bluuebunny/crossref_metadata_2025 huggingface dataset:
Early Autonomic Dysreflexia in Acute Paraplegia following Anterior Spinal Artery Thrombosis
Authors: Rooney K. D. , Mckinstry C.
Published: January 2019

This report discusses the diagnosis and management of autonomic dysreflexia. A 19-year-old man presented with an acute quadriplegia secondary to anterior spinal artery thrombosis. He required admission to the intensive care unit for ventilatory support and developed autonomic dysreflexia within 72 hours of his first symptoms, due to paralytic ileus with distension of the bowel. He was successfully treated by sublingual nifedipine and bowel decompression. Awareness of the potential for autonomic dysreflexia to occur in the acute phase of spinal cord injury will assist to direct management appropriately.
Inspiratory Muscle Training to Enhance Weaning from Mechanical Ventilation
Authors: Bissett B. , Leditschke I. A.
Published: January 2019

This report describes the use of specific inspiratory muscle training to enhance weaning from mechanical ventilation in a patient who had failed conventional weaning strategies. A 79-year-old man remained ventilator-dependent 17 days following laparotomy. A program of daily inspiratory muscle training was initiated. The mean training threshold increased progressively during the program and simultaneously the periods of unassisted breathing achieved gradually increased. By day 27, mechanical ventilation was no longer required. Inspiratory muscle training can be implemented effectively in the difficult to wean patient and should be considered for patients who have failed conventional weaning strategies.
Lemierre's Syndrome with Septic Shock Caused by Fusobacterium Necrophorum
Authors: Wang D. , Price A. K. , Leitch K. K. , Salvadori M. , Singh R. N. , Kornecki A. , Mckillop S. D. , Fraser D. D.
Published: January 2019

Fusobacterium necrophorum infections are rare. We report a 15-year-old male who presented with tachycardia, nausea, vomiting, diarrhoea and ankle pain. He rapidly deteriorated requiring ventilation and vasopressors. Imaging of his thorax showed airspace consolidation, pulmonary cavitations and empyema. The ankle required drainage of purulent material. A thrombus in his internaljugular vein (Lemierre's syndrome) and an abscess in his obturator internus were subsequently found. Fusobacterium necrophorum was identified in blood culture on day nine. The patient recovered with antibiotics and surgical interventions for empyema and septic arthritis. Fusobacterium necrophorum should be a suspected pathogen in septic shock complicated by metastatic abscess formation.
Computerised Tomography for the Detection of Pulmonary Emboli in Intensive Care Patients—a Retrospective Cohort Study
Authors: Licht A. , Sibbald W. J. , Levin P. D.
Published: January 2019

Pulmonary emboli are frequently considered as a cause for respiratory deterioration in intensive care unit (ICU) patients, however empirical observation suggests that computerised tomographic (CT) angiography is infrequently positive after the first 24 hours. This study aimed to determine the rate and risk factors for detection of pulmonary emboli by CT angiography in ICU patients.

All patients undergoing CT angiography >24 hours after ICU admission for respiratory deterioration from April 2000 until January 2004 were included. The positivity rate for pulmonary emboli was determined and risk factors analysed.

Seven (6%) out of 113 CT angiograms were positive for pulmonary emboli. All were found in trauma patients. Comparing positive to negative scans, predefined risk factors including head injury (5/7 positive scans, 71% vs. 23/106 negative scans, 22%, P=0.005), spine injury with neurological impairment (4/7, 57% vs. 9/106, 8%, P=0.002) and lower limb injury (3/7, 43% vs. 12/106, 9%, P=0.039) were significantly more frequent in patients with positive scans. Deep vein thrombosis prophylaxis was employed less frequently prior to a positive scan (in 3/7, 43% patients with positive scans vs. 91/106, 86% patients with negative scans P=0.015). Only the predefined risk factors were independently associated with positive CT angiography on limited logistic regression (OR 24.7 per risk factor, 95% CI 2.38 to 255.1, P=0.007).

Pulmonary emboli were infrequently diagnosed using CT angiography in ICU patients admitted for more than 24 hours and found only in patients with recognised risk factors.
Hyperglycaemia upon Onset of Icu-Acquired Bloodstream Infection is Associated with Adverse Outcome in a Mixed Icu Population
Authors: Vandijck D. M. , Oeyen S. G. , Buyle F. M. , Claus B. O. , Blot S. I. , Decruyenaere J. M.
Published: January 2019

This study aimed to assess whether a relationship exists between hyperglycaemia and outcome in a mixed cohort of critically ill patients with nosocomial bloodstream infection (BSI), and to evaluate patterns of blood glucose levels between survivors and non-survivors.

A historical observational cohort study was conducted in the intensive care unit (ICU) of a tertiary care referral centre. One-hundred-and-thirty patients with a microbiologically documented ICU-acquired BSI (period 2003 to 2004) were included. For the study, morning blood glucose levels were evaluated from one day prior until five days after onset of BSI. The contribution of hyperglycaemia, divided in three subgroups (≥150 mg/dl, ≥175 mg/dl and ≥200 mg/dl), to in-hospital mortality was estimated by logistic regression. In-hospital mortality was 36.2%. Over the seven study days, no differences were found in daily morning blood glucose levels between survivors (n=83) and non-survivors (n=47). Nevertheless, the trend of blood glucose levels upon onset of BSI showed a remarkable increase in the non-survivors, whereas it decreased in the survivors. Hyperglycaemia (≥175 mg/dl and ≥200 mg/dl) was observed more often among the non-survivors. Multivariate logistic regression showed that APACHE II (P=0.002), antibiotic resistance (P=0.004) and hyperglycaemia (≥175 mg/dl) upon onset of BSI (P=0.017) were independently associated with in-hospital mortality, whereas a history of diabetes (P=0.041) was associated with better outcome.

