bluuebunny/crossref_metadata_2025 huggingface dataset:
Glycaemic Control and Long-Term Outcomes following Transition from Modified Intensive Insulin Therapy to Conventional Glycaemic Control
Authors: Orford N. R. , Bailey M. , Kaukonen K. , Elderkin T. , Stow P. J. , Cattigan C. , Kotowicz M. , Bellomo R.
Published: January 2019

This retrospective observational cohort study compared glycaemic control and long-term outcomes following transition from a modified intensive insulin therapy (mIIT) regimen to conventional glycaemic control (CGC) in adult patients admitted to a tertiary adult general intensive care unit, during two 24-month periods, before and after the publication of the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial. The before NICE-SUGAR cohort received mIIT (target glycaemic ranges 4.4 to 7.0 mmol/1), while the after NICE-SUGAR cohort received CGC (target glycaemic range 7.1 to 9.0 mmol/1). A total of 5202 patients were included in the study. With transition from mIIT to CGC, the mean time-weighted glucose increased from 6.94 mmol/1 to 8.2 mmol/1 ( P <0.0001). A similar increase was observed in other glycaemic indices (mean, highest and lowest glucose values, P <0.0001 for all). The adjusted 90-day odds ratio for mortality decreased by 47% with transition from mIIT to CGC (odds ratio 1.47 (95% confidence interval, 1.22 to 1.78) (P <0.0001). The rate of severe and moderate hypoglycaemia also decreased from 1.2 to 0.4% ( P=0.004) and from 23.3 to 5.9% (P <0.0001), respectively. mIIT was associated with an increased risk of moderate and severe hypoglycaemia compared to CGC (odds ratio 3.1 (1.51 to 6.39) ( P=0.002), 6.29 (5.1 to 7.75) (P <0.0001)). Changes in recommended glycaemic control were translated into practice, with increased glycaemic indices and decreased rates of severe and moderate hypoglycaemia after the introduction of CGC. The associated decrease in 90-day mortality suggests mIIT was not superior to CGC, despite a lower hypoglycaemia rate than in previous IIT trials. Our findings support the continued use of CGC.
Management of Severe Hypercapnia Post Cardiac Arrest with Extracorporeal Carbon Dioxide Removal
Authors: Tiruvoipati R. , Gupta S. , Haji K. , Braun G. , Carney I. , Botha J. A.
Published: January 2019

Normocapnia is recommended in intensive care management of patients after out-of-hospital cardiac arrest. While normocapnia is usually achievable, it may be therapeutically challenging, particularly in patients with airflow obstruction. Conventional mechanical ventilation may not be adequate to provide optimal ventilation in such patients. One of the recent advances in critical care management of hypercapnia is the advent of newer, low-flow extracorporeal carbon dioxide clearance devices. These are simpler and less invasive than conventional extracorporeal devices. We report the first case of using a novel, extracorporeal carbon dioxide removal device in Australia on a patient with out-of-hospital cardiac arrest where mechanical ventilation failed to achieve normocapnia.
Sodium Concentration in Urine Greater than in the Plasma: Possible Biomarker of Normal Renal Function and Better Outcome in Critically Ill Patients
Authors: Maciel A. T. , Vitorio D. , Salles L. D. , Park M.
Published: January 2019

Correct interpretation of the urinary sodium concentration (NaU) and its relation to renal function in critically ill patients is lacking. Our aim was to evaluate the relationship between simultaneous NaU value and serum creatinine (sCr). The hypothesis is that a NaU value greater than 140 mmol/l (normal equivalent value in plasma) is only found in patients with normal sCr. We made a retrospective analysis of 1153 simultaneous samples of NaU and sCr, divided according to diuretic use in the previous 24 hours and grouped in five distinct NaU ranges (< 20, 20 to 39, 40 to 139, 140 to 169, ≥ 170 mmol/l). NaU values below 140 mmol/l were found simultaneously with both normal and increased sCr. NaU values above 140 mmol/l were almost always found in patients with normal sCr, even if diuretics were used. Median sCr values in the NaU ranges above 140 mmol/l were significantly lower than in the other NaU ranges. Estimated glomerular filtration rates were lower and intensive care unit and hospital mortalities were higher in patients with NaU values lower than 140 mmol/l compared to patients with a NaU higher than 140 mmol/l. We concluded that a high natriuretic capacity reflects significant residual renal function in the critically ill. NaU greater than normal plasma sodium is a possible biomarker of normal/improving renal function and also of better outcome. Sole NaU values below 140 mmol/l are difficult to interpret but it is possible that very low NaU values may signify some threat to normal kidney function and worse prognosis even in the presence of normal sCr. Our way to interpret NaU values in critically ill patients needs further careful evaluation.
Lateral Cutaneous Femoral Nerve Blockade—Limited Skin Incision Coverage in Hip Arthroplasty
Authors: Davies A. , Crossley A. P. , Harper M. W. , O'Loughlin E. J.
Published: January 2019

