bluuebunny/crossref_metadata_2025 huggingface dataset:
Dimensions of majority rule
Authors: Yumlu Ogan
Published: January 2019

The principle of majority rule is a concept that is often employed both in normative democratic theory and in practical politics. But not only that there are relatively few academic studies focusing exclusively on this concept, it is also possible to claim that the existing discussions usually overlook different dimensions of majority rule. This article aims to outline some suggestions for what these dimensions might be, such as: the nature of the participants, the subject matter of the decision and the context in which the decision is made. One underlying assumption in this study is that the normative prospects of the majority rule principle depend on the evaluation of these different dimensions.
Histopathological Findings in Cynomolgus Macaques (Macaca fascicularis) Consistent with Secondary Immunological Reaction to Biotherapeutics with an Emphasis on the CNS and Eye
Authors: Naylor Stuart W. , Czajkowski Melissa , Harvey Warren , Smith Matt , Bradley Alys E. , Cary Maurice
Published: January 2019

Biotherapeutics are pharmaceutical products derived from or synthesized by biological systems. Such molecules carry the potential for immunogenicity which may lead to adverse immune responses. The cynomolgus macaque ( Macaca fascicularis) is the species of choice in nonclinical safety assessment of biotherapeutics. The main aim of this study was to confirm whether mononuclear cell infiltrates at specific locations represent a generic effect of biotherapeutics, and therefore the result of their immunogenicity. Following a review of microscopic findings in studies conducted over a 10-year period at one test facility, 15% of biotherapeutics were reported to have such findings. The most commonly affected site was the choroid plexus and less frequently the meninges and ciliary body. The reporting of such findings as test article–related becomes more subjective as the severity and incidence decreases. To assess the accuracy of such associations, a mathematical approach was employed to determine the probability of obtaining the observed results by chance. There was good agreement between this approach and the original findings. In addition to an increased number and size of mononuclear cell infiltrates in the brain, biotherapeutic administration was strongly associated with the presence of plasma cells and eosinophils.
Insight into falls prevention programmes for people with visual impairments and intellectual disabilities: A scoping review
Authors: Enkelaar Lotte , Overbeek Mathilde , van Wingerden Evelien , Smulders Ellen , Sterkenburg Paula
Published: January 2019

The aim of this study was to review the current literature on falls prevention in people with visual impairment and to estimate the applicability of methods of fall prevention for people with visual impairment and intellectual disability. A scoping review was performed according to the Arksey and O’Malley framework. Relevant studies were collected from PubMed, Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL). All records covering the time span from January 1980 until November 2017 were collected. Studies were included if the participants had a visual impairment according to objective ophthalmic assessments, the article described interventions to reduce falls or risk factors for falls, and the study was written in English and published in a peer-reviewed journal. The methodological quality of the studies were determined by consensus of the authors on the PEDro scale. Fifteen articles were included in this scoping review. Three articles focused on screening and intervention programmes, five articles addressed the effectiveness of environmental adjustments, and seven articles involved training programmes for physical improvement. Environmental adjustments emerged as having the best evidence for falls prevention for people with a visual impairment. Physical training programmes improved balance in those with a visual impairment but could not reduce the number of falls. Environmental adjustments also may be effective for persons with a visual impairment and intellectual disability. In addition, multifactorial screening and intervention programmes are recommended as an important new research direction with important clinical implications.
Tenoxicam IV in Major Gynaecological Surgery— Pharmacokinetic, Pain Relief and Haematological Effects
Authors: Jones R. D. M. , Miles W. , Prankerd R. , Lang C. , Chilvers M. , Lo S. K.
Published: January 2019

This study compared postoperative analgesic dispensation and measures relating to haemostasis following intravenous administration, in a randomized double-blinded manner, of either placebo or tenoxicam 20 mg to 30 women presenting for major gynaecological oncology surgery under a standardized, combined epidural/general anaesthetic technique. Pharmacokinetic disposition of tenoxicam in this patient cohort was also described. There was no objective or subjective alteration in haemostatic function or increase in blood loss, nor any deviation from the normal range of values. Postoperative analgesia during the first 48 hours was delivered to achieve a VAS endpoint of less than five on leg-raising, by a combination of a nurse-controlled low-dose background epidural infusion and patient-administered epidural bolus. Greater VAS variability was observed during the first four postoperative hours (P=0.08). The tenoxicam group self-administered significantly fewer epidural bolus doses to maintain satisfactory analgesia compared with the placebo group during the first 24 hours (P=0.004) and 48 hours (P=0.01) post-operatively. Similar differences between the groups in the total dose of the epidural bupivacaine/fentanyl mixture delivered were described (4 h: P=0.148; 24h: P=0.033; 48 h: P=0.001) (Figure 2). Despite surgery, transfusion and the use of a renal protective fluid administration strategy, tenoxicam disposition was not greatly different from that widely described for healthy volunteers. There were no significant side-effects and no adverse events attributable to tenoxicam. In this small study we have shown that tenoxicam administered preoperatively reduced the epidural analgesic requirements during the first 48 hours following major gynaecological surgery. There was no clinical or pathological evidence of haematological impairment following a single IV administration of tenoxicam 20 mg.
The Effect of Adding Fentanyl to Ropivacaine 0.125% on Patient-Controlled Epidural Analgesia during Labour
Authors: Ruban P. , Sia A. T. H. , Chong J. L.
Published: January 2019

The use of patient-controlled epidural analgesia (PCEA) for labour analgesia is rapidly gaining acceptance. However, the ideal PCEA solution and PCEA program remains uncertain. We studied the effect of adding fentanyl 2 μg/ml on demand-only PCEA using ropivacaine 0.125% for labour analgesia.

