bluuebunny/crossref_metadata_2025 huggingface dataset:
Transient Lumbar Pain after 5% Hyperbaric Lignocaine Spinal Anaesthesia in Patients Having Minor Vascular Surgery
Authors: Davies M. J. , Cook R. J. , Quach K.
Published: January 2019

Transient lumbar pain has been reported to occur frequently in patients having surgery using 5% hyperbaric lignocaine for spinal anaesthesia. The incidence of transient lumbar pain is highest with this agent in patients having surgery in the lithotomy position and in outpatients. The aim of this audit was to determine the incidence of transient lumbar pain in patients having minor surgery for the complications of peripheral vascular disease, a group of patients in whom short duration spinal anaesthesia is desirable.

One hundred patients were audited prospectively. All patients had 5% hyperbaric lignocaine spinal anaesthesia and were followed up postoperatively utilizing a standardized questionnaire to determine the incidence of transient lumbar pain. The condition was found to occur in 4% of patients.

This low incidence of transient lumbar pain justifies the continued use of 5% hyperbaric lignocaine for spinal anaesthesia in this group of patients.
Deafness—A Complication of Nasopharyngeal Airways
Authors: Jones G. L. , Redfern R. M. , Jerwood D. C.
Published: January 2019

We report a patient who developed temporary deafness secondary to oedema of the uvula and soft palate following prolonged continuous positive airway pressure via a nasopharyngeal airway.
Outpatient Management of the Chronically Anticoagulated Patient for Elective Surgery
Authors: Watts S. A. , Gibbs N. M.
Published: January 2019

With the appropriate use of preadmission clinics, “hospital in the home” programs, and alternatives to intravenous heparin, the majority of chronically anticoagulated patients can be managed as outpatients prior to elective surgery. The preoperative management depends on the original indication for long-term anticoagulation, the interval since the last thromboembolic event, and the extent and type of surgery planned. Only patients who are undergoing major surgery, and who have a high risk of recurrent thrombosis or embolism, require preoperative admission to hospital and conversion to an intravenous heparin regimen. Patients undergoing minor surgery may require no change to their oral anticoagulation. The remainder require cessation of oral anticoagulation and alternative thromboprophylaxis preoperatively, which can be achieved on an outpatient basis using low molecular weight heparin. Outpatient anticoagulation management requires a clear protocol that is understood and agreed to by all parties involved in the care of surgical patients perioperatively.
Lack of Effect of Prophylactic N-acetylcysteine on Postoperative Organ Dysfunction following Major Abdominal Tumour Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial
Authors: Szakmany T. , Marton S. , Molnar Z.
Published: January 2019

Sepsis and respiratory dysfunction leading to multiple system organ failure remains the leading cause of postoperative morbidity and mortality following major surgical procedures. It has been suggested the oxygen free radicals might play a pivotal role in this process. The aim of this study was to investigate whether short-term infusion of N-acetylcysteine (N-acetylcysteine), a potent antioxidant, administered before and during extensive abdominal surgery, could ameliorate the progression of early postoperative organ dysfunction and improve oxygenation. Out of the 93 patients, 47 received N-acetylcysteine and 46 were given placebo in a randomized, controlled, double-blinded fashion. Patients received N-acetylcysteine (150 mg.kg -1 bolus followed by a continuous infusion of 12 mg.kg -1. h -1 ) or the same volume of placebo (5% dextrose) during surgery. Treatment effect on organ function was assessed by organ dysfunction scores according to physiological parameters of six main organ systems: respiratory, cardiovascular, renal, hepatic, haematological and central nervous system. The scores were obtained on admission, then daily during the first three postoperative days. For statistical analysis Mann-Whitney U and Chi-squared tests were used. There was no significant difference between the two groups in any of the six organ dysfunction parameters, length of intensive care stay, days of mechanical ventilation and mortality. Our results do not support the routine use of N-acetylcysteine as a prophylactic measure during surgery, and reinforce previous evidence which challenges the indication of N-acetylcysteine in the critically ill.
Use of the Internet for Patient Care: A Nationwide Survey of Australian Anaesthetists
Authors: Jones C. , Lambros M.
Published: January 2019

The internet is an increasingly important source of information for anaesthetists. We sought to determine the extent and patterns of internet use among Australian anaesthetists, and to assess its effect on clinical decision-making. A postal survey of all Australian Fellows of the Australian and New Zealand College of Anaesthetists (n=2344) was performed. The response rate was 48% (n=1109) and 1066 responses were analysed. Ninety-seven per cent of respondents, much higher than the national average of 72%, had internet access at work or home. The majority used the internet at least once a month for patient care, and over 50% had made clinical decisions influenced by information found on the internet. In contrast, less than 20% had had any training in its use. In terms of access, rural Australia did not appear to be disadvantaged.
Critical Illness and its Impact on the Aboriginal People of the Top End of the Northern Territory, Australia
Authors: Stephens D.
Published: January 2019