This paper seeks to assess the potential use of blocking the lateral cutaneous femoral nerve (LCN) for patients undergoing hip surgery. In this study, ultrasound guidance was used to specifically block the LCN using a small volume of local anaesthetic in 20 healthy volunteer anaesthetists. An orthopaedic surgeon then drew lines on the volunteers reflecting three common cutaneous incision lines (anterolateral, lateral, and posterior approach) for hip arthroplasty using an ultraviolet reflecting pen invisible in normal lighting. The relationship between the anaesthesia produced by this block and the marked incision lines was then assessed. More than half (32 of 60) of the drawn incision lines fell completely outside of the anaesthesia produced by the LCN block. Of the remaining incision lines drawn, most were less than half covered by LCN blockade with only three lines more than 50% covered and none more than 75% covered. The skin anaesthesia produced by LCN blockade was usually anterior and inferior to the surgical lines marked. This significant lack of overlap between common hip arthroplasty incision lines and the anaesthesia produced by blockade of the lateral cutaneous femoral nerve draws into question the utility of this block for hip surgery.
A Cohort and Database Study of Airway Management in Patients Undergoing Thyroidectomy for Retrosternal Goitre
Authors: Gilfillan N. , Ball C. M. , Myles P. S. , Serpell J. , Johnson W. R. , Paul E.
Published: January 2019

Patients undergoing thyroid surgery with retrosternal goitre may raise concerns for the anaesthetist, especially airway management. We reviewed a multicentre prospective thyroid surgery database and extracted data for those patients with retrosternal goitre. Additionally, we reviewed the anaesthetic charts of patients with retrosternal goitre at our institution to identify the anaesthetic induction technique and airway management. Of 4572 patients in the database, 919 (20%) had a retrosternal goitre. Two cases of early postoperative tracheomalacia were reported, one in the retrosternal group. Despite some very large goitres, no patient required tracheostomy or cardiopulmonary bypass and there were no perioperative deaths. In the subset of 133 patients managed at our institution over six years, there were no major adverse anaesthetic outcomes and no patient had a failed airway or tracheomalacia. In the latter cohort, of 32 (24%) patients identified as having a potentially difficult airway, 17 underwent awake fibreoptic tracheal intubation, but two of these were abandoned and converted to intravenous induction and general anaesthesia. Eleven had inhalational induction; two of these were also abandoned and converted to intravenous induction and general anaesthesia. Of those suspected as having a difficult airway, 28 (87.5%) subsequently had direct laryngoscopy where the laryngeal inlet was clearly visible. We found no good evidence that thyroid surgery patients with retrosternal goitre, with or without symptoms and signs of tracheal compression, present the experienced anaesthetist with an airway that cannot be managed using conventional techniques. This does not preclude the need for multidisciplinary discussion and planning.
Select Critically ill Patients at Risk of Augmented Renal Clearance: Experience in a Malaysian Intensive Care Unit
Authors: Adnan S. , Ratnam S. , Kumar S. , Paterson D. , Lipman J. , Roberts J. , Udy A. A.
Published: January 2019

Augmented renal clearance (ARC) refers to increased solute elimination by the kidneys. ARC has considerable implications for altered drug concentrations. The aims of this study were to describe the prevalence of ARC in a select cohort of patients admitted to a Malaysian intensive care unit (ICU) and to compare measured and calculated creatinine clearances in this group. Patients with an expected ICU stay of >24 hours plus an admission serum creatinine concentration <120 μmol/l, were enrolled from May to July 2013. Twenty-four hour urinary collections and serum creatinine concentrations were used to measure creatinine clearance. A total of 49 patients were included, with a median age of 34 years. Most study participants were male and admitted after trauma. Thirty-nine percent were found to have ARC. These patients were more commonly admitted in emergency ( P=0.03), although no other covariants were identified as predicting ARC, likely due to the inclusion criteria and the study being under-powered. Significant imprecision was demonstrated when comparing calculated Cockcroft-Gault creatinine clearance (Crcl) and measured Crcl. Bias was larger in ARC patients, with Cockcroft-Gault Crcl being significantly lower than measured Crcl ( P <0.01) and demonstrating poor correlation (rs=-0.04). In conclusion, critically ill patients with ‘normal’ serum creatinine concentrations have varied Crcl. Many are at risk of ARC, which may necessitate individualised drug dosing. Furthermore, significant bias and imprecision between calculated and measured Crcl exists, suggesting clinicians should carefully consider which method they employ in assessing renal function.
Factors Influencing Escalation of Care by Junior Medical Officers
Authors: Rotella J. A. , Yu W. , Ferguson J. , Jones D.
Published: January 2019

Patients can acutely deteriorate unexpectedly. Junior medical officers (JMOs) are often first to review patients who become unwell. Opportunities to escalate care to a senior colleague may exist prior to the need for a rapid response team review. Little is known about the factors that influence JMO decisions to escalate care. In this study, our objective was to investigate the self-reported factors that influence escalation of care by JMOs in a university-affiliated, tertiary level hospital. We designed a face-to-face questionnaire of JMOs using standardised introduction to minimise interviewer bias. Fifty JMOs participated in the study (a 100% response rate). Most (63.3%) felt that they would be able to identify a clinically deteriorating patient. They would be more likely to escalate care if they were not familiar with the patient's clinical problem. If handover plans were seen to be adequate, JMOs felt it was less necessary to escalate care. Few JMOs (12%) agreed that they limited escalation due to fear of criticism or fear of conflict with senior medical staff. Although 36% agreed that they were concerned about waking seniors overnight, only 6% feared that escalating care overnight would affect their future career prospects. Escalation of care appears to be mostly influenced by the confidence and familiarity of the JMO with the cause of deterioration. JMOs identified clear handover with documented goals of treatment and suggested actions in event of clinical deterioration as the best means by which to improve the process of escalation of care for clinically deteriorating patients.
The Impact of the Australian and New Zealand College of Anaesthetists’ Specialist Examinations on Trainee Learning and Wellbeing: A Qualitative Study
Authors: Weller J. M. , Henning M. , Butler R. , Thompson A.
Published: January 2019

