bluuebunny/crossref_metadata_2025 huggingface dataset:
Syringe Drivers: Incorrect Selection of Syringe Type from the Syringe Menu May Result in Significant Errors in Drug Delivery
Authors: Tooke L. J. , Howell L.
Published: January 2019

There have been many reported adverse incidents due to syringe driver use, most of which have been attributable to human error. In this paper we present a previously unreported, but potentially widespread practice which may result in significant over or under-delivery of medication. Even with the naked eye it is evident that syringes of equal volume have different dimensions and to quantify this we sectioned a range of syringes and measured the inner and outer dimensions. Extensive menus for syringe brand and volumes are available on syringe drivers, offering users greater flexibility. However, this feature also allows users to select an incorrect syringe brand with potential consequences for drug delivery. We measured outputs under all selectable permutations, to determine the degree of fluid delivery variation and discovered inaccuracies in volumes ranging from 10% under-delivery to 24% over-delivery. There is a wide variation in syringe metrics and complex syringe menus may increase errors, resulting in significant under or over-delivery of medication. Availability of more than one brand of syringe in a clinical area increases the risk of adverse drug delivery events. Systems need to be implemented to minimise the risk of adverse events.
Impact of Delirium and Suture-Less Securement on Accidental Vascular Catheter Removal in the ICU
Authors: Sundararajan K. , Wills S. , Chacko B. , Kanabar G. , O'Connor S. , Deane A.M.
Published: January 2019

The objectives were to describe the incidence of accidental vascular catheter removal (AVCR) in an Australian Intensive Care Unit (ICU) and evaluate whether the fixation method or patient delirium increased the risk of AVCR. This prospective observational study was based in a tertiary level ICU between April 2011 and October 2012. All vascular catheters were secured either by sutures or by a suture-less securement device (STATLOCK™, Bard Medical, Covington, GA, USA) as per the treating clinician. Data were obtained from bedside nursing staff, with daily screening for delirium completed by the ICU medical team using the Confusion Assessment Method-ICU. 2361 patients were admitted during this period with 1032 patients screened and data available for 322 patients (452 vascular catheters). AVCR occurred in 15 patients (16 vascular catheters) (5.0%) with an incidence of AVCR of 2.77 per 100 catheter-days. Delirious patients were 13-fold more likely to have an AVCR event (odds ratio=13.3; 95% confidence interval 4.36, 40.52; P <0.0001). There was a non-significant trend to an increase in AVCR when using the suture-less securement device (odds ratio=2.6; 95% confidence interval 0.87, 7.8; P=0.09) but delirious patients were no more likely to have an AVCR episode when a suture-less securement device was used ( P=0.95). In this study the use of suture-less securement did not seem to increase the risk of AVCR. However, there was a non-significant trend towards increased AVCR when using suture-less securement devices, which may reflect a β error.
CUSUM Method for Construction of Trainee Spinal Ultrasound Learning Curves following Standardised Teaching
Authors: Deacon A. J. , Melhuish N. S. , Terblanche N. C. S.
Published: January 2019

Spinal ultrasonography is a promising aid for epidural insertion. We aimed to determine the learning curve of spinal ultrasonography tasks and the number of training scans required to reach competency after undergoing standardised step-wise teaching. Trainees were required to complete a minimum of 60 assessed scans on selected non-pregnant models following attendance at two training sessions, with feedback from an expert after each scan. Learning curves were plotted using the non-risk cumulative summation technique and an acceptable failure rate of 20%. Five trainees completed between 65 and 75 scans each. All trainees were competent at identifying a randomly assigned intervertebral space after a median of five scans (range one to nine) and at measuring the depth from skin to the posterior complex after a median of 10 scans (range 1 to 42). Two trainees were competent at marking an ideal needle insertion point after 55 scans, while three trainees did not attain competency. All trainees were competent after 60 scans if the tolerance was changed from five to eight millimetre for marking the needle insertion point. The average time taken to complete a scan was 163 seconds. Our study showed that after a standardised educational intervention, anaesthetic trainees are able to identify a lumbar interlaminar space easily and can measure the depth to the posterior complex after a reasonable number of additional practice scans, but experienced difficulty accurately marking the needle insertion point whilst using spinal ultrasonography. We confirmed that it was hard to achieve competency in all aspects of spinal ultrasonography, based on assessment using our predefined competency criteria.
Experience with the Use of the Codonics Safe Label System™ to Improve Labelling Compliance of Anaesthesia Drugs
Authors: Ang S. B. L. , Hing W. C. , Tun S. Y. , Park T.
Published: January 2019