Hyperglycaemia (≥175 mg/dl) upon onset of ICU-acquired BSI is associated with worse outcome in a heterogeneous ICU population. Patterns of morning blood glucose levels have only limited value in the prediction of the individual course.
Pre-Existing Cardiac Disease, Troponin I Elevation and Mortality in Patients with Severe Sepsis and Septic Shock
Authors: Scott E. C. , Ho H. C. , Yu M. , Chapital A. D. , Koss W. , Takanishi D. M.
Published: January 2019

A prospective, observational study was undertaken to determine the frequency of troponin I elevation and the incidence of pre-existing cardiac disease in patients with severe sepsis and septic shock, and to determine their relationship to mortality.

The setting was the surgical intensive care unit of a tertiary care medical centre. Sixty-six consecutive patients admitted with severe sepsis or septic shock requiring pulmonary artery catheterisation for haemodynamic monitoring were studied. Measurement of troponin I was done at the time of pulmonary artery catheterisation and every six to eight hours if there was ongoing tachycardia, hypotension or arrhythmias requiring treatment. Preexisting cardiac disease was determined from the patient and/or family members as well as from the medical record. Significant cardiac history was defined as prior myocardial infarction; abnormal treadmill report, nuclear medicine study or coronary angiogram; history of congestive heart failure or arrhythmia requiring treatment.

Forty-two patients (64%) had elevated troponin I at study entrance and 23 patients (35%) had pre-existing cardiac disease. History of cardiac disease was associated with reduced cardiac index and oxygen delivery, and a nearly three-fold increase in mortality (44% vs. 16%, P=0.03), irrespective of elevated troponin I levels. Troponin I elevation alone was not associated with increased mortality.

We conclude that pre-existing cardiac disease and elevated troponin I are commonly found in surgical patients with severe sepsis and septic shock. In our study, pre-existing cardiac disease, and not troponin I elevation, was associated with increased mortality.
Safety of Percutaneous Tracheostomy in Obese Critically Ill Patients: A Prospective Cohort Study
Authors: Aldawood A. S. , Arabi Y. M. , Haddad S.
Published: January 2019

Obesity has been described as a relative contraindication for percutaneous tracheostomy. The objective of our study was to examine the safety and complications of percutaneous tracheostomy in obese patients. We conducted a prospective cohort study of all consecutive patients who underwent percutaneous tracheostomy at a tertiary medical-surgical intensive care unit between May 2004 and October 2005. We compared percutaneous tracheostomy in obese patients (body mass index ≥30 kg/m2) to non-obese patients. We documented the occurrence of the following complications: aborting the procedure, accidental extubation, conversion to surgical tracheostomy, paratracheal placement, the development of pneumothorax, major bleeding (requiring blood product transfusion or surgical intervention) or death. We also documented hypoxia, minor bleeding (requiring pressure dressing or suturing), subcutaneous emphysema and transient hypotension. During the study period, 227 percutaneous tracheostomies were performed. There were 50 percutaneous tracheostomies in the obese group and 177 in the non-obese group. In 45 obese patients, percutaneous tracheostomy was performed without bronchoscopic guidance. Major complications were significantly higher in obese patients (12% vs. 2%, P=0.04), while the rate of minor complications was not significantly different between the two groups. There were no instances of death or pneumothorax, subcutaneous emphysema or need for surgical intervention during or in the postoperative period in either group. Our study suggests that percutaneous tracheostomy can be performed safely in the majority of obese patients.
The Use of Epidural Analgesia in a New Zealand Tertiary Hospital before and after Publication of the Master Study
Authors: Werrett G. C. , Horton H. , Craig R. , French R. A.
Published: January 2019

We audited the total number of perioperative epidural techniques performed at Christchurch Hospital, New Zealand, for three years, before and after The Lancet published the MASTER Anaesthesia Trial in 2002. We also looked specifically at the number of epidural anaesthetic and analgesic techniques performed in combination with general anaesthesia for colonic surgery over the same period.

In both cases we found a statistically significant fall in epidural rate in the years after the publication (P<0.001). A subsequent survey of local specialist anaesthetists, who have worked throughout this period, revealed the majority (75%) were knowingly performing fewer epidural techniques and that the findings of the MASTER Anaesthesia Trial had influenced their decisions.
Anaesthesia for Excision of an Intraoral Mass in a Neonate: Use of a Laryngeal Mask during Removal of Congenital Epulis
Authors: Cheong S. P. , Fahy C. J. , Craigie M. J.
Published: January 2019

Congenital epulis is a rare intraoral tumour of the newborn arising from gingival mucosa, most commonly from the alveolar ridge1. It may interfere with normal feeding or potentially compromise respiration. We describe the anaesthetic management of one such case of a female infant born with a single epulis, approximately 3 cm in diameter, protruding from her mouth. The lesion was removed one day after delivery, under general anaesthesia using a laryngeal mask airway to control the infant's airway. The rationale for this management plan and alternatives to this strategy are discussed.
Central Diabetes Insipidus: A Rare Perioperative Cause of Severe Hypernatraemia
Authors: Hayanga A. J. , Kohen R. , Egeland B. , Charles A. , Spoor M. , Kuzon W. M. , Napolitano L. M.
Published: January 2019

