE OF THE MONTH ____________ Imagination is more important than knowledge. Knowledge is limited. Imagination encircles the world.

~ Albert Einstein ~

UPCOMING CONGRESSES ______________ Upcoming congresses: 2009 FCA Anaesthesiology Clinical Course - (2009-04-20 - 2009-04-24) · 2 DAY WORKSHOP: THE ESSENTIALS FOR CRITICAL READING AND INTERPRETATION OF MEDICAL LITERATURE -

We visited the Neurology Congress in Muldersdrift as guests of GSK earlier this month to show case MELiSA. (GSK has sponsored NASA members with access to MELiSA… go GSK!!) It was really fun and extremely exhausting. I have a new found respect for reps… their stamina is admirable! I can happily say all who saw MEliSA in action (even at ½ a G!… there is really bad signal in Mulders) loved it. It was interesting to note as well that Texbook of Clinical Neurology, the top Neuro textbook, is available in MELiSA books or you could go and buy it for R4500!! The next big April event for us was PubMed. We have loaded almost all our titles to PubMed. Now when you do a search in PubMed and find an article in a journal that is in MEliSA you will be able to get a direct link to the full text article. How you do it is to select the article/s you want to read from the PubMed results, then select ‘view abstract’. This will open most articles in the abstract but more importantly this is where you will find the MELiSA icon which will take you to the full text article. If you get an option of Publisher e.g. Science Direct or Journal e.g. Pain, choose the publisher. If you have no idea what I’m talking about have no fear because MELiSA is near with a new exciting workshop on how to use PubMed properly and all these details will be elaborated on as well as Mesh searching etc. etc. The workshops will be a hands on experience lasting about 2 hours. The first workshop is being held at the Wits Medical School Library on Tuesday the 5th of May starting at 14h00. CPD points will be awarded including one on ethics and the cost is R350. Limited seats are available so please contact us to book your place at info@melisa.co.za. We have a winner of the Mauritius Holiday… will Dr S Chobokoane please step forward. The winners of the 3 Intellipens are Drs Padia, Chundra and Gunguwo. Congratulations to you all and we hope you enjoy your prizes half as much as you enjoy MELiSA! To the CMSA members in the throws of exams, good luck! All the best and regards till next time. Ed.

(2009-05-08 - 2009-05-09)

MELiSA Medical Library of South Africa


TIP OF THE MONTH Use ‘My Favourites’ to make your MELiSA experience more efficient. You are able to personalize your ‘My Profile’ page by adding onto this page links to your favourite journals. You do this by clicking on the ‘blue folder’ icon displayed next to the journal title/s of your choice in the Library (see below). It is just as easy to remove them from the ‘My Profile’ page so try it out… you won’t break the system.

JUNIOR DOCTORS’ CORNER It’s hard to believe that in roughly two weeks’ time, it’ll be four months of 2009 under the belt. That means a sixth of internship and a third of community service already down. MELiSA has received a great deal of positive feedback from the many interns and community service doctors who have signed up for their free access to MELiSA for 2009. It appears that the most commonly accessed components on MELiSA, by junior doctors, are MD Consult and First Consult (affording doctors a quick and simple means of accessing up-to-date information on the differential diagnoses for a plethora of presenting problems and the management thereof). Just to recap: As a doctor registered with the HPCSA to do your internship or community service in 2009, MELiSA offers you 1000+ medical full-text journals, 100+ etextbooks, MD Consult and First Consult as well as vibrant medical information websites both at www.melisa.co.za and on our facebook page 100% free. We are committed to making medical knowledge more accessible and affordable for doctors and we believe that as a junior doctor-in-training or a ‘’medical servant’’ of the wider community you are entitled to develop your medical brainpower at no cost to you. So we’re giving you a world of medical knowledge at your computer or cellphone fingertips, fully sponsored. You’d be crazy not to utilise this gift while it is still available to you. Send us an email to dan@melisa.co.za and tell us about your experience. We’re looking out to ensure that MELiSA is fulfilling your needs. While you’re at it, visit our “Melisa for Interns and Com Serv Docs” page on Facebook and keep abreast with the latest happenings and developments in the junior doctor world! Assist us by informing your colleagues at other hospitals about this great opportunity. See you online soon! Dr. Daniel Israel Intern and Community Service member liaison