With the approval of the Hospital Ethics Committee, this prospective randomized controlled trial was conducted on 36 nulliparous ASA 1/2 parturients in early, but established, labour. Upon written consent, epidural analgesia was started with 10 ml ropivacaine 0.2%. The parturients subsequently were randomized to receive either ropivacaine 0.125% (n=18) or ropivacaine 0.125% with fentanyl 2 μg/ml (n=18). The PCEA was programmed to a demand-only mode with bolus of 5 ml, lockout time of 10 minutes and maximum volume per hour of 20 ml.

The degree of pain relief was similar in both groups. However, the total amount of ropivacaine used per hour was lower in the group that received fentanyl (median 7.1 vs 10.1 mg, P<0.05). This was not associated with a decrease in motor blockade or a decrease in instrumental deliveries. The ratio of successful PCEA demand to total number of demands, the satisfaction score and the maternal-fetal outcome were similar in both groups.

In conclusion, the addition of fentanyl had a dose-sparing effect on the requirement of ropivacaine. This PCEA regimen produced a low incidence of motor block, good labour pain relief and excellent patient satisfaction.
The McCoy Laryngoscope, External Laryngeal Pressure, and Their Combined Use
Authors: Harioka T. , Nomura K. , Mukaida K. , Hosoi S. , Nakao S.
Published: January 2019

The efficacy of the McCoy laryngoscope, external laryngeal pressure, and their combination to improve the laryngoscopic view was evaluated in 219 patients and compared with the Macintosh laryngoscope. An experienced laryngoscopist performed laryngoscopy twice using the Macintosh laryngoscope and the McCoy laryngoscope in a random sequence, and external laryngeal pressure was applied in each laryngoscopy with the laryngoscopist's right hand. The laryngoscopic view obtained was graded on our modified Cormack's method. Without external laryngeal pressure, the McCoy laryngoscope provided a better laryngoscopic view than that obtained by the Macintosh laryngoscope (P<0.001, signed rank test), but the view was worse than that with the Macintosh laryngoscope under external laryngeal pressure (P<0.001). The McCoy laryngoscope combined with external laryngeal pressure provided a better view than the Macintosh laryngoscope with external laryngeal pressure (P<0.001).
Efficacy of Securing Cannulae with Different Taping Methods
Authors: Found P. W. H. , Baines D. B.
Published: January 2019

This study compared locally available adhesive tapes and dressings in a block randomized, blinded study to determine the force required to dislodge a cannula. In the first stage of the study, various tapes and taping methods were used to secure a cannula to a polyvinylchloride (PVC) pipe. The cannula was attached to a section of a giving set which in turn was attached to a dynamic force transducer. The force required to dislodge the cannula, together with the methods of dislodgement were recorded. In stage two the best taping technique for each type of tape was tested by attaching a cannula to the surface of the forearm of an adult male volunteer. Of the tapes tested we found Leukoplast® to be the most effective tape for securing the cannula to the PVC model. On the adult forearm Sleek® was as effective as Leukoplast®. Orientating the tape parallel to the long axis of the cannula and taping the cannula hub-giving set connection both improved the adherence of the cannula. Under the conditions tested, sterile adhesive dressings and tapes were relatively ineffective in securing the cannulae.
Use of a Fibreoptic Stylet to Visually Evaluate Tracheal Intubation Technique
Authors: Takizawa D. , Sato E. , Saruki N. , Goto F. , Saito S.
Published: January 2019

To compare the tracheal intubation by novices with that of instructors, we videotaped the view obtained through a fibreoptic stylet during standard tracheal intubations with a Macintosh direct laryngoscope. The duration of visualization of the vocal cords was longer during intubation by instructors than during trainee attempts. The tracheal tube contact (with pharyngeal wall) time duration was higher during intubation attempts by trainees than instructors. The quality of the image of the vocal cords through the stylet was related to these video-view parameters. Our results demonstrated that visualization of the vocal cords by direct laryngoscope and manipulation of the tracheal tube in the oral cavity were different between anaesthesia trainees and instructors, and suggested that visually monitoring the tracheal intubation procedure through a fibreoptic stylet might be useful for the education of anaesthesia trainees.
Awake Intubation Made Easy and Acceptable
Authors: Jenkins S. A. , Marshall C. F.
Published: January 2019

This study examined the efficacy of a technique of administration of lignocaine 2% (with 1:200,000 adrenaline) to the nose, pharynx and larynx. A simple device constructed from a 22 gauge Optiva® cannula attached to a medical oxygen supply via green “bubble” tubing and the barrel of a 3 ml syringe, similar to that described by Mackenzie1, was used to administer aerosolized lignocaine initially via the nose and subsequently via a nasopharyngeal airway. Ten unsedated, unpremedicated volunteers were intubated. The mean time from the start of the administration of lignocaine to confirmation of placement of the endotracheal tube was 12 minutes (range 8 to 19 minutes). Intubating conditions were good and the procedure was well tolerated in all subjects. The mean dose of lignocaine was 4.8 mg.kg -1 (range 2.7 to 6.9 mg.kg -1 ) and plasma concentrations were well below toxic levels (highest concentration 3.12 mg.l -1 ). There was good haemodynamic stability and no episode of oxyhaemoglobin desaturation.
Blind Orotracheal Intubation with the Intubating Laryngeal Mask versus Fibreoptic Guided Orotracheal Intubation with the Ovassapian Airway. A Pilot Study of Awake Patients
Authors: Dhar P. , Osborn I. , Brimacombe J. , Meenan M. , Linton P.
Published: January 2019