In this case report we describe the management of severe hypernatraemia following inadvertent water restriction. A 21-year-old woman with no reported medical history presented on transfer from an outside hospital with a complex volar upper extremity injury. Management both operatively and postoperatively involved a prolonged period of fasting which limited her access to drinking water. Collateral history revealed that she had previously drunk copious amounts of water during the course of any given day and this had served to alleviate the dramatic symptoms of hypernatraemia that were rapidly manifest when her normal intake was curtailed. We outline the fluid management, administration of desmopressin and her subsequent recovery. A literature review of the management of central diabetes insipidus is also covered.
Use of Isotonic Sodium Bicarbonate to Prevent Radiocontrast Nephropathy in Patients with Mild Pre-Existing Renal Impairment: A Meta-Analysis
Authors: Ho K. M. , Morgan D. J.
Published: January 2019

Acute renal dysfunction after radiocontrast in patients with pre-existing renal impairment is not uncommon and is associated with significant morbidity and mortality. Isotonic sodium bicarbonate solution was first reported to reduce radiocontrast nephropathy in 2004. This first study was, however, limited by its small sample size and as such, the use of isotonic sodium bicarbonate to prevent radiocontrast nephropathy is still not widely used by many anaesthetists and intensivists. We meta-analysed relevant randomised controlled studies sourced from the Cochrane Controlled Trial Register (2007 issue 4), EMBASE and MEDLINE databases (1966 to April 15, 2008) without any language restriction. The use of isotonic sodium bicarbonate was associated with a significant reduction in risk of an incremental rise in serum creatinine concentration 25% above baseline (relative risk 0.22, 95% confidence interval [CI]: 0.11 to 0.44, P <0.0001; I 2 =0%>) and had a protective effect on the absolute change in serum creatinine concentration (weighted-mean-difference -9.4 μmol/l, 95% CI: -17.2 to -1.7, P=0.02; I 2 =0%>) and creatinine clearance (weighted-mean-difference 3.7 ml/min, 95% CI: 0.55 to 6.80, P=0.02; I 2 =57.1%) after radiocontrast. The incidence of acute renal failure requiring dialysis was low (1.4%) and was not significantly different after the use of isotonic sodium bicarbonate (relative risk 0.59, 95% CI: 0.15 to 2.42, P=0.47; I 2 =0%). With the limited data available, isotonic sodium bicarbonate appears to be safe and very effective in reducing radiocontrast nephropathy in patients with mild pre-existing renal impairment. A large randomised controlled study is needed to confirm whether isotonic bicarbonate can improve patient centred clinical outcomes.
Evaluation of Nasopharyngeal Oxygen, Nasal Prongs and Facemask Oxygen Therapy Devices in Adult Patients: A Randomised Crossover Trial
Authors: Eastwood G. M. , O'Connell B. , Gardner A. , Considine J.
Published: January 2019

Nasopharyngeal oxygen (NPO) therapy may overcome some of the difficulties associated with nasal prongs and facemask oxygen delivery devices. In response to a lack of published studies of NPO therapy in adults, we conducted a prospective randomised crossover trial to compare the effectiveness of NPO, nasal prongs (NP) and facemasks (FM) when used in an adult population (n=37) from the intensive care unit and general hospital wards. We measured oxygen saturation (SpO 2 using pulse oximetry, oxygen flow (litres per minute), respiration rate (per minute) and comfort using a horizontal visual analogue scale. All three devices were effective in maintaining a Sp0 2 of ≥95% (NP 97.0±1.9, NPO 97.7±1.7, FM 98.8±1.3%). NPO therapy consumed less oxygen than NP and FM therapy (NP 2.6±1.0, NPO 2.2±0.9, FM 6.1 ±0.4 l/min, P <0.001). There was no significant difference in patients’ respiratory rates (NP 19.9±3.2, NPO 19.9±3.0, FM 19.8±3.1 per minute, P=0.491). In terms of comfort, patients rated NP higher than NPO and FM using a horizontal visual analogue scale (100 mm=most comfortable) (NP 65.5±14.3, NPO 62.8±19.4, FM 49.4 ± 21.4 mm, P <0.001). We conclude that for adult patients, nasal prongs and nasopharyngeal oxygen therapy consume less oxygen and provide greater comfort than facemasks while still maintaining Sp0 2 ≥95%.
Haemophilus Influenzae Associated Guillain Barre Syndrome with Thrombocytopenic Purpura and Hyperthermia
Authors: Condon E. M. , Tobin A.
Published: January 2019

A 24-year-old female who had been intubated for respiratory distress was transferred to our intensive care unit, where a subsequent diagnosis of Guillain Barre Syndrome was made. Her only positive culture was Haemophilus influenzae from sputum. Despite having a severe form of the disease, with autonomic dysfunction and hyperthermia, she made a far better, more rapid recovery than expected. We review the evidence that patients with Haemophilus influenzae associated Guillain Barre Syndrome recover more quickly than those with other causative agents. We also discuss the implications of thrombocytopenia in these patients and the management of hyperthermia in an intensive care unit setting.
Anterior Ultrasound-Guided Superior Hypogastric Plexus Neurolysis in Pelvic Cancer Pain
Authors: Mishra S. , Bhatnagar S. , Gupta D. , Thulkar S.
Published: January 2019

