bluuebunny/crossref_metadata_2025 huggingface dataset:
Crystalloid Preload versus Rapid Crystalloid Administration after Induction of Spinal Anaesthesia (Coload) for Elective Caesarean Section
Authors: Dyer R. A. , Farina Z. , Joubert I. A. , Du Toit P. , Meyer M. , Torr G. , Wells K. , James M. F. M.
Published: January 2019

Current methods of crystalloid preload administration prior to spinal anaesthesia for elective caesarean section are relatively ineffective in preventing hypotension. This study examined the relevance of the timing of the fluid administered. Fifty women were randomly allocated to receive either 20 ml.kg–1 of crystalloid solution during 20 minutes prior to induction of spinal anaesthesia (preload), or an equivalent volume by rapid infusion immediately after induction (coload). Significantly more patients in the coload group did not require vasopressor therapy pre-delivery (P=0.047). The coload group required a lower median dose (P=0.03) and a lower median number (P=0.04) of ephedrine doses for the treatment of maternal hypotension pre-delivery. There was no between-group difference in either the total cumulative dose, or in the total number of doses of ephedrine. Neonatal outcomes among the two groups were similar.

Rapid crystalloid administration after, rather than over 20 minutes before the induction of spinal anaesthesia for elective caesarean section, may be advantageous in terms of managing maternal blood pressure prior to delivery.
Impediments to the Use of Ankle Block in Australia
Authors: Rudkin G. E. , Micallef T. A.
Published: January 2019

Anaesthetic trainees and consultants who enrolled in a regional anaesthetic workshop completed a questionnaire regarding their own ankle block practice. The questionnaire focused on frequency of use, barriers to use, technique and perceived success rate. One hundred and twelve respondents participated, with 73% performing less than 10 ankle blocks per year. Forty-eight per cent believed that they did not have an appropriate operating list or a suitable patient, whilst 27% believed time constraints were the major barrier. Of those performing less than 10 ankle blocks per year, 22% cited lack of anatomical knowledge or technique as their major barrier and 71% perceived their success rate as medium to low. Eighty per cent performed their ankle block with the patient fully awake or sedated. Sixty-five per cent did not know the length of action of their ankle block. This survey supports recent suggestions that the practice of ankle block is under-utilized. Teaching workshops and clinical training for peripheral nerve blocks should receive high priority for the future.
How Severe Acute Respiratory Syndrome (SARS) Affected the Department of Anaesthesia at Singapore General Hospital
Authors: Tan T. K.
Published: January 2019

The effects of the outbreak of severe acute respiratory syndrome (SARS) on the Singapore General Hospital's Department of Anaesthesia are described.

Urgent measures to protect staff and patients were implemented. Clear direction in administration issues and clinical pathways with good logistic support were essential. Anaesthetists were at risk and anaesthetic practice had to change in view of strict infection control provisions. Contingency planning for future infectious diseases outbreaks is required. Lessons can be learnt by hospitals yet to be visited by this virulent infection.
Effect of Etomidate on Endothelium-dependent Relaxation Induced by Acetylcholine in Rat Aorta
Authors: Sohn J-T. , Kim H-J. , Cho H-C. , Shin I-W. , Lee H-K. , Chung Y-K.
Published: January 2019

The goals of this in vitro study were to investigate effects of etomidate on endothelium-dependent relaxation induced by acetylcholine in rat aorta, and to elucidate the associated cellular mechanism. In endothelium-intact rings precontracted with phenylephrine 10−6 M, dose-response curves for acetylcholine (10−9 to 10−5 M) and calcium ionophore (10−9 to 10−6 M) were generated in the presence and absence of etomidate (5×10−6, 10−5 M). In endothelium-intact or -denuded rings precontracted with phenylephrine 10−6 M, sodium nitroprusside (10−9 to 10−6 M) dose-response curves were generated in the presence and absence of etomidate (10−5 M). Etomidate (5×10−6, 10−5 M) produced a significant rightward shift in the dose-response curves induced by acetylcholine (receptor-mediated endothelium-dependent agonist) and calcium ionophore A23187 (non receptor-mediated endothelium-dependent agonist). Etomidate (10−5 M) had no effect on sodium nitroprusside (endothelium-independent nitric oxide donor)-induced vasorelaxant response in both endothelium-intact and -denuded rings. These results indicate that etomidate at clinically relevant concentrations attenuates endothelium-dependent relaxation induced by acetylcholine by an acting at a site distal to the endothelial muscarinic receptor, but proximal to guanylate cyclase activation of vascular smooth muscle in rat aorta.
Effect of Laryngoscopy and Tracheal Intubation on Pulse Pressure and Influence of Age on this Response
Authors: Khan F. A. , Mahboobi S. K.
Published: January 2019

The study objective was to measure the change in pulse pressure associated with laryngoscopy and tracheal intubation and to relate these changes to trends in systolic, diastolic and mean blood pressure. The rationale was that the rise in systolic and diastolic blood pressure may be disproportionate and may result in either increase or decrease in pulse pressure. We also looked at the influence of age on this response. This prospective observational study measured the changes in pulse pressure secondary to laryngoscopy and tracheal intubation in eighty adult surgical patients. Two groups of forty patients each were included, young (group A) 18–25 years and middle-aged (group B) 45–55 years. The patients were ASA Class 1 or 2, of either gender, and non-hypertensive. Systolic, diastolic, and mean blood pressure, and heart rate were measured preinduction and 1, 2 and 3 minutes after induction. Thereafter they were measured every minute for five minutes after intubation. Pulse pressure was obtained by subtracting the diastolic from the systolic blood pressure. No pulse pressure change occurred in the young group despite of a significant increase in both systolic and diastolic blood pressures. The middle aged group showed an average rise of +18 mm of Hg in pulse pressure (taken at 1 minute post-intubation) compared to the baseline measurement (P<0.0001). These changes in pulse pressure during anaesthesia may indicate an additional pulsatile stress in vulnerable patients in addition to the changes associated with resistance alone and need to be studied further.
Barriers to Effective Perioperative Communication in Indigenous Australians: An Audit of Progress since 1996
Authors: Cheng W. Y. C. , Blum P. , Spain B.
Published: January 2019