The Codonics Safe Labeling System™ ( http://www.codonics.com/Products/SLS/flash/ ) is a piece of equipment that is able to barcode scan medications, read aloud the medication and the concentration and print a label of the appropriate concentration in the appropriate colour code. We decided to test this system in our facility to identify risks, benefits and usability. Our project comprised a baseline survey (25 anaesthesia cases during which 212 syringes were prepared from 223 drugs), an observational study (47 cases with 330 syringes prepared) and a user acceptability survey. The baseline compliance with all labelling requirements was 58%. In the observational study the compliance using the Codonics system was 98.6% versus 63.8% with conventional labelling. In the user acceptability survey the majority agreed the Codonics machine was easy to use, more legible and adhered with better security than the conventional preprinted label. However, most were neutral when asked about the likelihood of flexibility and customisation and were dissatisfied with the increased workload. Our findings suggest that the Codonics labelling machine is user-friendly and it improved syringe labelling compliance in our study. However, staff need to be willing to follow proper labelling workflow rather than batch label during preparation. Future syringe labelling equipment developers need to concentrate on user interface issues to reduce human factor and workflow problems. Support logistics are also an important consideration prior to implementation of any new labelling system.
A Patient with Acute Liver Failure and Extreme Hypoglycaemia with Lactic Acidosis who was not in Coma: Causes and Consequences of Lactate-Protected Hypoglycaemia
Authors: Oldenbeuving G. , Mcdonald J. R. , Goodwin M. L. , Sayilir R. , Reijngoud D. J. , Gladden L. B. , Nijsten M. W. N.
Published: January 2019

Lactate can substitute for glucose as a metabolic substrate. We report a patient with acute liver failure who was awake despite a glucose level of 0.7 mmol/l with very high lactate level of 25 mmol/l. The hypoglycaemia+hyperlactataemia combination may be considered paradoxical since glucose is the main precursor of lactate and lactate is reconverted into glucose by the Cori cycle. Literature relevant to the underlying mechanism of combined deep hypoglycaemia and severe hyperlactataemia was assessed. We also assessed the literature for evidence of protection against deep hypoglycaemia by hyperlactataemia. Four syndromes demonstrating hypoglycaemia+hyperlactataemia were found: 1) paracetamol-induced acute liver failure, 2) severe malaria, 3) lymphoma and 4) glucose-6-phosphatase deficiency. An impaired Cori cycle is a key component in all of these metabolic states. Apparently the liver, after exhausting its glycogen stores, loses the gluconeogenic pathway to generate glucose and thereby its ability to remove lactate as well. Several patients with lactic acidosis and glucose levels below 1.7 mmol/l who were not in a coma have been reported. These observations and other data coherently indicate that lactate-protected hypoglycaemia is, at least transiently, a viable state under experimental and clinical conditions. Severe hypoglycaemia+hyperlactataemia reflects failure of the gluconeogenic pathway of lactate metabolism. The existence of lactate-protected hypoglycaemia implies that patients who present with this metabolic state should not automatically be considered to have sustained irreversible brain damage. Moreover, therapies that aim to achieve hypoglycaemia might be feasible with concomitant hyperlactataemia.
I. K. Brunel's Crimean War Hospital
Authors: Merridew C. G.
Published: January 2019

“Those wonderful huts…” (Florence Nightingale). This is the story of the British Civil Hospital, erected in 1855 at Renkioi on the south Dardanelles coast of Turkey. The spectacular hospital was a portable one designed by British engineer I. K. Brunel. It was his only health-related project, and it was known as a Civil Hospital because its staff were all civilians, despite its patients being military.
Eugène-Louis Doyen's Pharyngeal Tubes
Authors: Haridas R. P.
Published: January 2019

Eugène-Louis Doyen published illustrations of two pharyngeal tubes in his five-volume surgical textbook, Traité de Thérapeutique Chirurgicale et de Technique Opératoire. The first volume of Doyen's textbook was published in 1908 and contains the earliest known illustration of one of Doyen's pharyngeal tubes. The Hewitt airway was described in Lancet in the same year. No information on the development of the Hewitt airway or Doyen's pharyngeal tubes was found. Doyen's pharyngeal tubes were functionally similar to modern supraglottic airways.
Applicability of Risk Scores for Postoperative Nausea and Vomiting in a Taiwanese Population Undergoing General Anaesthesia
Authors: Wu Y. H. , Sun H. S. , Wang S. T. , Tseng C-C. A.
Published: January 2019

Five popular scoring systems for postoperative nausea and vomiting (PONV) were validated and compared with two new predictive models in a Taiwanese population. Nine hundred and ninety-two patients receiving general anaesthesia in a tertiary hospital were investigated in a prospective observational cohort study. Patient demographic data and the incidence of nausea or vomiting in the first 24 hours after surgery were recorded. The overall incidence of PONV was 42%. The area under the curve (AUC) of the five published PONV risk scoring systems was 0.62 to 0.67. Logistic regression analysis in this study cohort showed that female sex and a history of PONV/car sickness were the only statistically significant independent risk factors for PONV (likelihood ratio test P <0.001). The AUCs of our two-predictor and gender-only models were 0.668 and 0.643, respectively (Nagelkerke R2=0.122 and 0.109). Goodness-of-fit showed that a two-predictor model predicted an outcome that was in agreement with the observed outcome ( P=0.973). Both the two-predictor model and the Apfel score had a similar AUC that was significantly different from the AUCs of the other models. The AUC for the gender-only model in our population was similar to that of the simplified Koivuranta and the Palazzo and Evans scores (AUC=0.659 and 0.632; P=0.137 and 0.513 respectively). All AUCs had only moderate discrimination power but our female gender-only model was much simpler. Using female gender as the only predictor of PONV had predictive power with 75% sensitivity and 54% specificity.
The Effect of Routine Reversal of Neuromuscular Blockade on Adequacy of Recurrent Laryngeal Nerve Stimulation during Thyroid Surgery
Authors: Marshall S. D. , Boden E. , Serpell J.
Published: January 2019

