bluuebunny/crossref_metadata_2025 huggingface dataset:
Cerebral Oximetry to Reduce Perioperative Morbidity
Authors: Cowie D. A. , Nazareth J. , Story D. A.
Published: January 2019

The use of cerebral oximetry to guide intraoperative management has been shown to improve patient outcomes in cardiac surgery. This pilot trial assessed the feasibility of performing a similar study of outcome in patients over the age of 70 years undergoing non-cardiac surgery. Patients over the age of 70 years undergoing total knee or hip arthroplasty or bowel resection surgery were randomly assigned to have cerebral oximetry values monitored (intervention group) or not monitored (control) while under general anaesthesia. Indicators of proof of concept were: rate of complications, rate of cerebral desaturation, relationship between cerebral desaturation and complications, and anaesthetist response to cerebral desaturation. Forty patients were recruited and randomised to a control group (n=20) or an intervention group (n=20). The proportion of the study population who had a complication was 40% (95% confidence interval [CI] 26% to 55%). Cerebral desaturation (<75% of baseline) occurred in only two patients (5.0% (CI 1.4% to 16%)), one in each group, and neither of those patients recorded a complication. Changes to anaesthetic management on the basis of cerebral oximetry values occurred in only two patients in the intervention group (10% (CI 2.8% to 30%)). Maintenance of cerebral oximetry values appeared to be closer to baseline in the intervention group than in the control group but this difference was not significant ( P=0.15). Our results indicated that complications occurred frequently in the study population but did not appear to be associated with cerebral desaturation events. These findings do not support a larger intervention study using the current study population.
Validation of the Vascular Pedicle width as a Diagnostic Aid in Critically Ill Patients with Pulmonary Oedema by Novice Non-Radiology Physicians-in-Training
Authors: Farshidpanah S. , Klein W. , Matus M. , Sai A. , Nguyen H. B.
Published: January 2019

Assessing intravascular volume status in the critically ill patient remains a challenge for intensivists, and the accuracy of such estimation based on bedside examination alone is reported to be nearly a coin toss. In this retrospective study we sought to validate a previously recommended chest radiographic vascular pedicle width (VPW) ≥70 mm for identifying cardiogenic pulmonary oedema (CPO). We additionally assessed whether novice physicians-in-training can reliably measure the VPW. The study included intensive care patients with an existing pulmonary artery catheter. Three independent raters performed measurements of VPW from chest radiographs obtained within three hours of pulmonary artery occlusion pressure measurements. In 80 patients enrolled, a VPW cut-off of ≥70 mm had a 55% sensitivity, 88% specificity, 81% positive predictive value, 69% negative predictive value and 73% accuracy for identifying patients with CPO. Receiver operating characteristic curve analysis showed an area under the curve of 0.72 (95% confidence interval 0.61 to 0.84) for VPW in discriminating CPO from non-cardiogenic pulmonary oedema. Kappa statistics for inter-rater reliability showed Kappa=0.41, 0.42 and 0.85 for each pair of the three raters. In conclusion, the previously accepted VPW cut-off of ≥70 mm is reasonably accurate in discriminating CPO from non-cardiogenic pulmonary oedema. VPW can be measured by physicians-in-training with a comparable performance to previous studies utilising expert radiologists.
Hybrid Measurement to Achieve Satisfactory Precision in Perioperative Cardiac Output Monitoring
Authors: Peyton P.
Published: January 2019

Advanced haemodynamic monitoring employing minimally invasive cardiac output measurement may lead to significant improvements in patient outcomes in major surgery. However, the precision (scatter) of measurement of available generic technologies has been shown to be unsatisfactory with percentage error of agreement with bolus thermodilution (% error) of 40% to 50%. Simultaneous measurement and averaging by two or more technologies may reduce random measurement scatter and improve precision. This concept, called the hybrid method, was tested by comparing accuracy and precision of measurement relative to bolus thermodilution using combinations of three component methods. Thirty patients scheduled for either elective cardiac surgery or liver transplantation were studied. Agreement with simultaneous bolus thermodilution of hybrid combinations of continuous thermodilution (QtCCO) or VigeleoTM/FloTracTM pulse contour measurement (QtFT) with pulmonary Capnotracking (QtCO2) was assessed pre- and post-cardiopulmonary bypass or pre- and post-reperfusion of the donor liver and compared with that of the component methods alone. Hybridisation of QtCO2 (% error 42.2) and QtCCO (% error 51.3) achieved significantly better precision (% error 31.3) than the component methods ( P=0.0004) and ( P=0.0195). Due to poor inherent precision of QtFT (% error 82.8), hybrid combination of QtFT with QtCO2 did not result in better precision than QtCO2 alone. Hybrid measurement can approach a 30% error, which is recommended as the upper limit for acceptability. This is a practical option where at least one component method, such as Capnotracking, is automated and does not increase the cost or complexity of the measurement process.
Comparison of the Effect of Propofol and Sevoflurane Anaesthesia on Acute and Chronic Postoperative Pain after Hysterectomy
Authors: Ogurlu M. , Sari S. , Küçük M. , Bakiş M. , Uğur B. , Eshraghi Y. E. , Galimberti F. , Turan A.
Published: January 2019