This prospective study was designed to elucidate barriers limiting effective perioperative communication between indigenous Australians and anaesthetists, and to identify strategies for improving communication.

A questionnaire was used to collect data on 1040 consecutive patients undergoing anaesthesia at Royal Darwin Hospital between February and March 2003. 27.1% of these patients described themselves as Aboriginal. Aboriginal patients were more likely to undergo emergency surgery and were more likely to be classified as ASA 3, 4 or 5 than non-indigenous patients. Communication difficulties were identified in 28.7% of all Aboriginal patients, which was 31 times higher than those in non-Aboriginal patients. The most common reason identified for this was difficulty in speaking English. Only 17.7% of Aboriginal patients presenting to the operating theatre spoke English as their first language. Unfortunately, the anaesthetic team utilized the Aboriginal interpreter service in only a minority of cases.

Communication difficulty in indigenous Australians is pervasive and often goes unrecognized. The results suggest that heath care providers may need staff training in cross-cultural communication and that protocols need to be developed within the health care system so that interpreters are called upon automatically early in the admission process.
Anaesthesia for Correction of Scoliosis in Children
Authors: Gibson P. R. J.
Published: January 2019

Surgical correction of spinal deformities in children presents a challenge to the anaesthetist because of the extensive nature of the surgery, the co-morbidities of the patients and the constraints on anaesthetic techniques of intraoperative neurophysiological monitoring of the spinal cord. Adolescent idiopathic scoliosis is the most common deformity. Patients with scoliosis secondary to neuromuscular conditions are at greatest risk of perioperative problems, particularly excessive blood loss and respiratory failure. The risk of spinal cord damage can be decreased by the use of intraoperative spinal cord monitoring, particularly monitoring of the lower limb compound muscle action potential evoked by transcranial electrical stimulation. Specific anaesthetic techniques are required for this monitoring to be reliable. Because of concerns about spinal cord perfusion there is now less reliance on induced hypotension and haemodilution to reduce blood loss, with emphasis on proper patient positioning, controlled haemodynamics and antifibrinolytic therapy. Effective postoperative pain management requires a multimodal approach.
Anaphylaxis to Intravenous Amiodarone
Authors: Fransi S. , Briedis J.
Published: January 2019

Amiodarone, a class III antiarrhythmic, has been widely used to treat both ventricular and supraventricular arrhythmias. Despite the multitude of side-effects seen with this drug, no case of amiodarone anaphylaxis (confirmed by mast cell tryptase levels and skin testing) has been reported in the medical literature. We report a case of anaphylaxis to intravenous amiodarone in a 77-year-old patient.
Reductions in Levels of Bacterial Superantigens/Cannabinoids by Plasma Exchange in a Patient with Severe Toxic Shock Syndrome
Authors: Kohro S. , Imaizumi H. , Yamakage M. , Masuda Y. , Namiki A. , Asai Y.
Published: January 2019

Toxic shock syndrome is a rare but potentially fatal toxin-mediated febrile illness. We report a case of toxic shock syndrome complicated by life-threatening organ dysfunction with high toxin-1 and staphylococcus enterotoxin type A levels that were successfully reduced by early introduction of plasma exchanges. The report shows the time course of the concentrations of anandamide and 2-arachidonyl glyceride and confirms that early introduction of plasma exchange can result in a rapid reduction of circulating toxins and mediators in the treatment of life-threatening multiple organ dysfunction.
Delayed Epidural Catheter Removal: The Impact of Postoperative Coagulopathy
Authors: Tsui S. L. , Yong B. H. , Ng K. F. J. , Yuen T. S. T. , Li C. C. F. , Chui K. Y.
Published: January 2019

A retrospective analysis of 413 patients who received postoperative epidural analgesia under a standardized protocol found that 84 (20%) had a duration of epidural catheterization of greater than four days. The most common reasons were significant pain (n=64, 15%) and coagulopathy (n=26, 6%). Risk factor analysis for coagulopathy showed an odds ratio of 10.1 (95% confidence interval 4.2-24.5) for prolonged epidural catheterization among patients undergoing hepatectomy. Magnetic resonance imaging, performed in four patients with clinical signs suggestive of epidural haematoma, was negative for a space-occupying lesion in all cases. Eleven patients developed fever and clinical signs suggestive of epidural catheter-related infection, necessitating early catheter removal. Sixteen patients had persistent lower limb weakness at 24 hours after catheter removal. The signs soon resolved in all except two, one of whom had neuropathy related to intraoperative positioning and the other preoperative weakness. Accidental epidural catheter dislodgement occurred in 29 patients (7%) and is potentially hazardous if coagulopathy is unresolved. The risk-benefit ratio and factors complicating catheter removal, especially coagulopathy, should be considered when deciding whether to use epidural techniques.
Monitoring of Acid-base and Regulating Variables during Abdominal Lavage
Authors: Scheingraber S. , Boehme J. , Scharbert G. , Dralle H.
Published: January 2019