The Royal Darwin Hospital (RDH) services a relatively large and geographically remote Aboriginal population who account for 45% of intensive care unit admissions. Critical illness in the Aboriginal population is different from the non-Aboriginal population of the “Top End” of the Northern Territory. The critically ill Aboriginal patient is younger, has more chronic health problems and a higher severity of illness at presentation. The city and the hospital environment are foreign to many Aboriginal patients retrieved from remote communities and this adds to the stress of the critical illness. English is a second, third or fourth language for many Aboriginal people from remote communities and strategies must be put in place to ensure informed consent and effective communication are achieved. Despite the increased severity of illness and complexity, the Royal Darwin Hospital ICU achieves the same survival rates for both Aboriginal and non-Aboriginal patients.
The Dangers of Trying to Make Ends Meet: Accidental Intravenous Administration of Enteral Feed
Authors: Ramsay S. J. , Gomersall C. D. , Joynt G. M.
Published: January 2019

We report a case of inadvertent intravenous administration of enteral feed, a very rare but potentially life-threatening complication of enteral feeding. Bacterial contamination of feed results in a severe septic response that requires broad-spectrum antibiotic cover and aggressive organ support. The failure of measures aimed at prevention of this complication must be investigated, and practice changed to ensure that further incidents are avoided.
An Unusual Cause of Locked Jaw and its Airway Management
Authors: Sivalingam P. , Pilditch D.
Published: January 2019

We describe the management of a patient impaled through the medial aspect of the left orbit by the brake lever of a mountain bike which immobilized her jaw by obstructing the right coronoid process of the mandible and blocked access to the mouth and trachea. The fire service used special equipment to cut out the rest of the bike from the handle bar. The patient with the penetrating brake lever attached to the handlebar in situ was transported to the hospital by rescue helicopter. The assessment and safe airway management and potential difficulties are discussed.
Spinal Cord Stimulation in Chronic Pain: A Review of the Evidence
Authors: Carter M. L.
Published: January 2019

This review looks at the evidence for the effectiveness of spinal cord stimulation in various chronic pain states. Spinal cord stimulation can only be effective when appropriate dorsal column fibres in the spinal cord are preserved and able to be stimulated. Spinal cord stimulation has been shown to have little to offer for patients with some diagnoses. Although 50 to 60% of patients with failed back surgery syndrome obtain significant pain relief with this technique, the strength of the evidence available is insufficient to clearly advocate its use in all patients with this condition. Though limited in quantity and quality, better evidence exists for its use in neuropathic pain, complex regional pain syndrome, angina pectoris and critical limb ischaemia. There is a lack of high quality evidence relating to spinal cord stimulation due to difficulties in conducting randomized controlled trials in this area. Serious methodological problems are encountered in blinding, recruitment and assessment in nearly all published trials of spinal cord stimulation. Suggestions regarding appropriate methodologies for trials which would produce better quality evidence are summarized.
Randomized Evaluation of the Single-use SoftSeal™ and the Re-useable LMA Classic™ Laryngeal Mask
Authors: Paech M. J. , Lain J. , Garrett W. R. , Gillespie G. , Stannard K. J. D. , Doherty D. A.
Published: January 2019

A number of laryngeal masks are available, including both re-usable and single-use masks. Single-use laryngeal masks may decrease the risk of transmitting prion infections. We performed a single-blind randomized trial in 200 spontaneously breathing female patients under general anaesthesia with nitrous oxide, to compare a new single-use laryngeal mask, the SoftSeal™ (Portex Ltd, U.K.), with a re-usable laryngeal mask, the LMA Classic™ (Laryngeal Mask Company Ltd., Cyprus). The primary outcome was successful insertion at the first attempt. Size 4 single-use (n=99) or re-usable (n=100) laryngeal masks, inserted by experienced anaesthetists, were equivalent for successful placement at the first attempt (90% versus 91% respectively). The single-use mask was less easy to insert (47% difficult versus 9%, P<0.001). Clinical and anatomical tests of position and function were similar. The cuff pressure of the re-usable mask increased significantly compared with the single-use mask (median +10 cm versus –2 cm H 2 O, P<0.001). Forty per cent of patients allocated the single-use mask and 20% of those allocated the re-usable mask experienced sore throat at 24 hours postoperatively (P<0.05). An estimation of cost per patient use was greater for the re-usable mask.

We conclude that the SoftSeal™ single-use laryngeal mask and the LMA Classic™ re-usable laryngeal mask airway are of similar clinical utility in terms of successful insertion and airway maintenance. The re-usable laryngeal mask was easier to insert and associated with less postoperative sore throat, but costs were higher.
Recovery from Bispectral Index-guided Anaesthesia in a Large Randomized Controlled Trial of Patients at High Risk of Awareness
Authors: Leslie K. , Myles P. S. , Forbes A. , Chan M. T. V. , Short T. G. , Swallow S. K.
Published: January 2019

Electroencephalographic monitors of anaesthetic depth are reported to assist anaesthetists in reducing recovery times. We explored the effect of bispectral index (BIS) monitoring on recovery times in a double-blind, randomized controlled trial of 2,463 patients at high risk of awareness. Patients were randomized to BIS-guided anaesthesia or routine care. In the BIS group, anaesthesia was adjusted to maintain a BIS value of 40–60 from the commencement of laryngoscopy to the start of wound closure, and 55–70 during wound closure. In the routine care group, anaesthesia was adjusted according to traditional clinical signs. In multivariate models, BIS monitoring, female gender, lower American Society of Anesthesiologists’ physical status and shorter duration of anaesthesia predicted faster time to eye-opening after anaesthesia, and faster time to post-anaesthesia care unit discharge. BIS monitoring did not affect times to tracheal extubation among patients admitted to the intensive care unit. We conclude that BIS monitoring has statistically significant, but clinically modest, effects on recovery times in high risk surgical patients.
A Survey of Chinese Herbal Medicine Intake Amongst Preoperative Patients in Hong Kong
Authors: Critchley L. A. H. , Chen D. Q. , Lee A. , Thomas G. N. , Tomlinson B.
Published: January 2019