MELISA JOURNAL WATCH - ANAESTHESIA

Journal name:New England Journal of Medicine / March 2009

Title: The Nice Sugar Study In the last week of March, The New England Journal of Medicine published the NICE SUGAR study. This probable landmark trial was designed to finally answer the question, should tight glucose control be targeted as a goal in critically ill patients. The Study was large and the conclusions were clear, there was increased mortality in the cohort of patients where a lower level of glucose was targeted. As Inzuchi and Siegel point out in their editorial, the reasons for this difference in mortality still remain to be elucidated. This study highlights once again the enormous challenge in identifying individual modifiable risk factors in improving critically ill patient’s outcomes and how difficult it is to tease out cause and effect, correlation, causation and association. To view the article click here Article Title:An observational study looking at the life saving efficacy of cricoid pressure in a large cohort of obstetric anaesthesia patients in Malawi. In this study and the accompanying editorial, the dogmatic teaching of the routine use of cricoid pressure as part of a rapid sequence induction for obstetric general anaesthesia, is questioned and revisited. Fenton and Reynolds review in a unique African setting where the standard of care is limited by training constraints the use of cricoid pressure during intubation of pregnant women undergoing cesarean sections. They retrospectively look at the incidence of aspiration and whether or not cricoid pressure is a mitigating factor. Surprisingly they found a non significant increased incidence of aspiration in the group who had cricoid pressure applied. This finding my have been due some form of bias but still questions if the practice is justified. The editorial examines some of the issues surrounding it including the difficulties in studying the practice further due to lack of equipoise which would allow randomization. It concludes that currently it has a place in high risk patients and that it can always be released if it creates difficulty with intubation. To view the article click here Journal name: International Journal of Obstetrics (A quarterly publication)/April Article Title: Introduction of Cell Salvage to a large Obstetric Unit, the first 6 months. King Et Al reviews the introduction of cell salvage technology to the obstetric unit of the Royal Infirmary in Sheffield. He outlines the main considerations in using this technology for obstetric patients in general, problems such a rhesus iso-immunisation as current technology cannot separate fetal from maternal cells, and the risks of amniotic fluid embolism as well as techniques to limit complications from these. A very useful list of indications for the routine use of cell salvage is also delineated where obstetric hemorrhage is likely. These include placenta praevia, uterine fibroids, low pre-operative hemoglobin levels, multiple repeat caesarean sections, previous post partum bleeding, intra-operative bleeding, transfusion refusal and low platelet count amongst others. The practice would appear to be successful and further studies regarding safety and efficacy still need to be done. To view the article click here


Article Title: What is the optimal bolus dose of phenylepherine to prevent hypotension and nausea in obstetric patients undergoing spinal anaesthesia for caesarean section? In this original prospective study from the university of Toronto, Tanaka attempts to elucidate what the optimal bolus dosing would be to prevent spinal anaesthetic induced hypotension and nausea in obstetric patients prior to delivery. Phenylepherine has been shown to be the vasopressor of choice in this population group but it is unclear what the most effective dose is. An up-down sequential allocation was used in a double blind fashion on fifty patients and the calculated dose was given immediately post spinal administration prior to the first measurement of the blood pressure. Heamodynamic variables were recorded. Using statistical methods it was determined that the optimal dose to achieve the end points would be in 159ug as a bolus although the highest bolus dose administered in the study was 120ug. There were cases of hypertension in the study group following the administration of the phenylepherine which was not strictly dose related. It was recommended to first measure the post spinal anaesthetic blood pressure before administering the vasopressor and that safety studies need to be conducted regarding the use of higher than what are now standard doses of these agents. To view the article click here

Article Title: Pulmonary Hypertension in Pregnancy, a Review Article. In this review article Madden looks at current concepts relating to pulmonary hypertension in pregnancy. The aetiology, physiology and Pathophysiology of this disease entity are described and the specific concerns during pregnancy are looked at. Due to the main treatment options being teratogenic and the fact that the pregnant state will exacerbate the disease, careful consideration of termination early in pregnancy should be undertaken although this is also not without risk. Close monitoring of the patient is mandatory throughout pregnancy and for some weeks after and the different strategies with their advantages and disadvantages are discussed. Management is mostly supportive and is aimed at preventing complications such as limiting the high risk that these patients have for thromboembolic events and avoiding the precipitants of pulmonary hypertensive crises. Regional vs. General for surgery is also discussed as well as the use of specific pulmonary vasodilator therapy such as nitric oxide. To view the article click here Article Title: Case report: The use of intravenous octreotide during labour under regional analgesia for a parturient with carcinoid syndrome. Le et Al report an interesting case of pregnancy complicated by carcinoid syndrome. The patient, a 43 year old female, known with metastatic carcinoid tumour presented in labour with symptoms of carcinoid syndrome. She was managed under regional anaesthetic during her labour and octreotide was infused as a continuous infusion to control her symptoms. They review this rare condition, its symptoms, signs and management with special reference to obstetric care. The anesthetic implications include avoiding drugs that result in release of histamine and avoiding other precipitants of a crisis such adrenergic stimulation. The relevant pharmacology of the currently most effective drug, octreotide, is reviewed. To view the article click here


