bluuebunny/crossref_metadata_2025 huggingface dataset:
Attitudes towards and Evaluation of Medical Emergency Teams: A Survey of Trainees in Intensive Care Medicine
Authors: Jacques T. , Harrison G. A. , Mclaws M.-L.
Published: January 2019

A survey was conducted to explore the perception of intensive care registrars on the impact of activities outside the intensive care unit (ICU), particularly in medical emergency teams, on their training and the care of patients.

An anonymous mail-out survey was sent to 356 trainees registered with the Joint Faculty of Intensive Care Medicine, half of whom were determined to be involved in ICU duties. No patients were involved and respondents participated voluntarily. The main outcome measures were barriers and predictors of satisfaction with ICU training.

One-hundred-and-thirty-six (38%) trainees responded. Seventy-eight percent had participated in a medical emergency team, of whom 99% of respondents stated the medical emergency team included an ICU registrar but rarely (3%) an ICU consultant. Sixty-six percent of respondents reported that medical emergency team involvement had a positive effect on training but 77% reported little or no supervision of team duties. While trainees did not believe they spent too much time performing medical emergency team duties, the time spent on medical emergency teams at night, when ICU staffing levels are at their lowest, was the same as during the day. Serious concern was expressed about the negative impact of medical emergency team activities on their ability to care for ICU patients and the additional stress on ICU medical and nursing staff.

Overall, ICU trainees regarded participation in a medical emergency team as positive on training and on patient care in wards, but other results have resource implications for the provision of clinical emergency response systems, care of patients in ICUs and the training of the future intensive care workforce.
Ergometrine Administration for Postpartum Haemorrhage in an Undiagnosed Pre-Eclamptic
Authors: Ng S. Y. , Ithnin F. , Sia A. T. H. , Ng C. C. M.
Published: January 2019

We report a case of a parturient who was well antenatally but presented with oliguria following delivery. The possibility of postpartum preeclampsia was obscured by simultaneous postpartum haemorrhage. Ergometrine was given and she suffered an eclamptic seizure shortly after. We discuss the diagnostic difficulties presented by simultaneous presentation of postpartum preeclampsia and haemorrhage and the likelihood that ergometrine precipitated eclampsia in a patient at risk. While ergometrine is an effective drug for the management of uterine atony, its potential role in precipitating eclampsia must be considered.
Effects of Arginine Vasopressin on Oxygenation and Haemodynamics during One-Lung Ventilation in an Animal Model
Authors: Hüter L. , Schwarzkopf K. , Preussler N. P. , Gaser E. , Bauer R. , Schubert H. , Schreiber T.
Published: January 2019

In a case of arterial hypotension during one-lung ventilation, haemodynamic support may be required to maintain adequate mean arterial pressure. Arginine vasopressin, a potent systemic vasoconstrictor with limited effects on the pulmonary artery pressure, has not been studied in this setting. Twelve female pigs were anaesthetised and ventilated and arterial, central venous and pulmonary artery catheters were inserted. A left-sided double lumen tube was placed via tracheostomy and one-lung ventilation was initiated. The animals were in the left lateral position, with the left lung ventilated and right lung collapsed. Respiratory and haemodynamic values were recorded before and during a continuous infusion of arginine vasopressin sufficient to double the mean arterial pressure. The arginine vasopressin caused a decrease in cardiac output (3.8±1.1 vs. 2.7±0.7 l/min, P <0.001) and mixed-venous oxygen tension (39.1±5.8 vs. 34.4±5 mmHg, P=0.003). Pulmonary artery pressure was unchanged (24±2 vs. 24±3 mmHg, P=0.682). There was no effect of the arginine vasopressin on arterial oxygen tension (226±106 vs. 231±118 mmHg, P=0.745). However, there was a significant decrease in shunt fraction (28.3±6.2 vs. 24.3±7.8%, P=0.043) and a significant proportional increase in perfusion of the ventilated lung (78.8±9.5 vs. 85.5±7.9%, P=0.036). In our animal model of one-lung ventilation, doubling mean arterial pressure by infusion of arginine vasopressin significantly affected global haemodynamics, but had no influence on systemic arterial oxygen tension.
Comparison of Caudal Epidural Bupivacaine with Bupivacaine plus Tramadol and Bupivacaine plus Ketamine for Postoperative Analgesia in Children
Authors: Choudhuri A. Hom , Dharmani P. , Kumar N. , Prakash A.
Published: January 2019

This study compared the effect of single-dose caudal epidural bupivacaine, bupivacaine plus ketamine and bupivacaine plus tramadol for postoperative pain management in children having surgery for inguinal hernia.

Following ethics committee approval and informed parental consent, 75 children ASA PS I and II, between three and nine years of age and scheduled for elective unilateral inguinal hernia repair with general anaesthesia were recruited. The patients were randomly divided into three groups to receive 0.5 ml/kg caudal bupivacaine 0.25% (group B), bupivacaine 0.25% plus tramadol 1 mg/kg (group BT) or bupivacaine 0.25% plus ketamine 0.5 mg/kg (group BK). The injections were performed under general anaesthesia. Mean arterial pressure, heart rate, pulse oximetry, respiratory rate and sedation and pain scores were recorded at defined intervals following recovery from anaesthesia.

The groups were similar in age, weight and duration of operation (P >0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was (mean±SD) 6.5±4.1 h in group B, 9.2±3.9 h in group BK, and 8.5±3.1 h in group BT (P <0.05). More patients in group B required supplementary analgesics in the first 24 h (P <0.05). Sedation scores were comparable in all groups. Incidence of emesis and pruritus was similar in all the groups.