Testing of the integrity of the recurrent laryngeal nerve during thyroid surgery has become routine practice for many surgeons to aid dissection and minimise the chance of inadvertent nerve injury. We hypothesised that routine reversal of an intermediate-acting, non-depolarising neuromuscular blocking agent would improve conditions for stimulation of the recurrent laryngeal nerve. We conducted a single-centre, randomised, double-blind placebo-controlled trial of patients undergoing thyroid surgery by the same surgeon. After randomisation, the participants received either neostigmine 2.5 mg with glycopyrrolate 0.4 mg or placebo, at 30 minutes after induction of anaesthesia and administration of 0.4 mg/kg of atracurium. The primary outcome was the subjective assessment by the surgeon as to whether the neuromuscular function was adequate for stimulation of the recurrent laryngeal nerve using a neuromuscular integrity monitor (NIM). Time to NIM stimulation was 44.6 minutes in the placebo group and 41.4 minutes in the intervention group ( P=0.268). Of the 21 patients who received the neuromuscular blockade reversal, 20 (95.2%) had adequate surgical conditions for NIM stimulation, compared to 9 out of 18 patients (50%) in the placebo group ( P=0.002). Three of the ten patients (30%) with inadequate reversal showed no evidence of residual blockade assessed peripherally. The routine reversal of neuromuscular blockade at 30 minutes post induction appears to result in adequate surgical conditions for safe stimulation of the recurrent laryngeal nerve. Return of neuromuscular function at a peripheral site does not guarantee adequate laryngeal muscle function for use of the NIM.
An Audit of the Haemodynamic and Emergence Characteristics of Single-Shot ‘ketofol’
Authors: Grace R. F. , Tang W. , Namel E.
Published: January 2019

‘Ketofol’, the single-syringe combination of ketamine and propofol (50 mg of ketamine and 90 mg of propofol in a 10 ml syringe) is becoming increasingly popular for short procedures, progressively replacing the more traditional use of ketamine and diazepam in some settings. This audit examined the haemodynamic, emergence and other characteristics of ketofol administration in 42, otherwise fit, women undergoing bilateral post-partum tubal ligation at Vila Central Hospital in Vanuatu. The combination of ketamine and propofol had no clinically important adverse haemodynamic effects. Wake-up from ketofol was favourable, with low rates of nausea and minimal emergence delirium. However, 43% of patients required airway support. For short procedures such as post-partum tubal ligation in fit patients, ketofol appears to have minimal adverse haemodynamic effects and favourable emergence characteristics.
The Incidence of Ocular Candidiasis and Evaluation of Routine Ophthalmic Examination in Critically Ill Patients with Candidaemia
Authors: Gluck S. , Headdon W. G. , Tang D. W. S. , Bastian I. B. , Goggin M. J. , Deane A. M.
Published: January 2019

Despite a paucity of data regarding both the incidence of ocular candidiasis and the utility of ophthalmic examination in critically ill patients, routine ophthalmic examination is recommended for critically ill patients with candidaemia. The objectives were to estimate the incidence of ocular candidiasis and evaluate whether ophthalmic examination influenced subsequent management of these patients. We conducted a ten-year retrospective observational study. Data were extracted for all ICU patients who were blood culture positive for fungal infection. Risk factors for candidaemia and eye involvement were quantified and details regarding ophthalmic examination were reviewed. Candida species were cultured in 93 patients. Risk factors for ocular candidiasis were present in 57% of patients. Forty-one percent of patients died prior to ophthalmology examination and 2% of patients were discharged before candidaemia was identified. During examination, signs of ocular candidiasis were only present in one (2.9%) patient, who had a risk factor for ocular candidiasis. Based on these findings, the duration of antifungal treatment for this patient was increased. Ocular candidiasis occurs rarely in critically ill patients with candidaemia, but because treatment regimens may be altered when diagnosed, routine ophthalmic examination is still indicated.
Idiopathic Interstitial Pneumonia in the ICU: An Observational Cohort Study
Authors: Martinez F. E. , Panwar R. , Kelty E. , Smalley N. , Williams C.
Published: January 2019

In the absence of a clearly identifiable cause, the prognosis of patients with interstitial lung disease is grim. This study describes our institutional experience in management of patients who are admitted to an ICU with respiratory insufficiency secondary to idiopathic interstitial pneumonia (IIP). This study was performed to obtain Australian data on patients admitted to an ICU with respiratory insufficiency secondary to IIP. This is a retrospective cohort study of patients with IIP who were admitted to the ICU between December 2007 and December 2013 at one of two university-affiliated academic hospitals in Newcastle, New South Wales. Thirty-six patients (69% male) were admitted to the ICU in respiratory insufficiency from IIP. The median age of the cohort was 71 (66 to 77) years. The median APACHE III score was 68 (56 to 97). Sixty-nine percent (25/36) of patients died in hospital. The median ICU and hospital lengths of stay were 6 (2 to 13.5) and 12 (4.8 to 18.3) days respectively. No significant difference was observed between admission characteristics and mortality. Patients admitted to ICU with respiratory failure secondary to IIP are aggressively investigated and treated, but still have a high mortality rate. Accurate predictors of mortality would be useful in offering aggressive treatment to patients who would benefit from it.
Fast-Track Rapid Warfarin Reversal for Elective Surgery: Extending the Efficacy Profile to High-Risk Patients with Cancer
Authors: Byrne T. J. , Riedel B. , Ismail H. M. , Heriot A. , Dauer R. , Westerman D. , Seymour J. F. , Kenchington K. , Burbury K.
Published: January 2019

