Background: Neonates undergoing major non-cardiac surgery are highly susceptible to anaemia, perioperative blood loss and transfusion exposure. Perioperative blood management (PBM) in this population is challenging due to limited physiological reserve and the absence of robust, neonatal-specific evidence to guide practice. Aim: To evaluate the epidemiology of blood transfusion and current evidence on PBM in neonates undergoing major non-cardiac surgery. Method: A state-of-the-art narrative review was conducted across PubMed, Web of Science and Scopus for studies published between January 2015 and December 2025. Eligible studies included primary research involving neonates (≤ 28 days) undergoing major non-cardiac surgery and reporting on transfusion practices, anaemia management, perioperative blood loss or related epidemiologic outcomes. Study selection followed predefined Population, Intervention/Exposure, Comparator and Outcomes criteria. Results: A very limited number of studies met inclusion criteria, with most excluded due to non-neonatal populations, a lack of surgical context or absence of blood management outcomes. Included studies were predominantly observational and demonstrated marked heterogeneity in transfusion practices. Evidence regarding transfusion thresholds, perioperative blood loss and PBM strategies was sparse and inconsistent. No high-quality trials directly evaluating PBM interventions in this population were identified. Conclusion: There is a critical lack of high-quality evidence guiding PBM in neonatal major non-cardiac surgery. Current practices are largely extrapolated from older populations. Well-designed prospective and multicentre studies are urgently needed to establish evidence-based transfusion thresholds and optimise PBM strategies in this vulnerable group. Contribution: This review synthesises evidence on neonatal perioperative blood management, revealing transfusion practice variability, evidence gaps, and the need for neonatal-specific guidelines.
Background: Fasting guidelines in paediatric patients aim to prevent regurgitation and aspiration during anaesthesia. The European Society of Anaesthesiology and Intensive Care recommends a 2-h fasting period for carbohydrate-containing fluids. Aim: This study aimed to compare gastric residual volumes (GRVs) in children at three time intervals after preoperative consumption of an oral carbohydrate-rich drink (OCD). Setting: This study was conducted at Charlotte Maxeke Johannesburg Academic Hospital. Methods: This prospective, single-centre study was conducted from November 2023 to April 2024 and included paediatric patients aged 2-18 years undergoing elective orthopaedic procedures who adhered to fasting guidelines and consumed 3 mL/kg of an OCD. Gastric residual volume was assessed with ultrasound at baseline, 1-and 2-h intervals post-ingestion. Statistical analyses were performed to evaluate changes in GRV between children and the change in each child over time. Results: Thirty-three children were included in the study. The study found no significant differences in mean GRV across the three time points, with all values remaining below the safe aspiration threshold of 1.5 mL/kg. Qualitative assessments showed that GRV decreased below baseline levels by 2 h. One-third of patients reported thirst preoperatively, but none experienced intraoperative hypoglycaemia or postoperative nausea or vomiting. Conclusion: The consumption of a modest volume of an OCD up to 1 h before surgery did not significantly increase GRV in paediatric patients. Contribution: These findings support the safety of preoperative carbohydrate intake at 1 h preoperatively, aligning with recent guidelines that advocate for reduced fasting times to enhance patient outcomes.