Assessment is an essential component of any medical specialist training program and should motivate trainees to acquire and retain the knowledge and skills essential for specialist practice, and to develop effective approaches to learning, essential for continuous professional development. Ideally, this should be achieved without creating an unreasonable burden of assessment. In this qualitative study we sought to investigate the underlying processes involved in trainees’ preparation for Australian and New Zealand College of Anaesthetists’ examinations, focusing on how the examinations helped trainees to learn the Australian and New Zealand College of Anaesthetists’ curriculum, and to identify any potential areas for improvement. We also explored the effect the examinations had on trainees’ lives, to identify if the examinations were a potential threat to their wellbeing. Using a phenomenological approach and purposive sampling, we conducted semi-structured interviews with post-fellowship trainees (n=20) selected from three different regions, with sampling continuing to achieve data saturation. We undertook a thematic analysis of the transcribed interview data utilising a general inductive approach. Our preliminary data suggest that, while the examinations are an important extrinsic motivator to learn and important for professional development, interviewees described many test-driven learning strategies, including rote learning and memorising past examination questions. A strong theme was the considerable impact on participants’ relationships and social activities for prolonged periods. Our findings support further research in this area and, in particular, into alternative testing strategies that might increase the proportion of time spent in useful study while decreasing less useful study time.
Tracheal Stenosis following Percutaneous Dilatational Trache-Ostomy using the Single Tapered Dilator: An MRI Study
Authors: Young E. , Pugh R. , Hanlon R. , O'Callaghan E. , Wright C. , Jeanrenaud P. , Jones T. M. , Dempsey G. A.
Published: January 2019

Despite widespread adoption of percutaneous dilatational tracheostomy within the critical care setting, there is still uncertainty regarding long-term complications, particularly in relation to missed or subclinical tracheal stenosis. In this study, all patients underwent tracheostomy using a single tapered dilator ≥ three months prior to enrolment and were evaluated using magnetic resonance imaging, spirometry and questionnaire. Tracheal area was recorded and deemed to be stenotic if a reduction of ≥10% was found. Fifty patients underwent magnetic resonance imaging and 49 attended for interview. Five patients were diagnosed with tracheal stenosis—none were symptomatic. Six of the 50 tracheostomies were technically difficult. Spirometry was not predictive of stenosis. A post critical care exercise tolerance of less than 100 metres was found in four tracheal stenosis patients. The prevalence of subclinical tracheal stenosis following percutaneous tracheostomy is low, with limited clinical significance. No patients required corrective surgery for tracheal stenosis. Routine airway follow-up in asymptomatic patients appears to be unwarranted.
A Randomised Controlled Trial of Fluid Restriction Compared to Oesophageal Doppler-Guided Goal-Directed Fluid Therapy in Elective Major Colorectal Surgery within an Enhanced Recovery after Surgery Program
Authors: Phan T. D. , An V. , D'Souza B. , Rattray M. J. , Johnston M. J. , Cowie B. S.
Published: January 2019

There is continued controversy regarding the benefits of goal-directed fluid therapy, with earlier studies showing marked improvement in morbidity and length-of-stay that have not been replicated more recently. The aim of this study was to compare patient outcomes in elective colorectal surgery patients having goal-directed versus restrictive fluid therapy. Inclusion criteria included suitability for an Enhanced Recovery After Surgery care pathway and patients with an American Society of Anesthesiologists Physical Status score of 1 to 3. Patients were intraoperatively randomised to either restrictive or Doppler-guided goal-directed fluid therapy. The primary outcome was length-of-stay; secondary outcomes included complication rate, change in haemodynamic variables and fluid volumes. One hundred patients, 50 in each group, were included in the analysis. Compared to restrictive therapy, goal-directed therapy resulted in a greater volume of intraoperative fluid, 2115 (interquartile range 1350 to 2560) ml versus 1500 (1200 to 2000) ml, P=0.008, and was associated with an increase in Doppler-derived stroke volume index from beginning to end of surgery, 43.7 (16.3) to 54.2 (21.1) ml/m2, P <0.001, in the latter group. Length-of-stay was similar, P=0.421. The number of patients with any complication (minor or major) was similar; 60% (30) versus 52% (26), P=0.42, or major complications, 1 (2%) versus 4 (8%), P=0.36, respectively. The increased perioperative fluid volumes and increased stroke volumes at the end of surgery in patients receiving goal-directed therapy did not translate to a significant difference in length-of-stay and we did not observe a difference in the number of patients experiencing minor or major complications.
Tracheal Cuff Pressure Monitoring in the ICU: A Literature Review and Survey of Current Practice in Queensland
Authors: Talekar C. R. , Udy A. A. , Boots R. J. , Lipman J. , Cook D.
Published: January 2019