This prospective clinical study was performed to determine acid-base regulating variables during abdominal lavage treatment for patients with severe peritonitis or after abdominal surgery. Arterial blood was sampled from twelve patients with secondary peritonitis and nine patients after abdominal surgery without peritonitis at three time points: immediately before, immediately after and 15 minutes after abdominal lavage with normal saline solution. The total++ – amount of irrigant fluid, the strong ion difference [(Na+ +K+)-(Cl- +lactate-)], and total protein concentrations were determined and standard bicarbonate, standard base excess were calculated from pH and PaCO2. Peritonitis patients developed a moderate alkalaemia (pH 7.440-7.485). The alkalaemia was unmasked after optimization of mild hypoventilation, but was supported by a decrease in protein concentration of about 3.4 mEql/l in the first 15 minutes after the lavage. There was no marked increase in chloride concentration in either the peritonitis or the control group. The data indirectly exclude major fluid absorption during abdominal lavage with 3000 to 6000 ml normal saline, given that we found no clinically relevant electrolyte and acid-base changes that might be expected after rapid fluid absorption. The factors of major influence in acid-base regulation were ventilation and protein loss in the course of abdominal lavage. Monitoring of the Stewart variables is an easily applicable method of monitoring acid-base regulating variables in the perioperative course of patients undergoing abdominal lavage therapy.
The Effects on Arterial Haemoglobin Oxygen Saturation and on Shunt of Increasing Cardiac Output with Dopamine or Dobutamine during One-lung Ventilation
Authors: Russell W. J. , James M. F.
Published: January 2019

Theoretically, if the cardiac output were increased in the presence of a given intrapulmonary shunt, the arterial saturation should improve as the venous oxygen extraction per ml of blood decreases if the total oxygen consumption remains constant. Previous work demonstrated that this was not achieved with adrenaline or isoprenaline as increased shunting negated any benefit from improved cardiac output and mixed venous oxygen content. However, pharmacological stimulation of cardiac output and venous oxygen without any increase in shunt should achieve the goal of improved arterial oxygenation. To test this hypothesis, seven pigs were subjected to one-lung ventilation and infused on separate occasions, with dopamine and with dobutamine in random order to increase the cardiac output. The mixed venous oxygen content, shunt fraction, oxygen consumption and arterial oxygen saturation were measured.

With both dopamine and dobutamine there was a consistent rise in venous oxygen content. However, with dopamine, the mean shunt rose from 28% to 42% and with dobutamine, the mean shunt rose from 45% to 59% (both changes P<0.01). With dopamine, the mean arterial oxygen saturation fell by 4.7%, and with dobutamine by 2.9%, but neither fall was statistically significant.

It is concluded that any benefit to arterial saturation which might occur from a dopamine- or dobutamine-induced increase in mixed venous oxygen content during one-lung ventilation is offset by increased shunting. During one-lung anaesthesia, there would appear to be no benefit to arterial saturation in increasing cardiac output with an infusion of either dopamine or dobutamine.
Pain during Injection of Propofol: The Effect of Prior Administration of Ephedrine
Authors: Agarwal A. , Dhiraaj S. , Raza M. , Singhal V. , Gupta D. , Ranjan R. , Singh P. K. , Singh U.
Published: January 2019

Propofol causes pain on intravenous injection in 28 to 90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. In a randomized, double-blind, placebo-controlled trial, we compared the efficacy of ephedrine 30 μg/kg pretreatment to lignocaine 40 mg for prevention of propofol-induced pain. Ninety-three adult patients, ASA 1 and 2, undergoing elective laparoscopic cholecystectomy were randomly assigned to three groups of 31 each. Group 1 received normal saline, group 2 received lignocaine 2% (40 mg) and group 3 received 30 μg/kg ephedrine. All pretreatment drugs were made up to 2 ml. Pain at the time of propofol injection was assessed on a four-point scale: 0=no pain, 1=mild pain, 2=moderate pain, and 3=severe pain. Twenty-seven patients (87%) of ephedrine pretreatment patients had pain during intravenous injection of propofol as compared to 24 (77%) in the normal saline group. In the lignocaine group, propofol-induced pain was observed in only 13 (42%) when compared with other study groups (P<0.05). Pretreatment with ephedrine 30 μg/kg did not attenuate pain associated with intravenous injection of propofol, nor did it improve haemodynamic stability during induction. However, pretreatment with 2% lignocaine (40 mg) was effective in attenuating propofol-associated pain.
Nasopharyngeal Oxygen in Adult Intensive Care—Lower Flows and Increased Comfort
Authors: Eastwood G. M. , Reeves J. H. , Cowie B. S.
Published: January 2019

Nasopharyngeal oxygen therapy, the delivery of supplementary oxygen into the nasopharynx via a fine catheter placed through the nose, is a simple technique used in postoperative anaesthetic care units and paediatric intensive care, but never described in the setting of adult intensive care. In a prospective crossover design, we compared nasopharyngeal oxygen therapy with semi-rigid plastic mask (Hudson Mask) in 50 unintubated adult patients receiving supplemental oxygen. We measured oxygen flow rate to achieve cutaneous saturations 93 to 96%, and patient comfort by visual analogue score. Nasopharyngeal oxygen therapy consumed significantly less oxygen than mask administration (3.0±0.9 vs 6.7±2.1 l/min, P<0.001) and was associated with significantly higher comfort than the mask (7.5± 1.6 cm vs 5.2±1.8, P<0.001).
The Use of End-tidal Carbon Dioxide Monitoring to Confirm Endotracheal Tube Placement in Adult and Paediatric Intensive Care Units in Australia and New Zealand
Authors: Erasmus P. D.
Published: January 2019