In a randomized, prospective pilot study, we compared awake blind orotracheal intubation using the intubating laryngeal mask airway (blind-ILM) with awake fibreoptic-guided orotracheal intubation using an Ovassapian airway (FOS-OA). Fifty-four patients (ASA 1 to 3, aged 18 to 85 years) requiring awake intubation for elective surgery were randomly allocated by coin toss into two groups: 31 patients were intubated blindly through the ILM (blind-ILM) and 23 were intubated using fibreoptic guidance through the Ovassapian airway (FOS-OA). Sedation to a target clinical end-point (spontaneous eye-closing, but responsive to verbal command) was obtained with fentanyl/midazolam and a cricothyroid puncture was performed with 3 ml lignocaine 4%. The oropharynx was then topicalized until tolerance of a Guedel airway was achieved. The number of failed attempts (maximum of three allowed), overall success rates, the time from insertion of the airway to capnographic (blind-ILM) or fibreoptic (FOS-OA) confirmation of intubation or until three failed attempts, and cardiovascular responses before and during intubation, were recorded. The first time (blind-ILM, 25/31 [81%]; FOS-OA, 20/23 [87%], P=0.6) and overall (blind-ILM, 26/31 [84%]; FOS-OA, 22/23 [96%], P=0.2) intubation success rates were similar. The mean±SD time to intubation was shorter for the blind-ILM group (104±65 vs 158±115 sec, P=0.05). There were no clinically significant differences in blood pressure or heart rate between groups. Compared with baseline values, there was no cardiovascular response to intubation in either group. We conclude that the blind-ILM and FOS-OA techniques have similar success rates and cardiovascular responses, but intubation is slightly quicker with the blind-ILM technique.
Performance of Transcutaneous Pco2 and Pulse Oximetry Monitors in Newborns and Infants After Cardiac Surgery
Authors: Carter B. G. , Wiwczaruk D. , Hochmann M. , Osborne A. , Henning R.
Published: January 2019

We examined the effect of core and skin temperature on the accuracy of two pulse oximeters (Nellcor Symphony and Hewlett Packard saturation module, M1020A) and a transcutaneous PCO 2 monitor (Fastrac Transcutaneous monitor) immediately after cardiac surgery in a group of newborns and infants. Seventy-nine sets of data were collected from 46 patients. Core temperatures ranged from 35.3°C to 39.4°C, skin temperatures ranged from 27.0°C to 37.4°C and core-skin temperature gradients ranged from 0.1°C to 10.1°C. Data analysis consisted of comparing the difference between transcutaneous PCO 2 and arterial PCO 2 and the differences between oxygen haemoglobin saturation measured by both pulse oximeters and oxygen haemoglobin saturation measured by co-oximeter to core temperature, skin temperature and core-skin temperature gradients. The mean differences±standard deviations and limits of agreement for transcutaneous PCO 2 and oxygen haemoglobin saturation measured by the Hewlett Packard and Nellcor pulse oximeters were 0.95±4.10 mmHg (-7.09 mmHg to 8.99 mmHg), -1.07±1.84% (-4.68% to 2.54%) and -1.23±2.23% (-5.60% to 3.14%) respectively. Analysis of correlation coefficients showed that the accuracy of the transcutaneous PCO 2 monitor and the pulse oximeters were not affected by core temperature, skin temperature or core-skin temperature gradient in the ranges encountered. We therefore conclude that these devices are acceptably accurate and suitable for use in infants when core and skin temperatures and core-skin temperature gradient are in the range normally found after cardiac surgery.
Retro-Orbital Tumour—An Uncommon Cause of Headache in Pregnancy
Authors: Roberts L. J. , Goucke C. R.
Published: January 2019

Retro-orbital tumour was the cause of headache and neuropathic facial pain in a 31-year-old pregnant woman. The diagnosis had been overlooked as a result of a long history of migraine. There was exacerbation of the pain throughout the pregnancy, particularly in the third trimester. Pharmacological agents commonly used to manage neuropathic pain states were relatively contraindicated due to potential adverse effects on the fetus. Cognisant of such limitations imposed by pregnancy, we used multimodal therapy in an attempt to control the pain. This included morphine, paracetamol, amitriptyline, ketamine and psychological support. The management challenges are described.
Missed Diaphragm Rupture following Blunt Trauma
Authors: Cupitt J. M. , Smith M. B.
Published: January 2019

Traumatic rupture of the diaphragm resulting from blunt trauma remains a challenging clinical entity. Diagnosis remains difficult and is often delayed. A prompt diagnosis requires a high index of suspicion. We describe two patients with ruptured diaphragms in whom the diagnosis was made at different stages of their illness. The diaphragmatic injury reflects the magnitude of their associated injuries and probably contributes to the overall mortality.
Severe Adult Botulism
Authors: Mackle I. J. , Halcomb E. , Parr M. J. A.
Published: January 2019

A case of severe adult botulism with paralysis, respiratory failure and cranial nerve palsies is presented. The pathophysiology, clinical manifestations, diagnosis and treatment options for botulism are discussed.
Fire during Thoracic Surgery
Authors: Lai A. , Ng K. P.
Published: January 2019

A 67-year-old male with bilateral lung lesions presented for median sternotomy. One-lung ventilation was complicated by arterial desaturation. Continuous positive airway pressure with oxygen was applied to the non-ventilated lung to relieve the hypoxaemia. However, the cotton gauze packed inside the operative site was ignited by the electrocautery. The burning gauze was immediately removed without any complication.