We have surveyed, by means of a questionnaire, the preoperative use of traditional Chinese medicines in 259 adult Chinese patients admitted to a Hong Kong teaching hospital. The spectrum and use of herbal remedies differed from that reported by Western sources. Of those patients surveyed 90% used Chinese herbs on a regular daily basis in traditional soups and teas while 44% had consulted a traditional Chinese medicine practitioner in the last twelve months prior to admission, but mainly for health promotion (59%) and minor ailments (30%). Only 25% sought advice for their current illness and 13% were taking regular traditional Chinese medicines prior to admission. The ingredients were difficult to identify. Patients with cancer were more likely to use ling zhi (odds ratio 5.4). Female patients with reproductive problems were more likely to visit a traditional Chinese medical practitioner (odds ratio 2.6) and use ginseng (odds ratio 5.1). The anaesthetic implications of preoperative traditional Chinese medicine in keeping with Hong Kong practices need to be investigated, and appropriate anaesthetic guidelines should be developed.
Phentermine and Anaesthesia
Authors: Stephens L. C. , Katz S. G.
Published: January 2019

We describe the case of a woman who had two perioperative hypertensive crises that may have been due to her use of phentermine, a little-known sympathomimetic anti-obesity medication. The currently available anti-obesity medications are discussed: phentermine, diethylpropion, and sibutramine; all of which are sympathomimetics possessing noradrenaline and serotonin reuptake inhibitor activity. These medications should be discontinued one week preoperatively and have potential interactions with tramadol and antidepressants. The drug orlistat inhibits gastrointestinal lipase and may lead to fat soluble vitamin (A, D, E, and K) deficiency, so consideration should be given to checking coagulation status preoperatively.
Relationship between Journal Impact Factor and Levels of Evidence in Anaesthesia
Authors: Bain C. R. , Myles P. S.
Published: January 2019

Evidence-based medicine uses a hierarchy of publication types according to their vulnerability to bias. A widely used measure of journal “quality” is its impact factor, which describes the citation rate of its publications. We investigated the relationship between impact factor for eight anaesthesia journals and publication type with respect to their level of evidence 1-4 using Spearman rank correlation (rho). There were 1418 original publications during 2001 included in the analysis. The number (%) of publication types according to evidence-based medicine level were: level 1: 6 (0.4%), level 2: 533 (38%) level 3: 329 (23%), level 4: 550 (39%). There was no correlation between journal ranking according to impact factor and publication type (rho=–0.03, P=0.25). The correlation between journal rank and the proportion of publications that were randomized trials was –0.35 (P<0.001). The correlation between journal rank and number of publications was 0.65 (P<0.001). The correlation between journal rank and number of level 1 or 2 studies was 0.58 (P<0.001). The overall level of evidence published in anaesthesia journals was high. Journal rank according to impact factor is related to the number of publications, but not the proportion of publications that are evidence-based medicine level 1 or 2.
New Zealand Anaesthesia Trainees and Implications for the Future Workforce
Authors: King S. Y. , Mcgeorge A. D.
Published: January 2019

Attempting to ensure an adequate anaesthesia workforce for New Zealand requires many variables to be taken into consideration. The difficulty lies in trying to predict and match the future needs of the population and the future needs of the workforce itself. This paper examines variables that affect anaesthesia trainees’ decisions in regard to future work plans which will affect anaesthesia distribution and manpower in New Zealand, particularly in smaller hospitals. It is already apparent that with distribution problems and/or actual shortages, the gaps in workforce availability for any professional group tend to be in the smaller centres. All New Zealand anaesthesia trainees were sent a questionnaire in 2002, with 110 of 138 trainees responding (79.7%). It appears enough specialists are being trained, with 80% indicating a desire to remain in New Zealand and 13% stating Australia as their choice of destination. The influence of student debt or encouragement of overseas training experience did not appear to be important in their decisions. Having a rotation during training to smaller hospitals had a positive effect on attitudes to working in smaller hospitals as specialists. The recruitment of these future specialists into smaller hospitals also depends upon broader lifestyle choices. Selection of smaller hospitals for anaesthesia practice is encouraged by good financial incentives, adequate professional support, including support by junior doctors, access to ongoing professional development and inclusion into a wider rotation with a larger hospital.
Anatomical Study of the Brachial Plexus using Surface Ultrasound
Authors: Royse C. F. , Sha S. , Soeding P. F. , Royse A. G.
Published: January 2019