The hypogastric plexus block is classically performed by a posterior approach, but there are recent reports of a computed tomography-guided anterior approach for patients who have difficult access to the hypogastric plexus by the posterior approach. We present two patients who were successfully given ultrasound-guided superior hypogastric plexus block by an anterior approach. The anterior ultrasound-guided superior hypogastric plexus neurolysis technique is simple to perform. We believe this block can be useful in cancer patients who are having difficulty in lying prone, because it is a bedside procedure performed in the supine position and it is less time-consuming. It also avoids the radiation exposure involved with a computed tomography-guided anterior approach.
Sore Throat or Hoarse Voice with Bronchial Blockers or Double-Lumen Tubes for Lung Isolation: A Randomised, Prospective Trial
Authors: Zhong T. , Wang W. , Chen J. , Ran L. , Story D. A.
Published: January 2019

Double-lumen endotracheal tubes and bronchial blockers allow lung isolation for one-lung ventilation. Few studies, however, directly compare these devices. Further, a new endobronchial blocker (Coopdech) is available in some countries. Our primary hypothesis was that bronchial blockers would be associated with less sore throat or hoarse voice than double-lumen tubes. Secondary outcomes were successful one-lung ventilation and surgical access. In this prospective trial, 120 Chinese patients undergoing elective surgery were randomly assigned to one of four groups of 30 patients: Coopdech blocker, Arndt blocker, Univent tube or double-lumen tube. Postoperative sore throat and hoarse voice were assessed in the recovery room and 24 hours after surgery. The incidence and severity of sore throat or hoarse voice was less in the blocker groups than double-lumen tube group: Coopdech 13%, Arndt 20%, Univent 30% and double-lumen tube 60%, P <0.001. The blocker groups did not significantly differ, P=0.28. Compared to the double-lumen tubes the bronchial blockers took about two minutes less to position but five minutes longer for lung deflation. Surgical exposure was uniformly good across the four groups. We conclude that clinical use of the Coopdech endobronchial blocker is similar to the Arndt and Univent blockers and that all three are associated with less sore throat or hoarse voice than double-lumen tubes.
In Vitro Effects of Propofol on Gravid Human Myometrium
Authors: Thind A. S. , Turner R. J.
Published: January 2019

The aim of this study was to evaluate the direct effect of propofol (di-isopropyl phenol) on the contractile properties of gravid human uterine muscle.

Six specimens of uterine muscle were obtained from term parturients undergoing elective lower segment caesarean section. Small strips (1 × 2 x 12 mm) of muscle were prepared and suspended in an organ bath containing oxygenated Kreb's solution at 36.5°C. Following preparation, spontaneous regular contractions developed at a rate of one contraction every six to 10 minutes. Force of contraction was recorded continuously using an isometric tension transducer. Following baseline measurements, propofol was introduced into the bath at concentrations corresponding to 2 /μg/ml, 5 /μg/ml and 8 /μg/ml. The specimens were also exposed to intralipid in concentrations equivalent to that found in the 8 μ/ml solution of propofol to determine whether this additive influenced uterine contractility. Contractility (defined as area under the tension/time curve) was decreased to 89 ± 6.5% of control at 2 μg/ml 53±4.3% at 5 μ/ml and 45 ± 4.1% at 8 μg/ml. This decrease in contractility was statistically significant at concentrations >2 μg/ml. Intralipid did not significantly affect uterine contractility. The results of this study show that propofol decreases isolated human uterine muscle contractility in a dose-dependent manner.
Postoperative Patient-Controlled Thoracic Epidural Analgesia: Importance of Dose Compared to Volume or Concentration
Authors: Dernedde M. , Stadler M. , Taviaux N. , Boogaerts J. G.
Published: January 2019

This randomised and blinded study evaluated the quality of analgesia and the incidence of side-effects of two concentrations of levobupivacaine (0.15% and 0.5%) given as an equal mg-bolus-dose (5 mg) via patient-controlled epidural analgesia after lower abdominal surgery. The patients were randomly assigned into two groups to receive either 0.15% levobupivacaine as a 3.3 ml bolus on demand, with a lockout interval of 30 minutes (n = 30), or 0.5% levobupivacaine as a 1 ml bolus on demand, with a similar lockout interval (n = 30). For both groups we combined the bolus on demand with a background infusion of 5 mg/hour levobupivacaine, i.e. 3.3 ml/hour 0.15% or 1 ml/hour 0.5% of levobupivacaine. The epidural catheters were inserted in a lower thoracic intervertebral space before induction of general anaesthesia. The following variables were registered in the 48 hours after surgery: upper and lower sensory block, pain scores at rest and after coughing, rescue morphine consumption, motor blockade, haemodynamic (arterial blood pressure and heart rate), nausea and vomiting, and patient satisfaction ratings. The two groups had similar sensory block, quality of analgesia, rescue morphine consumption requirement, motor blockade and side-effects, and both had a high satisfaction rate. These findings indicate that administering the same dose of levobupivacaine in either a low or high concentration via the patient-controlled epidural analgesia mode, combined with a background infusion, provides an equal quality of analgesia for low thoracic level epidurals with no difference in the incidence of side-effects.
Tumour Metastasis at the Site of a Previous Epidural Catheter
Authors: Chappell M. M. , Schoengen H. A.
Published: January 2019

Epidural catheters can cause a number of rare, serious complications. The following case report describes a patient who received continuous epidural analgesia following radical cystectomy for bladder cancer. Fifty-three days after the cystectomy, the patient underwent emergency surgery for a metastasis at the vertebral level where the epidural catheter had been inserted. A metastasis at the site of an epidural catheter, which may be a direct complication of epidural analgesia, is a previously unreported event. Local, anatomical and pathological factors which may have led to the patient developing a metastasis at the epidural site are discussed.
Guillain-Barré Syndrome with Absent Brainstem Reflexes – a Report of Two Cases
Authors: Joshi M. C. , Azim A. , Gupta G. L. , Poddar B. P. , Baronia A. K. , Singh R. K.
Published: January 2019