Caudally administered 0.5 ml/kg bupivacaine 0.25% plus ketamine or bupivacaine 0.25% plus tramadol 1 mg/kg provided significantly longer duration of analgesia without an increase in the adverse effects when compared to bupivacaine alone.
Comparison of 2% Lignocaine with Adrenaline and Fentanyl, 0.75% Ropivacaine and 0.5% Levobupivacaine for Extension of Epidural Analgesia for Urgent Caesarean Section after Low Dose Epidural Infusion during Labour
Authors: Sng B. L. , Pay L. L. , Sia A. T. H.
Published: January 2019

Low dose local anaesthetic and fentanyl epidural solutions are commonly ‘topped-up’ for urgent caesarean section. However, the block characteristics associated with newer local anaesthetics such as ropivacaine 0.75% and levobupivacaine 0.5% have not been fully determined. In a randomised double-blinded controlled clinical trial, we compared 2% lignocaine with adrenaline and fentanyl (LAF), 0.75% ropivacaine and 0.5% levobupivacaine for extension of low dose epidural analgesia for urgent caesarean section in 90 Asian parturients.

There was no significant difference in the median, interquartile range, time to T4 loss of sensation to cold between LAF (9.5, 7.0 to 13.3 minutes), 0.75% ropivacaine (10.0, 7.0 to 15.0 minutes) and 0.5% levobupivacaine (10.0, 7.0 to 15.0 minutes). No woman required conversion to general anaesthesia. The supplementation rate did not differ between groups. Levobupivacaine provided a longer duration of sensory block compared to LAF, but a similar duration to 0.75% ropivacaine.

Under the conditions of this study there was no significant difference in time to surgical readiness (defined as loss of sensation to cold to T4) between LAF, 0.75% ropivacaine and 0.5% levobupivacaine groups. Ropivacaine and levobupivacaine are suitable alternatives for extending epidural analgesia for urgent caesarean section.
Non-Invasive Cardiac Output Measurement using a Fast Mixing Box to Measure Carbon Dioxide Elimination
Authors: Killick C. J. , Parkin W. G.
Published: January 2019

This study investigated the accuracy of a new technique for measuring cardiac output using the derivative Fick principle based on the ratio of change in the partial pressures of end-tidal and mixed expired carbon dioxide produced by short periods of partial rebreathing.

A prospective clinical study involving 24 patients following cardiopulmonary bypass for coronary artery bypass grafting or valvular surgery was undertaken in the intensive care unit of a university-affiliated hospital.

Haemodynamic measurements were performed after admission to the intensive care unit. Cardiac output was measured simultaneously by bolus pulmonary artery thermodilution and by a noninvasive carbon dioxide partial rebreathing technique.

Cardiac output measurement using the new technique demonstrated a significant but consistent underestimate, with a bias of -0.60 ± 0.87 l/min.

This new adaptation of the partial rebreathing technique is reliable in measuring cardiac output in postoperative patients. Reasons for the consistent discrepancy between thermodilution and partial rebreathing techniques are discussed.
Glomerular Hyperfiltration and Albuminuria in Critically ILL Patients
Authors: Fuster-Lluch O. , Gerónimo-Pardo M. , Peyró-García R. , Lizán-García M.
Published: January 2019

Glomerular hyperfiltration and albuminuria are two pathological conditions that could alter renal drug elimination, but they have been rarely studied in a critical care setting.

The aims of this descriptive, prospective study performed on 89 critically ill patients are to determine rates of glomerular hyperfiltration (main objective) and albuminuria (secondary objective).

On admission, 17.9% of patients presented with glomerular hyperfiltration, climbing to rates as high as 30% during the first week of admission. Seventy-five percent showed albuminuria on admission, with rates remaining high throughout the week of the study.

Since glomerular hyperfiltration as well as albuminuria are frequent pathophysiological conditions in critical care patients, the implications that these phenomena may have regarding drug elimination need further evaluation.
An Audit of Perioperative Cardiac Arrests in a Southeast Asian University Teaching Hospital Over 15 Years
Authors: Ahmed A. , Ali M. , Khan F. A. , Khan M. U.
Published: January 2019

An audit of the incidence, causes and outcome of perioperative cardiac arrest was conducted in a university hospital in Pakistan. All perioperative cardiac arrests from induction of anaesthesia to post anaesthesia care unit discharge or intensive care unit admission during noncardiac surgery, from January 1992 to December 2006 were included. Patients’ demographic information, physical status and type of surgery and anaesthesia were noted. Outcome variables were noted as immediate survival and survival to discharge. Anaesthesia-related cardiac arrests were identified and their causes analysed. Forty-two cardiac arrests occurred among 140,384 patients. Overall frequency was 2.99 per 10,000 (95% confidence interval: 2.90 to 3.08). Twenty-four (3.77/10,000) were females. Thirty-four (13.59/10,000) patients were ASA physical status III to V, 10 (4.95/10,000) were children and 14 (4.28/10,000) above 60 years. Sixteen patients (6.48/10,000) were undergoing emergency surgery. Anaesthesia was deemed primarily responsible in nine cases (0.64/10,000). The causes of anaesthesia-related arrests were medication related (4), airway related (3), massive air embolism (1) and under-replacement of fluids (1). The event was considered to be avoidable in 26 cases. Seventeen patients died during the arrest, 15 survived more than one hour and 10 were discharged home. The number of perioperative cardiac arrests and their mortality was higher in patients with poor physical status and in emergency surgery. The number was also higher in infants, patients above 60 and females. The majority of the cases were considered avoidable, indicating the importance of prevention strategies.
Effects of Pregnancy on the Solubility of Halogenated Volatile Anaesthetics in Rat Blood and Tissues
Authors: Rao Y. , Wang Y.-L. , Li H. , Zhang W. , Liu J.
Published: January 2019