The aim of this study was to define the anatomy relevant to brachial plexus regional anaesthesia and to identify the extent of variation between individuals. Surface ultrasound examination of the brachial plexus was performed on twenty volunteers. In the axilla there was considerable individual variation in the location of the median, radial and ulnar nerves in relation to the axillary artery. There was often more than one venous structure in this region, which was easily compressed by surface palpation. In the supraclavicular region, neural elements were located inferiorly to the subclavian artery in two volunteers. In one volunteer, a vein was identified between nerve trunks in the interscalene region. These findings indicate that the anatomical variation is considerable, even within the relatively small sample studied. For this reason, use of surface ultrasound may lead to increased success of brachial plexus regional anaesthesia and a decreased risk of intravascular injection.
Predictive Performance of a Model of Anaesthetic Uptake with Desflurane
Authors: Kennedy R.
Published: January 2019

We have previously shown that a model of anaesthetic uptake and distribution, developed for use as a teaching tool, is able to predict end-tidal isoflurane and sevoflurane concentrations at least as well as commonly used propofol models predict blood levels of propofol. Models with good predictive performance may be useful as part of real-time prediction systems. The aim of this study was to assess the performance of this model with desflurane.

Twenty adult patients undergoing routine anaesthesia were studied. The total fresh gas flow and vaporizor settings were collected at 10-second intervals from the anaesthetic machine. These data were used as inputs to the model, which had been initialized for patient weight and desflurane. Output of the model is a predicted end-tidal value at each point in time. These values were compared with measured end-tidal desflurane using a standard statistical technique of Varvel and colleagues.

Data was analysed from 19 patients. Median performance error was 78% (95% CI 8-147), median absolute performance error 77% (6–149), divergence 10.6%/h (-80-101) and wobble 8.9% (-6-24).

The predictive performance of this model with desflurane was poor, with considerable variability between patients. The reasons for the difference between desflurane and our previous results with isoflurane and sevoflurane are not obvious, but may provide important clues to the necessary components for such models. The data collected in this study may assist in the development and evaluation of improved models.
Association of Obesity with Increased Mortality in the Critically Ill Patient
Authors: Aldawood A. , Arabi Y. , Dabbagh O.
Published: January 2019

The impact of obesity on critical care outcomes has been an issue for debate in the literature. Variable data and conflicting results have been reported. The purpose of our study is to examine the impact of obesity on the outcome of patients admitted to a tertiary closed Intensive Care Unit (ICU) in Saudi Arabia.

Data was obtained from a prospectively collected database from September 2001 to May 2004. Patients younger than 18, those with burns, brain death and readmissions were excluded. The study population was stratified into six groups according to their Body Mass Index (BMI). Primary endpoints were ICU and hospital mortality, duration of mechanical ventilation and ICU length of stay.

A total of 1835 patients were included in the analysis. Baseline characteristics were similar among the six groups including severity of illness scores, reflected by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. The ICU mortality was not statistically different among the groups. Hospital mortality was lower in patients with BMI 35–39.9 kg/m2 and BMI >40 kg/m2 compared to those with BMI 18.5–24.9 kg/m2. Multivariate analysis showed that a BMI >40 kg/m2 was an independent predictor of lower hospital mortality (odds ratio 0.51, 95% confidence interval 0.28–0.92, P 0.025) after adjustment for other confounding factors.

In conclusion, mortality of obese critically ill patients was not higher than patients with normal weight. In fact, the hospital mortality was lower for patients with BMI >40 kg/m2 compared to the normal BMI group despite similar severity of illness. Obesity might have a protective effect, although further studies are needed to substantiate this finding.
A Comparison of 5% Dextrose in 0.9% Normal Saline versus Non-Dextrose-Containing Crystalloids as the Initial Intravenous Replacement Fluid in Elective Surgery
Authors: Chin K. J. , Macachor J. , Ong K. C. , Ong B. C.
Published: January 2019

Intravenous fluid replacement in adult elective surgery is often initiated with dextrose-containing fluids. We sought to determine if this practice resulted in significant hyperglycaemia and if there was a risk of hypoglycaemia if non-dextrose-containing crystalloids were used instead.

We conducted a randomized controlled trial in 50 non-diabetic adult patients undergoing elective surgery which did not involve entry into major body cavities, large fluid shifts, or require administration of > 500 ml of intravenous fluid in the first two hours of peri-operative care. Patients received 500 ml of either 5% dextrose in 0.9% normal saline, lactated Ringer's solution, or 0.9% normal saline over 45 to 60 minutes. Plasma glucose, electrolytes and osmolality were measured prior to infusion, and at 15 minutes and one hour after completion of infusion.

None of the patients had preoperative hypoglycaemia despite average fasting times of almost 13 hours. Patients receiving lactated Ringer's and normal saline remained normoglycaemic throughout the study period. Patients receiving dextrose saline had significantly elevated plasma glucose 15 minutes after completion of infusion (11.1 (9.9–12.2, 95% CI) mmol/l). Plasma glucose exceeded 10 mmol/l in 72% of patients receiving dextrose saline. There was no significant difference in plasma glucose between the groups at one hour after infusion, but 33% of patients receiving DS had plasma glucose ≥8 mmol/l.

We conclude that initiation of intravenous fluid replacement with dextrose-containing solutions is not required to prevent hypoglycaemia in elective surgery. On the contrary, a relatively small volume of 500 ml causes significant, albeit transient, hyperglycaemia, even in non-diabetic patients.
Bispectral Index Guided Timing of Intubation without Neuromuscular Blockade during Sevoflurane Induction of Anaesthesia in Adults
Authors: Van Twest R. M.
Published: January 2019

The aim of this study was to assess the effectiveness of bispectral index monitoring (BIS) as a guide to the timing of intubation during sevoflurane induction of anaesthesia without the use of neuromuscular blocking agents in adults, and specifically, whether a target BIS value of 25 provides better intubating conditions than a target BIS of 40.