We report a case of electrocautery-induced fire during thoracic surgery done in supine position and discuss its implication on the choice of oxygen enrichment therapy during one-lung ventilation.
Comparison of Three Methods to Estimate Plasma Bicarbonate in Critically Ill Patients: Henderson-Hasselbalch, Enzymatic, and Strong-Ion-Gap
Authors: Story D. A. , Poustie S. , Bellomo R.
Published: January 2019

We have previously found poor agreement between Henderson-Hasselbalch and enzymatic methods for estimating plasma bicarbonate concentration in critically ill patients. In this study we compared these two established methods with a new method for estimating bicarbonate using the strong-ion-gap equation. The strong-ion-gap is derived from the Stewart approach to acid-base physiology. One hundred data sets were collected from records of routine daily blood samples in critically ill patients. Bland-Altman analyses were used to compare the three methods. We proposed that bias greater than ±1 mmol/l and limits of agreement wider than bias ±2 mmol/l were clinically important. Comparing the Henderson-Hasselbalch method to the enzymatic method, the bias was 2.1 mmol/l and the limits of agreement were -1.8 mmol/l to 5.9 mmol/l. Comparing the Henderson-Hasselbalch method to the strong-ion-gap method, the bias was -9.1 mmol/l and the limits of agreement were -17.1 mmol/l to -1.1 mmol/l. Comparing the enzymatic to the strong-ion-gap method, the bias was -11.2 mmol/l and the limits of agreement were -18.2 mmol/l to -4.2 mmol/l. This study found poor agreement between the two established bicarbonate assays and worse agreement between the established assays and the strong-ion-gap method. The strong-ion-gap method is currently too inaccurate for clinical application, but may have future use.
Sevoflurane Drawover Anaesthesia with Two Oxford Miniature Vaporizers in Series
Authors: Brook P. N. , Perndt H.
Published: January 2019

The output of sevoflurane from a drawover system utilizing two Oxford Miniature Vaporizers (OMVs) in series has been shown in bench-testing to be predictable. We have shown that adequate anaesthesia can be achieved with one vaporizer in most situations if an intravenous induction is used. Occasionally a second vaporizer is necessary to deepen the level of anaesthesia. For an inhalational technique to be successful it is necessary to use both vaporizers from the outset. Under these conditions, adequate operating conditions are easily produced. The method could be useful in field or military applications.
r-hirudin as Anticoagulant for Cardiopulmonary Bypass
Authors: Cameron R. J.
Published: January 2019

A 68-year-old woman with unstable angina and an episode of ventricular fibrillation developed a persistent and recurrent rash due to heparin. Medical therapy was continued with danaproid. For cardiopulmonary bypass and coronary artery grafting, r-hirudin was used as the anticoagulant. There were no thrombotic or coagulopathic complications. There is still no ideal alternative to unfractionated heparin for anticoagulation for cardiopulmonary bypass. The use of r-hirudin was successful and we describe our anticoagulant strategy.
Haemodynamic Compromise during Thoracoscopic/Laparoscopic Oesophagectomy
Authors: McConkey P. P. , Moore P. G. , Nguyen N. T.
Published: January 2019

Minimally invasive oesophagectomy is a relatively new procedure that is performed by means of thoracoscopy and laparoscopy. One stage of the procedure involves creation of a peritoneo-pleural communication in the presence of a pneumoperitoneum. In the case presented, severe hypotension occurred at this point. We believe this was caused by the escape of carbon dioxide from the peritoneal cavity into the right hemithorax, resulting in tension pneumothorax and cardiac tamponade. We believe this to be a predictable complication of this procedure but one that if expected, recognised and correctly managed, should not result in adverse outcomes.
Midazolam Pretreatment Reduces Etomidate-induced Myoclonic Movements
Authors: Schwarzkopf K. R. G. , Hueter L. , Simon M. , Fritz H. G.
Published: January 2019

During induction of anaesthesia with etomidate, myoclonic muscle movements are frequent. In this study, pretreatment with a small dosage of etomidate or midazolam was compared with placebo for the prevention of myoclonic muscle movements. Sixty patients, premedicated with oral midazolam, were pretreated in a randomized double-blinded fashion with etomidate 0.05 mg/kg IV, midazolam 0.015 mg/kg IV or normal saline IV (placebo) in three groups of 20 patients each. The pretreatment was followed after 90 seconds by etomidate 0.3 mg/kg IV. One minute after onset of hypnosis, induction of anaesthesia was completed with sufentanil and rocuronium. From the time of pretreatment to completion of anaesthesia, patients were observed for myoclonic muscle movements by a single physician, blinded to group allocation. Myoclonic movements were graded on a scale of 0 to 3. The incidence of myoclonic movements was significantly lower in patients pretreated with midazolam (4 of 20) compared with placebo (18/20) (P< 0.01). Midazolam 0.015 mg/kg IV, administered 90 seconds before induction of anaesthesia with etomidate, is effective in reducing etomidate-induced myoclonic muscle movements.
Intermittent Enteral Nutrition—A Comparative Study Examining the Effect on Gastric pH and Microbial Colonization Rates
Authors: Gowardman J. , Sleigh J. , Barnes N. , Smith A. , Havill J.
Published: January 2019

In a prospective randomized study we aimed to examine the effect on gastric pH and microbial colonization of enteral nutrition (EN) delivered both by intermittent and continual infusion. Forty-three mechanically ventilated patients were randomized to receive EN by one of three methods, intermittent or continual gastric or continual jejunal. We sampled gastric aspirate for pH and culture in all patients at 0600 hours and pH in gastric intermittent feeders at 2200 hours daily. Patients were studied for 12 days or until extubated.