Periprocedural management of patients on long-term warfarin therapy remains a common and important clinical issue, with little high-quality data to guide this complex process. The current accepted practice is cessation of warfarin five days preoperatively, but this is not without risk and can be complicated, particularly if bridging is required. An alternative method utilising low-dose intravenous vitamin K the day before surgery has been shown previously to be efficacious, safe and convenient in an elective surgical population receiving chronic warfarin therapy. The efficacy and utility of this ‘fast-track’ warfarin reversal protocol in surgical patients with cancer, who were at high risk of both thromboembolism and bleeding was investigated in a prospective, single-arm study at a dedicated cancer centre. Seventy-one patients underwent 82 episodes of fast-track warfarin reversal (3 mg intravenous vitamin K 18 to 24 hours before surgery). No patient suffered an adverse reaction to intravenous vitamin K, all but one achieved an International Normalized Ratio ≤1.5 on the day of surgery, and no surgery was deferred. Assays of vitamin K–dependent factor levels pre- and post-vitamin K demonstrated restoration of functional activity to within an acceptable range for surgical haemostasis. While this alternative method requires further validation in a larger prospective randomised study, we have now extended our use of fast-track warfarin reversal using vitamin K to patients with cancer, on the basis of our experience of its safety, convenience, reliability and efficacy.
Characteristics and Expectations of Fluid Bolus Therapy: A Bi-National Survey of Acute Care Physicians
Authors: Glassford N. J. , Jones S. L. , Mårtensson J. , Eastwood G. M. , Bailey M. , Cross A. M. , Taylor D. Mcd. , Bellomo R.
Published: January 2019

There is little consensus on the definition or optimal constituents of fluid bolus therapy (FBT), and there is uncertainty regarding its physiological effects. The aims of this study were to determine clinician-reported definitions of FBT and to explore the physiological responses clinicians expect from such FBT. In June and October 2014, intensive care and emergency physicians in Australia and New Zealand were asked to participate in an electronic questionnaire of the reported practice and expectations of FBT. Two hundred and fifty-one questionnaires were completed, 65.3% from intensivists. We identified the prototypical FBT given by intensivists is more than 250 ml of compound sodium lactate, saline or 4% albumin given in less than 30 minutes, while that given by emergency department physicians is a similar volume of saline delivered over a similar time frame. Intensive care and emergency physicians expected significantly different changes in mean arterial pressure ( P=0.001) and heart rate ( P=0.033) following FBT. Substantial variation was demonstrated in the magnitude of expected response within both specialties for each variable. Major variations exist in self-reported FBT practice, both within and between acute specialties, and wide variation can be demonstrated in the expected physiological responses to FBT. International explorations of practice and prospective quantification of the actual physiological response to FBT are warranted.
Evaluation of Perioperative Predictors of Acute Kidney Injury Post Orthotopic Liver Transplantation
Authors: Wyssusek K. H. , Keys A. L. B. , Yung J. , Moloney E. T. , Sivalingam P. , Paul S. K.
Published: January 2019

Acute kidney injury (AKI) is a common complication following orthotopic liver transplantation. It is associated with increased morbidity and mortality, as well as increased healthcare costs. The aetiology of AKI post liver transplantation is multifactorial and understanding these factors is pivotal in developing risk stratification and prevention strategies. This study aims to investigate the preoperative and intraoperative factors that may be associated with AKI in patients undergoing liver transplantation at the Princess Alexandra Hospital, Brisbane, Queensland. In our study, retrospective data of 97 consecutive orthotopic liver transplantations performed between January 2009 and August 2012 were recorded. Univariate and multivariate analyses were performed to investigate the preoperative and intraoperative risk factors for the development of AKI in this cohort. In the cohort of 97 patients who underwent orthotopic liver transplantation, 24 patients (25%) developed postoperative AKI. Univariate analysis demonstrated that high preoperative body mass index and intraoperative noradrenaline use were both associated with AKI. Multivariate analysis demonstrated that high body mass index, high Model for End-stage Liver Disease score and intraoperative noradrenaline use were associated with AKI. Overall mortaility was 4.1% during the study period and was not significantly different between the two groups. The high incidence of AKI following liver transplantation in this study cohort highlights the importance of this issue. This study has identified several potential pre- and intraoperative risk factors, providing a focus for patient surveillance and future research.
A Survey of Educator Needs to Support the Implementation of the Intrinsic ANZCA Roles in Practice
Authors: Bunbury K. M. , Castanelli D. J.
Published: January 2019