There is some evidence that propofol may reduce acute postoperative pain; however, the results are inconsistent. Furthermore, there is a paucity of information about the type of anaesthesia and chronic pain. This study was designed to evaluate the hypothesis that propofol reduces acute and chronic postoperative pain compared with sevoflurane. In a randomised, prospective, double-blind trial, we assigned 80 patients having open total abdominal hysterectomy surgery to anaesthesia with either sevoflurane or propofol. Anaesthesia was titrated to clinical needs and bispectral index values to between 40 and 60. Postoperative pain was managed with pethidine and diclofenac. Acute postoperative pain for 24 hours and chronic postoperative pain at one and three months after surgery were evaluated. The Hospital Anxiety and Depression Scale was used to evaluate patient anxiety and depression after one and three months. There were no significant differences between the groups for opioid consumption or opioid-induced side-effects. Pain scores in the first four hours were significantly higher in the sevoflurane group. Persistent surgical pain was observed less frequently (7 out of 40 patients in the propofol group and 21 out of 40 in the sevoflurane group at three months post-surgery, P <0.01) and pain scores were lower at one and three months in the propofol group (0.78±0.55 versus 2.23±0.73 for the sevoflurane group at three months post-surgery, P <0.01). Anxiety and depression scores were significantly lower in the propofol group at three months. In this study, general anaesthesia with propofol was associated with reduced early acute postoperative and persistent pain, compared to sevoflurane-based anaesthesia, among patients undergoing open abdominal hysterectomy.
Platypnoea-Orthodeoxia Syndrome Post Laparoscopic Surgery in a Patient with a Patent Foramen Ovale
Authors: Low Z. , Darvall J. N. , Radford S. T.
Published: January 2019

Platypnoea-orthodeoxia syndrome has the pathognomonic clinical findings of dyspnoea and arterial hypoxaemia relieved by recumbency. We report on a patient who presented with platypnoea-orthodeoxia syndrome post laparoscopic surgery. Platypnoea-orthodeoxia syndrome is an important diagnosis to consider when investigating hypoxia without an obvious cause.
Does Diabetic Status in the ICU Predict Haemofiltration Requirement? The Haemofiltration in the ICU and Diabetic Status (HIDS) Study
Authors: Williams P. D. , Chan S. C.
Published: January 2019

Diabetes is already a major health burden and prevalence is expected to double by 2025. The impact of diabetes and clinical outcomes in the intensive care unit is an evolving area of research. This study seeks to identify whether diabetic status is an independent risk factor for haemofiltration. This is a retrospective cohort study. All unique patients from a seven-year period from 2004 to 2010 at a major intensive care unit in Melbourne, Australia were analysed using multivariate regression to look for an association between diabetic status and haemofiltration. After exclusion criteria there were 7262 patients, 1674 with a history of diabetes (median age of 69, 66.72% male) and 5588 without a history of diabetes (median age 64, 64.13% male). Diabetic status was an independent risk factor (odds ratio 1.401, 95% confidence interval 1.079 to 1.820, P=0.011) for haemofiltration. Further research may identify intensive care unit-based renoprotective measures specifically for patients with diabetes.
Preoperative Hydroperoxide Concentrations are Associated with an Increased Risk of Postoperative Complications after Cardiac Surgery
Authors: Suehiro K. , Tanaka K. , Matsuura T. , Funao T. , Yamada T. , Mori T. , Tsuchiya M. , Nishikawa K.
Published: January 2019

This study aimed to assess whether preoperative oxidative stress levels can predict postoperative complications in patients undergoing cardiac surgery. Ninety-five cardiac surgery patients received an assessment of preoperative oxidative stress by measurement of hydroperoxide values in blood via the d-Rom test. Area under the receiver operating characteristic curve and also multivariate logistic regression were used to evaluate the prognostic significance of preoperative hydroperoxide concentrations in predicting the occurrence of major organ morbidity and mortality (MOMM). MOMM included death, deep sternal infection, reoperation, stroke, renal failure requiring haemodialysis and prolonged ventilation (>48 hours). The ability of preoperative hydroperoxide concentrations to predict MOMM was not significantly different from that of the European system for cardiac operative risk evaluation (EuroSCORE) (area under the receiver operating characteristic curve 0.822 versus 0.821 respectively, P=0.983). The optimal threshold value of hydroperoxide concentration to differentiate between patients with and without MOMM was 450 UCarr (sensitivity, 87.0%; specificity, 81.9%). Duration of intensive care unit stay, mechanical ventilation time and hospital stay were significantly longer in patients with preoperative hydroperoxide concentrations ≥450 UCarr (H group) compared to those patients with preoperative hydroperoxide concentrations <450 UCarr (L group). An increase in preoperative hydroperoxide concentrations remained associated with an increased risk of MOMM (odds ratios: 1.01, 95% confidence interval: 1.00 to 1.03) and prolonged intensive care unit stay (odds ratio 1.01, 95% confidence interval: 1.00 to 1.02), after adjusting for age, gender and EuroSCORE. In conclusion, an increased hydroper-oxide concentration before cardiac surgery is an independent risk factor for severe postoperative complications.
The Historical Significance of Anaesthesia Events at Pearl Harbor
Authors: Crowhurst J. A.
Published: January 2019