This study was designed to evaluate the effects of pregnancy on the solubility of halogenated volatile anaesthetics in rat blood and tissues. Tissue samples from 10 pregnant and 10 non-pregnant adult female Sprague Dawley rats, including the heart, liver, kidney and brain, were obtained and made into respective homogenates. Blood/gas and tissue/gas partition coefficients for halothane, sevoflurane and isoflurane were determined by the method of two-stage headspace equilibration by gas chromatography with each of the homogenates. Values were analysed by t-test or one-way analysis of variance. The solubility within blood and brain for halothane in the pregnant group (2.90 ± 0.44, 5.55 ± 0.73) was significantly lower than that of the non-pregnant group (3.42±0.23, 6.33±0.64; P <0.05). However, there were no significant differences between the two groups for liver, kidney or heart solubility. For sevoflurane and isoflurane, there were no significant differences in solubility between the two groups. In conclusion, pregnancy decreased the solubility of halothane within the blood and brain, whereas the solubility of halothane in other tissues including the liver, kidney and heart showed no significant alteration. Pregnancy did not affect the solubility of sevoflurane or isoflurane within blood or the other tissues studied.
Lumbar Wedge versus Pelvic Wedge in Preventing Hypotension following Combined Spinal Epidural Anaesthesia for Caesarean Delivery
Authors: Zhou Z. Q. , Shao Q. , Zeng Q. , Song J. , Yang J. J.
Published: January 2019

Aortocaval compression is a major cause of maternal hypotension. A randomised controlled clinical trial was designed to compare two wedged supine positions for prevention of hypotension following combined spinal epidural anaesthesia for caesarean delivery. Sixty parturients undergoing elective caesarean delivery were randomly assigned to two different wedged supine positions. After the completion of subarachnoid injection, parturients were placed with either a wedge under the right pelvis (group P, pelvic wedge) or under the right lumbar region (group L, lumbar wedge). Systolic blood pressure and heart rate were recorded every minute for 20 minutes from the subarachnoid injection. Hypotension, defined as systolic blood pressure <100 mmHg or 80% of the baseline, was treated with intravenous ephedrine 5 mg. The incidence of hypotension, ephedrine use and neonatal Apgar scores and umbilical arterial pH were recorded. The incidence of hypotension was significantly higher in group P than that in group L (23/30 [77%] vs. 14/30 [47%], P=0.016). Systolic blood pressure decreased significantly in both groups at seven, eight and nine minutes (P <0.001); moreover it was lower at seven, eight and nine minutes in group P than in group L (P <0.01). Heart rate did not change significantly in either group. There were no significant differences between the two groups for Apgar score and umbilical arterial pH. A lumbar wedge is more effective than a pelvic wedge in preventing hypotension following combined spinal epidural anaesthesia for caesarean delivery, although it does not eliminate hypotension.
Postpartum Septic Sacroiliitis Coincident with Labour Epidural Analgesia
Authors: Mulvey J. M.
Published: January 2019

A 22-year-old woman presented to hospital 10 days after emergency caesarean section with severe back pain, fever, tachycardia and a raised C-reactive protein. She had received labour epidural analgesia and was investigated for an epidural abscess. After repeat magnetic resonance imaging she was ultimately diagnosed with septic sacroiliitis. Although an uncommon cause of back pain, pregnancy-associated sacroiliitis should be considered in the differential diagnosis of post-epidural back pain, as the presentation and symptoms of an epidural infection and sacroiliitis are similar. We recommend imaging to include the sacroiliac joints when considering the diagnosis of an epidural collection.
Intubation through the LMA-Supreme™: A Pilot Study of Two Techniques in a Manikin
Authors: Joffe A. M. , Liew E. C.
Published: January 2019

The LMA-Supreme™ is a single-use disposable laryngeal mask that combines features of several laryngeal mask air-ways in one device. The primary aim of our study was to compare ease of use and operator preference for fibreoptic-aided intubation through the LMA-Supreme™ using an Aintree Intubating Catheter™ or Arndt Airway Exchange Catheter Set. Twenty participants experienced in fibreoptic-aided intubation performed a total of 40 intubations on an AirSim™ airway manikin through a #4 LMA-Supreme™. Intubation using the Arndt Airway Exchange Catheter Set was easier than with the Aintree Intubating Catheter™. Half of the participants preferred Aintree Intubating Catheter™-assisted intubation, citing fewer steps and faster performance as the reasons. All 20 (100%) Arndt Airway Exchange Catheter Set-assisted intubations and 18120 (90%) of Aintree Intubating Catheter™-assisted intubations were successful. Aintree Intubating Catheter™ and Arndt Airway Exchange Catheter Set-assisted intubations can be performed quickly, successfully and with minimal difficulty through the LMA-Supreme™ by experienced operators. While the Arndt Airway Exchange Catheter may be easier, the Aintree Intubating Catheter™ is faster.
Airway Management for Infants with Severe Micrognathia Having Mandibular Distraction Osteogenesis
Authors: Brooker G. E. , Cooper M. G.
Published: January 2019

We retrospectively reviewed the charts of seven neonates and infants with severe micrognathia and upper airway obstruction who underwent mandibular distraction osteogenesis as an alternative to long-term tracheostomy at the Children's Hospital at Westmead, Sydney, from 2004 to 2007.