The ‘Roles in Practice’ framework was introduced into the revised ANZCA curriculum in 2013. We conducted an online survey of Supervisors of Training in Australia and New Zealand to assess understanding of this framework, and teaching and perceived value of the non-scholar intrinsic roles within the framework. One hundred and forty-three survey responses were received (response rate 60.8%). The majority of respondents (52.1%) reported only a fair understanding of the framework. Formal teaching of all the roles was consistently reported as infrequent, with most teaching occurring through the informal curriculum. The Communicator, Collaborator and Professional Roles were rated as better taught and more important to teach than the roles of Health Advocate and Manager. The Communicator Role was perceived as being the role for which the development of resources would be most valuable. Respondents overwhelmingly nominated small group teaching as the preferred medium for resource development of all intrinsic roles. Our survey indicates that there is a need to increase both the understanding of the Roles in Practice framework and the teaching resources available in the ANZCA Supervisor of Training community.
Hereditary Antithrombin III Deficiency and Neuraxial Anaesthesia
Authors: Piper B. J. , Farrell P. T.
Published: January 2019

Antithrombin III (ATIII) deficiency offers unique challenges to the anaesthetist in the perioperative setting due to the inherent thrombophilia, the anticoagulant therapies instituted and replacement of the deficient intrinsic natural anticoagulant. A particular challenge is the use of intrathecal anaesthesia, which requires a safe level of coagulation at the time of subarachnoid puncture. We describe the use of intrathecal anaesthesia on two occasions in a patient with ATIII deficiency who received human-derived ATIII concentrate as part of a perioperative anticoagulant regimen. The patient sustained no thrombotic or bleeding events. Our experience suggests that ATIII deficiency does not preclude the use of regional anaesthetic techniques so long as there is timely referral to a multidisciplinary perioperative service for anticoagulant management and that ATIII concentrate is used to ensure safe levels of ATIII throughout the perioperative period.
A Six-Month Evaluation of the Vivasight™ Video Double-Lumen Endotracheal Tube after Introduction into Thoracic Anaesthetic Practice at a Single Institution
Authors: Rapchuk I. L. , Kunju S. A. M. , Smith I. J. , Faulke D. J.
Published: January 2019

For a six-month period, all airway options used for non-emergent patients undergoing thoracic surgery requiring one-lung ventilation at a single institution were assessed after introduction of the VivaSight™ double-lumen endotracheal tube (VivaSight-DL), a novel double-lumen tube with an integrated camera. This device displays a continuous view of the position of the tube relative to the carina. A total of 72 patients had lung separation with the VivaSight-DL. Lung separation was achieved on first attempt without additional manipulation in 85% of cases. In only three cases (4%) was a fibreoptic bronchoscope required, in each instance to reposition the tube after intraoperative dislodgement. The VivaSight-DL represents a novel method of one-lung ventilation allowing rapid identification of intraoperative airway problems and reducing the need for fibreoptic bronchoscopy.
Survey of Research Capability at Australian and New Zealand College of Anaesthetists Accredited Training Sites
Authors: Goulding K. R. , Peyton P. J. , Story D. A. , Parker A. , Network K. Leslie
Published: January 2019

The Australian and New Zealand College of Anaesthetists (ANZCA) has more than 200 accredited training sites in Australia, New Zealand, Hong Kong, Malaysia and Singapore, many of which participate in ANZCA Clinical Trials Network (CTN)–endorsed clinical trials. We undertook a survey of accredited sites to determine research capability, activity and potential. With ethics committee approval an electronic survey was distributed to accredited sites in July 2015. Of 207 accredited sites, 167 were sent the questionnaire (after eliminating ineligible sites) and 128 responded. Response rates for Australia, New Zealand, Hong Kong, Malaysia and Singapore were 100%, 100%, 35%, 25% and 75% respectively. Forty-four (34%) of 128 responding sites had a head of research; 101 (80%) of 126 responding sites were active in research; 42 (33%) of 126 responding sites had no publications since January 2011 and 15 (12%) had >50 publications; 95 (76%) of 125 responding sites had at least one specialist anaesthetist engaged in research (median = 4 [range 1–25]); and 45 (36%) of 125 responding sites had at least one research coordinator (median = 2 [range 1–15]). Fifty-eight (28%) of the 207 accredited sites were identified as participating in recent ANZCA CTN–endorsed clinical trials. Research capability and activity were higher in these sites. This survey has identified a strong base upon which to expand clinical trial activity, and regions, sectors, investigators and research coordinators who may benefit from additional support.
Global Tidal Variations, Regional Distribution of Ventilation, and the Regional Onset of Filling Determined by Electrical Impedance Tomography: Reproducibility
Authors: Caruana L. R. , Barnett A. G. , Tronstad O. , Paratz J. D. , Chang A. T. , Fraser J. F.
Published: January 2019