Up to the end of World War II, less than 10% of the general anaesthetics administered were with intravenous barbiturates. The remaining 90% of anaesthetics given in the USA were with diethyl ether. In the United Kingdom and elsewhere, chloroform was also popular. Diethyl ether administration was a relatively safe and simple procedure, often delegated to nurses or junior doctors with little or no specific training in anaesthesia. During the Japanese attack on the US bases at Pearl Harbor, with reduced stocks of diethyl ether available, intravenous Sodium Pentothal®, a most ‘sophisticated and complex’ drug, was used with devastating effects in many of those hypovolaemic, anaemic and septic patients. The hazards of spinal anaesthesia too were realised very quickly. These effects were compounded by the dearth of trained anaesthetists. This paper presents the significance of the anaesthesia tragedies at Pearl Harbor, and the discovery in the next few years of many other superior drugs which caused medical and other health professionals to realise that anaesthesia needed to be a specialist medical discipline in its own right. Specialist recognition soon followed, aided by the foundation of the National Health Service in the UK, the establishment of faculties of anaesthesia and appropriate training in pharmacology, physiology and other sciences. Modern anaesthesiology, as we understand it today, was born and a century or more of ether anaesthesia finally ceased.
Dr Pugh and the Myth of the Illicit Still
Authors: Paull J. D.
Published: January 2019

In her valuable history of the arrival of the news of etherisation in Australia and its implementation by many doctors and dentists, titled One Grand Chain, the late Dr Gwen Wilson asserted that the dentist and the doctor who pioneered etherisation in Australia, Belisario and Pugh… were charged by the authorities with possession of an illicit still”. This paper examines the evidence for the truth or otherwise of this assertion, in relation to Dr Pugh.
A Randomised Controlled Trial Comparing Three Analgesia Regimens following Total Knee Joint Replacement: Continuous Femoral Nerve Block, Intrathecal Morphine or Both
Authors: Olive D. J. , Barrington M. J. , Said S. A. , Kluger R.
Published: January 2019

This randomised controlled trial compared three analgesia regimens following primary unilateral total knee joint replacement: continuous femoral nerve block (CFNB), intrathecal morphine (ITM), and both. The primary outcome was pain ratings over the first 24 hours. Secondary outcomes included morphine consumption, nausea, pruritus and sedation ratings, oxygen saturation (SpO2) ratings, and ability to mobilise postoperatively. All patients received a spinal anaesthetic and a postoperative patient-controlled morphine pump. Patients were randomised to receive CFNB, ITM, or both. In patients with no CFNB, the use of ITM was blinded. Eighty-one patients were randomised and there were no withdrawals. At 24 hours, the ITM-only group had higher pain ratings than either of the other groups ( P=0.04 versus CFNB, P=0.01 versus combination). In the 18 to 24-hour period, the ITM group used more morphine than either of the other groups. There were no statistically significant differences in pain ratings or morphine consumption at earlier time intervals. The ITM group were less likely to be able to sit out of bed on day one. Patients who received ITM were more likely to have pruritus. There were no statistically significant differences in nausea, SpO2 or sedation ratings. This study showed that a CFNB resulted in reduced pain and was also associated with less morphine consumption and improved mobilisation at 24 hours compared to ITM. This study did not show any statistically significant differences between CFNB alone and CFNB+ITM.
Comparison of Ultrasound-Guided Supraclavicular, Infraclavicular and Below-C6 Interscalene Brachial Plexus Block for Upper Limb Surgery: A Randomised, Observer-Blinded Study
Authors: Bharti N. , Bhardawaj N. , Wig J.
Published: January 2019

This prospective, randomised, observer-blinded study was conducted to compare the ease of performance and surgical effectiveness of interscalene block below the C6 nerve root with supraclavicular and infraclavicular techniques of brachial plexus block for upper arm and forearm surgery. Sixty adult patients of American Society of Anesthesiologists grade 1 to 3, undergoing upper limb surgery, were randomly allocated into three groups. Group SC received supraclavicular blockade, group IC received infraclavicular blockade and Group IS received interscalene blockade. All blocks were guided by ultrasound with nerve stimulator confirmation. The anaesthetic mixture consisted of 0.5 ml/kg of equal volumes of 0.75% ropivacaine and 2% lignocaine-adrenaline. The imaging and block performance time, onset time, success rate, duration of block, and duration of postoperative analgesia were recorded by a blinded observer. The onset time was significantly longer in the interscalene group as compared with supraclavicular and infraclavicular approaches. The imaging time and block performance time were comparable between groups. No significant differences were observed between the three groups in terms of block-related pain scores, success rates, duration of block or of postoperative analgesia. Two patients in the interscalene group developed clinically detectable phrenic nerve palsy. Our findings indicate that, although interscalene block below the C6 nerve root can provide surgical anaesthesia for forearm and hand surgery, it appears to have a longer onset time than supra- and infraclavicular approaches and an unacceptable incidence of phrenic nerve palsy.
Sevoflurane for Analgesia—Testing a Modified Vaporiser for Delivery
Authors: Miller L. A. , Makins H. , Eltringham R. , Neighbour R.
Published: January 2019