The application of tracheal cuff pressure monitoring is likely to vary between institutions. The aim of this study was therefore to review current evidence concerning this intervention in the intensive care unit (ICU) and to appraise regional practice by performing a state-wide survey. Publications for review were identified through searches of PubMed, EMBASE and Cochrane (1977 to 2014). All studies in English relevant to critical care and with complete data were included. Survey questions were developed by small-group consensus. Public and private ICUs across Queensland were contacted, with responses obtained from a representative member of the medical or nursing staff. Existing literature suggests significant variability in tracheal cuff pressure monitoring in the ICU, particularly in the applied technique, frequency of assessment and optimal intra-cuff pressures. Twenty-nine respondents completed the survey, representing 80.5% (29/36) of ICUs in Queensland. Twenty-eight out of twenty-nine respondents reported routinely monitoring tracheal cuff function, primarily employing cuff pressure measurement (26/28). Target cuff pressures varied, with 3/26 respondents aiming for 10 to 20 cmH2O, 10/26 for 21 to 25 cmH2O, and 13/26 for 26 to 30 cmH2O. Fifteen out of twenty-nine reported they had no current guideline or protocol for tracheal cuff management and only 16/29 indicated there was a dedicated area in the clinical record for reporting cuff intervention. Our results indicate that many ICUs across Queensland routinely measure tracheal cuff function, with most utilising pressure monitoring devices. Consistent with existing literature, the optimum cuff pressure remains uncertain. Most, however, considered that this should be a routine part of ICU care.
Veno-Venous Extracorporeal Membrane Oxygenation and Apnoeic Oxygenation for Tracheo-Oesophageal Fistula Repair in a Previously Pneumonectomised Patient
Authors: Collins N. F. , Ellard L. , Licari E. , Beasley E. , Seevanayagam S. , Doolan L.
Published: January 2019

The use of extracorporeal membrane oxygenation (ECMO) for elective thoracic surgical procedures has been infrequently reported in the anaesthetic literature. We report the use of intraoperative veno-venous ECMO support for a patient with a previous left pneumonectomy who required a right-sided thoracotomy for repair of a tracheo-oesophageal fistula. To avoid traumatising or pressurising the fistula, a spontaneous ventilation technique was used prior to intubation with a single-lumen endotracheal tube positioned above the level of the fistula. The ECMO cannulas were inserted after induction and ECMO was instituted prior to transfer to the lateral position. Oxygenation during ECMO was augmented with apnoeic oxygen delivery via the breathing circuit. This was associated with an increase in the oxygen saturations from 80% to 99% without compromising surgical access. The use of apnoeic oxygenation via the breathing circuit significantly improved gas exchange in this case and should be considered as an adjunct to veno-venous ECMO.
Understanding Australian Families’ Organ Donation Decisions
Authors: Neate S. L. , Marck C. H. , Skinner M. , Dwyer B. , Mcgain F. , Weiland T. J. , Hickey B. B. , Jelinek G. A.
Published: January 2019

Numbers of deceased organ donors in Australia have increased, but rates of consent to donation remain at around 60%. Increasing family consent is a key target for the Australian Organ and Tissue Authority. Reasons for donation decisions have been reported in the international literature, but little is known of reasons for Australian families’ decisions. Potential organ donors in four Melbourne hospitals were identified and 49 participants from 40 families (23 consenting and 17 non-consenting) were interviewed to understand reasons for consent decisions. Themes for consent to organ donation included that: donation was consistent with the deceased's explicit wishes or known values, the desire to help others or self—including themes of altruism, pragmatism, preventing others from being in the same position, consolation received from donation and aspects of the donation conversation and care that led families to believe donation was right for them. Themes for non-consent included: lack of knowledge of wishes, social, cultural and religious beliefs; factors related to the donation process and family exhaustion; and conversation factors where negative events influenced decisions. While reasons for consent were similar to those described in international literature, reasons for non-consent differed in that there was little emphasis on lack of trust of the medical profession, concerns regarding level of care provided to the potential donor, preserving the deceased's body, fears of body invasion or organ allocation fairness.
Clinical Predictors of a Low Central Venous Oxygen Saturation after Major Surgery: A Prospective Prevalence Study
Authors: Litton E. , Silbert B. , Ho K. M.
Published: January 2019

Optimising perioperative haemodynamic status may reduce postoperative complications. In this prospective prevalence study, we investigated the associations between standard haemodynamic parameters and a low central venous oxygen saturation (ScvO2) in patients after major surgery. A total of 201 patients requiring continuous arterial and central venous pressure monitoring after major surgery were recruited. Simultaneous arterial and central venous blood gases, haemodynamic and biochemical data and perfusion index were obtained from patients at a single time-point within 24 hours of surgery. A low ScvO2 (<70%) was observed in 109 patients (54%). Use of mechanical ventilation, mean arterial pressure, central venous pressure, haemoglobin concentrations, arterial pH and lactate concentrations, arterial oxygen (PaO2) and carbon dioxide tensions (PaCO2) were all associated with a low ScvO2 in the univariate analyses. In the multivariate analysis, only a higher perfusion index (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78 to 0.98), PaO2 (OR 0.98 per mmHg increment, 95% CI 0.97 to 0.99) and PaCO2 (OR 0.88 per mmHg increment, 95% CI 0.82 to 0.95) and a lower central venous pressure (OR 1.14 per mmHg increment, 95% CI 1.04 to 1.25) were significantly associated with a reduced risk of a low ScvO2, all in a linear fashion. In conclusion, PaO2, PaCO2, perfusion index and central venous pressure were significant predictors of a low ScvO2 in patients after major surgery including cardiac surgery, suggesting that ScvO2 should always be interpreted with the arterial blood gases and that liberal perioperative fluid therapy aiming at a high central venous pressure may be detrimental in optimising ScvO2.
Near-Infrared Spectroscopy-Based Microcirculatory Assessment in Acute Atrial Fibrillation
Authors: Barrett O. S. H. , Macdonald S. P. J. , Playford D. A.
Published: January 2019

