Death due to anaesthesia at Groote Schuur Hospital, Cape Town--1956-1987. Part II. Causes and changes in aetiological pattern of anaesthetic-contributory death

A general analysis of the clinical failures that were responsible for deaths attributable to anaesthesia over a 30-year period, 1956-1987, is presented. Four particular general failures in clinical management were responsible for 80% of anaesthetic-contributory deaths (ACD). These were in descending order of frequency: (i) failures in airway management, of which the majority were associated with the complications of endotracheal intubation (27% of ACD); (ii) failures in pulmonary ventilation management (20% of ACD); (iii) failures in blood volume control (19% of ACD); and (iv) failures in arrhythmia control (17% of ACD). Computation of these groups of causes by the decade reveals a distinct and progressive change in the aetiological pattern of these deaths with time. While the incidence of ACD over the period decreased 6-fold from 0.43 to 0.07/1,000 anaesthetics, that proportion due to failures in airway management, in general, and complications of intubation, in particular, has progressively increased. This has been accompanied by a reciprocal decrease in deaths due to circulatory factors. It is postulated that this change arises from the fact that the physical skills, manual dexterity and clinical judgement demanded by the former have not changed with time, whereas the latter depend on intellectual responses to information derived from ever-improving vital function monitoring.     

Book Reviews

Book reviewed in this articles: Essential Paediatric Dermatology . By J, Verbov Skin Disorders in the Elderly . Edited by B. E. Monk , R. A. C. Graham     

Autonomy and modernisation: the management of change in an English primary care trust

Recent New Labour policy for the ‘modernisation’ of Government places a good deal of emphasis on decentralisation. This emphasis is particularly marked in relation to the organisation of primary care. However, like hospitals and other National Health Service institutions, primary care trusts (PCTs) are subject to a substantial raft of centrally established performance targets and indicators, including those which contribute to the public award of between zero and three performance ‘stars’. This raises questions about the extent to which employees can exercise autonomy in the context of rigid top‐down directives. This paper presents findings from a study using participant observation and interviews to examine the impact of a training course aimed ostensibly at increasing employee autonomy in an English PCT. The suggestion is that attempts to make employees more autonomous can be seen as a strategy for increasing central control based upon the internalisation by the employees of centrally promulgated values. The attraction of such strategies is that they may be potentially more effective and less costly than alternative strategies of direct control. However, the study suggests that the outcome of attempts by such methods as programmes to increase employee autonomy may be very different from those intended.     

Mediastinal pancreatic pseudocysts in children.

Mediastinal pseudocyst is an unusual complication of pancreatitis, with only four cases previously reported in children. The extent of the pseudocyst can be defined by computed tomography or magnetic resonance imaging scan and preoperative aspiration of cyst fluid for amylase level can establish the diagnosis. Endoscopic retrograde cholangiopancreatography to define ductal anatomy can help plan the appropriate drainage procedure. Although exceedingly rare, the diagnosis of pseudocyst should be considered for any cystic mass in the abdomen or thorax, even in the absence of elevated amylase or history suggesting pancreatitis.     

Fluoroscopic peroperative cholangiography: technique and associated radiation hazards

The techniques specific to peroperative fluorocholangiography are discussed based on an experience of 632 cholangiograms and an estimation has been made of the associated radiation doses to staff and patients. Rapid and accurate information can be obtained during fluorocholangiography using appropriate techniques with acceptably low radiation hazards.     

Reflections of a distance education facilitator.

After nearly a year of preparation, 'Therapeutic Communication', the first nursing unit in our new Bachelor of Nursing degree was taught for the first time in 1988. The unit has developed and grown since this time, with both educational and financial factors determining such things as design of student materials and assessment mode. The geographically scattered--and often isolated--students are formally recognised for their individuality and their personal and professional life experiences, and given choices within the unit of what they want to learn and how they will present this material, through introduction of a learning contract as part of the unit assessment. Difficulties encountered by these students in maintaining their self-esteem when moving from the demanding and complex world of clinical nursing to the arena of tertiary study are discussed. The provision of speedy, comprehensive feedback with general as well as specific guidance with essay writing and referencing, focuses on the process skills many nurses lack as they enter this unit. The applicability of therapeutic communication to clinical practice and the diversity of projects undertaken by students within the limits of the unit demonstrate its appeal to a wide range of registered nurses. Some of the often ignored or minimised factors that differentiate external study from on-campus work are highlighted for both students and unit facilitator, and the creation of an in-house booklet to assist students in developing their skills in external study is outlined.     

Development of the brachial spinal cord in the marsupial Macropus eugenii (tammar wallaby).

The development of the brachial spinal cord was studied in the marsupial Macropus eugenii (tammar wallaby) on postnatal days 1-34. On day 1 the spinal cord was histologically immature, with a deep central canal, proliferating neuroepithelium and roof and floor plates. The lateral motor column had formed, and forelimb muscles contained primary myotubes. The spinal cord gradually attained a mature appearance between days 1-34. The results confirm the suitability of the wallaby spinal cord for studies of early mammalian development.