The use of end-tidal carbon dioxide monitoring to assist in confirming endotracheal tube placement is currently not mandatory in intensive care units (ICUs) in Australia and New Zealand. Early detection of failed tracheal intubation is vital to optimize management and to prevent complications. Questionnaires were sent to the lead clinician/head of department of all 66 intensive care units approved for training purposes by the Joint Faculty of Intensive Care Medicine in Australia and New Zealand. The methods used to confirm correct endotracheal tube placement, the availability of end-tidal carbon dioxide monitoring and its role in confirming endotracheal tube placement in the intensive care unit were explored. Completed questionnaires were received from 61 of the 66 centres (92.4%). Wide variation in the method of confirmation of endotracheal tube position was demonstrated, with 23 (37.7%) of units using sub-optimal methods. Sixty (98.3%) of units had end-tidal carbon dioxide monitoring available. Thirty-eight (62%) units shared monitors between several beds; and 22 (36%) had one monitor per bed. End-tidal carbon dioxide monitoring was used routinely to confirm endotracheal tube placement in 42 (68.8%) units. Fifty-two respondents (83.3%) felt that end-tidal carbon dioxide monitoring was superior to other methods for confirming endotracheal tube placement in critically ill patients. Thirty-eight respondents (62.3%) thought that end-tidal carbon dioxide monitoring should be mandatory to confirm tracheal intubation in the intensive care unit. If it were available, 42 respondents (68.8%) would use end-tidal carbon dioxide monitoring for confirmation of every intubation. Mandatory end-tidal carbon dioxide confirmation of endotracheal tube placement was policy in 33 (54.1%) of the intensive care units.
Suggestion, Hypnosis and Hypnotherapy: A Survey of Use, Knowledge and Attitudes of Anaesthetists
Authors: Coldrey J. C. , Cyna A. M.
Published: January 2019

Clinical hypnosis is a skill of using words and gestures (frequently called suggestions) in particular ways to achieve specific outcomes. It is being increasingly recognised as a useful intervention for managing a range of symptoms, especially pain and anxiety. We surveyed all 317 South Australian Fellows and trainees registered with ANZCA to determine their use, knowledge of, and attitudes towards positive suggestion, hypnosis and hypnotherapy in their anaesthesia practice. The response rate was 218 anaesthetists (69%). The majority of respondents (63%) rated their level of knowledge on this topic as below average. Forty-eight per cent of respondents indicated that there was a role for hypnotherapy in clinical anaesthesia, particularly in areas seen as traditional targets for the modality, i.e. pain and anxiety states. Nearly half of the anaesthetists supported the use of hypnotherapy and positive suggestions within clinical anaesthesia. Those respondents who had experience of clinical hypnotherapy were more likely to support hypnosis teaching at undergraduate or postgraduate level when compared with those with no experience.
The Single-connector Technique for Initial Placement of Double-lumen Tubes
Authors: Pfitzner J. , Alexander H. I. , Hung P. K.
Published: January 2019

Due to the presence of major lung or extra-pulmonary pathology, which may be unilateral or bilateral, the initial placement of a double-lumen tube is not always straightforward. Although fibreoptic bronchoscopy is often used to confirm “correct” placement, a “blind” technique is frequently used for the initial insertion. The currently widely taught blind technique involves tracheal cuff inflation and ventilation of both lungs as a first manoeuvre, with a subsequent assessment of single-lung ventilation by clamping off, in turn, the two limbs of the double-lumen tube double-connector. An alternative approach involves the bronchial cuff being inflated first, and then using a single-connector to transfer ventilation from one lung to the other. In this paper this technique is described and compared to the more traditional method. On a purely “number of steps” basis, the single-connector approach has several advantages. Furthermore, use of a technique that involves bronchial cuff inflation and single-lung ventilation as a first manoeuvre may reduce the risk of a temporarily malplaced double-lumen tube creating a potentially harmful ball-valve effect in a partially obstructed lobe or lung.
Night-shift Discharge from Intensive Care Unit Increases the Mortality-risk of ICU Survivors
Authors: Duke G. J. , Green J. V. , Briedis J. H.
Published: January 2019

Intensive Care (ICU) survivors discharged from ICU to the general ward at night have a higher mortality1,2. We sought to clarify which factors, including night-shift discharge, influence outcome following ICU discharge in a metropolitan hospital, using a cohort study of critically-ill patients between 1/1/1999-30/4/2003. Patients were excluded from analysis if they (a) died in ICU, (b) were transferred to another hospital, (c) had an ICU length of stay <8 hours, or (d) age <16 years.

Logistic regression was used to derive a predictive model based on the following variables: patient demographics, severity of illness following ICU admission (APACHE II mortality-risk, pm), final diagnosis, discharge timing including premature or delayed (>4 hours) ICU discharge, and “limitation of medical treatment” orders. The outcome measures were patient status at hospital discharge and ICU readmission rate.

Of the 1870 ICU survivors, 92 (4.9%) died after discharge from ICU. Patients discharged to the ward during the night-shift (2200-0730 hours) had a higher APACHE II score and crude mortality. The difference in APACHE II pm did not reach statistical significance. No significant calendar or seasonal pattern was identified. Logistic regression identified night-shift discharge (RR=1.7; 95% CI 1.03-2.9; P=0.03), limited medical treatment order (RR=5.1; 95% CI 2.2-12) and admission APACHE II pm (RR=3.3; 95% CI 1.3-7.6) as independent predictors of patient outcome following ICU transfer to the ward.