The Diamedica Sevoflurane Inhaler (Diamedica UK Ltd, Bratton Fleming, UK) (DSI) is a breathing system which includes a modification of an existing vaporiser (Diamedica Draw-over Vaporiser, Diamedica UK Ltd, Bratton Fleming, UK), to enable the delivery of 0.8% sevoflurane. Previous studies have suggested that self-administered sevoflurane at sub-anaesthetic concentration can provide useful pain relief during the first stage of labour and that it may be more effective than Entonox. Further research and potential clinical use have been impeded by the lack of a practical delivery system. In this study, the performance of two versions of the DSI (DSI-1 and DSI-2) was investigated. DSI-1 was tested over a range of minute volumes (1 to 30 l/min) and ambient temperatures (10°C to 40°C). The sevoflurane output increased unacceptably with rising ambient temperature, therefore the design was modified to create the DSI–2. The results from testing this revised version are also described. Mean sevoflurane output from the DSI-2 was found to be within a clinically acceptable range at the minute volumes tested (0.78% to 0.88%) and ambient temperatures tested (0.69% to 0.9%). Based upon these results, the authors propose to undertake further studies of sevoflurane analgesia using the DSI-2.
Deviation from Accepted Drug Administration Guidelines during Anaesthesia in Twenty Highly Realistic Simulated Cases
Authors: Webster C. S. , Andersson E. , Edwards K. , Merry A. F. , Torrie J. , Weller J. M.
Published: January 2019

Deviations from accepted practice guidelines and protocols are poorly understood, yet some deviations are likely to be deliberate and carry potential for patient harm. Anaesthetic teams practise in a complex work environment and anaesthetists are unusual in that they both prescribe and administer the drugs they use, allowing scope for idiosyncratic practice. We aimed to better understand the intentions underlying deviation from accepted guidelines during drug administration in simulated cases. An observer recorded events that may have increased the risk of patient harm (‘Events of Interest’ [EOIs]) during 20 highly realistic simulated anaesthetic cases. In semi-structured interviews, details of EOIs were confirmed with participating anaesthetic teams, and intentions and reasoning underlying the confirmed deviations were discussed. Confirmed details of EOIs were tabulated and we undertook qualitative analysis of interview transcripts. Twenty-four EOIs (69% of 35 recorded) were judged by participants to carry potential for patient harm, and 12 (34%) were judged to be deviations from accepted guidelines (including one drug administration error). Underlying reasons for deviations included a strong sense of clinical autonomy, poor clinical relevance and a lack of evidence for guidelines, ingrained habits learnt in early training, and the influence of peers. Guidelines are important in clinical practice, yet self-identified deviation from accepted guidelines was common in our results, and all but one of these events was judged to carry potential for patient harm. A better understanding of the reasons underlying deviation from accepted guidelines is essential to the design of more effective guidelines and to achieving compliance.
Teaching and Learning in Undergraduate Anaesthesia: A Quantitative and Qualitative Analysis of Practice at the University of Auckland
Authors: Sidhu N. S. , Weller J. M. , Mitchell S. J.
Published: January 2019

Anaesthesia encompasses a broad range of knowledge and skills of relevance to graduating doctors. For the majority of new doctors, an undergraduate clinical rotation is their only exposure to anaesthesia practice. However, the content and approach to undergraduate anaesthesia education varies between institutions. We explored our students’ views and experiences, and teaching approaches and expectations of consultant anaesthetists during a clinical attachment in anaesthesia. Our mixed-method design included student and staff surveys, logbook analysis and student focus groups. Logbook analysis of all 202 students showed mean numbers of attempts for bag-mask ventilation, laryngeal mask insertion, tracheal intubation and IV cannulation were 6.8, 3.9, 3.3 and 4.5, respectively. Focus group responses (11 students, three groups) suggested a mismatch between students’ expectations of performing clinical skills and the available opportunities, particularly for IV cannulation. Students often felt reluctant to ask anaesthetists to teach them, and appreciated clinician-led engagement in all aspects of learning patient management. Among the 78 anaesthetists (29.3%) responding to the survey, the five tasks most frequently identified as suitable for teaching to students all related to airway management. Our study found much unanticipated variability in student exposure, teaching practice and attitudes to teaching various skills or procedures between anaesthetists, and student opinion of their clinical attachment. The findings resulted in a review of many aspects of the attachment. It is likely that other institutions will have similar variability and we recommend they undertake similar exercises to optimise teaching and learning opportunities for undergraduate anaesthesia.
Australian and New Zealand Anaesthetic Allergy Group/ Australian and New Zealand College of Anaesthetists Perioperative Anaphylaxis Management Guidelines
Authors: Kolawole H. , Marshall S. D. , Crilly H. , Kerridge R. , Roessler P.
Published: January 2019

Anaphylaxis is an uncommon but important cause of serious morbidity and even mortality in the perioperative period. The Australian and New Zealand College of Anaesthetists (ANZCA) with the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) have developed clinical management guidelines that include six crisis management cards. The content of the guidelines and cards is based on published literature and other international guidelines for the management of anaesthesia-related and non–anaesthesia-related anaphylaxis. The evidence is summarised in the associated background paper (Perioperative Anaphylaxis Management Guidelines [2016] www.anzca.edu.au/resources/endorsed-guidelines and www.anzaag.com/Mgmt%20Resources.aspx ). These guidelines are intended to apply to anaphylaxis occurring only during the perioperative period. They are not intended to apply to anaphylaxis outside the setting of dedicated monitoring and management by an anaesthetist. In this paper guidelines will be presented along with a brief background to their development.
Patient and Procedural Factors Associated with An Increased Risk of Harm Or Death in the First 4,000 Incidents Reported to webAIRS
Authors: Gibbs N. M. , Culwick M. D. , Merry A. F.
Published: January 2019