The reproducibility of the regional distribution of ventilation and the timing of onset of regional filling as measured by electrical impedance tomography lacks evidence. This study investigated whether electrical impedance tomography measurements in healthy males were reproducible when electrodes were replaced between measurements. Part 1: Recordings of five volunteers lying supine were made using electrical impedance tomography and a pneumotachometer. Measurements were repeated at least three hours later. Skin marking ensured accurate replacement of electrodes. No stabilisation period was allowed. Part 2: Electrical impedance tomography recordings of ten volunteers; a 15 minute stabilisation period, extra skin markings, and time-averaging were incorporated to improve the reproducibility. Reproducibility was determined using the Bland–Altman method. To judge the transferability of the limits of agreement, a Pearson correlation was used for electrical impedance tomography tidal variation and tidal volume. Tidal variation was judged to be reproducible due to the significant correlation between tidal variation and tidal volume (r2 = 0.93). The ventilation distribution was not reproducible. A stabilisation period, extra skin markings and time-averaging did not improve the outcome. The timing of regional onset of filling was reproducible and could prove clinically valuable. The reproducibility of the tidal variation indicates that non-reproducibility of the ventilation distribution was probably a biological difference and not measurement error. Other causes of variability such as electrode placement variability or lack of stabilisation when accounted for did not improve the reproducibility of the ventilation distribution.
Ambu® Auragain™ versus LMA Supreme™ Second Seal™: A Randomised Controlled Trial Comparing Oropharyngeal Leak Pressures and Gastric Drain Functionality in Spontaneously Breathing Patients
Authors: Shariffuddin I. I. , Teoh W. H. , Tang E. B. K. , Hashim N. H. M. , Loh P. S.
Published: January 2019

Newer second generation supraglottic airway devices may perform differently in vivo due to material and design modifications. We compared performance characteristics of the Ambu® AuraGain™ and LMA Supreme™ Second Seal™ in 100 spontaneously breathing anaesthetised patients in this randomised controlled study. We studied oropharyngeal leak pressures (OLP) (primary outcome) and secondarily, ease of insertion, success rates, haemodynamic response, time to insertion, and complications of usage. We found no significant difference in OLP between the AuraGain versus the LMA Supreme, mean (standard deviation, SD) 24.1 (7.4) versus 23.6 (6.2) cmH2O, P=0.720. First-attempt placement rates of the AuraGain were comparable to the LMA Supreme, 43/50 (86%) versus 39/50 (78%), P=0.906, with an overall 98% insertion success rate for the AuraGain and 88% for the LMA Supreme after three attempts, P=0.112. However, the AuraGain was deemed subjectively harder to insert, with only 24/50 (48%) versus 37/50 (74%) of AuraGain insertions being scored 1 = easy (on a 5 point scale), P=0.013, and also took longer to insert, 33.4 (SD 10.9) versus 27.3 (SD 11.4) seconds, P=0.010. The AuraGain needed a smaller volume of air (16.4 [SD 6.8] versus 23.0 [SD 7.4] ml, P <0.001) to attain intracuff pressures of 60 cmH2O, facilitated more successful gastric tube insertion (100% versus 90.9%, P=0.046), and had significantly decreased sore throat incidence (10% versus 38%, P=0.020). One AuraGain and six LMA Supremes failed to be placed within the stipulated 120 seconds trial definition of ‘success’; these patients had risk factors for failed supraglottic insertion. In conclusion, both devices had similar OLPs and performed satisfactorily. However, the AuraGain resulted in less postoperative sore throat despite being harder to, and taking longer to, insert.
Buprenorphine-Related Complications in Elderly Hospitalised Patients: A Case Series
Authors: Richards S. , Torre L. , Lawther B.
Published: January 2019

We report a case series of buprenorphine-related respiratory and neurological depression in opioid-naïve elderly hospitalised patients who received buprenorphine for acute pain management at our institution over a 24-month period. All six patients had risk factors for respiratory depression such as advanced age, concurrent comorbidities, or the ingestion of other potential central nervous system depressants. All patients required escalation of management with additional monitoring, with some transferred to a high dependency or intensive care unit. Five patients had attempted naloxone reversal with varying results. Our cases highlight the fact that while buprenorphine has been demonstrated to have a ceiling effect in relation to respiratory depression in healthy volunteers, it remains an important side-effect and may result in significant respiratory depression in patients with reduced respiratory or neurological reserve. Difficulties with buprenorphine's reversal using naloxone are described. We recommend additional caution when considering buprenorphine for acute pain management in elderly opioid-naïve patients, especially if they have comorbidities or are taking other central nervous system depressants. When buprenorphine is used in patients with risk factors, we recommend additional monitoring and education about potential adverse respiratory effects and their management.
Coming Full Circle: Thirty Years of Paediatric Fluid Resuscitation
Authors: Glassford N. J. , Gelbart B. , Bellomo R.
Published: January 2019

Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization–recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.
Efficacy and Safety of Ultra Rapid Iron Polymaltose Infusion during General Anaesthesia
Authors: Browning R. M. , Alakeson N. , O'Loughlin E. J.
Published: January 2019