Data was obtained on 41 patients, of whom 73% had a diagnosis of trauma. Median APACHE II score was 17 and ventilation time 11 days. Twelve patients received gastric continuous, 15 gastric intermittent and 14 jejunal nutrition. No significant difference was observed between the three groups with regard to median 0600 pH (P=0.16). This was lowest in the jejunal group (3.2) followed by the gastric intermittent group (4.0) and then gastric continuous group (5.0). With overnight cessation of EN in the gastric intermittent group, the median pH fell from 5.2 at 2200 to 4.0 at 0600 (P=0.01) with no effect on gastric colonization. The probability of gastric colonization over time however was significantly lower in the jejunal group compared with the two gastric groups (Log rank test, P=0.02).

These results demonstrate that in a patient population consisting predominantly of trauma, overnight cessation of EN made no overall difference to 0600 gastric pH or colonization rates. The preservation of pH and lowered colonization in those given jejunal feeding may have implications in the pathogenesis of ventilator-associated infection and may warrant further study using larger patient numbers.
Comparison of Peripheral and Central Venous Pressures in Critically Ill Patients
Authors: Charalambous C. , Barker T. A. , Zipitis C. S. , Siddique I. , Swindell R. , Jackson R. , Benson J.
Published: January 2019

We conducted a prospective study to determine the relationship between central (CVP) and peripheral (PVP) venous pressures in critically ill patients. CVP and PVP were measured on five different occasions in 20 critically ill patients in the intensive care unit. Results showed that the mean difference between PVP and CVP was 4.4 mmHg (95% CI= 3.7 to 5.0). However, PVP might be 1.9 mmHg below (95% CI=0.7 to 3.1) or 10.6 mmHg above (95% CI=9.4 to 11.8) the CVP. The mean difference between changes in PVP and corresponding changes in CVP was 0.3 mmHg (95%CI=-0.1 to 0.7). The actual change in PVP could be 3.0 mmHg below (95% CI=2.3 to 3.7) or 3.6 mmHg above (95% CI=2.9 to 4.3) the change in CVP. Overall, the direction of change in PVP (rise or drop) predicted a same direction of change in CVP with an accuracy of 78%. Changes in PVP ≥2 mmHg predicted a change in same direction of CVP with an accuracy of 90%. The direction of changes in CVP ≥2 mmHg were predicted by the direction of change in PVP with an accuracy of 91%. We conclude that PVP measurement does not give an accurate estimate of the absolute value of CVP in individual patients. However, as changes in PVP parallel, in direction, changes in CVP, serial measurements of PVP may have a value in determining volume status and guiding fluid therapy in critically ill patients.
The Effects of a One Unit Blood Donation on Auto-haemodilution and Coagulation
Authors: Ruttmann T. G. , Roche A. M. , Gasson J. , James M. F. M.
Published: January 2019

The effect of haemodilution on coagulation has been extensively investigated. We investigated auto-haemodilution following a 10% blood loss (480 ml) and its effect on coagulation.

Ten healthy, unstarved volunteers were enrolled. One unit of blood was taken from each volunteer. Concurrently blood was taken from the opposite arm prior to and immediately after the blood donation, and at 1, 2, 4 and 6 hours. It was tested for thrombelastography, haematocrit and endorphins.

There was a significant decrease in r-time from the control sample to the sample taken immediately post blood donation. This value returned to baseline at 1 hour post donation and did not change again. There were no other significant changes in thromboelastographic parameters. Fractional plasma noradrenaline changes were significantly raised at 1 hour post donation (P=0.048), returning to baseline by 2 hours post donation. The haematocrit showed a rapid (~4%) fall during donation followed by a slow, but progressive decrease over six hours, falling by a mean of 8.3% from pre-donation values.

A state of relative hypercoagulability is found immediately after a rapid 10% loss in circulating blood volume. This may be related to the rapid immediate haemodilution. It is unlikely that the sympathetic response to blood loss plays a role. However, after the initial drop, slow restoration of circulating blood volume by autodilution takes six to eight hours, and is not associated with enhanced coagulation. Of interest is that a 10% blood loss in a healthy person does not require volume replacement.
A Prospective Clinical Audit of Central Venous Catheter Use and Complications in 1000 Consecutive Patients
Authors: Webster C. S. , Merry A. F. , Emmens D. J. , Van Cotthem I. C. , Holland R. L. , Middleton N. G.
Published: January 2019

