Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018

The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

154 Exosomes in Follicular Fluid Protect the Bovine Oocyte from Heat Shock

Elevated temperature can compromise the ability of the mammalian oocyte to develop to the blastocyst stage after fertilization. The microenvironment of the oocyte is determined by the cellular and non-cellular components of the follicle including cumulus cells and follicular fluid. Here we tested whether follicular fluid contains molecules that can protect the bovine oocyte from heat shock during maturation, and if so, whether some of these protective molecules are present in exosomes. The experiments utilised ovaries from Bos taurus and admixtures of B. taurus and Bos indicus. Four separate pools of follicular fluid were prepared by aspiration of follicles from 48 to 70 slaughterhouse ovaries. Exosomes were isolated from follicular fluid by a series of centrifugation, filtration, and ultracentrifugation steps before being reconstituted in PBS. Each of the 4 exosome preparations was subject to particle size and concentration analysis. The experiments were designed as 2 × 3 factorial to test the effect of temperature and supplementation. Cumulus-oocyte complexes (COC) obtained from slaughterhouse ovaries were matured at 38.5°C for 22 h (control) or 41°C for 14 h followed by 38.5°C for 8 h (heat shock). Maturation was performed in the presence of vehicle (PBS), 10% (v/v) follicular fluid, or exosomes (16 × 109 particles/mL). Data were analysed by least-squares ANOVA. Orthogonal contrasts and the mean separation test pdiff were used to compare means. Effects of treatment on cumulus cell expansion (change in diameter after maturation) were replicated 5 times using 119 to 122 COC per treatment. Effects of treatment on embryonic development after fertilization of treated COC was determined in 6 replicates using 244 to 286 embryos per replicate. Expansion was reduced by heat shock (P < 0.001), and affected by treatment (P < 0.05), with both follicular fluid and exosomes preventing the decrease in expansion caused by heat shock. Cleavage was reduced by heat shock (P < 0.001) and affected by treatment (P < 0.05) and the interaction between temperature × supplementation (P < 0.05). Although heat shock reduced the cleavage rate for vehicle-treated oocytes (77 v. 67%), there was no effect of heat shock for oocytes treated with follicular fluid FF (78 v. 74%) or exosomes (79 v. 78%; SEM = 1.4%). Heat shock also reduced the percent of cleaved embryos becoming blastocysts for the vehicle group (27 v. 17%; P < 0.05) but had no effect on percent of cleaved embryos becoming blastocysts for the follicular fluid (31% v. 26%) or exosome groups (28 v. 26%). Uptake of exosomes into isolated cumulus cells and oocytes cultured at 38.5°C for 0.5, 1, 14 and 22 h was examined using labelling of exosomes with 10 µM BODIPY® Ceramide TR (Thermo Fisher Scieintific, Waltham, MA, USA) and confocal microscopy. Exosomes were taken up by cumulus cells after culture for 1 h or later but were not taken up by oocytes. In conclusion, follicular fluid exosomes protected the oocytes from heat shock and this effect seems to be mediated by cumulus cells. Study supported by BARD US-4719-14.

THE EFFECT OF ETHNICITY ON THE INCIDENCE OF POSTOPERATIVE NAUSEA AND VOMITING IN MODERATE TO HIGH RISK PATIENTS UNDERGOING GENERAL ANESTHESIA IN SOUTH AFRICA: A CONTROLLED OBSERVATIONAL STUDY

BACKGROUND

We conducted this prospective controlled observational study to compare the effect of ethnicity on the risk of postoperative nausea and vomiting (PONV) between moderate to high-risk African and non-African patients undergoing general anesthesia.

METHODS

Using Apfel score risk factors and predicted length of surgery (>30 minutes), 89 moderate to high risk patients undergoing general anesthesia were recruited in a university hospital between March 2009 and November 2010. Thirty patients in the non-African group and 59 patients in the African group were allocated using an ethnicity self identification questionnaire. Intraoperative anesthesia was standardized. PONV was assessed at 0 minutes, 15 minutes, 90 minutes, 180 minutes, and 24 hours. Generalized linear mixed effects models was used to determine the effect of ethnicity on PONV.

RESULTS

Despite similar Apfel scores, cumulative incidence of postoperative nausea was higher in the non-African group at 0 minutes (46.67% vs 22.03%, P = 0.019), 15 minutes (70% vs 23.73%, p<0.001) and 90 minutes (36.67% vs 16.95%, P = 0.04). The non-African group had more episodes of vomiting over 24 hours (13.33% vs 1.69%, P = 0.055). Non-Africans had a 25 times higher reported nausea incidence than Africans over 24 hours.

CONCLUSION

The incidence of PONV in non-Africans is significantly higher than in Africans. Non-African ethnicity is an independent risk factor for PONV. Current risk prediction models may be limited in multi-ethnic populations and further investigations are warranted to examine ethnicity as a risk factor.