This report describes an analysis of patient and procedural factors associated with a higher proportion of harm or death versus no harm in the first 4,000 incidents reported to webAIRS. The report is supplementary to a previous cross-sectional report on the first 4,000 incidents reported to webAIRS. The aim of this analysis was to identify potential patient or procedural factors that are more common in incidents resulting in harm or death than in incidents with more benign outcomes. There was a >50% higher proportion of harm (versus no harm) for incidents in which the patient's body mass index (BMI) was <18.5 kg/m2, for incidents in post-anaesthesia care units and non-theatre procedural areas, and for incidents under the main category of cardiovascular or neurological. The proportion of incidents associated with death was also higher (risk ratio >1.5) for BMI <18.5 kg/m2, incidents in non-theatre procedural areas, and incidents under the main category of cardiovascular or neurological. In addition, the proportion of incidents associated with death was higher for incidents in which the patient's age was >80 years, the American Society of Anesthesiologists physical status was 4 or 5, incidents involving non-elective procedures, and incidents occurring afterhours (1800 to 0800 hours). When faced with incidents with these potential risk factors, anaesthetists should consider earlier interventions and request assistance at an earlier stage. Educational strategies on incident prevention and management should place even further emphasis on scenarios involving these factors.
The Tracheal Accordion and the Position of the Endotracheal Tube
Authors: Herway S. T. , Benumof J. L.
Published: January 2019

The purpose of this review is to, first, determine the static factors that affect the length of the human trachea across different populations and, second, to investigate whether or not there are dynamic factors that cause the length of the human trachea to vary within the same individual. We also investigated whether these changes in tracheal length within the same individual are significant enough to increase the risk of endobronchial intubation or accidental extubation. A PubMed/MEDLINE and a Web of Science database English-language literature search was conducted in May 2016 with relevant keywords and MeSH terms when available. We found that gender, extremes of age, patient height, postsurgical changes and co-existing disease are static patient factors that affect the length of the human trachea. Dynamic clinical changes that occur under anaesthesia, including Trendelenburg position, head and neck flexion and extension, paralysis of the diaphragm and pneumoperitoneum, cause the trachea to act as an accordion, decreasing and increasing its length. The length of the human trachea in both awake and anaesthetised and paralysed patients is a critical consideration in preventing both endobronchial intubation and tracheal extubation. It is clear from the literature that tracheal length varies widely across populations and, additionally, with the dynamic clinical changes that occur under anaesthesia, the trachea acts as an accordion decreasing and increasing its length within the same individual. Knowledge of the magnitude of the change in tracheal dimensions in response to these factors is an important clinical consideration.
A Clinical Audit to Assess the Efficacy of the Coolsense® Pain Numbing Applicator for Intravenous Cannulation in Children
Authors: Ragg P. G. , Cahoon G. , Yeo A. , Chalkiadis G.
Published: January 2019

The Coolsense® device is a topical applicator that is used to anaesthetise the skin before a painful procedure. It is a handheld device with a temperature-controlled head that acts on application, without chemicals, to cool and anaesthetise the site of injection. This prospective observational audit of 100 children and adolescents aged six to 18 years studied the analgesic efficacy and patient and carer satisfaction rating of the device during intravenous cannulation and complications arising from its use. The audit demonstrated effective skin analgesia for intravenous cannulation in children and adolescents. Ninety-four percent of patients rated the pain during cannulation as less than or equal to three on a numerical pain rating scale of zero to ten. Patient and carer satisfaction with the device and cannulation success rates were high; 66% of patients and 82% of carers ‘really liked’ the device and 28% of patients and 12% of carers ‘liked’ it. Ninety-five percent of patients were cannulated on the first attempt. The incidence of complications using the device was low. The Coolsense device appears to be a useful tool that provides effective analgesia for intravenous cannulation in children with minimal complications. Comparative studies with topical local anaesthesia creams are warranted.
Endothelial Glycocalyx: Basic Science and Clinical Implications
Authors: Pillinger N. L. , Kam P. C. A.
Published: January 2019

The classic Starling principle proposed that microvascular fluid exchange was determined by a balance of hydrostatic and oncotic pressures relative to the vascular wall and this movement of water was regulated by gaps in the intercellular spaces. However, current literature on the endothelial glycocalyx (a jelly-like protective layer covering the luminal surface of the endothelium) has revised Starling's traditional concepts. This article aims to summarise the literature on the glycocalyx related to its basic science, clinical settings inciting injury, protective strategies and clinical perspectives. Perioperative damage to the glycocalyx structure can increase vascular permeability leading to interstitial fluid shifts, oedema, and increased surgical morbidity. Pathological shedding of the glycocalyx occurs in response to mechanical cellular stress, endotoxins, inflammatory mediators, atrial natriuretic peptide, ischaemia–reperfusion injury, free oxygen radicals and hyperglycaemia. Increased understanding of the endothelial glycocalyx may change perioperative fluid management, and therapeutic strategies aimed at its preservation may improve patient outcomes.
Assessing Contemporary Intensive Care Unit Outcome: Development and Validation of the Australian and New Zealand Risk of Death Admission Model
Authors: Paul E. , Bailey M. , Kasza J. , Pilcher D. V.
Published: January 2019