Conclusion: At the time of ICU discharge to the ward three factors are predictive of hospital outcome: timing of ICU discharge, limited medical treatment orders and initial illness severity.
Successful Use of ECMO in Adults with Life-threatening Infections
Authors: MacLaren G. , Pellegrino V. , Butt W. , Preovolos A. , Salamonsen R.
Published: January 2019

Two cases of critically ill patients who received extracorporeal membrane oxygenation (ECMO) using different forms of circuitry and for different indications are presented. Both patients had life-threatening infections with septic shock and were not able to be supported by conventional means. The first patient had staphylococcal septicaemia and received venoarterial ECMO for circulatory failure. The second patient had psittacosis and received venovenous ECMO for respiratory failure. We discuss the expanding indications for this technology and the role it has to play in adult intensive care.
Use of Sengstaken-Blakemore Tube to Stop Massive Upper Gastrointestinal Bleeding from Dieulafoy's Lesion in the Lower Oesophagus
Authors: Ho K. M.
Published: January 2019

Massive upper gastrointestinal bleeding from Dieulafoy's lesion in the gastrointestinal tract is uncommon. The use of the Sengstaken-Blakemore tube in acute gastrointestinal bleeding has become less common since endoscopic sclerotherapy and banding procedures have become widely available. The successful use of a Sengstaken-Blakemore tube to control acute massive upper gastrointestinal bleeding from a Dieulafoy's lesion in the lower oesophagus in an elderly man with severe coronary artery disease and heart failure is described.
Rate-dependent Left Bundle Branch Block during Anaesthesia
Authors: Tyagi A. , Sethi A. K. , Agarwal V. , Mohta M.
Published: January 2019

Rate-dependent left bundle branch block during general anaesthesia is rare. Its occurrence makes electrocardiographic diagnosis of acute myocardial ischaemia or infarction difficult. It can also be confused with a slow rate ventricular tachycardia. We present a case of rate-dependent left bundle branch block in a patient with no previous history of ischaemic heart disease. Carotid sinus massage resulted in a decrease in heart rate and reversion to normal sinus rhythm.
Granisetron and Ondansetron for Prevention of Nausea and Vomiting in Patients Undergoing Modified Radical Mastectomy
Authors: Dua N. , Bhatnagar S. , Mishra S. , Singhal A. K.
Published: January 2019

Modified radical mastectomy is associated with a relatively high incidence of postoperative nausea and vomiting (PONV). This study was undertaken to evaluate the comparative profile and efficacy of ondansetron and granisetron to prevent PONV after modified radical mastectomy. In a randomized, double-blind, placebo-controlled trial, sixty female patients received ondansetron 4 mg, granisetron 1 mg or saline intravenously just before induction of anaesthesia (n=20 for each group). A standardized general anaesthetic technique was employed. The incidence of PONV and adverse events were recorded for the first 24h postoperatively. The incidence of PONV was 25% with ondansetron, 20% with granisetron and 70% with saline (P<0.05, Chi-square test with Yates’ correction factor). The incidence of adverse events was comparable among the groups. Ondansetron and granisetron are both effective for reducing the incidence of PONV in female patients undergoing modified radical mastectomy.
A Randomized Crossover Trial of Tenoxicam Compared with Rofecoxib for Postoperative Dental Pain Control
Authors: Zacharias M. , De Silva R. K. , Herbison P. , Templer P.
Published: January 2019

Two non-steroidal anti-inflammatory drugs, tenoxicam and rofecoxib, were compared for the control of postoperative pain following surgical extraction of bilaterally and symmetrically impacted wisdom teeth performed under intravenous sedation and local anaesthesia. Thirty-five young fit adult patients received each analgesic treatment for four days in a randomized, crossover design. The results suggest statistically better pain relief for the selective COX-2 inhibitor rofecoxib compared to tenoxicam, a traditional NSAID. There were side-effects with both treatments. Abdominal discomfort was significantly more common following rofecoxib compared to tenoxicam. Both analgesics were acceptable to most participants in the trial.
Blood Usage in an Australian Intensive Care Unit: Have We Met Best Practice Goals?
Authors: Farrar D. , Robertson M. S. , Hogan C. J. , Roy S. , Boyce C. A. , Howe B. D. , Presneill J. J. , Cade J. F.
Published: January 2019

The transfusion of blood products, especially red cell concentrates, in critically ill patients is controversial and benefits of red cell concentrate transfusion in these patients have not been clearly demonstrated.

We performed a prospective observational study to compare best evidence to actual practice of red cell concentrate and other blood product administration in an intensive care unit (ICU) in a university-associated tertiary hospital. All primary admissions during a 28-day period were included in the study and data collected included transfusion of red cells and blood products, patient demographics and ICU and hospital outcome.