Near-infrared spectroscopy is a means of assessing microcirculatory function, but has not been studied in atrial fibrillation (AF). We evaluated the effect of acute AF on thenar eminence near-infrared spectroscopy-derived microcirculatory variables. Stable patients presenting to the emergency department with acute onset AF underwent dynamic near-infrared spectroscopy assessment with a three minute vascular occlusion test (VOT). This was repeated after cardioversion to sinus rhythm (SR). Each assessment included baseline tissue oxygen saturation (StO2), slope of StO2 decrease during VOT, slope of StO2 increase post VOT, minimum and maximum StO2, amplitude of StO2 response and post-ischaemic hyperperfusion. Pre and post cardioversion values were compared by Wilcoxon signed-rank test. Twelve participants (seven male, five female) with a median age of 63 years (interquartile range 52 to 70 years) were enrolled. Median baseline StO2 was 74% before and 77% after cardioversion ( P=0.03). The median slope of StO2 decrease during VOT was -0.19%/second and -0.16%/second ( P=0.018) and the median slope of StO2 increase post VOT was 3.03%/second and 2.56%/second ( P=0.002), pre and post cardioversion, respectively. Minimum StO2 was lower (39% versus 52%, P=0.002) and the amplitude of StO2 response greater (49% versus 40%, P=0.005) in AF, but there was no significant difference in maximum StO2 or the degree of reperfusion hyperaemia. In summary, baseline and minimum StO2 were lower with a greater ischaemic decrease in StO2 during AF, reflecting reduced tissue perfusion, compared with sinus rhythm. Recovery after ischaemia was higher in AF, suggesting normalisation of capillary recruitment during ischaemia. Our findings suggest that acute onset AF decreases capillary recruitment rather than causing microcirculatory dysfunction.
Debriefing after Simulation-Based Non-Technical Skill Training in Healthcare: A Systematic Review of Effective Practice
Authors: Garden A. L. , Le Fevre D. M. , Waddington H. L. , Weller J. M.
Published: January 2019

Non-technical skills training in healthcare frequently uses high-fidelity simulation followed by a facilitated discussion known as debriefing. This type of training is mandatory for anaesthesia training in Australia and New Zealand. Debriefing by a skilled facilitator is thought to be essential for new learning through feedback and reflective processes. Key elements of effective debriefing need to be clearly identified to ensure that the training is evidence-based. We undertook a systematic review of empirical studies where elements of debriefing have been systematically manipulated during non-technical skills training. Eight publications met the inclusion criteria, but seven of these were of limited generalisability. The only study that was generalisable found that debriefing by novice instructors using a script improved team leader performance in paediatric resuscitation. The remaining seven publications were limited by the small number of debriefers included in each study and these reports were thus analogous to case reports. Generally, performance improved after debriefing by a skilled facilitator. However, the debriefer provided no specific advantage over other post-experience educational interventions. Acknowledging their limitations, these studies found that performance improved after self-led debrief, no debrief (with experienced practitioners), standardised multimedia debrief or after reviewing a DVD of the participants’ own eye-tracking. There was no added performance improvement when review of a video recording was added to facilitator-led debriefing. One study reported no performance improvement after debriefing. Without empirical evidence that is specific to the healthcare domain, theories of learning from education and psychology should continue to inform practices and teaching for effective debriefing.
Research without Informed Patient Consent in Incompetent Patients
Authors: Dobb G. J.
Published: January 2019

Most patients needing intensive care cannot give informed consent to participation in research. This includes the most acutely and severely ill, with the highest mortality and morbidity where research has the greatest potential to improve patient outcomes. In these circumstances consent is usually sought from a substitute decision maker, but while survivors of intensive care believe substitute decision makers will look after their interests, evidence suggests substitute decision makers are poorly equipped for this task. Various models have been suggested for research without patient informed consent when intervention is urgent and cannot wait until first person consent is possible, including a waiver of consent if conditions are met. A nationally consistent model is proposed for Australia with a robust process for initial waiver of consent followed by first person consent to further research-related procedures or ongoing follow-up when this can be competently provided.
Predictors of an Increased in Vitro Thrombotic and Bleeding Tendency in Critically Ill Trauma and Non-Trauma Patients
Authors: Ho K. M. , Duff O. C.
Published: January 2019