We conducted a prospective audit of central venous catheter (CVC) use in 1000 consecutive patients to better define the rates of postoperative complications (particularly vascular perforation) and the pattern of CVC and pulmonary artery catheter (PAC) usage (particularly the number of lumens inserted and utilized). Details of CVCs, complications, and the number of lumens in place and used, were recorded daily until all CVCs were removed. A total of 1546 CVCs and 223 PACs were placed in study patients. Two non-fatal perforations occurred: a perforated right atrium in a patient who received an Arrow triple-lumen CVC (previously reported), and a perforated pulmonary artery in a patient upon withdrawal of a Baxter PAC. The risk per patient of any CVC-related perforation was 0.2% (95% confidence interval (CI): 0.02% to 0.7%). The rates of CVC-related sepsis and local infection were 3% (95% CI: 2% to 4%) and 2% (95% CI: 1% to 3%) respectively. At the peak of CVC use (day 1 in the ICU) the overall number of lumens placed was significantly correlated with lumens used (r=0.53), endorsing clinical judgement in the anticipation of the needs of the patient. The modal number of lumen uses in adults and children was four. However, in children, fewer catheters were inserted per patient than in adults (1.28 vs 1.63, P=0.01), and placed lumens were used more intensively (P< 0.001). Data appear to justify the routine selection of a triple-lumen CVC in adult patients, but not of a quad-lumen CVC.
Anti-factor Xa Monitoring of Anticoagulation during Cardiopulmonary Bypass in a Patient with Antiphospholipid Syndrome
Authors: Lennon M. J. , Thackray N. M. , Gibbs N. M.
Published: January 2019

The activated clotting time (ACT) may be an unreliable monitor of coagulation for patients with the antiphospholipid syndrome. We describe a patient with antiphospholipid syndrome in whom adequate anticoagulation during cardiopulmonary bypass was confirmed by monitoring both the ACT and anti-factor Xa levels. The cardiopulmonary bypass was uneventful, and there were no thrombotic or bleeding complications. The use of anti-factor Xa levels provided confirmation of adequate anticoagulation (and reversal of anticoagulation) that was not possible using the ACT alone.
Angioedema of the Tongue Due to Acquired C1 Esterase Inhibitor Deficiency
Authors: Dobson G. , Edgar D. , Trinder J.
Published: January 2019

We describe the management of an 83-year-old woman who presented with upper airway obstruction due to angioedema of the tongue. Following definitive airway management, investigation showed a diagnosis of acquired C1 esterase inhibitor deficiency (acquired angioedema) that was considered to be subsequent to haematological malignancy. Resolution of the macroglossia followed treatment with C1 esterase inhibitor concentrate, but the patient failed to wean from ventilatory support and died in the Intensive Care Unit. This case report highlights the potential for acquired angioedema to cause upper airway obstruction. The various treatment modalities for acquired C1 esterase inhibitor deficiency are summarized.
Use of Intravenous Tranexamic Acid to Reduce Allogeneic Blood Transfusion in Total Hip and Knee Arthroplasty: A Meta-analysis
Authors: Ho K. M. , Ismail H.
Published: January 2019

Total hip or knee arthroplasty is associated with significant blood loss. Techniques such as the use of antifibrinolytics or desmopressin, or normovolaemic haemodilution have been used to reduce the need for allogeneic blood transfusion. Tranexamic acid has been used to reduce blood loss and transfusion requirement for total hip and knee arthroplasty, with variable results. This meta-analysis aims to evaluate whether intravenous tranexamic acid, when compared with placebo, reduces blood loss and transfusion requirement in total hip and knee joint replacement surgery and whether it might increase the risk of thromboembolic complications. The literature search was based on MEDLINE, EMBASE, Cochrane Controlled Trials Register, and information from the pharmaceutical company that produces tranexamic acid (Pharmacia-Upjohn). We identified 15 clinical trials and 12 were considered suitable for detailed data extraction. Tranexamic acid reduces the proportion of patients requiring allogeneic blood transfusion (OR 0.16, 95% CI: 0.09–0.26), total amount of blood loss (WMD 460 ml, 95% CI: 274–626 ml), and the total number of units of allogeneic blood transfused (WMD 0.85 unit, 95% CI: 0.36–1.33). Tranexamic acid does not increase the risk of thromboemobolic complications such as deep vein thrombosis, pulmonary embolism, thrombotic cerebral vascular accident, or myocardial infarction (OR 0.98, 95% CI: 0.45–2.12). Intravenous tranexamic acid appears effective and safe in reducing allogeneic blood transfusion and blood loss in total hip and knee arthroplasty.
An Easy Method of Mentally Estimating the Metabolic Component of Acid/base Balance Using the Fencl-Stewart Approach
Authors: Boyle M. , Lawrence J.
Published: January 2019

The Stewart approach defines acid/base abnormalities as resulting from changes in PCO 2, strong ion difference (SID), and weak acids (mainly albumin) but needs a computer for calculation. The base excess (BE) is a measure of the net effect of changes in SID and weak acids, therefore, metabolic acid/base balance can be described as BE effects of their change from normal.

We compared our mental estimation of BE effects with the more complex calculation.

Acid/base abnormalities were identified in 44 critically ill patients. The BE effects of change in strong ions, change in albumin, and the BE-gap (“other species” or unmeasured anion effect) were calculated using standard equations. An estimate of the BE effects was determined. The difference between SID (using [Na + ]+[K+ ]-([Cl]+lactate)) and normal SID (42 mEq/l) estimated the effect of a change in SID. The effect of a change of albumin from normal was estimated as 0.252 (normal albumin-measured albumin). The predicted BE was defined as estimated change in SID plus albumin effect. The estimated BE-gap (BE-gap est ) was actual BE minus predicted BE. The Bland-Altman method was used to test agreement.