One hundred and seventy-five admissions were studied; 44% followed cardiac surgery. Forty-one patients (23%) received red cell concentrates in ICU, with 120 units transfused in 61 separate episodes. Other blood product usage was minimal. One third (20/61) of red cell concentrate transfusion episodes were of a single unit. The mean (±SD) pre-transfusion haemoglobin was 7.9±1.1 g/dl. Despite transfusion, such patients left ICU with a lower haemoglobin concentration compared with untransfused ICU patients (9.5±1.0 versus 10.5±2.1 g/dl; P<0.001). Cardiac surgical patients received similar red cell transfusion to general ICU patients. Univariate analysis showed no significant difference in mortality between patients who did or did not receive red cell concentrate transfusion (P=0.17). However, red cell concentrate transfusion was associated with a reduced adjusted mortality both in ICU (OR 0.13, 95% CI 0.02-0.73) and in hospital at 28 days (OR 0.10, 95% CI 0.02-0.58). The low red cell concentrate and blood product usage in our ICU were consistent with restrictive transfusion practice and selective red cell concentrate transfusion was associated with reduced mortality.
Multiple Embolic Events in a Patient with Heparin Induced Thrombocytopaenic Thrombotic Syndrome and Mural Thrombus
Authors: Bennett G. , Hanley M. R.
Published: January 2019

This report describes a 55-year-old man admitted for renal colic and found to have an infarcted right kidney, for which he was treated with heparin. Heparinization for this condition was stopped on day 12 when the patient developed pain in his left foot. Heparin-induced thrombocytopaenic thrombotic syndrome was confirmed, and despite treatment with danaparoid and bilateral femoral embolectomy, a left above-knee amputation was required. Echocardiogram showed a sessile mural thrombus in the left ventricle, which was considered a likely embolic source. The preoperative development of acute renal failure delayed recovery and necessitated haemodialysis. Anticoagulation of the patient was complicated; however, warfarin was introduced slowly and with good effect.
Extensive Spinal Epidural Abscess Associated with an Unremarkable Recovery
Authors: Ansari A. , Davies D. W. L. , Lohn J. W. G. , Culpan P. , Etherington G.
Published: January 2019

Spinal epidural abscess is a rare complication of epidural catheter insertion, with an incidence reported to be as low as 0.02%, but with a high morbidity and mortality. This reflects the difficulty in diagnosis of the condition, as early symptoms and signs are usually non-specific with late neurological manifestations. We report a case of spinal epidural abscess in a diabetic patient who underwent splenectomy and distal pancreatectomy. Early investigation with magnetic resonance imaging was effective in demonstrating an extensive epidural abscess involving the thoracic spine, with extension to the base of the skull and associated cord compression. Extensive multilevel laminectomies with thorough irrigation and washout of the epidural space were successful in treating this patient and preventing the development of permanent neurological sequelae.
Tamponade as a Rare Complication of CPAP Use following Cardiac Surgery
Authors: John L. C. H. , Kimberley A. P. S.
Published: January 2019

A 64-year-old woman developed tamponade more than 48 hours following cardiac surgery. The cause for this was haemorrhage from the site of multiple attempted cannulations of the right internal jugular vein. However this was a secondary haemorrhage and appeared to be precipitated by the use of CPAP on the second postoperative day. CPAP should be used with caution following difficult neckline insertions.
A Randomized Trial of Ultrasound-guided Brachial Plexus Anaesthesia in Upper Limb Surgery
Authors: Soeding P. F. , Sha S. , Royse C. F. , Marks P. , Hoy G. , Royse A. G.
Published: January 2019

Ultrasound guidance allows real-time identification of relevant anatomy and needle position when performing brachial plexus regional anaesthesia. The aim of this investigation was to determine whether the use of surface ultrasound could improve the quality of brachial plexus anaesthesia for upper limb surgery. Forty patients were randomized to either conventional “landmark-based” plexus anaesthesia, or to an ultrasound-guided approach using a 13 mHz linear array transducer. Both interscalene and axillary techniques were used. The use of ultrasound significantly improved the onset and completeness of sensory (P=0.011) and motor (P=0.002) block. Ultrasound guidance also significantly reduced (P=0.012) the incidence of paraesthesia during the performance of the blocks. Ultrasound guidance increases the quality of sensory and motor blockade in brachial plexus regional anaesthesia, and by reducing the incidence of paraesthesia during performance of the blocks, may confer greater safety.
Precise Control of End-tidal Carbon Dioxide Levels Using Sequential Rebreathing Circuits
Authors: Somogyi R. B. , Vesely A. E. , Preiss D. , Prisman E. , Volgyesi G. , Azami T. , Iscoe S. , Fisher J. A. , Sasano H.
Published: January 2019

Anaesthesiologists have traditionally been consulted to help design breathing circuits to attain and maintain target end-tidal carbon dioxide (PETCO2). The methodology has recently been simplified by breathing circuits that sequentially deliver fresh gas (not containing carbon dioxide (CO2)) and reserve gas (containing CO2). Our aim was to determine the roles of fresh gas flow, reserve gas PCO2 and minute ventilation in the determination of PETCO2. We first used a computer model of a non-rebreathing sequential breathing circuit to determine these relationships. We then tested our model by monitoring PETCO2 in human volunteers who increased their minute ventilation from resting to five times resting levels. The optimal settings to maintain PETCO2 independently of minute ventilation are 1) fresh gas flow equal to minute ventilation minus anatomical deadspace ventilation, and 2) reserve gas PCO2 equal to alveolar PCO2. We provide an equation to assist in identifying gas settings to attain a target PCO2. The ability to precisely attain and maintain a target PCO2 (isocapnia) using a sequential gas delivery circuit has multiple therapeutic and scientific applications.
Comparison of the Re-usable LMA Classic™ and Two Single-use Laryngeal Masks (LMA Unique™ and SoftSeal™) in Airway Management by Novice Personnel
Authors: Tan M. G. E. , Chin E. R. C. , Kong C. S. , Chan Y. H. , Ip-Yam P. C.
Published: January 2019