All patients required a variety of airway interventions at an early age and had poor feeding or failure to thrive. These children had other anomalies and required many investigations and procedures and presented repeated airway challenges for the anaesthetist. The mean number of anaesthetics per child in this series was 6.7 (range 4 to 13).

Under anaesthesia, four patients had grade 4 laryngoscopy, one was grade 3 but two were only grade 2. Patients with a preoperative grade 4 laryngoscopy were very likely to need fibreoptic endotracheal intubation. Duration of intubation after surgery for mandibular distraction was a mean of 8.17 days (range 1 to 19). Three were extubated in the operating theatre and three in intensive care. Five patients had an improved laryngoscopy grade after completion of mandibular distraction and one remained grade four. The remaining patient had a tracheostomy from birth.
Fibreoptic Assessment of Paediatric Sized Laryngeal Mask Airways
Authors: von Ungern-Sternberg B. S. , Wallace C. J. , Sticks S. , Erb T. O. , Chambers N. A.
Published: January 2019

Laryngeal mask airways (LMA) are commonly used in paediatric anaesthesia. A well-placed LMA should provide a direct view of the vocal cords facilitating bronchoscopy or fibreoptic intubation. The aim of this audit was to assess the bronchoscopie view of the glottis obtained through an LMA with regard to its size.

We prospectively assessed the position of LMAs in relation to the glottic aperture in 350 children (zero to seven years) undergoing elective fibreoptic examination of the upper and/or lower airways. Following induction of anaesthesia and positioning of the LMA, a fibreoptic evaluation of the view of the glottis was performed (complete, partial or no visualisation).

Chest movement on manual ventilation was judged as good in the majority of patients and adequate for the remainder. No overt signs of airway obstruction were noted in any patient. However, a complete view of the glottic aperture was present in only 50% of size 1 LMAs, 57.5% of size 1.5, 72.7% of size 2 and 77.8% of size 2.5. The epiglottis impinged on the LMA opening, partially obstructing the view of the glottis in 36.3% of size 1 LMAs, 31.5% of size 1.5, 21% of size 2 and 17.8% of size 2.5. In 13.7% of size 1 LMAs, 11% of size 1.5, 6.3% of size 2 and 4.4% of size 2.5, the epiglottis was completely downfolded, obstructing the view of the glottic aperture.

The findings indicate that even if ventilation is judged as adequate, smaller paediatric LMAs are more commonly associated with suboptimal anatomical positioning with partial obstruction of the glottic aperture than larger LMAs, and therefore may require repositioning more often.
Fentanyl Dosage and Timing when Inserting the Laryngeal Mask Airway
Authors: Wong T. H. K. , Critchley L. A. H. , Lee A. , Khaw K. S. , Kee W. D. Ngan , Gin T.
Published: January 2019

The study objective was to show that fentanyl given five minutes prior to induction improved insertion conditions for the Classic Laryngeal Mask Airway. Previous work had shown fentanyl at 90 seconds to be unpredictable. A probit analysis design was used in which success I failure rates of different doses of fentanyl were measured and dose-response curves drawn from which the ED50 and ED95 with 95% confidence intervals were determined.

Adult Chinese patients with American Society of Anesthesiologists physical status classification I or II and requiring anaesthesia for minor surgery with a laryngeal mask were recruited. They were randomly assigned to one of six dosage groups: 0.25, 0.5, 1.0, 1.5, 2.0 and 3.0 μg.kg-1. Fentanyl was given prior to propofol 2.5 mg.kg-1, and insertion was assessed 90 seconds later using six categories of patient response.

Ninety-six patients, aged 18 to 63 years, were studied. The six dosage groups were similar. As the fentanyl dose increased, fewer patients responded to insertion (P <0.01). Dose-responses could be predicted for all categories, except resistance to insertion and laryngospasm. Probit analysis predicted an ED50 of 0.5 μg.kg-1 and ED95 of 7.5 pg.kg-1 for ideal insertion conditions (i.e. no swallowing, gagging, body movement or laryngospasm). Commonly used fentanyl doses of 1 to 2 μg.kg-1 only prevented patients responding to insertion in 70 to 80% of cases.

When using propofol 2.5 mg.kg-1, administering fentanyl five minutes before laryngeal mask insertion does not provide ideal insertion conditions in 95% of cases unless excessively large doses are used. An ideal dose of fentanyl that produces optimum insertion conditions could not be determined.
Fentanyl dose for the Insertion of Classic™ Laryngeal Mask Airways in Non-Paralysed Patients Induced with Propofol 2.5 mg/kg
Authors: Tan A. S. B. , Wang C. Y.
Published: January 2019

The aim of this randomised, controlled trial was to determine the optimum dose of fentanyl in combination with propofol 2.5 mg.kg-1 when inserting the Classic™ Laryngeal Mask Airway.

Seventy-five ASA I or II patients were randomly assigned to five groups of fentanyl dosage: 0 μg.kg-1 (placebo), 0.5 μg.kg-1, 1.0 μg.kg-1, 1.5 μg.kg-1 and 2.0 μg.kg-1 Anaesthesia was induced by first injecting the study drug over 10 seconds. Three minutes after the study drug was injected, propofol (2.5 mg.kg-1) was injected over 10 seconds. The Classic™ Laryngeal Mask Airway was inserted four minutes and 30 seconds after injection of the study drug. Insertion conditions were evaluated using a four-category score.