Background: Climate change is one of the greatest threats to global health, and anaesthesia contributes via inhalational anaesthetic gases (IAGs), intravenous agents, disposable equipment, and reprocessing of reusable equipment. Africa faces unique healthcare challenges, yet the extent to which environmentally sustainable anaesthesia has been studied on the continent remains unclear. Understanding existing knowledge and practices is crucial to developing context-specific strategies. Aim: This scoping review aimed to map existing literature on environmentally sustainable anaesthesia in Africa, identifying current knowledge, practices, and implementation challenges. Setting: The study was conducted on research findings in Africa. Methods: A scoping review was conducted using the Arksey and O'Malley framework and PRISMA-Scoping Review guidelines. Databases searched included PubMed, EBSCOhost, Scopus, Web of Science, and the Environmental Science Collection. Eligible studies were peer-reviewed, English-language articles published between 2000 and 2025, focusing on environmentally sustainable anaesthesia in Africa. Data were charted using an extraction form and underwent thematic analysis. Results: Sixteen studies met the inclusion criteria. Most were cross-sectional and descriptive, with research largely conducted in South Africa. Key barriers included limited education and training, financial constraints, and the absence of formal institutional policies on environmental sustainability. Resource limitations influenced practice patterns, with increased reliance on total intravenous anaesthesia and regional techniques, both with relatively lower environmental footprints. Waste management practices were inconsistently implemented and often poorly understood. Anaesthetists generally showed limited awareness of the environmental impact of IAGs, and the reuse of equipment-frequently driven by necessity-raised ongoing concerns about infection control. Conclusion: Research on environmentally sustainable anaesthesia in Africa is largely confined to South Africa, with scarce data from the rest of the continent. Clinical practice is heavily shaped by resource scarcity. Contribution: This is the first synthesis of environmentally sustainable anaesthesia practices in Africa, highlighting resource-driven environmentally sustainable techniques, gaps in knowledge and policy.
Background: Internal jugular vein (IJV) cannulation is widely performed, yet complication rates remain substantial, often associated with anatomical variation. Existing evidence is predominantly derived from non-African populations and frequently lacks bilateral, multi-level assessment. A clearer understanding of IJV–common carotid artery (CCA) relationships in African patients is needed to support safer vascular access. Aim: To characterise sonographic anatomical variations of the IJV–CCA relationship across three cervical levels and both sides of the neck in adult surgical patients. Setting: Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. Methods: A cross-sectional ultrasound study was conducted in 178 adults. A point-of-care ultrasound (POCUS) certified investigator performed bilateral scans at the upper thyroid cartilage, cricoid cartilage and Sedillot’s triangle. Radial IJV position, vessel diameters, depth from skin, centre-to-centre distance, degree of overlap and atypical variants were recorded. Results: Typical IJV position was consistently more frequent on the right (upper = 84.3%, middle = 70.8%, lower = 52.8%) than on the left (66.9%, 52.8%, 16.3%). Overlap > 50% occurred less often on the right at all levels (0.7% – 34.3%) compared with the left (24.2% – 67.4%). The IJV was larger on the right at all depths, while CCA depth differed significantly between sides. Atypical variants, including absence, duplication, bifurcation or valves, were rare (2.3%). Increasing age and body mass index were associated with greater overlap and deeper vessel position. Conclusion: Marked variability exists in IJV–CCA relationships, with the right side demonstrating more favourable anatomy for cannulation. Contribution: This study provides the first bilateral, multi-level sonographic dataset from an African cohort.
Background: Paediatric pre-operative anxiety is common. Pharmacological and non-pharmacological methods can reduce pre-operative anxiety. Low- and middle-income countries require safe, affordable, accessible methods such as soft toys to minimise anxiety. Aim: This study aimed to describe pre-operative anxiety in children and the effect of soft toys in managing anxiety. Setting: The study involved children ages 2–17 years receiving general anaesthesia for elective surgery at a South African academic hospital. Methods: This prospective, cross-sectional observational study assessed 114 children using the modified Yale Pre-operative Anxiety Scale (mYPAS) at three points: Waiting area (T1); after being offered a soft toy (T2); and at mask introduction (T3). Scores of 30 or greater indicated high anxiety. Results: At baseline, 54% of children displayed high anxiety (T1 median mYPAS = 30). Those who refused a toy were more anxious than those who accepted a toy (median mYPAS = 37 vs 30; p = 0.10). Anxiety decreased after toy introduction (T2 median mYPAS = 28) with significantly lower scores in children who chose a toy (p = 0.006). Anxiety spiked at mask introduction (T3 median mYPAS = 41) with 93% showing high anxiety regardless of toy presence (p = 0.63). Toys were associated with lower anxiety at T2 (p = 0.039) but not at T3 (p = 0.61). Older age correlated with lower anxiety at T3 only (p < 0.001). Caregiver presence approached statistical significance at T3 (p = 0.054). Conclusion: Soft toys help reduce anxiety initially, but not during mask introduction. Combining low-cost, non-pharmacological strategies may improve outcomes in resource-limited settings. Contribution: Soft toys are safe, affordable, and accessible for peri-operative anxiolysis in low- and middle-income countries.