In a single-blind randomized trial, three types of laryngeal masks: the reusable LMA Classic™, the single-use LMA Unique™ and SoftSeal™ were inserted by novice medical officers in anaesthesia. Five successive attempts were undertaken with each mask type. The order of the mask type insertion was randomly selected. Mean (SD) insertion times for LMA Classic™, LMA Unique™ and Soft Seal™ were 32.9 (12.3), 39.6 (23.4) and 49.4 (50.4) seconds respectively. Differences were only significant between LMA Classic™ and SoftSeal™ (P=0.012). There were no significant differences in first attempt success rates (LMA Classic™ 80%, LMA Unique™ 77% and SoftSeal™ 62%). The SoftSeal™ was most frequently associated with blood on the mask (32%) compared to the LMA Unique™(9%) and LMA Classic™ (6%). Sore throat was experienced in 14% of patients in the LMA Unique™ group versus 41% and 42% in the LMA Classic™ and SoftSeal™ groups respectively. Mean±SD oropharyngeal leak pressure was significantly higher in the SoftSeal™ (21±6 cmH2O) compared to the LMA Classic™ (17±7 cmH2O) and LMA Unique™ (16±6 cmH2O).

Novice medical doctors can be taught to insert disposable laryngeal masks. The SoftSeal™ took longer to insert, which resulted in a higher incidence of blood on the mask, but success rates did not differ. The LMA Unique™ was associated with the lowest incidence of sore throat in the immediate postoperative period. A higher oropharyngeal leak pressure with the SoftSeal™ may indicate improved airway seal and protection against aspiration.
The Effect of Supplemental Oxygen on Postoperative Nausea and Vomiting in Children Undergoing Dental Work
Authors: Donaldson A. B. P.
Published: January 2019

Administration of 80% intraoperative oxygen has been proposed as being a cheap, safe and effective means reducing postoperative nausea and vomiting (PONV) but no studies have been performed in the high risk paediatr population. We tested whether 80% intraoperative oxygen reduces PONV in well children undergoing electi day-stay dental treatment under general anaesthesia. Ninety-five children received standardized sevoflurane, morphin vecuronium anaesthesia with either 30% or 80% intraoperative oxygen and no antiemetic prophylaxis in a randomize double blind, prospective trial. There was no difference in PONV or in the use of rescue ondansetron between the groups. The total incidence of PONV was 40% in the group that received 30% oxygen and 33% in those that receive 80% oxygen. High inspired intraoperative oxygen was not found to significantly reduce PONV in well children undergoing dental work under general anaesthesia.
Evaluation of the SLIPA™ (Streamlined Liner of the Pharynx Airway), a Single Use Supraglottic Airway Device, in 60 Anaesthetized Patients Undergoing Minor Surgical Procedures
Authors: Hein C. , Plummer J. , Owen H.
Published: January 2019

The Streamlined Liner of the Pharyngeal Airway, SLIPA™ (Hudson RCI) is a new disposable supraglottic airway device that has no inflatable cuff and has features designed to reduce aspiration risk. This study aimed to assess the insertion success and effectiveness of the SLIPA™ in 60 patients who presented for elective surgery. Ethics committee approval was obtained. Patients were excluded if they were less than 18 years, had not provided written consent or were at risk of pulmonary aspiration. The first 20 SLIPA™ were inserted by the principal investigator (Group A) followed by another 40 inserted by medical officers and anaesthetists of varying experience (Group B). Twenty-one males and 39 females were recruited into the study. Median time to ventilation was 20.4 seconds in Group A (range 12.9-109) and 24.8 seconds in Group B (range 8.2-82.5). Overall success rate was 100% in Group A and 92.5% in Group B. The lowest recorded SpO2 was 91% in Group B. The incidence of blood and sore throat score >3 (0-10 scale) was 23% and 7% respectively (Groups A and B). Group B reported that use of the device was very easy in 16%, easy in 76%, difficult in 5%, and very difficult in 3%. The SLIPA™ proved to be a reliable airway providing adequate ventilation in both spontaneous breathing and assisted respiration. Most users found the SLIPA™ to be easy or very easy to use.
The Influence of the Current Medicolegal Climate on New South Wales Anaesthetic Practice
Authors: Beckmann L. A.
Published: January 2019

A survey was posted to all New South Wales and Provisional Fellows of the Australian and New Zealand College of Anaesthetists to assess the influence of the current medicolegal climate on their anaesthetic practice. Information collected included demographics, opinions regarding the current medico-legal climate, medical defence organizations, and the implications for anaesthetic practice. The response rate was 78% (640/820). Nearly all (95.3%) were concerned about the current medical indemnity crisis and 80.5% felt concerned about the financial security of medical insurers. Of all these respondents 23.6% had personal experience of litigation and 73.6% expected to have a claim made against them during their career. Respondents spent an average of 8.3% of their gross annual income on medical insurance premiums and 47.2% are concerned about the viability of their practice given the rising costs of medical insurance. Obstetric anaesthesia was the most common area of practice to be ceased due to medicolegal concerns. In the next two years, 20.2% of obstetric anaesthetists who responded intend to cease practice. In the past two years, 3.1% of respondents retired due to their litigation concerns, while 12.8% (average age 56.7y) are intending to retire in the next two years for the same reasons. Changes to the conduct of the preoperative consultation were common. Other changes to practice included more thorough documentation of complications (50.8%) and a strong reluctance to perform neuraxial blocks (54%). This survey suggests that anaesthetists are concerned about the current medicolegal climate and as a result, some are retiring earlier and giving up high-risk areas of practice.
Arterial Oxygen Desaturation during One-lung Ventilation in a Patient with Segmental Pulmonary Infarction
Authors: Pfitzner J. , Lance D. G. , Peacock M. J.
Published: January 2019