The Australian and New Zealand Risk of Death (ANZROD) model currently used for benchmarking intensive care units (ICUs) in Australia and New Zealand utilises physiological data collected up to 24 hours after ICU admission to estimate the risk of hospital mortality. This study aimed to develop the Australian and New Zealand Risk of Death admission (ANZROD0) model to predict hospital mortality using data available at presentation to ICU and compare its performance with the ANZROD in Australian and New Zealand hospitals. Data pertaining to all ICU admissions between 1 January 2006 and 31 December 2015 were extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database. Hospital mortality was modelled using logistic regression with development (two-thirds) and validation (one-third) datasets. All predictor variables available at ICU admission were considered for inclusion in the ANZROD0 model. Model performance was assessed using Brier score, standardised mortality ratio and area under the receiver operating characteristic curve. The relationship between ANZROD0 and ANZROD predicted risk of death was assessed using linear regression. After standard exclusions, 1,097,416 patients were available for model development and validation. Observed mortality was 9.5%. Model performance measures (Brier score, standardised mortality ratio and area under the receiver operating characteristic curve) for the ANZROD0 and ANZROD in the validation dataset were 0.069, 1.0 and 0.853; 0.057, 1.0 and 0.909, respectively. There was a strong positive correlation between the mortality predictions with an overall R2 of 0.73. We found that the ANZROD0 model had acceptable calibration and discrimination. Predictions from the models had high correlations in all major diagnostic groups, with the exception of cardiac surgery and possibly trauma and sepsis.
The Use of Sodium Bicarbonate in the Treatment of Tricyclic Antidepressant-Induced Arrhythmias
Authors: Brown T. C. K. , Barker G. A. , Dunlop M. E. , Loughnan P. M.
Published: January 2019

Sodium bicarbonate has been successfully used clinically to treat arrhythmias induced by tricyclic antidepressant drugs (imipramine, amitriptyline, nortriptyline, dibenzepin). Experiments conducted on puppies showed that arrhythmias caused by amitriptyline disappear when acidosis is adequately treated. Plasma protein binding of amitriptyline increases as pH rises, reducing the unbound fraction of drug. This mechanism is an important factor in the antiarrhythmic action of sodium bicarbonate in tricyclic antidepressant overdosage.
The Axillary Approach to Brachial Plexus Anaesthesia
Authors: Hopcroft S. C.
Published: January 2019

A method of brachial plexus block using the axillary approach is described.

The method differs from previously described techniques and allows anaesthesia to be obtained using between 7 and 20 ml of local anaesthetic solution.

The results of 100 consecutive cases are reported.
Report: Contamination of Medical Oxygen
Authors: Herlihy W. J.
Published: January 2019

The results are presented of chemical investigations of the contents of a medical oxygen cylinder which was found to be contaminated. Fortunately the contaminant was detected before the gas was administered to a patient.
Blood Pressure, D-Tubocurarine and the Effect of Preservatives
Authors: Torda T. A. , Bakry B. J. , McCulloch C. H. , Gibb D. B.
Published: January 2019

The hypotensive effect of d-tubocurarine 0·5mg/kg, with and without benzyl alcohol and sodium metabisulphite as preservatives, was studied in 38 pairs of subjects in a double blind, controlled, sequential trial. It is concluded that the preservatives do not significantly contribute to the hypotension produced by d-tubocurarine in clinical practice.
Piritramide—A New Long-acting Analgesic
Authors: Gibb David B. , Pikler Nicholas
Published: January 2019

Piritramide is a synthetic analgesic of the piperidine group. Reports indicate that it is a potent, long-acting drug and that the incidence of nausea and vomiting following its administration is very low. In this series of 60 cases piritramide 15 mg was compared with morphine 10 mg in a double-blind trial. The drug was found to have a potency similar to that of morphine and a mean duration of action of greater than 6½ hours (morphine 4 ½ hours). The incidence of nausea and vomiting was low with both drugs and piritramide appeared to exert a slight anti-emetic effect.
Coeliac Plexus Block
Authors: Black Andrew , Dwyer Brian
Published: January 2019

Coeliac plexus blocks have had a reasonable success rate (approximately 70 per cent) in the relief of the pain of carcinoma of the pancreas or upper abdominal malignancy and were helpful for pancreatitis and in some cases of inoperable arterial insufficiency.

Diagnostic coeliac plexus blocks sometimes provided useful information about some types of pain. There were no dangerous complications in this series so that this seems a reasonable form of therapy for patients for whom there is often little else to offer.
The Use of Acupuncture in Anaesthesia
Authors: Ferguson N. L.
Published: January 2019

Impressions formed on a visit to China about acupuncture as an anaesthetic technique are recorded and discussed. At its present stage of development the technique appears to have little to offer.
Some Anaesthetic Problems in Corrective Spinal Surgery in Children in Hong Kong
Authors: Shin Felix T.
Published: January 2019