Background: The greater occipital nerve block is indicated for pain relief in children undergoing, among others, posterior fossa craniotomies. This nerve, which arises from the C2 spinal nerve, travels alongside the occipital artery and provides sensation to the posterior scalp. Aim: The aim of this study was to anatomically determine the location of the greater occipital nerve and accompanying occipital artery, as it travels through the hiatus in the trapezius muscle aponeurosis, in the occipital region, in embalmed neonatal cadavers. Setting: Study was conducted at the Department of Anatomy, University of Pretoria, South Africa. Methods: Following ethical approval, the greater occipital nerve and occipital artery were bilaterally dissected and exposed in 35 embalmed neonatal cadavers from the Department of Anatomy at the University of Pretoria. The distance between the external occipital protuberance, the rudimentary mastoid process and the greater occipital nerve was measured, while the relationship between the neurovascular structures was observed. Results: The greater occipital nerves were found to be on average 19.85 mm +/- 4.70 mm from the external occipital protuberance in neonates, while the external occipital protuberance and rudimentary mastoid process are 42.55 mm +/- 8.46 mm apart. In 77.3% of the specimens, the greater occipital nerve was located medial to the occipital artery, while in the remaining cases, the artery lies between the cutaneous branches of the greater occipital nerve at the trapezius muscle hiatus. Conclusion: In this neonatal sample, the greater occipital nerve is located at the approximate midpoint of the line between the external occipital protuberance and rudimentary mastoid process.
Anaesthesia plays a critical role in maternal care. In approximately 30% of maternal death cases in South Africa, an anaesthetic is given. As the country enters a new triennium of the Confidential Enquiry into Maternal Deaths (CEMD), strengthening anaesthesia representation and reporting is essential to support national efforts to reduce maternal mortality in line with the Sustainable Development Goals. Emerging data from the National Committee for the Confidential Enquiry into Maternal Deaths (NCCEMD) highlight significant gaps in anaesthesia reporting, with incomplete provincial participation and substantial underreporting in the Database for the Retrospective Analysis of Maternal Anaesthesia (DRAMA). These deficiencies limit the accuracy of national audits and hinder the identification of avoidable factors and system failures. Challenges are compounded by a workforce largely consisting of non-specialist providers with variable levels of experience and support. This article argues for strengthened anaesthesia involvement in the CEMD through formalised provincial assessor roles, improved data alignment, and structured feedback mechanisms. Enhanced anaesthesia support is essential to improve clinical governance and reduce preventable maternal morbidity and mortality.
Background: Point-of-care ultrasound (PoCUS) enhances clinical assessment and decision-making, but undergraduate integration remains inconsistent, especially in low- and middle-income countries. Barriers include limited faculty training, ultrasound access and the absence of standardised curricula. Aim: This study evaluated the impact of a structured PoCUS training programme on medical students’ knowledge, attitudes and practical utilisation of PoCUS. Setting: The study was conducted at the University of the Witwatersrand, Johannesburg. Methods: A quasi-experimental study was conducted among final-year medical students (n = 70). Participants attended a 1-day PoCUS workshop featuring didactic lectures and hands-on training between April 2024 and September 2024. Pre-course questionnaires assessed PoCUS usage, attitudes and knowledge. Post-training questionnaires were completed 6 weeks later. Paired tests were used, with significance set at p < 0.05. Results: Point-of-care ultrasound usage significantly increased following training (p < 0.001). Supervised usage increased from 37.1% to 47.1%, while passive observation decreased from 47.1% to 14.3%, and independent use remained static (1.4%). Attitudes improved, with greater recognition of PoCUS value in clinical practice (mean score: 6.00 to 6.63; p < 0.001) and procedural safety (mean score: 6.70 to 6.83; p < 0.05). Knowledge scores improved across domains (p < 0.001), particularly in vascular access (47.6% to 64.8%) and eFAST (51.4% to 67.7%). Conclusion: Structured PoCUS training improves undergraduate knowledge and clinical application, but limited mentorship and ultrasound access hinder independent use. Contribution: Future research could explore strategies for longitudinal curriculum integration, postgraduate knowledge and skill retention and the broader impact of PoCUS training on clinical outcomes.