Forty patients were randomized into one of two groups, a target BIS 25 (n=21) or a target BIS 40 (n =19). Patients received premedication with midazolam 20 μg/kg and fentanyl 0.5 μg/kg. Sevoflurane induction of anaesthesia was initiated and titrated to reach the target BIS value and maintained within the target range for two minutes. The trachea was then intubated, with intubating conditions being assessed using a standardized scale.

The BIS 25 group had a superior median intubating score of 4 (range 3–9, [IQR 4–5]) vs the BIS 40 group with a median of 7 (5–10, [6–9], P<0.001).

The time to reach target BIS values was not statistically different (BIS 25 group 6.6 min, BIS 40 group 5.1 min, P=0.054). End-tidal sevoflurane concentration upon reaching the target BIS was higher in the BIS 25 group (5.3%±1.2%) vs the BIS 40 group (3.5% ±0.95) (P<0.001). There was no statistical difference in haemodynamic parameters between groups.

A target BIS value of 25 provides good to excellent intubating conditions and better intubating conditions than a target BIS of 40 during sevoflurane induction of anaesthesia without the use of neuromuscular blocking agents.
Critical Incidents in a Multidisciplinary Intensive Care Unit
Authors: Chacko J. , Raju H. R. , Singh M. K. , Mishra R. C.
Published: January 2019

We aimed to determine the type and frequency of critical incidents in a multidisciplinary intensive care unit, to determine outcomes consequent to these incidents and to devise corrective strategies.

Prospectively collected data on critical incidents during a 33-month period were analysed. In all, 1918 patients were admitted to the unit during the study period. Each incident was analysed in detail. A system-based corrective strategy was sought for and implemented as appropriate.

In these patients, 280 critical incidents were reported during the study period, resulting in 3.4 incidents per 100 patient days. Airway-related incidents were the most frequent (32.8%) followed by line-related (21.8%) and drug-related (15%) incidents. Thirty-two incidents (11.4%) led to adverse outcomes. There were four deaths that occurred as a direct consequence of or contributed to by the incident, all due to airway-related incidents. A major physiological change occurred in 3.6% of incidents, while 6.4% of incidents resulted in a minor physiological change. Critical incidents were common in our multidisciplinary ICU, although adverse outcomes were rare.
Mycoplasma Pneumoniae Associated with Stevens Johnson Syndrome
Authors: Mulvey J. M. , Padowitz A. , Lindley-Jones M. , Nickels R.
Published: January 2019

We describe a case of Mycoplasma pneumoniae chest infection associated with Stevens Johnson syndrome. The patient had extensive epidermal bullous vesicles, oropharyngeal and genital ulceration and required prolonged ventilation due to respiratory failure. Mycoplasma pneumoniae infections are often asymptomatic but can involve multiple organ systems. Respiratory tract involvement is generally benign though 3 to 10% of patients develop clinical pneumonia. Secondary skin reactions are common (20 to 25%), although few patients infected develop Stevens Johnson syndrome. It has been suggested that Mycoplasma pneumoniae may be the most common infectious cause of Stevens Johnson syndrome.
Presentation of Hemiplegic Migraine—Hemiplegia and Hemi-Sensory Loss following General Anaesthesia
Authors: Lin L. , Adey C.
Published: January 2019

We report a case of a 15-year-old male who developed severe left-sided hemiplegia and hemi-sensory loss 20 minutes after arrival in post anaesthetic care unit following an uneventful general anaesthesia for removal of a cannulated screw of left hip. Initial CT and MRI/MRA with diffusion-weighted imaging were unremarkable. The patient was transferred to The Royal Children's Hospital Melbourne and was commenced on heparin infusion pending investigation results. Complete recovery occurred within 36 hours. Eventually, hemiplegic migraine was diagnosed on the basis of negative investigations and a retrospective history of the patient's migraine. This case demonstrates that the management of perioperative neurological deficits must be approached in a systematic fashion. Hemiplegic migraine is a well-defined clinical syndrome. It is not merely a diagnosis of exclusion.
After-Hours Discharge from Intensive Care Increases the Risk of Readmission and Death
Authors: Pilcher D. V. , Duke G. J. , George C. , Bailey M. J. , Hart G.
Published: January 2019

Despite reports showing night discharge from an intensive care unit (ICU) is associated with increased mortality, it is unknown if this has resulted in changes in practice in recent years. Our aim was to determine prevalence, trends and effect on patient outcome of discharge timing from ICU throughout Australia and New Zealand.

Two datasets from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) were examined:

1. All submissions to the APD from 1.1.2003 to 31.12.2004 to determine contemporary practices.

2. Forty hospitals which had submitted continuous data between 1.1.2000 and 31.12.2004 to determine trends in practice over time.

Outcomes investigated were hospital mortality and ICU readmission rate.