Thirty-nine males and 36 females aged 19 to 59 years were studied. The incidence of prolonged apnoea increased as fentanyl dose increased. We found that there was a high rate of successful first attempt at insertion with 1 μg.kg-1 and 1.5 μg.kg-1, 93% and 87% respectively, compared to 87% in the 2.0 μg.kg-1 group. The 1.0 μg.kg-1 group also achieved an 80% optimal insertion conditions score of 4, compared to 73% in the 1.5 μg.kg-1 group and 80% in the 2 μg.kg-1 group. Therefore we recommend 1.0 pg.kg-1 as the optimal dose of fentanyl when used in addition to propofol 2.5 mg/kg for the insertion of the Classic™ Laryngeal Mask Airway.
Monitoring of Extubated Patients: Are Routine Arterial Blood Gas Measurements useful and how Long Should Patients be Monitored in the Intensive Care Unit?
Authors: See K. C. , Phua J. , Mukhopadhyay A.
Published: January 2019

Restitution of respiratory support, which may include continuous positive airway pressure, non-invasive ventilation or reintubation, is needed in some patients post-extubation. We aimed to investigate whether serial arterial blood gas measurements done in the post-extubation period would help to identify such patients and to delineate the optimal post-extubation duration for close monitoring. We retrospectively analysed 115 consecutive adult patients who were extubated following successful spontaneous breathing trials in the medical intensive care unit, excluding patients who were extubated to immediate non-invasive ventilation. Arterial blood gases were measured at one and three hours post-extubation and patients were followed for any restitution of respiratory support for the remainder of their hospital stay. Restitution of respiratory support was required for 22 of 115 (19.1%) patients, of whom 20 were originally intubated for pneumonia. These patients could all be detected clinically from deteriorating pulse oximetry or increasing drowsiness. Performing serial arterial blood gas measurements following extubation did not improve the detection rate or allow earlier detection of patient deterioration. Among the patients with pneumonia, restitution of respiratory support was required within 24 hours of extubation for 16 patients (80%) and after more than 49 hours for four patients. Serial arterial blood gas measurements at one and three hours after a planned extubation are not useful and patients originally intubated for pneumonia should be monitored post-extubation for at least 24 hours in the intensive care unit.
Evaluation of P Wave and Corrected QT Dispersion in Subarachnoid Haemorrhage
Authors: Hanci V. , Gül S. , Dogan S. M. , Turan I. O. , Kalayci M. , Açikgöz B.
Published: January 2019

The aim of our study was to investigate P wave dispersion (Pwd), QT, corrected QT (QTc), QT dispersion (QTd) and corrected QT dispersion (QTcd) intervals in subarachnoid haemorrhage.

Thirty-five subarachnoid haemorrhage patients (Group S) and 35 neurologically normal patients (Group C) were included in this retrospective study. The standard 12 derivations of the electrocardiograms of all patients were analysed and Pwd, QT and QTd intervals were measured. QTc and QTcd intervals were determined with the Bazett formula.

There was no significant difference between the study groups according to demographic characteristics, hypertension and diabetes mellutus incidences (P >0.05). The Pwd, QT, QTc, QTd and QTcd durations of Group S were significantly longer than those of Group C (P <0.001).

Subarachnoid haemorrhage patients may have a higher likelihood of arrhythmia during anaesthesia and in intensive care due to extended QTcd and Pwd durations.
The Entropy Module® and Bispectral Index® as Guidance for Propofol-Remifentanil Anaesthesia in Combination with Regional Anaesthesia Compared with a Standard Clinical Practice Group
Authors: Ellerkmann R. K. , Soehle M. , Riese G. , Zinserling J. , Wirz S. , Hoeft A. , Bruhn J.
Published: January 2019

This study was designed to investigate the impact of the Entropy Module® and Bispectral Index® (BIS) monitoring on drug consumption and recovery times compared with standard anaesthetic practice in patients undergoing orthopaedic surgery using a combination of regional and general anaesthesia as performed by an experienced anaesthesiologist. We hypothesised that electroencephalogram monitoring would lead to a lower drug consumption as well as shorter recovery times.

With institutional review board approval and written informed consent, 90 adult patients undergoing surgery to the upper or lower extremity received regional anaesthesia for post- and intraoperative pain control and were randomised to receive general anaesthesia by propofol/remifentanil infusion controlled either solely by clinical parameters or by targeting Entropy or BIS values of 50. Recovery times and drug consumption were recorded.

Data from 79 patients were analysed. Compared with standard practice, patients with Entropy or BIS monitoring showed a similar propofol consumption (standard practice 101±22 μg/kg/minute, Entropy 106±24 μg/kg/minute, BIS 104±20 μg/kg/minute) and showed similar Aldrete scores (10/10) one minute after extubation: 9.1∓0.3, 9.2±0.6 and 9.3±0.5, respectively. Time points of extubation were 7.3±2.9 minutes, 9.2∓3.9 minutes and 6.8±2.9 minutes, respectively, demonstrating a significant difference between Entropy and BIS (P=0.023).

Compared with standard practice, targeting an Entropy or BIS value of 50 did not result in a reduction of propofol consumption during general anaesthesia combined with regional anaesthesia as performed by an experienced anaesthesiologist in orthopaedic patients.
An Overview of Evidence from Systematic Reviews Evaluating Early Enteral Nutrition in Critically Ill Patients: More Convincing Evidence is Needed
Authors: Heighes P. T. , Doig G. S. , Sweetman E. A. , Simpson F.
Published: January 2019

International quality improvement initiatives such as Fast-Hug bring a focus on improving the delivery of early enteral nutrition to critically ill patients, however surveys demonstrate current practice remains variable. One way to reduce variability in practice is to provide strong evidence to convince clinicians to change. The purpose of this overview was to identify current best evidence supporting the delivery of early enteral nutrition in critical illness.