Background: Postoperative pain (POP) significantly affects patient recovery and well-being, with preoperative anxiety being a potential contributor to its development and severity. Aim: The primary aim of this study was to investigate the prevalence of POP and secondarily to explore the association between preoperative anxiety and POP in patients undergoing orthopaedic and general surgical procedures. Setting: A tertiary hospital in Johannesburg, South Africa. Methods: This was a cross-sectional study, which enrolled 105 adults undergoing elective orthopaedic or general surgery. Preoperative anxiety was measured before surgery using the Amsterdam Preoperative Anxiety and Information Scale (APAIS), and POP was assessed once within 12 h-24 h after surgery using the Numeric Pain Rating Scale (NPRS). Results: Preoperative anxiety was present in 24.8% of patients and was associated with female sex (odds ration [OR]: 2.63, 95% confidence interval [CI]: 1.06-6.50) and high need for information (OR: 8.43, 95% CI: 3.08-23.04). Post-surgery, 65.7% reported experiencing moderate-to-severe pain at the time of interview, with orthopaedic surgery strongly associated with higher pain (OR: 5.19, 95% CI: 2.17-12.46). No significant association was found between preoperative anxiety and POP (adjusted OR [aOR]: 1.65, 95% CI: 0.57-4.77), although a weak correlation was observed for procedure-specific anxiety (rho = 0.21, p = 0.036). Conclusion: Postoperative pain remains a significant challenge in the study setting, with a high prevalence of moderate-to-severe pain, highlighting persistent gaps in pain management. Contribution: This finding is consistent with studies in Africa and globally. Although preoperative anxiety prevalence was lower than global estimates from meta-analyses, our results aligned with a similar local study, possibly reflecting contextual factors. No association was observed between preoperative anxiety and POP. However, as the study was not powered for definitive conclusions, these findings should be interpreted as exploratory.
Background: In South Africa, blood and blood products are critical yet limited resources, with only 1% of the population actively donating. Despite their scarcity, blood products are frequently administered in hospitals. Issues of mismanagement, including inadequate informed consent, waste and improper transfusions, have a multi-factorial negative impact on health services. Intern doctors who regularly make transfusion decisions from the outset of their medical careers often lack sufficient knowledge, contributing to these challenges. Given the inherent risks of blood transfusions, it is essential for physicians to have a thorough understanding of potential complications to ensure informed consent, optimal patient care and appropriate resource management. Aim: This study aims to assess intern doctors' knowledge of transfusion medicine, identifying gaps in their understanding and highlighting areas for improvement in education and practice. Methods: A validated exam with 20 questions was distributed to all interns within the Port Elizabeth intern complex. The exam assessed the transfusion medicine knowledge of intern doctors within the complex. Results: The survey was completed by 87 intern doctors over four sites within the Port Elizabeth intern complex. An overall median score of 33% (standard error [s.e.] 1) was obtained by the participants. The category of the questionnaire that was answered poorly was transfusion reactions, with a median of 14.3%, and the categories that demonstrated better scores were transfusion thresholds and safe administration of blood products. Conclusion: Intern doctors across the Port Elizabeth intern complex demonstrated inadequate transfusion medicine knowledge, especially relating to transfusion reactions. These findings require attention and action to improve our healthcare service. Contribution: This study identifies significant gaps in intern doctors' transfusion medicine knowledge, particularly regarding transfusion reactions, with implications for patient safety and resource use. It supports the need for targeted education to improve clinical practice. These findings align with the goals of anaesthetists, as safe and effective transfusion practice is central to perioperative and critical care within anaesthesia.