Guillain-Barré syndrome, known for its diverse, atypical and heterogeneous range of presentations, can rarely present in an apparent comatose state with absent brainstem reflexes. Two patients presented in an unresponsive state with flaccid quadriplegia, total areflexia with no response to cephalic or peripheral painful stimuli. Pupils were mid-dilated with absent direct and consensual light reflex. All cranial nerve reflexes were absent. Preliminary laboratory investigations and complementary tests were normal. Cerebrospinal fluid evaluation showed albumin-cytological dissociation. Brain magnetic resonance imaging and electroencephalogram were normal. Both were diagnosed as fulminant Guillain-Barré syndrome. Despite an absence of brainstem reflexes neither patient fulfilled diagnostic criteria for brain death.
Airway Assessment Based on a three Column Model of Direct Laryngoscopy
Authors: Greenland K. B.
Published: January 2019

Airway assessment has remained a problematic area, largely due to the low sensitivities, specificities and/or positive predictive values of most bedside tests. In this paper, a structured overview of the common preoperative airway assessment tests is presented, based on a model for direct laryngoscopy that has been previously described. This model is composed of three columns: anterior, middle and posterior. The anterior column tests are classified into the assessment of volume and compliance of the submandibular space, the range of movement of the temporomandibular joints and the flexibility of the stylohyoid ligament. Reductions in volume of the anterior column may be absolute or relative. An absolute reduction may occur with shortening of either the incisor-hyoid distance, the temporomandibular joint-incisor distance or the temporomandibular joint-temporomandibular joint distance. A relative reduction may be seen with either prominent upper front incisors or large tongues. Testing of the middle column includes a history and physical examination of the upper respiratory system, imaging of the airway (such as X-ray, computed tomography scans and/or magnetic resonance imaging scans) and nasopharyngoscopy. The posterior column may be assessed by the range of movement of the neck, especially the range of extension of the occipito-atlanto-axial complex.

By integrating common tests of the anterior, middle and posterior columns within this three-column model, the practitioner may be better positioned to understand the complexity of direct laryngoscopy in both normal and difficult airway scenarios.
Practice Patterns for Predicted Difficult Airway Management and access to Airway Equipment by Anaesthetists in Queensland, Australia
Authors: Zugai B. M. , Eley V. , Mallitt K. A. , Greenland K. B.
Published: January 2019

A postal survey was conducted to investigate difficult airway management, training and equipment availability among Fellows of the Australian and New Zealand College of Anaesthetists in Queensland. The survey aimed to determine practise patterns for predicted difficult airways and investigate equipment availability.

Participants were asked to nominate an induction method, intubation method and airway adjunct for each of the five difficult airway scenarios. The cases consisted of one elective and four emergency scenarios. Availability of difficult airway devices in their institution was also assessed, as well as demographics of practice and airway-related maintenance of professional standards participation.

There were 454 surveys distributed and 250 returned (response rate 55%). Direct laryngoscopy and flexible fibreoptic intubation were the most commonly selected techniques for all five cases. Difficult intubation trolleys were available to 98% of responders. Certain types of equipment (such as fibreoptic bronchoscopes and cricothyroidotomy kits) were available less frequently in private institutions. We recommend a standardisation of difficult airway management equipment and an on-going training program to provide support for anaesthetists in all locations.
Patient- and Operator-Related Factors Associated with Successful Glidescope® intubations: A Prospective Observational Study in 742 Patients
Authors: Siu L. W. L. , Mathieson E. , Naik V. N. , Chandra D. , Joo H. S.
Published: January 2019

The Glidescope® Video Laryngoscope (Glidescope, Verathon Medical, Bothell, WA, USA) is a relatively new intubating device. It has been proposed to be useful for securing both routine airways and those where direct laryngoscopy may be difficult. In this prospective observational study, data for 742 intubations using the Glidescope were collected to investigate whether four factors are associated with successful tracheal intubation at first attempt using the Glidescope: previous Glidescope experience, previous direct laryngoscopy experience, level of anaesthesia training and clinical airway assessment.

The likelihood of successful tracheal intubation at first attempt using the Glidescope increased with increasing previous Glidescope experience. Similarly, success was more likely in airways that were assessed as normal compared with those where direct laryngoscopies were either predicted or known to be difficult. Subgroup analysis indicated 83% first attempt success by ‘experienced’ Glidescope users in patients with documented difficult direct laryngoscopies. This supports its use as an adjunct device for management of airways where direct laryngoscopies prove difficult. With regard to the level of anaesthesia training, only medical students were more likely to fail with the Glidescope. Success was not associated with previous experience in direct laryngoscopy. The lack of association with direct laryngoscopy experience and level of anaesthesia training (beyond student level) suggests that expertise with traditional airway tools is not necessary to become proficient with the Glidescope.
An Evaluation of P Wave Dispersion, QT, Corrected QT and Corrected QT Dispersion Intervals on the Electrocardiograms of Malnourished Adults
Authors: Hanci V. , Ayoğlu H. , Yurtlu S. , Yildirim N. , Okyay R. D. , Erdoğan G. , Sayin E. , Turan I. O.
Published: January 2019

The aim of our study was to investigate P wave dispersion (Pwd), QT, corrected QT (QTc), QT dispersion (QTd) and corrected QT dispersion (QTcd) intervals in subjects with malnutrition diagnosed in the pre-anaesthetic assessment, compared to those without malnutrition.