We sought high-quality evidence in the form of systematic reviews containing meta-analyses of randomised controlled trials. Two authors independently identified studies and assessed methodological quality. Data sources included Medline, EMBASE and hand-searching of guideline reference lists.

The literature search identified five systematic reviews that summarised 30 clinical trials. These systematic reviews focused on acutely hospitalised patients, critical illness, bums, elective intestinal surgery and pancreatitis. Early enteral nutrition significantly reduced mortality in elective intestinal surgery patients (relative risk 0.41, 95% confidence interval 0.18 to 0.93, P=0.03, I2=0.0%) and significantly reduced infectious complications in acutely ill hospitalised patients (relative risk 0.45, 95% confidence interval 0.3 to 0.66, P=0.00006, heterogeneity P=0.049). Four of five identified systematic reviews had key methodological quality deficiencies.

The results of this overview highlight the variability in the evidence regarding the benefits of early enteral nutrition in critically ill patient populations. The inconsistent delivery to critically ill patients may be explained by the lack of convincing evidence. Better evidence may be needed to reduce the irregularity in the provision of early enteral nutrition to critically ill patients.
Comparison of Actual Tidal Volume in Neonatal Lung Model Volume Control Ventilation using Three Ventilators
Authors: Toyama H. , Endo Y. , Ejima Y. , Matsubara M. , Kurosawa S.
Published: January 2019

In neonates, small changes in tidal volumes (VT) may lead to complications. Previous studies have shown a significant difference between ventilator-measured tidal volume and tidal volume delivered (actual VT). We evaluated the accuracy of three different ventilators to deliver small VT during volume-controlled ventilation.

We tested Servo 300, 840 ventilator and Evita 4 Neoflow ventilators with lung models simulating normal and injured neonatal lung compliance models. Gas volume delivered from the ventilator into the test circuit (VTV) and actual VT to the test lung were measured using Ventrak respiration monitors at set VT (30 ml). The gas volume increase of the breathing circuit was then calculated.

Tidal volumes of the SV300 and PB840 in both lung models were similar to the set VT and the actual tidal volumes in the injured model (20.7 ml and 19.8 ml, respectively) were significantly less than that in the normal model (27.4 ml and 23.4 ml). PB840 with circuit compliance compensation could not improve the actual VT. VTV of the EV4N in the normal and the injured models (37.8 ml and 46.6 ml) were markedly increased compared with set VT, and actual VT were similar to set VT in the normal and injured model (30.2 ml and 31.9 ml, respectively). EV4N measuring VT close to the lung could match actual VT to almost the same value as the set VT, however the gas volume of the breathing circuit was increased.

If an accurate value for the patient's actual VT is needed, this VT must be measured by a sensor located between the Y-piece and the tracheal tube.
Systemic Levels of Local Anaesthetic after Intra-Peritoneal Application – a Systematic Review
Authors: Kahokehr A. , Sammour T. , Vather R. , Taylor M. , Stapelberg F. , Hill A. G.
Published: January 2019

There is a lack of cohesive reports on the systemic levels of local anaesthetic after intraperitoneal application. A comprehensive systematic review with no language restriction was conducted. Eighteen suitable articles were identified. Data were compiled and presented according to local anaesthetic agent. Intraperitoneal local anaesthetic has been studied in many different procedures, including open and laparoscopic surgery. A total of 415 patients were included for analysis. There were no cases of clinical toxicity. There were 11 (2.7%) cases with a systemic level above or close to a safe threshold (as determined by the report authors) in three trials utilising intraperitoneal local anaesthetic after laparoscopic cholecystectomy. Intraperitoneal lignocaine doses varied from 100 to 1000 mg, mean Cmax ranged from 1.01 to 4.32 μg/ml and mean Tmax ranged from 15 to 40 minutes. Intraperitoneal bupivacaine doses varied from 50 to 150 mg (weight based doses also reported), mean Cmax ranged from 0.29 to 1.14 μg/ml and mean Tmax ranged from 15 to 60 minutes. Intraperitoneal ropivacaine doses varied from 100 to 300 mg, mean Cmax ranged from 0.66 to 3.76 μg/ml and mean Tmax ranged from 15 to 35 minutes. The addition of adrenaline to intraperitoneal local anaesthetic almost halves systemic levels and prolongs Tmax. Intraperitoneal local anaesthetic results in detectable systemic levels in the perioperative setting. Despite a lack of clinical toxicity, careful attention to dose is still required to prevent potential systemic toxic levels. Clinicians should also consider the addition of adrenaline to intraperitoneal local anaesthetic solutions to further add to the systemic safety profile.
Anti-Emetic Doses of Dexamethasone Suppress Cortisol Response in Laparoscopic Cholecystectomy
Authors: Cowie B. S. , Allen K. J. , Said S. A. , Inder W. J.
Published: January 2019

The efficacy of dexamethasone alone or in combination with a serotonergic antagonist to prevent nausea and vomiting in laparoscopic cholecystectomy is well established, but few data exist regarding its effects on perioperative cortisol and glucose levels.

Fourteen non-diabetic subjects having elective laparoscopic choleycystectomy and standardised general anaesthesia were randomised to receive 8 mg of intravenous dexamethasone and tropisetron or tropisetron alone. Plasma cortisol and glucose were measured preinduction, at five and 24 hours postoperatively. There was no difference in plasma cortisol at five hours postoperatively in patients who received dexamethasone, but by 24 hours there was marked suppression compared to the control group (P <0.005) to less than 5% of the preoperative value. There was a small but statistically significant elevation in blood glucose at 24 hours (P <0.01) in the dexamethasone-treated group.