Background: Chronic pain is one of the most prevalent chronic conditions globally. Health-related quality of life (HRQoL) is emerging internationally as a key outcome to inform management through evidence-based practices. Aim: This study assessed the impact of chronic pain on patients' quality of life (QoL) using a modified, generic and validated instrument (RAND 36-Item Health Survey 1.0). Setting: Quality of life was assessed among patients diagnosed with chronic pain attending the only specialised public pain clinic in Gauteng, the Helen Joseph Hospital (HJH) Chronic Pain Clinic. Methods: A descriptive, quantitative cross-sectional study was conducted among patients with chronic pain attending routine follow-up consultations at the HJH Chronic Pain Clinic. Quality of life was measured using a self-administered modified RAND 36-Item Health Survey 1.0. Results: In total, 181 patients participated; 75.1% were female, and 59.7% were aged >= 60 years. Quality of life was assessed across eight RAND-36 domains scored from 0 to 100. Pain severity (0 = very severe pain; 100 = no pain) was the independent variable in regression and correlation analyses. Seven scales scored below 50, indicating poor QoL. Significant associations were found between pain severity and energy, emotional well-being, social functioning, and general health (all p < 0.001). Significant correlations were also observed with role limitations due to emotional problems and physical health. Conclusion: Chronic pain significantly impairs multiple aspects of QoL. Integrating generic HRQoL measures into clinical practice may aid risk identification and guide targeted therapy. Contribution: Given the paucity of literature on chronic pain in low- and middle-income countries such as South Africa, this research contributes to evidence on chronic pain by evaluating patient-reported outcomes and highlighting their multidimensional impact on QoL.
Desflurane has been removed from practice across the National Health Service (NHS) hospitals in the United Kingdom (2024)1 and the European Parliament has prohibited the use of desflurane from 2026, with restricted exceptions. Given desflurane’s disproportionate greenhouse gas impact (GGI), we should consider whether South Africa should phase out the use of desflurane.
Background: In-hospital cardiac arrest survival rates remain suboptimal globally - approximately 36% in children and 17% - 25% in adults. Prompt intervention with appropriate skills, equipment and drugs is essential to improve outcomes. Aim: This study aimed to assess the availability and functionality of resuscitation equipment and drugs at Tygerberg Hospital, a tertiary institution in South Africa. Setting: Tygerberg Hospital, a tertiary institution in South Africa. Methods: A prospective, quantitative, observational study was conducted to audit resuscitation trolleys throughout the hospital. The Emergency Medicine Society of South Africa guidelines served as the audit standard. Results: A total of 102 resuscitation trolleys were assessed: 80 for combined adult and paediatric use and 22 for neonatal care. In adult and paediatric areas, 42.6% of items were available and functional, 2.4% were non-functional and 55% were unavailable. In neonatal areas, 39.7% were available and functional, 1.3% non-functional and 59% unavailable. Highest compliance was seen in high-care areas (48.8% for adult and paediatric, 46.3% for neonatal), with lowest compliance in clinics (35.3%) and neonatal wards (36.4%). Conclusion: The audit revealed substantial deficiencies in the availability and functionality of resuscitation equipment and drugs, which may negatively impact patient outcomes during cardiac arrest scenarios.
Background: Less than half of all orthopaedic patients undergoing surgery report adequate pain relief. PAIN OUT is an international registry that collects and compares patient-reported outcomes to support quality improvement in postoperative pain management. Aim: The aim of this study was to assess the impact of implementing a four-part perioperative pain management bundle by comparing pain outcomes pre-and post-bundle implementation in orthopaedic patients at a private hospital in Gauteng, South Africa. Setting: A single private hospital providing elective orthopaedic surgical care in Gauteng, South Africa. Methods: A pre-post observational audit was conducted using the PAIN OUT registry. Baseline data were collected from 86 patients (November 2021-March 2023), and post-implementation data from 105 patients (September 2023-March 2024). The bundle included patient education, non-opioid analgesia, regional anaesthesia and structured pain assessment. Results: In the post-implementation group, 95.23% of participants had their pain assessed and reassessed regularly, compared with 58.13% at baseline. All participants received regional anaesthesia and/or wound infiltration, compared with 30.23% at baseline. Overall, 65.71% of patients received all four elements of the bundle compared with 0% before implementation. Total pain composite scores, pain-related interference and side effects of pain management significantly improved post-implementation. Fewer patients reported wanting more analgesia (21.9% vs 48.84%; p < 0.01). Conclusion: Implementation of a four-part perioperative pain management bundle improved postoperative pain outcomes among orthopaedic patients and supports broader application of bundled approaches in diverse settings. Contribution: This study provides South African PAIN OUT data and demonstrates the feasibility and effectiveness of a standardised perioperative pain management bundle in the private hospital setting.