Calculations were made on 46 data sets from 44 individuals. The bias (limits of agreement) for calculated and estimated strong ion effects, calculated and estimated albumin effect, and calculated and estimated BE-gap were -1.26 (-3.14 to 0.66) mEq/l, 0.5 (-0.05 to 1.05) mEq/l, and 0.76 (-1.27 to 2.79) mEq/l respectively. However the bias (limits of agreement) for BE-gap and BE-gap est and strong ion gap were poor, being 1.1 (-4 to 14) mEq/l and 0.4 (-9.2 to 10) mEq/l respectively.

The BE-gap and BE-gap est are unsuitable to quantify gap ions. However, our easy-to-perform estimation has a clinically acceptable bias compared to calculated BE effects and is a simple method for identifying the components of acid/base abnormalities.
Outcome Prediction in a Surgical ICU Using Automatically Calculated SAPS II Scores
Authors: Engel J. M. , Junger A , Bottger S. , Benson M. , Michel A. , Rohrig R. , Jost A. , Hempelmann G.
Published: January 2019

The objective of this study was to establish a complete computerized calculation of the Simplified Acute Physiology Score (SAPS) II within 24 hours after admission to a surgical intensive care unit (ICU) based only on routine data recorded with a patient data management system (PDMS) without any additional manual data entry. Score calculation programs were developed using SQL scripts (Structured Query Language) to retrospectively compute the SAPS II scores of 524 patients who stayed in ICU for at least 24 hours between April 1, 1999 and March 31, 2000 out of the PDMS database. The main outcome measure was survival status at ICU discharge. Score evaluation was modified in registering missing data as being not pathological and using surrogates of the Glasgow Coma Scale (GCS). Computerized score calculation was possible for all investigated patients. The 459 (87.6%) survivors had a median SAPS II of 28 (interquartile range (IQR) 13) whereas the 65 (12.4%) deceased patients had a median score of 43 (IQR 16; P<0.001). Of the physiological variables for SAPS II score calculation, bilirubin was missing in 84%, followed by P a O 2/ FiO 2 ratio (34%), and neurological status (34%). Using neurological diagnoses and examinations as surrogates for the GCS, a pathological finding was seen in only 8.8% of all results. The discriminative power of the computerized SAPS II checked with a receiver operating characteristic (ROC) curve was 0.81 (95% confidence interval (CI): 0.74–0.87). The Hosmer-Lemeshow goodness-of-fit statistics showed good calibration (H=5.55, P=0.59, 7 degrees of freedom; C=5.55, P=0.68, 8 degrees of freedom). The technique used in this study for complete automatic data sampling of the SAPS II score seems to be suitable for predicting mortality rate during stay in a surgical ICU. The advantage of the described method is that no additional manual data recording is required for score calculation.
Incident Reporting in Anaesthesia: A Survey of Practice in New Zealand
Authors: Yong H. , Kluger M. T.
Published: January 2019

A postal survey of anaesthetists practising in New Zealand assessed their practice and attitudes to anaesthetic incident reporting. 136 replies were received (57% response rate). Respondents indicated a high awareness of the Anaesthetic Incident Monitoring Study (AIMS) based incident monitoring yet individual utilization may be declining due to a perception that this system is ineffective. Seventy-five per cent of respondents used AIMS forms in their current institute, whilst 87% had at some time completed an AIMS form. Two-thirds of respondents used the forms for morbidity and mortality audit activities. Support for the continuing practice of incident reporting was high, yet opinion suggested that the present system was not being used productively. Almost half the anaesthetists felt that the AIMS reporting system had changed their practice. Common concerns with the system included a need to simplify the reporting process and to ensure that information is managed to provide a useful outcome. This study suggests that incident reporting in its present form needs to be re-evaluated in light of changing priorities in anaesthesia quality improvement activities.
Inadvertent Subdural Spread Complicating Cervical Epidural Steroid Injection with Local Anaesthetic Agent
Authors: Bansal S. , Turtle M. J.
Published: January 2019

Although cervical epidural steroid injection with local anaesthetic is considered a safe technique and widely practised, complications may occur. We report a patient experiencing unexpected delayed high block, moderate hypotension and unconsciousness eight to ten minutes after an apparently normal cervical epidural steroid injection. The most probable diagnosis was a subdural block. Anatomical peculiarities of the epidural and subdural space in the cervical region increase the risk of subdural spread during cervical epidural injection. Fluoroscopic guidance is important during cervical epidural injection to increase certainty of correct needle placement, thus minimizing the risk of complications.
Anaesthetic Management of the Parturient with Protein S Deficiency and Lumboperitoneal Shunt
Authors: Gupta Babita , Prakash S. , Gujral K.
Published: January 2019

Protein S, a vitamin K-dependent plasma protein, is a cofactor for protein C, an essential component of the regulatory system of coagulation. We describe the anaesthetic management of a parturient with protein S deficiency and an indwelling lumboperitoneal shunt, which was placed following transverse and sagittal sinus thrombosis. She was treated with aspirin and enoxaparin during pregnancy and underwent caesarean section under general anaesthesia without complication.
Tracheal Rupture following Endotracheal Intubation
Authors: Stannard K. , Wells J. , Cokis C.
Published: January 2019