Trauma patients are at a high risk of both bleeding and thromboembolism. This study assessed whether conventional coagulation blood tests were reliable predictors of an increased in vitro thrombotic and bleeding tendency of trauma and non-trauma patients. Conventional coagulation blood tests and thromboelastographs of 63 trauma and 63 randomly selected, critically ill non-trauma patients were compared. Increased in vitro thrombotic and bleeding tendencies were defined by a maximum amplitude >72 mm or an angle >74° on the thromboelastograph and a maximum amplitude < 54 mm or an angle <47°, respectively. In vitro thrombotic tendency was more common than bleeding tendency and this was not different between the critically ill trauma and non-trauma patients (59% versus 67% with thrombotic tendency, P=0.461; 11% versus 10% with bleeding tendency, respectively, P=0.999). Thrombocytopenia (<150 × 109 /l) and low fibrinogen concentrations (<2 g/l) were the only two factors associated with an increased in vitro bleeding tendency (both P=0.001) and thrombocytopenia was the only factor associated with a lower risk of in vitro thrombotic tendency (21% versus 75%, P=0.001). Platelet counts (Pearson's correlation coefficient [ r]: 0.59, P=0.001) and fibrinogen concentrations ( r 0.61, P=0.001) both had a relatively linear association with maximum amplitude of the thromboelastograph. Prolonged International Normalized Ratio (>1.5) and activated Partial Thromboplastin Time (>40 seconds) were, however, not significantly associated with an increased in vitro thrombotic or bleeding tendency. In conclusion, in vitro thrombotic tendency was more common than bleeding tendency in critically ill trauma and non-trauma patients. Platelet counts and fibrinogen concentrations were better predictors of increased in vitro thrombotic and bleeding risks than International Normalized Ratio or activated Partial Thromboplastin Time.
Protocolised Approach to End-of-Life Care in the ICU—The ICU PALCare Pilot Project
Authors: Rajamani A. , Barrett E. , Weisbrodt L. , Bourne J. , Palejs P. , Gresham R. , Huang S.
Published: January 2019

International literature on end-of-life care in intensive care units (ICUs) supports the use of ‘protocol bundles’, which is not common practice in our 18-bed adult general ICU in Sydney, New South Wales. We conducted a prospective observational study to identify problems related to end-of-life care practices and to determine whether there was a need to develop protocol bundles. Any ICU patient who had ‘withdrawal’ of life-sustaining treatment to facilitate a comfortable death was eligible. Exclusion criteria included organ donors, unsuitable family dynamics and lack of availability of research staff to obtain family consent. Process-of-care measures were collected using a standardised form. Satisfaction ratings were obtained using de-identified questionnaire surveys given to the healthcare staff shortly after the withdrawal of therapy and to the families 30 days later. Twenty-three patients were enrolled between June 2011 and July 2012. Survey questionnaires were given to 25 family members and 30 healthcare staff, with a high completion rate (24 family members [96%] and 28 staff [93.3%]). Problems identified included poor documentation of family meetings (39%) and symptom management. Emotional/spiritual support was not offered to families (39.1%) or ICU staff (0%). The overall level of end-of-life care was good. The overwhelming majority of families and healthcare staff were highly satisfied with the care provided. Problems identified related to communication documentation and lack of spiritual/emotional support. To address these problems, targeted measures would be more useful than the adoption of protocol bundles. Alternate models of satisfaction surveys may be needed.
Predicting Intensive Care and Hospital Outcome with the Dalhousie Clinical Frailty Scale: A Pilot Assessment
Authors: Fisher C. , Karalapillai D. K. , Bailey M. , Glassford N. G. , Bellomo R. , Jones D.
Published: January 2019

Frailty may help to predict intensive care unit (ICU) patient outcome. The Dalhousie Clinical Frailty Scale (DCFS) is validated to assess frailty in ambulatory settings but has not been investigated in Australian ICUs. We conducted a prospective three-month study of patients admitted to a tertiary level ICU. Within 24 hours of ICU admission, the next of kin or nurse in charge assigned a DCFS score to the patient. Data were obtained to assess the association between frailty and patient outcome. The DCFS score was completed in 205 of 348 (59%) of eligible patient admissions. The mean DCFS score was 3.2 (±1.6). Overall frailty (DCFS >4) occurred in 28 of 205 patients (13%, confidence interval 9% to 17%), 13 of 93 (15%, confidence interval 10% to 25%) in patients aged >65 years and 5 of 11 (45%, confidence interval 21% to 71%) in those >85 years. Patients with chronic liver disease ( P <0.001) and end-stage renal failure ( P=0.009) were more likely to be frail. The DCFS score was not significantly associated with ICU or hospital mortality: odds ratio 0.98 (95% confidence interval 0.6 to 1.6) and odds ratio 1.07 (95% confidence interval 0.8 to 1.4), respectively. However, after adjustment for illness severity and requirement for palliative care, the DCFS score was significantly associated with increased (log) hospital length-of-stay ( P=0.04) and age ( P=0.001). Approximately 1 in 10 ICU patients were frail and this frequency increased with age. The DCFS was associated with patient age and comorbidities and potentially predicts increased hospital length-of-stay but not other outcomes. Strategies to improve compliance with DCFS completion are needed.
Findings of the First ANZICS Conference on the Role of Intensive Care in Rapid Response Teams
Authors: Jones D. , Hicks P. , Currey J. , Holmes J. , Fennessy G. J. , Hillman K. , Psirides A. , Rai S. , Singh M. Y. , Pilcher D. V. , Bhonagiri D. , Hart G. K. , Fugaccia E.
Published: January 2019