Background: The erector spinae plane block (ESPB), a novel anaesthetic technique, has been shown to be a safer alternative to neuraxial and paravertebral blocks in adults. The exact mechanism of action of the ESPB in the cervical region-performed at the C6 and C7 vertebral levels-remains unclear in both adult and paediatric patients. Aim: The aim of this study was to determine the spread of a simulated cervical ESPB in a neonatal sample and to translate the clinical relevance of the anatomical findings for anaesthesia providers. Setting: Study was conducted at the Department of Anatomy, Faculty of Health Sciences, University of Pretoria, South Africa. Methods: Nine fresh-frozen low-normal birth weight neonatal cadavers were injected with contrast medium (0.1 mL/kg) at both C6 (anterior tubercle of the transverse process) and C7 (transverse process) vertebral levels. The ultrasound-guided injections were done with the cadavers in a prone position, utilising a 5 cm 22G Tuohy needle. Following the injections, cone-beam computed tomography scans were performed using the Planmeca G7 scanner, operated with Romexis software (version 6.4.5.136; Planmeca, Helsinki, Finland). Results: Twelve simulated blocks were performed; seven at C6 and five at C7. The contrast medium spread most consistently between the C5 and C7 levels when performing the simulation at the C6 vertebral level and between C6 and T1 when performing the simulation at the C7 vertebral level. Conclusion: The study results suggest that the cervical ESPB may be a promising regional anaesthesia technique for neonates and infants undergoing procedures involving the cervical spine or upper limbs. Contribution: This study offers valuable anatomical insights into the cervical ESPB in a neonatal cadaveric sample, demonstrating the consistent spread of the contrast medium across the C5-C7 dermatomes, with additional, less consistent spread observed from C2 to T1.
Fanconi syndrome (FS) due to tenofovir disoproxil fumarate (TDF) can lead to proximal renal tubular acidosis (type 2 RTA), bone fragility and pathological fractures. Perioperative fluid and acid-base management in this setting is complex and not well described. To outline the perioperative fluid approach, acid-base management and early outcome in a young woman with TDF-related FS and type 2 RTA undergoing major orthopaedic surgery. Case report of a 29-year-old human immunodeficiency virus-positive woman with kyphoscoliosis and bilateral subtrochanteric fractures who underwent bilateral femur osteotomies and cephalomedullary nail fixation. Perioperative care included multidisciplinary optimisation, adjustment of antiretroviral therapy, avoidance of nephrotoxins, correction of electrolytes, preference for balanced crystalloids, titrated bicarbonate therapy and close monitoring with serial blood gases and fluid balance in the intensive care unit (ICU). The patient was admitted to the ICU with severe non-anion gap metabolic acidosis (pH 7.22; base excess-11.3). With balanced crystalloids and bicarbonate therapy, acid-base status normalised within 72 h (Day 3: pH 7.39; HCO3 26.4 mmol/L), lactate resolved, haemodynamics stabilised and electrolytes corrected. Renal function remained stable, and she was discharged from the ICU with normal acid-base status for further orthopaedic rehabilitation. Contribution: In patients with TDF-associated FS and proximal RTA, a tailored physiology-based perioperative strategy emphasising balanced crystalloids, electrolyte correction and guided bicarbonate therapy can restore acid-base balance and allow safe recovery after major surgery. This case highlights practical considerations for fluid management in a high-risk group.