A total of 76 adult patients were included. Main diagnoses, anthropometric measurement, body mass index, electrocardiogram and serum sodium, potassium, chloride, magnesium and calcium levels were recorded for all patients. Pwd, QT and QTd intervals were measured on all electrocardiogram records and QTc and QTcd intervals determined with the Bazett formula. Protein-energy malnutrition was diagnosed with the nutritional risk index.

No statistically significant difference was found between the age, gender and malignant cancer diagnosis rates between patients with malnutrition (group M) and those not suffering from malnutrition (group N) (P >0.05). Serum albumin, total protein, potassium, calcium, magnesium and chloride values of group M were found to be significantly lower than group N (P <0.05). In group M, Pwd, QT, QTc, QTd and QTcd intervals were significantly longer than in group N (P <0.001).

Patients diagnosed with malnutrition during pre-anaesthetic assessment had significantly longer Pwd, QTc and QTcd interval durations than the control group. We attribute such extended Pwd, QTc and QTcd durations in these patients to malnutrition and malnutrition-related electrolyte imbalance.
Magnesium Sulphate for Treatment of Tetanus in Adults
Authors: Mathew P. J. , Samra T. , Wig J.
Published: January 2019

There are reports that suggest that magnesium sulphate alone may control muscle spasms thereby avoiding sedation and mechanical ventilation in tetanus, but this has not been confirmed. We examined the efficacy and safety of intravenous magnesium sulphate for control of rigidity and spasms in adults with tetanus.

A prospective clinical study of intravenous magnesium sulphate was carried out over a period of two years in a tertiary care teaching hospital. In addition to human tetanus immunoglobulin and parenteral antibiotics, patients with tetanus received magnesium sulphate 70 mg/kg intravenously followed by infusion. The infusion was increased by 0.5 g/hour every six hours until cessation of spasms or abolishment of patellar tendon jerk. The primary outcome measure was efficacy determined by control of spasms. Secondary outcomes included frequency of autonomic instability, duration of ventilatory support, hospital stay and mortality.

Thirty-three patients were enrolled. At presentation, the incidence of severity of tetanus was as follows: Grade I: 5 (15%), Grade II: 13 (39%), Grade III: 14 (42%) and Grade IV: 1 (3%). Rigidity and mild spasms were controlled with magnesium therapy alone in six patients; all were Grades I or II. Additional sedatives were required in severe forms of tetanus. The average duration of ventilatory support was 18.3±16.0 days and the overall mortality was 22.9%. Asymptomatic hypocalcaemia was a universal finding.

Magnesium sulphate therapy alone may not be efficacious for the treatment of severe tetanus.
Compression of the Common Carotid Artery following Clavicle Fracture in a Twelve-Year-Old
Authors: Keating M. , von Ungern-Sternberg B. S.
Published: January 2019

Posterior dislocation of the clavicle in the sternoclavicular joint is rare, but can result in severe complications caused by secondary damage to the adjacent structures on relocation. We present a case of a 12-year-old boy who sustained a dislocated clavicle while playing football. Against the initial request to perform immediate relocation, we opted for further computed tomography evaluation of the dislocation, which demonstrated compression of the left common carotid artery by the clavicle. Since there was no cardiothoracic standby available in our hospital on that day, the patient was transferred to the nearest centre with cardiothoracic facilities where the relocation of the clavicle was performed uneventfully. However, to avoid the potential for major complications, the risk of secondary damage to the central vessels must be kept in mind in this type of injury and adequate precautions must be in place.
Bedside Percutaneous Tracheostomy: A Prospective Randomised Comparison of PercuTwist® versus Griggs’ Forceps Dilational Tracheostomy
Authors: Montcriol A. , Bordes J. , Asencio Y. , Prunet B. , Lacroix G. , Meaudre E.
Published: January 2019

Tracheostomy is considered the airway management of choice for patients who require prolonged mechanical ventilation. The development of percutaneous techniques offers many advantages including the ability to perform the procedure in the intensive care unit. The aim of this study was to compare the controlled rotating dilation method (PercuTwist®) and the Griggs’ forceps dilational tracheostomy.

Patients over 18 years of age undergoing tracheostomy in the intensive care unit were included in the study. They were divided in two random samples – either PercuTwist or forceps dilational tracheostomy. Data collected prospectively included demographic characteristics, procedure duration, blood gas analysis, intracranial pressure, arterial blood pressure and heart rate before and after the procedure. Any complications during or after the procedure due to the tracheostomy were also recorded.

Contrary to the main hypothesis, PercuTwist technique took significantly longer to perform than forceps dilational tracheostomy technique (five minutes [2 to 25] vs three minutes [1 to 17][P=0.006]). A significant increase in PaCO2 and decrease in arterial pH were observed in both groups between the pre-tracheostomy and post-tracheostomy blood gas analysis. Haemodynamic tolerance was good. Our results show that intracranial pressure is affected by the procedure whatever the technique used. However we did not observe a decrease in cerebral perfusion pressure. The incidence of complications was 23% (20/87). These complications were minor in 18/20 and were not significantly different between the two groups.