Rapid Response Teams (RRTs) are specialised teams introduced into hospitals to improve the outcomes of deteriorating ward patients. Although Rapid Response Systems (RRSs) were developed by the intensive care unit (ICU) community, there is variability in their delivery, and consultant involvement, supervision and leadership appears to be relatively infrequent. In July 2014, the Australian and New Zealand Intensive Care Society (ANZICS) convened the first conference on the role of intensive care medicine in RRTs in Australia and New Zealand. The conference explored RRSs in the broader role of patient safety, resourcing and staffing of RRTs, effect on ICU workload, different RRT models, the outcomes of RRT patients and original research projects in the area of RRSs. Issues around education and training of both ICU registrars and nurses were examined, and the role of team training explored. Measures to assess the effectiveness of the RRS and RRT at the level of health system and hospital, team performance and team effectiveness were discussed, and the need to develop a bi-national ANZICS RRT patient database was presented. Strategies to prevent patient deterioration in the ‘pre-RRT’ period were discussed, including education of ward nurses and doctors, as well as an overarching governance structure. The role of the ICU in deteriorating ward patients was debated and an integrated model of acute care presented. This article summarises the findings of the conference and presents recommendations on the role of intensive care medicine in RRTs in Australia and New Zealand.
The Utility of a Personal Values Report for Medical Decision-Making
Authors: Henderson W. , Corke C.
Published: January 2019

Our aim was to determine if a patient's Personal Values Report (PVR) has a positive impact on a doctor's decisions regarding treatment. We conducted a prospective cohort study delivering a short, web-based hypothetical case-centred questionnaire to intensive care doctors practising in Australia and New Zealand. One hundred and twenty-four intensive care consultants and registrars agreed to participate in an online questionnaire in two routine mailings between November 2013 and February 2014. We evaluated the effect of a PVR on clinical decision-making in a case-based scenario. In addition, participants rated the utility of the PVR on their decision-making process. Participants were presented with a difficult scenario in a frail elderly man where death was almost inevitable without aggressive support but survival with severe disability was possible with significant intervention. Most doctors (52.4%) elected to continue ventilation and admit to ICU. After the PVR was made available, only 8.1% of doctors continued to choose to admit the patient to the ICU. In all cases where admission to the ICU was chosen after seeing the PVR, the admission to the ICU was stated to be to permit family to arrive before withdrawing support (an approach which was consistent with the values stated in the PVR). One hundred and twenty-one of the 124 participants (97.6%) agreed or strongly agreed that the PVR helped them get an understanding of the patient's wishes, whereas none of the participants (0%) were unsure, disagreed or strongly disagreed with this statement. The remaining 2.4% did not answer the question. It is surmised that PVRs pre-written by patients are potentially an effective and valuable tool for use in helping doctors make decisions regarding patient care.
Iron-Restricted Erythropoiesis and Risk of Red Blood Cell Transfusion in the Intensive Care Unit: A Prospective Observational Study
Authors: Litton E. , Xiao J. , Allen C. T. , Ho K. M.
Published: January 2019

Intravenous (IV) iron can decrease transfusion requirements in selected patients with low, normal and moderately elevated ferritin. Whether the syndrome of iron-restricted erythropoiesis (IRE), diagnosed by iron studies, identifies critically ill patients at risk for subsequent red blood cell (RBC) transfusion, and hence, provides a simple method to determine response to IV iron therapy, is uncertain. We aimed to describe the characteristics of patients with IRE on admission to intensive care and determine the optimal variables to identify patients at risk of RBC transfusion who may benefit from early administration of IV iron. The study included 201 consecutive ICU admissions from a single 23-bed combined medical/surgical ICU. The prevalence of IRE on admission to ICU, defined according to ferritin <300 μg/l and transferrin saturation <20%, was 26.2% (95% CI 19.9 to 32.4). The proportion of patients with IRE subsequently receiving RBC transfusion was significantly lower than the proportion of patients without IRE receiving RBC transfusion (absolute mean difference 18.9% [95% CI 4.7 to 33.1, P <0.001]). IRE was not independently associated with risk of transfusion on multivariate analysis, however, a prognostic model with three risk factors (RBC transfusion prior to ICU admission, Hb <100 g/l and ICU length of stay >3 days), had good discrimination and calibration for predicting transfusion (receiver operator curve area under the curve 0.87 [95% CI 0.79 to 0.94, P=0.88], Hosmer–Lemeshow 6.21; P=0.1). Excluding iron overload and using simple prognostic criteria to identify patients at high risk of RBC transfusion may be a preferable strategy for identifying critically ill patients who may benefit from IV iron.
Central Venous-to-Arterial Carbon Dioxide Gradient as a Marker of Occult Tissue Hypoperfusion after Major Surgery
Authors: Silbert B. I. , Litton E. , Ho K. M.
Published: January 2019

