The effect of cold-chain re-introduction on the molecular integrity of rocuronium bromide

Introduction: This study aimed to examine the effect of breakages and re-introduction into cold chain on the rocuronium bromide compound. Rocuronium bromide is frequently used in routine theatre lists and plays a vital role in modified rapid sequence induction and intubation for emergency patients who have contraindications to the primarily used muscle relaxant, succinylcholine. With the current practice of removing the drug from, and then reintroducing it into the cold chain, unpredictable clinical effects, including delayed onset of action and shortened duration of action have been observed. This may pose significant risks to the patient. Methods: Rocuronium bromide was subjected to different clinically applicable storage and temperature scenarios, after which the compound was analysed for integrity and quantities of the active compound, including detection of possible degradation products, by mass spectrometry, and compared to cold chain control samples. Results: There were no significant differences between any of the temperature exposure groups (18 °C or 24 °C) or between single or double exposures at these temperatures. No statistically significant difference could be demonstrated between the two control groups (cold chain preserved and room temperature controlled) with testing done at weeks one and six. However, week twelve analysis revealed a statistically significant result which translates to a 26 μg/ml difference, which clinically would have no effect. Substantial results were obtained with a secondary exposure to air; which lead to a 20% decrease in rocuronium concentration (p = 0.02). Conclusion: Practice should be adapted by keeping careful documentation as to when cold-chain was broken, and when the recommended 12 week period will lapse. Vial sharing as a standard is not recommended. If small quantities are repeatedly withdrawn from the vial during a prolonged case, the unused contents should be discarded after eight hours.

Airway management in COVID-19: Time to start thinking outside the box?

Faced with limited time, severely constrained resources and a lack of manpower in the face of the overwhelming numbers in Xerxes’ invading Persian Army, the Greeks strategised to halt their foe using two natural barriers which restricted movement: the Straits of Atremisium, and the narrow pass at Thermopylae. King Leonidas of Sparta led 7 000 mettlesome troops to engage at the Hot Gates, preparing to face a force today believed to have exceeded 150 000 fighters. When told that the Persians were so multitudinous that each volley of their arrows would block out the sun, Herodotus writes that the plucky Spartan soldier, Dienekes, replied laconically: “In the shade, then, we will fight!” The Battle of Thermopylae is history interwoven with legend, but speaks of the power of strategic interventions applied at the right place, at the right time, by the right people, even in the face of overwhelming odds.

Anaesthetic nurse training in KwaZulu-Natal government hospitals: exploring strengths and deficiencies

Background: The anaesthetic nurse is a key assistant to the anaesthetist and integral to the provision of safe anaesthesia. Inadequate undergraduate training in South Africa necessitates anaesthetic nurses to acquire the requisite skills and knowledge in the workplace. Few studies explore the challenges faced by practising nurses to acquire such skills. This study sought to explore the experiences of working anaesthetic nurses to gain their perspectives on workplace-based learning, skills acquisition and how to improve anaesthetic nurse training. Methods: We used qualitative methodology comprising an English-medium, self-administered, anonymous questionnaire. A purposive sampling method was used, and 73 anaesthetic nurses working in five government hospitals in eThekwini, KwaZulu-Natal were recruited. Questionnaires were thematically analysed, and simple statistical analysis was used for quantitative data. Results: Most anaesthetic nurses received little or no undergraduate anaesthesia training and participants identified subsequent workplace-based training as inconsistent, and insufficient. Despite most participants’ arbitrary allocation to the position of anaesthetic nurse, the majority found their work stimulating and identified themselves as team-players, adaptable, and willing to learn. Further training and hands-on skills acquisition were keenly sought. Factors impacting positively on their learning and job satisfaction included a confident anaesthetist who was willing to teach and collaborate on learning, provide positive feedback, and include the anaesthetic nurse in case planning. Participants identified crucial areas for further development. In theatre teaching and practical group tutorials led by anaesthetists were suggested as preferred training modalities. Responses to hypothetical case scenarios demonstrated qualities in the participants that are valued in the anaesthetists’ non-technical skills framework. Conclusion: It is evident that there is insufficient formal training and inconsistent training methods of the current anaesthetic nurses in the five study hospitals. The workplace-based learning experiences of our study participants has given us a unique perspective from practising anaesthetic nurses and may be used to inform the formulation of appropriate training curricula and improve the learning partnership with anaesthetists. This should ultimately improve anaesthetic nurse job satisfaction and the theatre team experience.