In conclusion, we consider that the PercuTwist technique is safe despite the longer duration of the procedure. Nevertheless the forceps dilational technique remains our routine procedure.
Randomised Controlled Trial Comparing Oral and Intravenous Paracetamol (Acetaminophen) Plasma Levels when given as Preoperative Analgesia
Authors: van der Westhuizen J. , Kuo P. Y. , Reed P. W. , Holder K.
Published: January 2019

Gastric absorption of oral paracetamol (acetaminophen) may be unreliable perioperatively in the starved and stressed patient. We compared plasma concentrations of parenteral paracetamol given preoperatively and oral paracetamol when given as premedication.

Patients scheduled for elective ear, nose and throat surgery or orthopaedic surgery were randomised to receive either oral or intravenous paracetamol as preoperative medication. The oral dose was given 30 minutes before induction of anaesthesia and the intravenous dose given pre-induction. All patients were given a standardised anaesthetic by the same specialist anaesthetist who took blood for paracetamol concentrations 30 minutes after the first dose and then at 30 minute intervals for 240 minutes. Therapeutic concentrations of paracetamol were reached in 96% of patients who had received the drug parenterally, and 67% of patients who had received it orally. Maximum median plasma concentrations were 19 mg.l-1 (interquartile range 15 to 23 mg.l-1) and 13 mg.l-1 (interquartile range 0 to 18 mg.l-1) for the intravenous and oral group respectively. The difference between intravenous and oral groups was less marked after 150 minutes but the intravenous preparation gave higher plasma concentrations throughout the study period. It can be concluded that paracetamol gives more reliable therapeutic plasma concentrations when given intravenously.
Intensity of Continuous Renal Replacement Therapies in Patients with Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis
Authors: Latour-Pérez J. , Palencia-Herrejón E. , Gómez-Tello V. , Baeza-Román A. , García-García M. á. , Sánchez-Artola B.
Published: January 2019

The purpose of this study was to assess the efficacy of continuous renal replacement therapies in patients with severe sepsis or septic shock, with or without acute kidney injury. We performed a systematic search in Medline, Embase, Web of Knowledge, Cochrane Library and Clinicaltrials.gov and a hand search of the retrieved studies. We included both randomised controlled clinical trials and subgroups of randomised trials that assessed the effect of continuous renal replacement therapies (at traditional or high doses) and reported clinical outcomes in adult patients with severe sepsis or septic shock. The study selection and data extraction were performed by duplicate. Analysis of heterogeneity and meta-analysis was performed according to the Cochrane Collaboration guidelines for conducting systematic reviews of interventions.

Twelve studies (1895 patients) met the inclusion criteria. Pooling of all studies resulted in a mortality risk ratio of 0.96 (95% confidence interval 0.83 to 1.12). The studies showed moderate statistical heterogeneity (I2 statistic 52%, P=0.02). The effect on mortality was not modified (interaction P values non significant) by the dose of continuous renal replacement therapies, the severity of illness or the risk of bias. The available evidence suggests that these therapies in patients with severe sepsis or septic shock are not associated with an improvement in other outcomes such as haemodynamics, pulmonary gas exchange, multiple organ dysfunction syndrome or length of stay. The best available evidence does not support the routine use of continuous renal replacement therapies (at traditional or high doses) in patients with severe sepsis or septic shock.
The Critical Care Costs of the Influenza A/H1N1 2009 Pandemic in Australia and New Zealand
Authors: Higgins A. M. , Pettilä V. , Harris A. H. , Bailey M. , Lipman J. , Seppelt I. M. , Webb S. A.
Published: January 2019

The aim of this study was to determine the critical care and associated hospital costs for 2009 influenza A/H1N1 patients admitted to intensive care units (ICU) in Australia and New Zealand during the southern hemisphere winter. All 762 patients admitted to ICUs in Australian and New Zealand between 1 June and 31 August 2009 with confirmed 2009 H1N1 influenza A were included. Costs were assigned based on ICU and hospital length-of-stay, using data from a single Australian ICU which estimated the daily cost of an ICU bed, along with published costs for a ward bed. Additional costs were assigned for allied health, overheads and extracorporeal membrane oxygenation services. The median (interquartile range) ICU and total hospital costs per patient were AU$35,942 ($10,269 to $82,152) and AU$51,294 ($22,849 to $110,340) respectively, while the mean (standard deviation) ICU and total hospital costs per patient were AU$63,298 ($78,722) and AU$85,395 ($147,457), respectively. A multivariate analysis found death was significantly associated with a reduction in the log of total costs, while the use of mechanical ventilation and ICU admission with viral pneumonitis/acute respiratory distress syndrome or secondary bacterial pneumonia were significantly associated with an increase in the log of total costs. The cost of 2009 H1N1 patients in ICU was significantly higher than the previously published costs for an average ICU admission, and the total cost of treating 2009 H1N1 patients in ICU admitted during winter 2009 was more than $65,000,000.
Effect of Daily Sedative Interruption on Sleep Stages of Mechanically Ventilated Patients Receiving Midazolam by Infusion
Authors: Oto J. , Yamamoto K. , Koike S. , Imanaka H. , Nishimura M.
Published: January 2019

Daily sedative interruption (DSI) may reduce excessive sedation and shorten the duration of mechanical ventilation. It is not clear, however, how DSI affects sleep characteristics. For patients receiving mechanical ventilation, we compared the effect on sleep quality of DSI and continuous sedation (CS).

Twenty-two mechanically ventilated patients who were receiving midazolam by infusion were randomly assigned to two groups, DSI (n=11) or CS (n=11). In the DSI group, sedatives were interrupted until the patients awoke and expressed discomfort, after which midazolam or opioids were administered intermittently as needed during the daytime (0600 to 2100 hours); during the night (2100 to 0600) midazolam was administered intravenously to maintain Ramsay sedation scale 4 to 5. In the CS group, the sedatives were titrated to obtain Ramsay sedation scale 4 to 5 throughout the day. The polysomnography of each patient was recorded continuously over a 24 hour period. Sleep stages were analysed using Rechtschaffen and Kales criteria.