To assess the efficacy and safety of ultra rapid (15 minute) infusion of iron polymaltose to iron deficient patients during general anaesthesia, we performed a prospective, interventional non-randomised study on 99 adult patients with iron deficiency with or without anaemia presenting for surgery under general anaesthesia. Over 15 minutes during the maintenance phase of anaesthesia, patients were given iron polymaltose, 500 mg if not anaemic, or 1,000 mg if anaemic. Haemodynamic stability, immediate or delayed iron-related side-effects and efficacy at six weeks were assessed. The incidence of significant hypotension or the requirement for vasopressor was not different before, during or after the iron infusion. There were no serious intraoperative events (allergic reactions or skin staining). Mean (standard deviation, SD) haemoglobin rose from 121 (14) g/l preoperatively to 131 (12) g/l at six weeks (P <0.001). Mean (SD) ferritin rose from 17 (12) μg/l to 110 (83) μg/l by six weeks (P <0.001). At six weeks only four out of 64 contactable patients (6.25%) had a ferritin of <30 μg/l. The incidence of immediate or delayed side-effects was similar to patients undergoing outpatient iron polymaltose infusions and reflective of a post-surgical population. We conclude that up to 1,000 mg of iron polymaltose can be given over 15 minutes without significant haemodynamic compromise to selected patients undergoing general anaesthesia. Iron polymaltose administered in this way appears efficacious in treating iron deficiency.
Relationship between Functional Status Prior to Onset of Critical Illness and Mortality: A Prospective Multicentre Cohort Study
Authors: Rivera-Lopez R. , Gutierrez-Rodriguez R. , Lopez-Caler C. , Aguilar-Alonso E. , Castillo-Lorente E. , Garcia-Delgado M. , Arias-Verdu M. D. , Iglesias-Posadilla D. , Barrueco-Francioni J. E. , Quesada-Garcia G. , Rivera-Fernandez R.
Published: January 2019

This prospective study aimed to assess the association between prior functional status and hospital mortality for patients admitted to four intensive care units in Spain between 2006 and 2012. Prior functional status was classified into three groups, using a modification of the Glasgow Outcome Scale (GOS), including group 1 with no limitations on activities of daily living; group 2 with some limitations but self-sufficient; and group 3 who were dependent on others for their activities of daily living. Of the 1,757 patients considered (mean Simplified Acute Physiology Score [SAPS] predicted mortality 14.8% and hospital mortality 13.7%), group 1 had the lowest observed hospital mortality (8.3%) compared to the SAPS 3 predicted mortality (11.6%). The observed mortality for group 2 (20.6%) and group 3 (27.4%) were both higher than predicted (19.2% and 21.2% respectively; odds ratio [OR] 1.97, 95% confidence interval [CI] 1.38–2.82 for group 2 and OR 2.90, 95% CI 1.78–4.72 for group 3 compared to group 1). Combining prior functional status and Sequential Organ Failure Assessment (SOFA) score with SAPS 3 further improved the ability of the SAPS 3 scores in predicting hospital mortality (area under the receiver operating characteristic curve 0.85 [95% CI 0.82–0.88] versus 0.84 [95% CI 0.81–0.87] respectively). In summary, patients with limited functional status prior to ICU admission had a higher risk of observed hospital mortality than predicted. Assessing prior functional status using a relatively simple questionnaire, such as a modified GOS, has the potential to improve the accuracy of existing prognostic models.
Severe Hyperkalaemia Complicating Parathyroidectomy in Patients with End-Stage Renal Disease
Authors: Pauling M. , Lee J. C. , Serpell J. W. , Wilson S.
Published: January 2019

We evaluated the incidence of perioperative hyperkalaemia in end-stage renal disease (ESRD) patients undergoing parathyroidectomy and investigated possible contributors to this phenomenon. This was a retrospective cohort study looking at patients who had undergone parathyroidectomy for chronic kidney disease–associated mineral bone disease (CKD-MBD) at The Alfred Hospital, Melbourne, since 2001. Baseline demographics including age, gender, aetiology of renal failure and mode of renal replacement therapy as well as anaesthetic technique and duration of surgery were studied as possible contributors. Perioperative potassium values were compared to preoperative baseline. Following stratification into normokalaemic and hyperkalaemic groups, demographic and operative data were compared. Twenty-two patients met the inclusion criteria with a median (interquartile range, IQR) age of 48.5 (42–59) years. There was a male predominance of 68%. The median (IQR) surgical time was 131 (115–164) minutes. Potassium levels rose perioperatively, with a 27.3% incidence of perioperative hyperkalaemia. Median duration of surgery was longer in the hyperkalaemic patients (167 minutes versus 125 minutes). Following the withdrawal of cinacalcet, parathyroidectomy is increasingly required in ESRD patients with CKD-MBD. Potentially life-threatening hyperkalaemia poses a significant risk in the perioperative period. Serial electrolyte monitoring is crucial to safety in this patient group. A multidisciplinary approach to perioperative management is required to ensure optimal timing of renal replacement therapy and appropriate means of serial blood sampling.
Effect of Pre-Hospital Advanced Airway Management for Out-Of-Hospital Cardiac Arrest Caused by Respiratory Disease: A Propensity Score–Matched Study
Authors: Ohashi-Fukuda N. , Fukuda T. , Yahagi N.
Published: January 2019