Between 1.1.2003 and 31.12.2004, the ANZICS APD reported 76,690 patients discharged alive from ICU; 13,968 (18.2%) were discharged after-hours (between 1800 and 0559 hours). After-hours discharges had a higher readmission rate (6.3% vs. 5.1%; P= <0.0001) and higher mortality (8.0% vs. 5.3%; P= <0.0001). Peak readmission (8.6%) and mortality rates (9.7%) were seen in patients discharged between 0300 and 0400 hours. After-hours discharge was a predictor of mortality (odds ratio 1.42, 95% confidence interval 1.32-1.52; P= <0.0001) in multivariate analysis. Between 2000 and 2004, after-hours discharges increased (P=0.0015) with seasonal peaks during winter. The risk of death increased as the proportion of patients discharged after-hours rose.

After-hours discharge from ICU is associated with increased risk of death and readmission to ICU. It has become more frequent. The risk of death increases as more after-hours discharges occur.
Ropivacaine 0.25% is as Effective as Bupivacaine 0.25% in Providing Surgical Anaesthesia for Lumbar Plexus and Sciatic Nerve Block in High-Risk Patients: Preliminary Report
Authors: Kocum A. , Turkoz A. , Ulger H. , Sener M. , Arslan G.
Published: January 2019

Ropivacaine is potentially less cardiotoxic and neurotoxic than bupivacaine. The aim of this study was to compare the effectiveness of ropivacaine 0.25% and bupivacaine 0.25% for surgical anaesthesia and postoperative analgesia during lumbar plexus and sciatic nerve block in high-risk patients. We performed combined lumbar plexus and sciatic nerve blockade on 62 consecutive ASA III or IV patients undergoing unilateral hip or femur surgery. The first 30 patients received bupivacaine (Group 1) and the remaining 32 patients received ropivacaine (Group 2). Perioperative management was otherwise similar. The groups were compared for the time of onset of the block, additional analgesics and sedatives required, time from end of surgery to the first analgesic requirement and the need for rescue analgesia. Ninety percent (29/32) of the patients in the ropivacaine group and 86% (26/30) of the patients in the bupivacaine group reached surgical anaesthesia. The time from the end of the surgery to the first analgesic requirement was similar between the two groups (10.3±5.2 hours for ropivacaine, 11.2±4.6 hours for bupivacaine). There was no statistically significant difference between the two groups in any of the measured variables (P>0.05). The results of this preliminary study suggest that ropivacaine 0.25% is as effective as bupivacaine 0.25% when used for blocking lumbar plexus and sciatic nerve in high-risk patients undergoing hip or femur surgery.
Anaesthesia for Hemipelvectomy—A Series of 49 Cases
Authors: Molnar R. , Emery G. , Choong P. F. M.
Published: January 2019

We undertook an audit of 49 consecutive hemipelvectomies performed for primary or secondary malignancy. Combined epidural and general anaesthesia was used in 41 patients. The operations were long(range 90 to 600 minutes). The median crystalloid requirement was 8500 ml (range 1000 to 42000 ml) and a median of seven units of packed red blood cells were transfused (range 0 to 44 units). All measures of coagulation were normalised by the first postoperative day using fresh frozen plasma, platelets and cryoprecipitate. Warmed blood was administered at high flow rates using a custom designed system consisting of a roller pump and high capacity fluid warmer. Thirty-five patients were managed postoperatively in the intensive care unit, of whom 31 remained intubated for postoperative ventilation. In 41 patients, postoperative pain management was by a continuous epidural infusion of local anaesthetic and opioid. The average duration of infusion was 4.25 days (range 3 to 6 days). One patient died during surgery from complications relating to massive blood loss, 14 had wound infections and one had an acute brain syndrome. There was significant utilisation of resources involving anaesthesia, surgery, intensive care and blood transfusion services. Anaesthesia for hemipelvectomy is challenging because of the extensive tissue trauma involved, the potential for massive blood loss and the potential for severe postoperative pain. The perioperative management necessitates care from a well coordinated, directed and focused healthcare team.
Prospective Audit Comparing Intrathecal Analgesia (Incorporating Midazolam) with Epidural and Intravenous Analgesia after Major Open Abdominal Surgery
Authors: Duncan M. A. , Savage J. , Tucker A. P.
Published: January 2019

Potentiation of opioid analgesia can be achieved by the addition of midazolam intrathecally. At our institution, analgesia following open abdominal surgery is provided by continuous infusion of analgesic solutions either intravenously, intrathecally (incorporating midazolam) or epidurally. We report the results of a study comparing outcomes with these three analgesic regimens following major open abdominal surgery. This was an unblinded prospective audit of pain service intervention rates, pain scores and other outcomes after intravenous, intrathecal and epidural analgesia after open abdominal surgery in patients over 60 years of age. Both elective and emergency cases were included over a nine-month period. Patients ventilated for 24 hours or more were excluded. The analgesic regimens were as follows:

1. Intravenous: patient controlled analgesia with morphine + ketamine infusion 0.1 to 0.2 mg/kg/h.

2. Intrathecal: (morphine 10 μg/ml+midazolam 100 μg/ml + bupivacaine 0.05%) commenced at 2 ml/h.

3. Epidural: bupivacaine 0.125% + fentanyl 2 μg/ml at 6 to 14 ml/h. Co-analgesic administration was as per our usual practice but was not standardised.