A left thoracotomy for decortication of an infected haemothorax was performed on a 52-year-old man with a partially infarcted left lower lobe that occurred as a rare complication of a pulmonary venous embolus. Before the completion of surgery, after an uncomplicated 40 minutes of one-lung ventilation, the left lung was temporarily re-expanded to assess air leak. On the resumption of one-lung ventilation the SpO2 fell rapidly to 85%, despite apnoeic oxygenation of the non-ventilated lung. In the absence of evidence of double-lumen tube displacement, intra-pulmonary shunting as a consequence of impaired hypoxic pulmonary vasoconstriction in the newly expanded markedly pathological lung is considered the most likely mechanism.
Severe Uncontrolled Pain in Buttock in a Patient on Naltrexone: A Diagnostic Challenge
Authors: Graham J. M. , Evans B.
Published: January 2019

A 26-year-old woman with a history of intravenous drug use was admitted to hospital with worsening pain in the right buttock radiating to the lateral part of the thigh and to the calf with no suspicion of cauda equina compression. Eventually, a diagnosis of sacroiliitis was made and appropriate antibiotics were administered. Provision of analgesia for this patient was difficult. On admission her medications included naltrexone, venlafaxine and tramadol. Initially naltrexone was continued and analgesia provided by epidural local anaesthetic and clonidine, intravenous ketamine and oral agents. After several days, naltrexone was ceased and opioids were used in addition to the other analgesics. The epidural analgesia was only partially effective, perhaps because of inadequate blockade of the L4-S1 nerve roots, which carry sensation from the sacroiliac joint.

Naltrexone is a long-acting opioid antagonist. If opioid analgesia is planned, it is necessary to cease naltrexone for 24 to 72 hours. In an emergency, if non-opioid techniques prove ineffective, short-acting opioids can be titrated to effect in a monitored environment.
An Audit of Intrathecal Morphine Analgesia for Non-Obstetric Postsurgical Patients in an Adult Tertiary Hospital
Authors: Lim P. C. , Macintyre P. E.
Published: January 2019

We conducted a retrospective audit of adult non-obstetric patients who had received a single dose of intrathecal morphine for postoperative analgesia. These patients were predominantly admitted to a regular postsurgical ward with strict hourly nursing observations, treatment protocols in place and supervision by an Acute Pain Service for the first 24 hours after intrathecal morphine administration. A total of 409 cases were examined for sedation score, incidence of respiratory depression and other side-effects, admission to the high dependency or intensive care unit and opioidtolerance. Respiratory depression was defined as requiring treatment with naloxone (implying a sedation score of 3 irrespective of respiratory rate), or a sedation score of 2 with a respiratory rate less than six breaths per minute. The patients were predominantly elderly (57.2% were over the age of 70 years) and 84.8% had undergone vascular surgery. Of the total of 409 cases, only one case of respiratory depression was observed. A total of 77 patients were admitted to high dependency or intensive care unit for various reasons including management of postsurgical complications and patient co-morbidities. Our findings suggest that elderly patients who receive intrathecal morphine analgesia can be safely managed in a regular postsurgical ward.
Anaesthesia for Robot-Assisted Anatomic Prostatectomy. Experience at a Single Institution
Authors: Costello T. G. , Webb P.
Published: January 2019

Robot-assisted anatomic prostatectomy is an emerging technique for management of prostate cancer. It requires a coordinated approach by anaesthetist and surgeon as the surgery is performed using a modified laparoscopic technique and is potentially of long duration in a Trendelenberg position. We describe some aspects of the surgical technique and our anaesthetic approach with the first 40 cases at our institution. The mean hospital stay was 4.2 days and none of the patients required blood transfusion. A retrospective audit indicated that the use of epidural analgesia in the early postoperative period reduced opioid analgesic requirements.
Continuing Medical Education: A Needs Analysis of Anaesthetists
Authors: Tucker A. P. , Miller A. , Sweeney D. , Jones R. W.
Published: January 2019

The continuing medical education (CME) needs of anaesthetists within Australia, New Zealand, Hong Kong, Malaysia and Singapore have been largely unknown. The aim of this study was to undertake a comprehensive survey of the attitude to CME, learning preferences, attitudes and abilities relating to self-paced material, literature and information searching, preferred content and preferred approach to CME of anaesthetists within these countries. A survey tool was developed and refined for ease of use by pilot-testing. The survey was mailed to 3,156 anaesthetists throughout Australia, New Zealand, Hong Kong, Malaysia and Singapore. Three options for data return were offered; postal reply, facsimile and a data entry web-page.

There were 1800 responses, which represented a response rate of 57%. The demographics of the respondents were similar to the overall demographics of Fellows of the Australian and New Zealand College of Anaesthetists. A large majority of respondents (92%) stated that their involvement in CME improved patient care. However, almost half the respondents reported that they have difficulty either in participating in current CME activities (31 %) or implementing new knowledge into their workplace (14%).

Anaesthetists within this region appear to be motivated by the need to make better decisions based on independent standards of practice. While Australia is a world leader in flexible education, it is still emerging as a discipline. Flexible education may be used to facilitate anaesthetists’ participation in CME activities and in implementation of new knowledge in their workplace.