Journal: Journal of cardiovascular and vascular anaesthesia (bi-monthly) April 2009 http://melisa.redi.co.za:2075/science/journal/10530770 Article title: The Inflammatory Response to Cardiopulmonary Bypass: Part 1—Mechanisms of Pathogenesis In the first of two articles on this important topic, Warren et al takes a close look in a very structured fashion at the inflammatory effects of being on cardiac pulmonary bypass. The article gives a historical perspective of the use of the technique highlighting its advantages in facilitating complex cardiac surgery. It then looks step by step at the different components involved in setting up the inflammatory cascade. These include an early phase, involving the protein and cellular components and a late phase. The contact, complement, coagulation and fibrinolytic systems are all activated and the effects on these are discussed as well as the effects on each of the cellular components, red blood cells, leukocytes and platelets. Another component of the response is ischaemic reperfusion injury that occurs on the release of the aortic cross clamp that plays a significant role as well as the release of endotoxin through translocation from potentially poorly perfused gastro-intestinal tract during the procedure. The complexity of the response is highlighted and potential therapeutic options are discussed in the second part of the two part series. to view the article click here Article title: Recent advances in the management of coronary artery disease, highlights from the literature. In this excellent review, up to date best evidenced based answers are provided to some of the big questions regarding the management of patients with coronary artery disease. These include, decisions regarding the need for stress testing prior to angiography, the benefits of computed tomography angioplasty and whether this will replace standard cardiac catheterisation, stents vs. vascular grafts, are the outcomes post off pump surgery better than on pump, does the use of an intra-aortic balloon pump improve outcome in high risk CABG improve outcome, do statins improve outcomes and what are the implications on patients presenting for cardiac surgery on clopidogrel. The authors state that the studies chosen for inclusion in the review are all recent and of high quality. Certainly a cook’s tour well worth taking in “what’s current in the management of coronary artery disease”. to view the article click here Article Title: A Pro Con Debate is presented to discuss the issues surrounding the use of Carotid Endarterectomy vs. Carotid Artery Stenting. In these two articles, the authors review the recent relevant literature regarding the management of carotid vascular disease. The history of the management of the disease and the technologically advances to where we are today makes fascinating reading particularly in the second of the articles The concept as with all emerging technologies is discussed, how the newer techniques that these are initially reserved only for patients who are otherwise to ill to undergo what is considered to be, the current standard of care, in this case Carotid Endarterectomy. As the benefits of the percutaneous method of carotid angioplasty and stenting are realized, the question then arises, should this not be the new gold standard. To answer this question a solid evidence base is required to ensure our patients offered the best and the safest management option. This question requires further studies to attain a conclusion, some of which are currently underway. The articles review current indications and implications of each of these therapeutic modalities. to view the article click here


Journal Current opinion in Anaesthesiology April 2009 Article Title: This journal publishes review articles by experts in sub specialty fields in anaethesia. Its aim is to provide up to date information to the practicing clinician based on the most recent relevant literature. The discipline of anaesthesia is divided by the journal into fifteen sub-specialties each of which is reviewed once during the year. One section of the current journal is devoted to “The Microcirculation�, and the role it has to play in modifying a patients response to sepsis, shock and trauma. Some of the articles related to this look specifically at mitochondrial dysfunction, an important component of the cascade involved. The journal then has a series of articles on the management of coagulopathy in trauma patients including the effect of transfusion, the use of activated clotting factor VII and the role thromboelastography has to play. Several other articles look at safety issues in anaesthesia, cost efficient management of theatres and intensive care units and issues regarding quality of care. to view the article click here

MELiSA Medical Library of South Africa


Melisa Newsletter April '09 Anaesthesia