The central venous-arterial carbon dioxide tension gradient (‘CO2 gap’) has been shown to correlate with cardiac output and tissue perfusion in septic shock. Compared to central venous oxygen saturation (SCVO2), the CO2 gap is less susceptible to the effect of hyperoxia and may be particularly useful as an adjunctive haemodynamic target in the perioperative period. This study investigated whether a high CO2 gap was associated with an increased systemic oxygen extraction (O2ER >0.3) or occult tissue hypoperfusion in 201 patients in the immediate postoperative period. The median CO2 gap of all patients was 8 mmHg (IQR 6 to 9), and a large CO2 gap was very common (>6 mmHg in 139 patients [69%], 95% CI 63 to 75; >5 mmHg in 170 patients [85%], 95% CI 79 to 89). A CO2 gap <5 mmHg had a higher sensitivity (93%) and negative predictive value (74%) than a CO2 gap <6 mmHg in excluding occult tissue hypoperfusion. Of the four variables that were predictive of an increased O2ER in the multivariate analysis—CO2 gap, arterial pH, haemoglobin and arterial lactate concentrations—the CO2 gap (odds ratio 4.41 per mmHg increment, 95% CI 1.7 to 11.2, P=0.002) was most important and explained about 34% of the variability in the risk of occult tissue hypoperfusion. In conclusion, a normal CO2 gap (<5 mmHg) had a high sensitivity and negative predictive value in excluding inadequate systemic oxygen delivery and may be useful as an adjunct to other haemodynamic targets in avoiding occult tissue hypoperfusion in the perioperative setting when high inspired oxygen concentrations are used.
Measurement of Peak Aortic Jet Velocity in the Perioperative Period—Machine Variability: Implications for Assessment of Aortic Stenosis Severity
Authors: Cowie B. S. , Kluger R.
Published: January 2019

Variation in echocardiography machines and probes are not well described in the perioperative period. We aimed to compare the estimation of severity of aortic stenosis with transthoracic echocardiography (TTE) using two semi-portable ultrasound machines. Experienced cardiac anaesthetists performed a limited transthoracic echocardiogram with two different semi-portable ultrasound machines in patients with known aortic stenosis. The peak aortic jet velocity with continuous-wave Doppler and the time taken to obtain an acceptable envelope were recorded. The Sonosite M Turbo often underestimated the peak jet velocities (median jet velocity [IQR] 2.25 m/s [1.95 to 3.4] versus 3.85 m/s [3 to 4.2]; P <0.001) and required more time to get a satisfactory envelope than the GE Vivid I. There was no statistically or clinically significant difference between the velocities obtained from the Vivid I and those measured on the patient's formal cardiology preoperative transthoracic echocardiogram (median [IQR]: 3.95 m/s [3.0 to 4.7]; P=0.3). However, the velocities obtained by the M Turbo were significantly lower than those obtained by the formal preoperative transthoracic echocardiogram ( P <0.001). With the expansion of transthoracic echocardiography amongst anaesthetists, underestimation of the peak aortic jet velocity can significantly underestimate the severity of aortic stenosis with potentially lethal clinical consequences. Semi-portable ultrasound machines with echocardiographic capability are not necessarily equivalent and can result in underestimation of severity of aortic stenosis.
Pioneers of Laryngoscopy: Indirect, Direct and Video Laryngoscopy
Authors: Pieters B. M. , Eindhoven G. B. , Acott C. , Van Zundert A. A. J.
Published: January 2019

Airway management is one of the core skills of the anaesthetist and various techniques of airway management have developed over many years. Initially, the only view of the glottis that could be obtained was an indirect view (indirect laryngoscopy). Late in the 19th century, a direct view of the glottis was obtained via various direct laryngoscopes. Currently, in the early 21st century, there has been a return to indirect laryngoscopy via videolaryngoscopy using a videolaryngoscope. The aim of this paper is to give a historical overview of the development of both direct and indirect laryngoscopy.
Becoming a Physician Anaesthetist—Difficulties Encountered for Half a Century
Authors: Sundararaman L. V. , Desai S. P.
Published: January 2019

William T.G. Morton was not the first to use ether or nitrous oxide as an anaesthetic. However, his public demonstration on 16 October, 1846 (Ether Day), and the notoriety that followed thereafter, are credited for announcing man's victory over surgical pain to the entire world. The use of ether during surgery spread rapidly through most of the world. One would expect that the careers of Ether Day participants would have been greatly affected by this seminal event and that some would go on to become anaesthetists. An examination of the participants’ professional lives shows that some became strong advocates of anaesthesia and ether was used extensively for their patients. Some were prolific writers and helped spread the use of anaesthesia. However, attracting physicians to this new discipline proved difficult and there were segments of the medical establishment and society who were unwilling to accept this most significant advancement. In this article, we examine the reasons why many physicians and patients resisted the use of anaesthesia.
The Heister Mouth Gag or ‘Speculum Oris’
Authors: Haridas R. P.
Published: January 2019

The Heister mouth gag is attributed to Lorenz Heister, an eighteenth century German surgeon. There is no evidence that Heister designed the mouth gag, the earliest known illustration of which is in the 1719 edition of Heister's Chirurgie. In the first half of the twentieth century, the Heister gag was widely available for use during anaesthesia. It is now rarely used by anaesthestists, but occasionally used by surgeons during oral surgery.
Professor Tess Cramond (1926–2015): Contributions to Anaesthesia and Pain Medicine
Authors: Boyle R. , van Zundert A. A. J.
Published: January 2019

Professor Tess Cramond joined the Queensland anaesthesia workforce in 1958, and contributed to high standards of clinical practice, pain management, training, scholarship and research. Evidence of her excellence, within the clinical, political and community spheres was recognised by multiple awards. Though deceased in 2015, she remains a role model for all physicians, using her expert knowledge, technical skills, clinical reasoning, emotions and values for the benefit of the individuals and community which she served.