Corrective spinal surgery in children usually involves repeated and extensive operations. Endotracheal intubation may be difficult. Pulmonary function in these patients is often poor and pulmonary reserve minimal. Respiratory failure in the post-operative period is not uncommon and oxygen therapy, sometimes with intermittent positive pressure, is essential. Rapid and massive blood loss requires frequent and careful assessment and rapid replacement. Careful monitoring and active therapeutic measures are essential to prevent post-operative complications.
An Introduction to Control Engineering
Authors: Brown W. A.
Published: January 2019

The viewpoint, terminology and technique of the control engineer are introduced in the context of biological control systems. The centrality of the feedback principle in the operation of control systems is emphasized, and the advantages of feedback control described. It is indicated that the control engineer frequently employs mathematical analysis and tends to take an overall or” systems” approach to design. Control engineering is becoming increasingly important in medicine, both in the analysis of biological systems and in medical treatment and prosthesis.
Electronic Digital Computer Control of Ventilation and Anaesthesia
Authors: Lampard D. G. , Coles J. R. , Brown W. A.
Published: January 2019

The use of a small digital computer to control a number of interactive physiological variables is demonstrated. It is shown that by monitoring the values of end tidal per cent CO2, inspired O2 percentage and mean arterial blood pressure, a computer-controlled system can regulate the ventilation and anaesthesia of an animal within fine tolerances. Similarly it is shown that by controlling the infusion of muscle relaxant, the integrated electromyogram of a muscle can be maintained at any desired level.

The computer control system automatically allows for random disturbances in system parameters in maintaining set levels of the controlled variables. The system responds rapidly to changes in the desired level of variables, and prescribed time courses of variables can be followed.
A Method of Resuscitation in Advanced Cases of Superior Mediastinal Syndrome
Authors: Chan C. S.
Published: January 2019

A method of endobronchial intubation through a tracheostome is described. In some cases of advanced superior mediastinal syndrome, it serves as a resuscitative step to tide the patient over a critical phase.
Case Report: Diuretics and Non-respiratory Alkalosis
Authors: Poole John L.
Published: January 2019

A patient with chronic respiratory failure and cor pulmonale was admitted to hospital with an exacerbation of cardiac failure. In attempting to control cardiac failure, intensive diuretic therapy resulted in the development of dehydration, alkalosis, grand mal convulsions and signs of a left hemiparesis. Correction of the electrolyte and acid-base abnormalities resulted in complete neurological recovery.

Mechanisms of production by diuretics and the treatment of non-respiratory alkalosis is discussed.
Respiratory Function in Infants
Authors: Phelan Peter D.
Published: January 2019

Measurements of respiratory function in infants under 12 months of age are reviewed and compared with those in adults. It is shown that allowing for differences in body size the findings in infants are similar to those in older age groups. However, it is important that anyone involved in the respiratory care of small infants be aware of the consequences of the difference in body size as it effects pulmonary function.
Paediatric Pharmacology
Authors: Brown T. C. K.
Published: January 2019

Infants and children differ pharmacologically from adults because the progressive maturation of various systems during development leads to variations in drug action and dosage. These differences are reviewed. Pharmacogenetic factors which affect anaesthesia and the problems of drug overdosage, as seen in paediatric intensive care units, are briefly considered.
The Management of Respiratory Failure in Infancy
Authors: Stocks J. G.
Published: January 2019

The management of respiratory failure in infancy has altered considerably over the past two decades, due both to an increasing understanding of the underlying pathophysiological mechanisms involved and the development of new techniques of treatment. This paper outlines the rationale, indications, and details of the therapy which may be required in neonates and infants suffering from illnesses affecting respiratory function.
Dental Anaesthesia in Children
Authors: Bell James M.
Published: January 2019

Traditional methods of out-patient general anaesthesia for dentistry in children are critically examined.

A method is described which is acceptable to anaesthetists; the safety of performing this on an out-patient basis is discussed in detail.
The Position of Central Venous Catheters Inserted through Arm Veins: A Preliminary Report
Authors: Woods D. G. , Lumley Jean , Russell W. J. , Jack R. D.
Published: January 2019

Fifty-three central venous catheters were followed up by radiography or direct observation during open-heart surgery. Forty of these were satisfactorily positioned for recording central venous pressure or for sampling central venous blood. Radiography showed that the catheter tip was in an unsatisfactory position in 21 per cent of cases. It is recommended that radiographic confirmation of the site of the catheter tip be obtained as a routine and if necessary the catheter can be re-positioned and another radiograph taken.
The Use of Large Doses of Adrenaline and Other Vasopressors in the Low Cardiac Output Syndrome after Cardiac Surgery—A Report of Four Cases
Authors: Callanan V. I. , Harrison G. A.
Published: January 2019

Four cases are described of the use of prolonged and/or high doses of adrenaline in the treatment of the low cardiac output syndrome following cardiac surgery. Adrenaline was chosen because it produced a more favourable effect on central cardiovascular haemodynamics and myocardial metabolism when compared with isoprenaline, while its detrimental effects on renal function were less marked than those found when using noradrenaline. The renal insufficiency encountered was reversed in those cases without previous renal disease. Tachyphylaxis was demonstrated and weaning was achieved by gradual withdrawal of the vasopressor with concomitant blood volume expansion. Two cases with predominant right ventricular failure developed gross ascites and peripheral oedema, making control of fluid balance difficult. These problems are discussed with a summary of the relevant pharmacology of isoprenaline, noradrenaline, adrenaline and glucagon. The conclusions reached regarding the use and management of adrenaline infusion are given.
Phaeochromocytoma in a Child
Authors: Wotherspoon G. P. , Overton J. H. , Lomaz J. G.
Published: January 2019

A case of phaeochromocytoma in an eight-year-old child is presented with emphasis on drug preparation, fluid replacement, and intraoperative monitoring. Comparison with two previous cases is made to indicate advances in management.
Paediatric Endotracheal Suction
Authors: Poole John L. , Abrahams N. , Fisk G. C.
Published: January 2019

Catheters for paediatric endotracheal suction were studied using an artificial lung with compliances in the range encountered in paediatric practice.