We describe a case of tracheal rupture diagnosed after an apparently routine endotracheal intubation for otherwise uneventful lower abdominal surgery in a 33-year-old woman. Risk factors for tracheal rupture, presenting symptoms and signs, management of tracheal rupture and methods of airway management during the surgical repair of the tracheal laceration are discussed. In this case, “side-by-side” microlaryngoscopy tubes, one endobronchial and the other with the tip in the upper trachea, placed with fibreoptic assistance were used for airway management during the tracheal repair.
Terlipressin Infusion in Catecholamine-resistant Shock
Authors: Jolley D. H. , De Keulenaer B. L. , Potter A. , Stephens D. P.
Published: January 2019

Catecholamine-resistant shock is not uncommon in intensive care. Bolus dose terlipressin (a vasopressin analogue) has been used successfully in this setting allowing cessation of other vasopressor agents. The relative vasopressin deficiency in combination with the restoration of the vascular tone (by blocking adenosine triphosphate potassium-sensitive channels) by exogenous vasopressin may be the explanation of these beneficial effects. We describe a case report where the use of a continuous terlipressin infusion was associated with a dramatic improvement. To our knowledge there have been no previous reports of the use of terlipressin by continuous infusion for the treatment of catecholamine-resistant shock.
Implementing Intensive Insulin Therapy: Development and Audit of the Bath Insulin Protocol
Authors: Laver S. , Preston S. , Turner D. , McKinstry C. , Padkin A.
Published: January 2019

Intensive insulin therapy to control blood glucose has been found to reduce mortality among critically ill patients in a surgical intensive care unit, though a simple prescriptive insulin infusion protocol to achieve this has not been published previously. This study documents the development and routine use of a simple prescriptive intravenous insulin infusion protocol for critically ill patients and compares the results with previous practice. During development the protocol was optimized and practical issues of implementation addressed. The optimized protocol was then used for all ICU admissions, and a prospectively defined retrospective chart audit performed for the first month of use. Results were compared with a similar time period the previous year. In September 2002, 27 admissions were started on the protocol. Blood glucose for the time on the protocol had a median value of 6.2 (IQR 5.9-7.1) mmol/l compared with 9.2 (IQR 8.1-10.2) mmol/l for those on insulin in 2001. Blood glucose for the whole ICU stay for those on the protocol in 2002 had a median value of 6.6 (IQR 6.0-7.4) mmol/l compared with 8.6 (IQR 8.0-9.4) mmol/l in 2001. Blood glucose for all ICU patients in 2002 had a median value of 6.5 (IQR 6.0-7.3) mmol/l compared with 7.2 (IQR 6.3-8.3) mmol/l in 2001.

Three blood glucose recordings were less than 2.2 mmol/l in September 2002. This study provides initial effectiveness and safety data for the Bath Insulin Protocol. Further audits in a larger patient population are now needed.
Propofol Infusion Syndrome— Report of an Adult Fatality
Authors: Ernest D. , French C.
Published: January 2019

This report describes a fatal case of the propofol infusion syndrome in an adult patient being sedated for a closed head injury using high doses of propofol. The features of circulatory collapse, metabolic acidosis, mild rhabdomyolysis and renal impairment are consistent with the syndrome and not readily attributable to alternative aetiologies. Potential mechanisms for the syndrome may relate to antagonism of beta-receptors, impaired myocardial oxygen utilization and a specific disruption to fatty-acid oxidation.

This is the first published Australian case of the propofol infusion syndrome in an adult and should serve as an additional case report to the existing literature highlighting this potentially fatal syndrome in adults.
Is the Degree of Sensitivity to Nondepolarizing Muscle Relaxants Related to Requirements for Postoperative Ventilation in Patients with Myasthenia Gravis?
Authors: Kadoi Y. , Hinohara H. , Kunimoto F. , Niijima A. , Saito S. , Goto F.
Published: January 2019

The purpose of this study was to examine whether the degree of sensitivity to nondepolarizing muscle relaxants is related to the requirement for postoperative ventilatory support in patients with myasthenia gravis.

Thirty-six patients with myasthenia gravis undergoing trans-sternal thymectomy were monitored by electromyography in order to assess the neuromuscular response to vecuronium. After calibration to 100% of baseline electromyographic response values using an EMG monitor, incremental doses of 5, 10 and 20 μg/kg of vecuronium were administrated to produce 95% neuromuscular blockade and to obtain a cumulative dose-response curve for each patient. A univariable logistic regression with odds ratio was used to examine the predictive variables of prolonged postoperative ventilation. Depending on their postoperative ventilatory needs, patients were divided into an early extubation group and a prolonged ventilatory group.

There were no significant differences between the two groups in terms of vecuronium ED95 (prolonged ventilation group: 23.2±18 μg/kg; early extubation group: 23.2±18 μg/kg, P=0.129) and vecuronium requirement to maintain less than 25% neuromuscular blockade (prolonged ventilation group: 2.4±1.7 mg/kg; early extubation group: 3.8±4.5 mg/kg, P=0.249). There were, however, significant differences in the incidence of a history of previous respiratory crises and the presence of bulbar palsy between the early extubation and prolonged ventilation groups. History of previous respiratory crisis (odds ratio (OR), 3.5; 95% confidence interval (CI), 1.0-13; P=0.03) and presence of bulbar palsy (OR, 3.7; 95%CI, 0.9-15; P=0.049) were associated with the need for prolonged postoperative ventilation. However, we failed to demonstrate that the degree of sensitivity to nondepolarizing muscle relaxants was related to an increased requirement for postoperative ventilation in patients with myasthenia gravis.