In the DSI group, the amount of stage 3 and 4 non-rapid eye movement sleep (slow wave sleep) was longer (6 vs 0 minutes, P=0.04) and rapid eye movement sleep was longer than in CS (54 vs 0 minutes, P=0.02). In the CS group, total sleep time during night-time was longer (8.7 vs 7.3 hours, P=0.047) and frequency of arousal was lower (2.2 vs 4.4 event/hour, P=0.03) than those in the DSI group. All mechanically ventilated patients demonstrated abnormal sleep architecture, but, compared with CS, DSI increased the amount of slow wave sleep and rapid eye movement sleep.
Meta-Analysis of Randomised Controlled Trials on Daily Sedation Interruption for Critically Ill Adult Patients
Authors: Augustes R. , Ho K. M.
Published: January 2019

Sedation is often used to improve comfort, reduce anxiety and stress and to facilitate nursing care of critically ill patients in the intensive care unit. This meta-analysis examined the benefits and risks of daily sedation interruption in critically ill adult patients. A total of five randomised controlled trials, comparing daily sedation interruption with no interruption in 699 critically ill patients, from the Cochrane controlled trials register, Embase and MEDLINE databases (1966 to April 2010) were identified and subject to meta-analysis. With the limited data available, daily sedation interruption was not associated with a significant reduction in duration of mechanical ventilation, length of intensive care unit and hospital stay, or mortality. Daily sedation interruption was associated with a reduced risk of requiring tracheostomy (odds ratio 0.57, 95% confidence interval 0.35 to 0.92, P=0.02; I2=3%) but not an increased risk of removal of the endotracheal tube by the patients (odds ratio 1.3, 95% confidence interval 0.41 to 4.10, P=0.65; I2=49%). The current evidence suggests that daily sedation interruption appears to be safe, but the significant heterogeneity and small sample sizes of the existing studies suggest that large randomised controlled studies with long-term survival follow-up are needed before daily sedation interruption can be recommended as a standard sedation practice for critically ill adult patients.
Mini-Ventilation for Improved Oxygenation during Lung Resection Surgery
Authors: Shechtman M. Y. , Ziser A. , Barak M. , Ben-Nun A.
Published: January 2019

Lung separation is frequently used during lung resection to facilitate surgery and hypoxaemia may occur because of increasing pulmonary shunt. In this study, we tested a method of mini-ventilation to the non-dependent lung and compared it to continuous positive airway pressure (CPAP) to improve oxygenation during lung resection.

Thirty-eight adult patients participated in this randomised, single-blinded crossover study. Following lung separation, mini-ventilation and CPAP of 5 cmH2O were alternately applied every 15 minutes to the non-dependent lung. Mini-ventilation was performed by a portable time-cycled ventilator with a respiratory rate of 8 breaths/minute and a tidal volume of 0.1 to 0.15 l. Arterial blood gases, peak inspiratory pressure, the dynamic compliance in the dependent lung and the surgeon's evaluation of the surgical field exposure were recorded.

The arterial oxygen partial pressure was significantly higher during mini-ventilation compared to CPAP (379 vs 228 mmHg). No difference was noted in the dependent lung peak inspiratory pressure or in the dynamic compliance. The surgical conditions were similar with both methods in 53% of the patients, while the surgeon preferred CPAP in 44% and mini-ventilation in 3%.

In conclusion, mini-ventilation is a simple method which improves oxygenation during lung resection. However, due to interference with surgical field exposure, it should be reserved for cases in which CPAP does not relieve hypoxaemia.
A Checklist for Streamlining Organ Donation after Cardiac Death
Authors: Sidiropoulos S. , Mcevoy L. , Steel S. , Silvester W. , Warrillow S. , Bolch S. , Jones D.
Published: January 2019

There is currently a shortage of organ donors to meet the demands of transplantation waiting lists. In recent years there has been renewed interest in donation after cardiac death in order to increase the pool of potential donors. The Organ and Tissue Authority has recently developed a national policy for donation after cardiac death. We describe here a checklist that is used by our hospital-based staff for organ donation which outlines important steps in the donation after cardiac death process.
Successful Treatment of Peripartum Massive Pulmonary Embolism with Extracorporeal Membrane Oxygenation and Catheter-Directed Pulmonary Thrombolytic Therapy
Authors: Weinberg L. , Kay C. , Liskaser F. , Jones D. , Tay S. , Jaffe S. , Seevanayagam S. , Doolan L.
Published: January 2019

Chronic thromboembolic pulmonary hypertension during pregnancy is uncommon but is associated with maternal mortality in excess of 35%. We report a case of decompensated thromboembolic pulmonary hypertension requiring emergency caesarean section and postpartum treatment with extracorporeal membrane oxygenation and thrombolytic therapy with urokinase. The use of extracorporeal membrane oxygenation, catheter-directed pulmonary thrombolytic therapy and other pulmonary vasodilators for management of this life-threatening disease is discussed.
The History of Pain Measurement
Authors: Ball C. , Westhorpe R. N.
Published: January 2019

“How we come by our knowledge of another person's pain is a nice study in communication. It has much in common with the sort of communication attempted by the painter, the poet and the musician – the conveying of moods and feelings.” James Parkhouse, 19631.