With various combinations of “lung” compliance, size of endotracheal tube, endotracheal connector and catheter,” tracheal” pressure and air flow between endotracheal tube and catheter were measured.

Recommendations for combinations of endotracheal tube, connector and catheter size are made. The maximum negative pressure applied to the catheter should be limited.
Initial Clinical Experiences with Althesin (CT 1341) in Malaysian Patients
Authors: Delilkan A. E.
Published: January 2019

The history of steroidal intravenous anaesthesia is traced.

Althesin was used as an induction agent in 60 elective minor gynaecological procedures requiring general anaesthesia, followed by nitrous oxide/oxygen maintenance anaesthesia.

Clinical assessment showed predominantly a transient hypotension (10–20 mm Hg fall in systolic blood pressure), a rise in pulse and respiratory rates. Recovery was smooth, rapid and pleasant.

As an induction agent Althesin (CT 1341) has effects similar to the well-known and established side-effects of the ultra-short-acting barbiturates. The obvious advantage would be for patients in whom barbiturates are contraindicated. The clear-headed, pleasant recovery should enhance its value for outpatient minor procedures requiring general anaesthesia.
A Volume-Preset Device for Mechanical Ventilation of Infants and Children
Authors: Fisk G. C. , Nutter R. , Abrahams N. , Vonviller J. B. , Butchers D. J. M.
Published: January 2019

A bag-in-bottle system for mechanical ventilation of infants and children is described. It is a modification of the C.I.G. Vent-Viva, which may be driven by an adult ventilator such as the Bennett P.R.2 or the Bird Mark 7.
Pulmonary Consequences of Upper Abdominal Surgery—Therapeutic Considerations
Authors: Saady Albert
Published: January 2019

Pulmonary complications following abdominal surgery are the largest single cause of morbidity and mortality in the post-operative period. This paper discusses the predisposing factors and clinical features, including the changes in ventilatory function tests. Important concepts in post-operative pain management are outlined, with emphasis on extradural analgesia.
The Social Psychology of the Bedside
Authors: Hore Terry
Published: January 2019

This paper discusses the role of nonverbal communication in the establishment of rapport with a patient during a pre-operative interview. It is suggested that (a) observation of the nonverbal behaviour of the patient can provide a check on the validity of the information provided verbally by that patient, and (b) that the doctor can change his own nonverbal behaviours to assist him establish a relationship or extricate himself from one. The use of space, orientation, posture and eye-contact are discussed.
Regional Anaesthesia for Trans-Urethral Resection of the Prostate—Which Method and Which Segments?
Authors: Evans T. I.
Published: January 2019

Four methods of regional anaesthesia for trans-urethral prostatectomy were compared in 350 patients. Complete analgesia was produced in all cases where the level of the block reached the third lumbar segment. Caudal analgesia was unreliable because of the low levels achieved. It is likely that the “capsular sign “is lost if the level reaches the tenth thoracic segment. Anatomical explanations are considered.
Reliability of Blood Sugar Reagent Strips
Authors: McCleave D. J.
Published: January 2019

Two cases of severe hypoglycaemia following the use of insulin after blood sugar reagent strips indicated an erroneously high value, precipitated an investigation into the reliability of all reagent strips currently being used at the Royal Adelaide Hospital. It was found that when compared to Autoanalyzer values, such a method of blood sugar estimation is unacceptable for clinical useage. Reagent Strips taken from recently opened containers gave reasonably accurate results for lower blood sugar values. It is concluded that such inaccurate results are related to the stability of the reagent strips.
A Simple Plan for the Management of Drug Overdosage
Authors: Wright R. C.
Published: January 2019

Using a purely supportive regime of management a survival rate of 99·6 per cent has been obtained in 1,166 patients admitted to hospital as a result of drug overdosage. Based on this experience, the principles of treatment are discussed.
Drug Overdosage in Children
Authors: Brown T. C. K. , Bishop F. I. , Mullins G. C.
Published: January 2019

The epidemiology and prevention of drug overdosage in children is discussed. The emergency treatment of acute drug overdosage is outlined together with aspects of the intensive care management in relation to conscious state, convulsions, respiratory failure, circulatory failure and arrhythmias with some emphasis on tricyclic antidepressants.
Psychiatric Aspects of Drug Overdose in Adults
Authors: Burrows Graham D. , Harari Edwin
Published: January 2019

Psychiatric aspects of drug overdose in adult suicide and suicide attempts are reviewed. Particular reference is given to studies reported from Australia. The findings of a recent study from the Royal Melbourne Hospital with regard to age-sex distribution, drugs used in self-poisonings, clinical state of the patient on admission and psychiatric diagnosis are presented and discussed.