The median number of calls per patient to the pain service differed between the intravenous (1), intrathecal (1) and epidural (3) groups. The number of unintentional analgesic regimen terminations differed between the intravenous (1), intrathecal (1) and epidural (5) groups. Pain scores differed significantly between groups and were lowest in the intrathecal group at all time points.

The findings indicate that the intrathecal group had both a low requirement for postoperative interventions/ resources and excellent analgesia. It appears to be a suitable alternative to the other techniques.
A Comparison of Tape-Tyingc versus a Tube-Holding Device for Securing Endotracheal Tubes in Adults
Authors: Murdoch E. , Holdgate A.
Published: January 2019

During the transfer of intubated patients, endotracheal tube security is paramount. This study aims to compare two methods of securing an endotracheal tube in adults: tying with a cloth tape versus the Thomas Endotracheal Tube Holder (Laerdal).

A manikin-based study was performed using paramedics and critical care doctors (consultants and senior trainees) as participants. Each participant was asked to secure an endotracheal tube that had been placed within the trachea of a manikin a total of six times, the first three times using tied cloth tape and the last three times using a Thomas Endotracheal Tube Holder. Following each 'fixation' and after the participant had left the room, the security of the tube was tested by applying a fixed force laterally and to the right by dropping a 1.25 kg weight a distance of 50 cm. The amount of movement of the tube with respect to the teeth was measured and recorded in millimetres.

Two-hundred-and-seventy tube fixations (135 tied vs. 135 tube holder) were performed by 45 participants. The degree of tube movement was significantly higher when the tube was secured with a tie compared with when the tube holder was used (median movement 22 mm vs. 4 mm, P <0.0001).

We have demonstrated that the tube holder device minimised tube movement in a manikin model when compared with conventional tape tying. The use of this device when transporting intubated patients may reduce the risk of tube displacement though further clinical studies are warranted.
Hospital and 28-Day Mortality Amongst ‘High Risk’ Surgical Patients. A Retrospective Cohort Study
Authors: Gomersall C. D. , Ramsay S. J. , Leung P.
Published: January 2019

The likely mortality benefit from pre-optimisation of high risk surgical patients depends on the baseline risk of death. The baseline risk estimated from the control groups of studies of pre-optimisation may not reflect the risk in other institutions. We determined the 28-day mortality of ‘high risk’ adult surgical patients in our institution by performing a retrospective cohort study of 554 patients undergoing major or ultra-major general or vascular surgery lasting more than two hours. Patients were identified as being high risk based on the presence of risk factors used in previous studies of pre-optimisation. The 28-day mortality (95% CI) was 0% for patients with no risk factors and 2.3 (0.8 to 3.7)% for patients with at least one risk factor. These data indicate that the risk of death amongst high risk surgical patients may vary considerably between institutions.
Immediate Management of Inadvertent Dural Puncture during Insertion of a Labour Epidural: A Survey of Australian Obstetric Anaesthetists
Authors: Newman M. J. , Cyna A. M.
Published: January 2019

Immediate management of inadvertent dural puncture during insertion of an epidural needle during labour is controversial and evidence to guide clinical practice is limited. We surveyed Australian obstetric anaesthetists by anonymous postal questionnaire. Of the 671 surveys sent, 417 (62%) were returned. Following dural puncture, 265 respondents (64%) indicated that they “would usually remove the Tuohy needle and resite”. The most common reason for this decision was concern regarding the safety of intrathecal catheters (ITC) (n=236, 89%), in particular, the risk of misuse (n=182, 70%).

The most frequently reported reason for “usually inserting an ITC” was that this reduced the incidence (n=120, 84%) and severity (n=110, 77%) of post dural puncture headache. Increased frequency of ITC insertion was reported by respondents who practised more frequent sessions of obstetric anaesthesia, had fewer years of experience as a consultant anaesthetist and worked in a public hospital. The more widespread use of ITCs seems to be limited by safety concerns.
The Role of Extra Corporeal Membrane Oxygenation for Treatment of the Adult Respiratory Distress Syndrome: Review and Quantitative Analysis
Authors: Chalwin R. P. , Moran J. L. , Graham P. L.
Published: January 2019

The role of Extra corporeal membrane oxygenation (ECMO) has not been formally validated for patients with adult respiratory distress syndrome. In anticipation of publication of the conventional ventilation versus ECMO in severe adult respiratory failure (CESAR) trial, the role of ECMO in this setting was reviewed.

An electronic search for studies reporting the use of ECMO for the treatment of adult respiratory distress syndrome revealed two randomised controlled trials and three non-controlled trials. Bayesian analysis on the two randomised controlled trials produced an odds ratio mortality of 1.28 (credible interval 0.24 to 6.55) demonstrating no significant harm or benefit. Pooling was not possible for the non-controlled studies because of differing admission status and ECMO selection criteria and an inability to control for these differences in the absence of individual patient data. A large number (n=35) of case series have been published with generally more positive results. We also present a comprehensive narrative commentary on the history, current practice and future for ECMO.