In patients undergoing laparoscopic cholecystectomy, an anti-emetic dose of dexamethasone (8 mg) markedly suppresses plasma cortisol at 24 hours and causes a minor elevation in blood glucose.
Elective Caesarean Section for a Woman with Emery-Dreifuss Muscular Dystrophy
Authors: Kim O. M. O. , Elliott D.
Published: January 2019

Emery-Dreifuss muscular dystrophy is a rare form of muscular dystrophy involving both cardiac and skeletal muscles. Cardiac involvement frequently leads to dilated cardiomyopathy, arrhythmias and may precipitate sudden cardiac death. Skeletal involvement is characterised by early contractures and muscle weakness in the humeroperoneal distribution. We describe the anaesthetic management of a 29-year-old patient with Emery-Dreifuss muscular dystrophy presenting for elective caesarean section and discuss the disorder and its potential anaesthetic implications.
Acute Psychiatric Syndrome Leading Young Patients to ICU: Consider Anti-NMDA-Receptor Antibodies.
Authors: Varvat J. , Lafond P. , Page Y. , Coudrot M. , Reynaud-Salard M. , Tardy B.
Published: January 2019

We report on a case of anti-N-Methyl-D-Aspartate receptor antibody encephalitis, and review cases and series previously published in the literature. Anti-N-Methyl-D-Aspartate receptor antibody encephalitis usually occurs in young female patients with no past medical history, in whom an ovarian teratoma is often detected. They subacutely develop predominantly psychiatric symptoms, followed by severe neurological disorders requiring transfer to the intensive care unit and prolonged ventilatory support. Complete or substantial recovery depends on early diagnosis, removal of the teratoma and immunotherapy. Our purpose is to focus intensivists’ attention on this potentially lethal disorder, which should always be considered in young women admitted to the intensive care unit with characteristic neuropsychiatric disorders.
The use of Drotrecogin Alfa in Severe Falciparum Malaria
Authors: Robak O. , Bojic A. , Locker G. J. , Laczika K. , Ramharter M. , Staudinger T.
Published: January 2019

We report the case of a 55-year-old male European who became septic after he returned from a four-week holiday to Uganda. Soon after, he was diagnosed with severe falciparum malaria and developed multi-organ failure. Due to the worsening condition of the patient, drotrecogin alfa (activated) was started, soon after which the patient's condition significantly improved. He returned home on day 36 after admission, without neurologic sequelae.

Looking at those few cases of severe forms of malaria where drotrecogin alfa (activated) was successfully used, it should at least be considered for administration in patients with severe falciparum malaria with disseminated intravascular coagulation and cerebral involvement who do not respond to or deteriorate during standard treatment.
Antimicrobial Utilisation in 37 Australian and New Zealand Intensive Care Units
Authors: Dulhunty J. M. , Paterson D. , Webb S. A. R. , Lipman J.
Published: January 2019

This multi-centre point prevalence study reports on antimicrobial dosing patterns, including dose, mode of administration and type of infection, in 37 Australian and New Zealand intensive care units. Of 422 patients admitted to an intensive care unit on 8 May 2007, 195 patients (46%) received antimicrobial treatment, 123 patients (29%) received no antimicrobials and 104 patients (25%) received prophylactic antimicrobials only. Dosing data were available for 331 antimicrobials used to treat 225 infections in 193 patients. Respiratory (40%), abdominal (13%) and blood stream (12%) infections were most common. For adult patients, ticarcillin/clavulanate (23% or 40/177), meropenem (20% or 35/177) and vancomycin (18% or 32/177) were the most frequently used antibiotics; vancomycin was most commonly used in children (31% or 5/16). The majority of antimicrobials were administered as bolus doses or infusions of less than two hours (98% or 317/323); only six patients received extended or continuous infusions. The mode of administration was unknown in eight cases (4.1%). The total defined daily dose for adult patients receiving antimicrobial therapy was 2051 defined daily doses per 1000 patient days. Our results confirm that the use of continuous infusions remains rare, despite increased interest in continuous infusions for time-dependent antibiotics.
The Utility of Procalcitonin in Diagnosis of H1N1 Influenza in Intensive Care Patients
Authors: Hammond N. E. , Corley A. , Fraser J. F.
Published: January 2019

Procalcitonin (PCT) has been reported to differentiate between bacterial and viral causes of respiratory tract infections. We aimed to assess its ability to discriminate between viral and bacterial infection during the H1N1 pandemic of 2009. The design of this study was a retrospective single centre case series review. Subjects were 17 adult patients admitted to the intensive care unit with suspected or confirmed isolated H1N1 influenza infection, from whom a PCT level was assessed within 24 hours of admission. All patients were admitted during the H1N1 pandemic in Queensland from 6 July 2009 to 2 August 2009.

The relationship between PCT levels and H1N1 status was measured by a Wilcoxon rank sum test. Patients were proven to have isolated H1N1 infection as judged by Polymerase Chain Reaction, with no bacterial super-infection. Of this number, 37% had a PCT <1 μg/l, and 63% of patients had an indeterminate PCT between 1 and 10 μg/l.

The demographics of all 17 patients were mean age 48.2 years (SD 13.6 years); 59% female; mean Acute Physiological and Chronic Health Evaluation II score 20.3 (SD 5.8); mean intensive care unit 477.5 hours (SD 330.0 hours); 82% of cases required mechanical ventilation; 24% of cases required extracorporeal membrane oxygenation and 94% of cases were alive at intensive care unit discharge.