Optimal pre-hospital care for out-of-hospital cardiac arrest (OHCA) caused by respiratory disease may differ from that for OHCA associated with other aetiologies, especially with respect to respiratory management. We aimed to investigate whether pre-hospital advanced airway management (AAM) was associated with favourable outcomes after OHCA caused by intrinsic respiratory disease. This nationwide, population-based, propensity score–matched study of adult patients in Japan with OHCA due to respiratory disease from 1 January 2005 to 31 December 2012 compared patients with and without pre-hospital AAM. The primary outcome was neurologically favourable survival at one month after the OHCA. Of 49,534 eligible patients, 20,458 received pre-hospital AAM and 29,076 did not. In a propensity score–matched cohort (18,483 versus 18,483 patients), the odds of neurologically favourable survival were significantly lower for patients receiving pre-hospital AAM (0.6% versus 1.5%; odds ratio [OR] 0.42 [95% confidence interval {CI} 0.34 to 0.52]). The results from multivariable logistic regression analysis also showed that pre-hospital AAM was significantly associated with a decreased chance of neurologically favourable survival (adjusted OR 0.43 [95% CI 0.35 to 0.52]). Similar findings were observed for one-month survival and pre-hospital return of spontaneous circulation. In subgroup analyses, pre-hospital AAM was associated with poor neurological outcomes, regardless of the type of airway device used (laryngeal mask airway, adjusted OR 0.35 [95% CI 0.19 to 0.57]; oesophageal obturator airway, adjusted OR 0.44 [95% CI 0.35 to 0.55]; and endotracheal tube, adjusted OR 0.47 [95% CI 0.30 to 0.69]). In conclusion, pre-hospital AAM was associated with poor neurological outcome among patients with OHCA caused by intrinsic respiratory disease.
Airway Heat and Humidity during Endotracheal Intubation: I. Inspiration of Arid Gases via a Non-Rebreathing Circuit
Authors: Shanks Colin , Sara Charles
Published: January 2019

Investigation into the patterns of respiratory heat and moisture exchange in intubated patients, under general anaesthesia, is detailed. This paper gives the inspiratory and expiratory temperatures and humidities found in a non-rebreathing circuit near the valve and near the trachea. A model lung was constructed to control and determine factors which have been implicated in playing a major part in heat and moisture homeostasis within the respiratory tract. Laboratory and clinical results are compared.
Anaesthesia for Thyroid Surgery
Authors: Holmes J. L. , Hooper M. J. , Barraclough B. H. , White B. , Reeve T. S.
Published: January 2019

The principles involved in preoperative assessment and management of the patient who is to undergo thyroidectomy are discussed.

The techniques of anaesthesia that have been found most successful for thyroidectomy at The Royal North Shore Hospital of Sydney are described. The effectiveness of these techniques is indicated by reference to the complications found following review of 200 consecutive thyroidectomies.
The Relationship between Examinations and Training Schemes
Authors: Harrison G. A.
Published: January 2019

The relationship between examinations and training schemes is reviewed with special reference to post-graduate training in anaesthetics. Five basic types are described. Type 1 has internal assessment but no external standard setting body, Type 2 has internal assessment with an external standard setting body, Type 3 has the features of Type 2 plus an external multiple choice examination, Type 4 has a completely external examination, and Type 5 has a completely external examination but with strong feedback systems similar to Types 1, 2 and 3.
Airway Heat and Humidity during Endotracheal Intubation: III. Rebreathing from the Circle Absorber System at Low Fresh Gas Flow
Authors: Shanks C. A. , Sara C. A.
Published: January 2019

Gas temperatures and humidities were examined when the fresh gas flow into a circle absorber system was one 1/minute. The environment cooled gases in the circuit to a minimum at the patient end of the inspiratory tubing; here the saturated gas was 2°C above room temperature. Moisture uptake kept pace with temperature gain during inspiration and relative humidities remained high. Under these conditions, heat and moisture exchange in the artificial airways produced end-inspired temperatures and humidities in the gases entering the trachea which were close to normal subglottic values.
Intensive Care of the High Risk Foetus in Labour
Authors: Spurrett Brian
Published: January 2019

A brief outline is given of intensive care methods to monitor the foetus during labour. Attention is drawn to the need for more widespread emphasis on the early detection of foetal hypoxia, so that morbidity, in the form of anoxic cerebral damage, will be reduced.
A Reappraisal of the Multiple Gauze Heat and Moisture Exchanger
Authors: Shanks C. A. , Sara C., A.
Published: January 2019

The multiple gauze heat and moisture exchanger was assessed under standardized conditions, at five levels of predetermined fresh gas humidity. As predicted theoretically, the unit functioned best when presented with fresh gases with high water vapour content. The ordinary unit moistened arid gases during inspiration to a level unacceptable for prolonged use. Unheated simple humidification systems dampen anhydrous stored gases and combined with the standard condenser-humidifier produce a microclimate suitable for entry into the trachea during spontaneous or controlled ventilation.

Quadrupling the number of gauzes improved heat and moisture exchange with all but the saturated fresh gases. However, there was a considerable increase in weight.
Anaesthesia for Laryngoscopy and Microlaryngeal Surgery in Children
Authors: Lines Verlie
Published: January 2019

The problems of anaesthesia for laryngoscopy and microlaryngeal surgery in children are discussed. The author's current techniques are described. For laryngoscopy, deep inhalational anaesthesia with halothane, combined with the topical application of lignocaine, is most commonly used. Microlaryngeal surgery may be performed using a pharyngeal insufflation technique to give unobstructed surgical access to the larynx. In other cases, tracheal intubation is acceptable to the surgeon, and may be used with spontaneous respiration or with muscle paralysis and controlled ventilation. Other methods, past and present, are reviewed.
Acute Epiglottitis—Management by Intubation
Authors: Sweeney D. B. , Allen T. H. , Steven I. M.
Published: January 2019

The clinical features of acute epiglottitis are described. A method of managing the condition by nasotracheal intubation is given.

The results in a series of 56 cases are discussed. The one death that occurred in this series followed conservative management.