ECMO, as rescue therapy for adult respiratory distress syndrome, appears to be an unvalidated rescue treatment option. Analysis and review of trial data does not support its application; however the body of reported cases suggests otherwise. Until the CESAR trial provides an authoritative answer ECMO will continue to be offered on a case by case basis.
Fully Developed Burnout and Burnout Risk in Intensive Care Personnel at a University Hospital
Authors: Lederer W. , Kinzl J. F. , Traweger C. , Dosch J. , Sumann G.
Published: January 2019

We assessed the prevalence of fully developed burnout, burnout risk and the influence of work and employment related factors in five intensive care units at a university hospital. A cross-sectional study was conducted using self-reporting questionnaires for the evaluation of the frequency and intensity of burnout syndrome (Maslach Burnout Inventory) and work and employment related factors. From a total of 320 eligible intensive care personnel, 33 physicians and 150 nurses participated in the study (59% response rate). Applying the process model for burnout, 63 participants (34.4%) were at risk for burnout and another 11 respondents (6.0%) revealed evidence of fully developed burnout (emotional exhaustion ≥4.0 and lack of personal accomplishment ≤4.0). No statistically significant difference in prevalence of fully developed burnout or burnout risk was detected in subgroups according to age, gender, level of training, years of employment and family status. The desire to choose the same profession again was significantly less in respondents with fully developed burnout (P=0.006). The opportunity to regularly attend facilitation was significantly lower for participants with fully developed burnout (P=0.002) compared to participants with no burnout. Fully developed burnout and burnout risk are common in intensive care personnel. Support from facilitators appeared to be an important preventive factor.
Dreaming and Recall during Sedation for Colonoscopy
Authors: Stait M. L. , Leslie K. , Bailey R.
Published: January 2019

Dreaming is reported by one in five patients who are interviewed on emergence from general anaesthesia, but the incidence, predictors and consequences of dreaming during procedural sedation are not known. In this prospective observational study, 200 patients presenting for elective colonoscopy under intravenous sedation were interviewed on emergence to determine the incidences of dreaming and recall. Sedation technique was left to the discretion of the anaesthetist. The incidence of dreaming was 25.5%. Patients reporting dreaming were younger than those who did not report dreaming. Doses of midazolam and fentanyl were similar between dreamers and non-dreamers, however propofol doses were higher in patients who reported dreams than those who did not. Patients reported short, simple dreams about everyday life - no dream suggested near-miss recall of the procedure. Frank recall of the procedure was reported by 4% of the patients, which was consistent with propofol doses commensurate with light general anaesthesia. The only significant predictor of recall was lower propofol dose. Satisfaction with care was generally high, however, dreamers were more satisfied with their care than non-dreamers.
An Audit of Analgesia Requirements for High-Dose-Rate Prostate Brachytherapy
Authors: Doyle C. A. , Loadsman J. A. , Hruby G.
Published: January 2019

We audited the analgesic, anti-emetic and anti-spasmodic drug usage of patients undergoing high-dose-rate brachytherapy for prostate cancer at the Royal Prince Alfred Hospital. With institutional ethics committee approval, we retrospectively reviewed the records of the first 45 patients undergoing high-dose-rate prostate brachytherapy from January 2003 to July 2005. We collected data regarding the dose of intra- and postoperative analgesics and the anti-emetic and anti-spasmodic drugs administered for the duration of the patients’ hospital stay. We converted oral oxycodone doses to parenteral morphine equivalents for the purposes of this study, dividing the oxycodone dose by three.

The median age of the patients was 69 (range 55 to 80) years. All had general anaesthesia for the catheter insertion procedure. Twenty-five patients (56%) received intraoperative morphine from 5 to 12 mg (mean 9 mg). Forty-three patients (96%) received regular postoperative paracetamol (1 g qid). Thirty-six patients (80%) required additional postoperative opioid administration with an overall mean (all 45 patients included) of 14.5 mg of parenteral morphine equivalents over the entire postoperative course. Thirty-nine patients received intraoperative hyoscine butylbromide to reduce bladder spasm. Fourteen patients were administered antiemetics.

These findings indicate that analgesic requirements during the period in which the prostate brachytherapy catheters remained in place were minimal in most cases. Simple analgesic regimens (regular oral paracetamol, antispasmodics as required for bladder spasm and oral/subcutaneous opioids as required) appear to have been adequate for our patients.
Abdominal Compartment Syndrome Complicating Paediatric Extracorporeal Life Support: Diagnostic and Therapeutic Challenges
Authors: Lam M. C. W. , Yang P. T. , Skippen P. W. , Kissoon N. , Skarsgard E. D.
Published: January 2019

We report three paediatric cases, and summarise the reported experience in two others, with cardiorespiratory failure requiring extracorporeal life support for which supportive pump flows could not be maintained due to abdominal compartment syndrome.

In two of our patients, the mechanism of abdominal compartment syndrome was massive intra-abdominal fluid extravasation secondary to sepsis, while in the third, the mechanism was post-traumatic intra-abdominal haemorrhage. Although all three children eventually died, decompressive laparotomy and arrest of haemorrhage in the trauma patient restored venous return and enabled technically adequate extracorporeal life support. In two previously reported cases of sepsis with massive fluid resuscitation resulting in abdominal compartment syndrome, one patient died without attempted decompression, while the other patient survived after peritoneal catheter placement restored venous return.

Once correctable causes of inadequate venous cannula drainage have been excluded, abdominal compartment syndrome should be considered in any patient on extracorporeal life support with a taut abdomen and reduced venous return. If abdominal compartment syndrome can be proven or is strongly suspected, there may be a role for selective decompressive laparotomy.