PCT was neither sensitive nor specific in determining isolated H1N1 infection in this series of patients. The use of PCT to assist in isolation triage of patients suspected of infection with H1N1 influenza in the intensive care unit should be made with caution. A larger study may be required.
Preferences of Critical Care Registrars in Fluid Resuscitation of Major Trauma Patients: Concordance with Current Guidelines
Authors: Cade J. A. , Truesdale M.
Published: January 2019

Fluid resuscitation of patients with major trauma remains a controversial topic. We hypothesised that current practice amongst critical care registrars at our centre might differ from current clinical guidelines. Sixty-six registrars from anaesthesia, intensive care and emergency medicine completed a survey giving their preferences for fluid resuscitation in major trauma patients. Most (85%) appropriately would choose a crystalloid (normal saline 68%, Hartmann's solution 17%), although intensive care registrars reported an early preference for colloids (20% of intensive care registrars would choose a colloid vs 0% of other departmental registrars, P <0.01). Many responses indicated that the presence of an acidosis would not influence their choice of primary resuscitation fluid. Few participants were unfamiliar with the current practice of avoiding colloids as a primary resuscitation fluid in head-injured patients. Most (62%) would choose to transfuse trauma patients after 2 litres of crystalloid, although there was significant inter-departmental variation (P <0.01). In addition, participants would transfuse an older patient (P=0.02) or an actively bleeding patient (P <0.01) earlier than the younger or not visibly bleeding trauma patient. We concluded that our study demonstrated general consistency with current clinical guidelines but with interesting interdepartmental variations. We suggest that this type of study could enhance clinical practice by pointing to targeted additional learning opportunities.
Scientific Publications in International Anaesthesiology Journals: A 10-Year Survey
Authors: Li Z. , Qiu L.-X. , Wu F.-X. , Yang L.-Q. , Sun S. , Yu W. F.
Published: January 2019

Significant growth has been seen in the field of anaesthesiology in recent decades. The current geographic distribution of the publications on anaesthesia research may be different from ten years ago. We performed this literature survey to examine the national origin of articles published in international anaesthesiology journals and to evaluate their contribution to anaesthesia research. Articles published in 18 major anaesthesiology journals from 2000 to 2009 were identified from the PubMed database and the Science Citation Index. A total of 30,191 articles were published in the selected 18 journals from 2000 to 2009. The country responsible for the largest number of articles was the United States of America (29.4%), followed by the United Kingdom, Germany, Japan, Canada, Australia and France. Denmark, Switzerland and Finland had the largest number of articles per capita. Anesthesia & Analgesia published the most number of articles from 2000 to 2009, followed by Anesthesiology, Pain and the British Journal of Anaesthesia. The numbers of clinical studies and randomised controlled trials decreased markedly from 2000 to 2009.
The use of Rocuronium in a Patient with Cystic Fibrosis and End-Stage Lung Disease Made Safe by Sugammadex Reversal
Authors: Porter M. V. , Paleologos M. S.
Published: January 2019

While the pharmacology of sugammadex has been extensively reviewed, there is limited literature regarding its use in specific clinical settings. Several case reports describe its use in patients with the potential for postoperative respiratory dysfunction; in the settings of myasthenia gravis, Duchenne muscular dystrophy and myotonic dystrophy. We describe the use of sugammadex in a patient with severe bronchiectasis related to cystic fibrosis who required neuromuscular block for percutaneous endoscopic gastrostomy insertion. The use of rocuronium for neuromuscular block was preferred in order to avoid the potential complications associated with the use of suxamethonium. However, we wished to ensure complete neuromuscular block reversal for this short duration procedure in this high-risk patient and also to avoid the side-effects of traditional reversal agents. We therefore planned in advance to use sugammadex for neuromuscular block reversal, and this approach proved successful. Overall, the combination of rocuronium and sugammadex improved perioperative surgical and anaesthetic management in this patient.
The History of Simple Analgesics
Authors: Ball C. , Westhorpe R. N.
Published: January 2019

The Reverend Edward Stone, resting beneath his willow trees in 1758, chewed on a piece of the bark, whereupon the bitter taste “… immediately raised in me a suspicion of its having the properties of the Peruvian bark”1. Peruvian bark, which contains quinine, was known to be effective in some cases of ague, a term used to describe a nonspecific group of symptoms including headache, fever and rigors. Many of these patients would have suffered from malaria, hence the response to quinine, but Peruvian bark grew only in South America and an alternative treatment would have been a great breakthrough. Stone conducted experiments over the next five years. He determined that the willow bark was also effective in treating the fever of ague and presented his findings to the Royal Society. His work was published in the transactions but there was little excitement about his discovery for a further 40 years when chemists began pondering the active ingredients of plant-based medication.
Daily Sedation Interruption; A Glass Half Empty?
Authors: Shehabi Y. , Weisbrodt L.
Published: January 2019

The last decade witnessed an exponential rise in the number of publications addressing management of sedation during critical illness. In 1998 Kollef and colleagues1 suggested that the use of continuous infusions of sedatives may be associated with prolonged duration of mechanical ventilation and intensive care unit (ICU) stay. This was followed by a landmark study by Kress and colleagues2 who demonstrated significant reduction in ventilation time and ICU stay with daily interruption of sedative infusions (DSI). Subsequent investigations have been consistent with the notion that strategies that reduce sedation depth such as algorithms and protocols for sedation management3-5 and the use of validated sedation scales6 can improve patient outcomes. This academic exuberance led to an endorsement of these strategies, and in particular DSI, by the UK Department of Health ( www.clean-safe-care.nhs.uk ), the Institute for Healthcare Improvement ( www.IHI.org ) and Safer Health Care Now! ( www.saferhealthcarenow.ca ).