bluuebunny/crossref_metadata_2025 huggingface dataset:
The Analgesic Effect of Intrathecal Dexmedetomidine or Clonidine, with Bupivacaine, in Trauma Patients Undergoing Lower Limb Surgery: A Randomised, Double-Blind Study
Authors: Solanki S. L. , Bharti N. A. , Batra Y. K. , Jain A. , Kumar P. , Nikhar S.
Published: January 2019

This randomised, double-blind study was designed to compare the duration of analgesia and adverse effects following intrathecal administration of dexmedetomidine or clonidine, both with bupivacaine, in trauma patients. Ninety adult trauma patients of American Society of Anesthesiologists physical status I—II, scheduled for lower limb surgery under subarachnoid block, were randomly allocated to one of three groups. All groups received hyperbaric bupivacaine 0.5% 3 ml, to which was added saline 0.5 ml (Group B): clonidine 50 μg (Group C) or dexmedetomidine 5 μg (Group D). The onset and duration of sensory and motor blockade, severity of postoperative pain, time to first rescue analgesia and total analgesic requirement for 24 hours were noted. There was no significant difference in the onset time of the block but the duration of sensory and motor blockade was prolonged in Groups C and D, compared with Group B. The time to analgesia was significantly prolonged in Group D (824±244 minutes) compared with Group C (678±178 minutes; P=0.01), the latter being longer than Group B (406±119 minutes; P=0.0001). Postoperative pain scores were lower in Groups C and D compared with Group B. The requirement for rescue analgesia during the first 24 postoperative hours was significantly less in Groups C and D as compared to Group B ( P=0.0001), but comparable between Group C and D ( P=0.203). In conclusion, dexmedetomidine 5 μg added to intrathecal bupivacaine 15 mg produces longer postoperative analgesia than clonidine 50 μg among trauma patients undergoing lower limb surgery.
Australian Paediatric Hyperbaric Oxygen Therapy 1998–2011
Authors: Frawley G. , Bennett M. , Thistlethwaite K. , Banham N.
Published: January 2019

For a large number of ischaemic, infective, inflammatory or traumatic conditions, hyperbaric oxygen therapy is either the only treatment or an adjunct that significantly reduces morbidity and mortality. The primary aim of this review is to identify clinical conditions treated in a paediatric population referred to Australian hyperbaric units. Secondary aims are to describe outcomes of treatment and detail any complications occurring during treatment or during transfer between units.

This was a retrospective cohort study (January 1998–December 2011) of children treated at four Australian hyperbaric medical units. A total of 112 children underwent 1099 hyperbaric treatments for 14 indications. Ages were not normally distributed with a median age of 14 years (interquartile range 11–16; range 0.25–16 years). Treatments were completed as planned in 81.5% of cases with 25 patients’ treatment terminated at the request of physicians, parents or patients. Complications relating to hyperbaric oxygen therapy occurred in 58 treatments (5.3%). Central nervous system oxygen toxicity occurred in 1:366 treatments. Our findings indicate that provision of hyperbaric oxygen therapy to children is feasible in major regional hyperbaric units and is associated with low complication rates. Management of children in an adult hyperbaric facility, however, requires significant cooperation between paediatric, intensive care and hyperbaric consultants, as the need for transfer to another hospital and prolonged transports often impacts on optimal ongoing surgical and intensive care management.
Epidural Anaesthesia with Goal-Directed Administration of Ropivacaine Improves Haemodynamic Stability when Combined with General Anaesthesia in Elderly Patients Undergoing Major Abdominal Surgery
Authors: Zhou Q. H. , Xiao W. P. , Yun X.
Published: January 2019

The use of epidural ropivacaine may result in significant haemodynamic fluctuations during combined epidural and general anaesthesia. We designed this study to investigate whether epidural anaesthesia with a goal-directed approach, when combined with general anaesthesia, improved haemodynamic stability in elderly patients undergoing major abdominal surgery. Seventy-five elderly patients undergoing major abdominal surgery were randomly and evenly assigned to one of three groups receiving intraoperative epidural anaesthesia with either ropivacaine 0.1% (Group 1), ropivacaine 0.375% (Group 2) or ropivacaine 0.375% for abdominal wall pain and ropivacaine 0.1% for visceral pain (Group 3). General anaesthesia was induced using a target-controlled infusion of combined propofol and remifentanil. The remifentanil target concentration was adjusted according to the mean arterial pressure and heart rate, and vasoactive agents were administered to maintain stable haemodynamics. The need for vasoactive drug administrations was 1.4 (standard deviation 0.9) in Group 3 (n=24), representing a significantly lower frequency of administration compared with Groups 1 (n=24) and 2 (n=24) ( P <0.05 versus Group 1; P <0.01 versus Group 2). The total intraoperative dose of remifentanil was significantly greater in Group 1 (P <0.01 versus Group 2; P <0.05 versus Group 3) but did not differ significantly between Groups 2 and 3. Goal-directed epidural anaesthesia with different ropivacaine concentrations can improve haemodynamic stability when combined with general anaesthesia for elderly patients undergoing major abdominal surgery.
The Anaesthetic Pre-Admission Clinic is Effective in Minimising Surgical Cancellation Rates.
Authors: Emanuel A. , Macpherson R.
Published: January 2019

Pre-admission clinics (PAC) are now well-established in most hospitals. However, there have been few studies examining the efficacy of PACs in minimising day of surgery cancellations due to anaesthetic reasons.

A retrospective cross-sectional descriptive study was carried out in a metropolitan tertiary hospital over a four-year period to assess reasons for anaesthetic-related day of surgery cancellations in elective surgical patients who attended the PAC. Of 12,537 patients who attended the PAC during the study period, 58 (0.46%) were cancelled on the day of surgery for anaesthetic reasons. The most common cause was non-preventable misadventure such as acute respiratory tract infections, seen in 19 patients (33% of all anaesthetic cancellations). The next most common cause was classified as being due to patient or system error (16 patients). This included patients’ failure to adhere to fasting or medication guidelines, or a failure to detect and respond to abnormal laboratory results. Clinical disagreement between anaesthetic assessment at the PAC and the attending anaesthetist on the day of surgery was low (12 patients, 21%), and clinical deterioration in a pre-existing condition (six patients, 10%) accounted for the majority of other cancellations. Although patient misadventure constituted the major cause of anaesthetic cancellations, non-adherence to fasting and medication guidelines constituted the next major reason for surgery cancellation due to anaesthetic causes. This is important as such cancellations are potentially preventable and the overall cancellation rate could potentially be improved by instituting relatively simple changes to clinic function.
A Survey of Aseptic Precautions and Needle Type for Paediatric Caudal Block in Australia and New Zealand
Authors: Fahy C. J. , Costi D. A. , Cyna A. M.
Published: January 2019

This cross-sectional survey was designed to evaluate the current practice of anaesthetists in Australia and New Zealand with regard to aseptic technique and needle type during the performance of single-shot caudal blocks. Professional bodies suggest that full aseptic precautions be taken during the administration of caudal or epidural blocks. It has been suggested that using an intravenous cannula or a styletted needle may obviate the occurrence of epidermoid tumours. A total of 202 members of the Society for Paediatric Anaesthesia in New Zealand and Australia were invited to participate in this internet-based survey. Eighty-four responses were received. Most respondents used some form of antiseptic handwash (81%), wore sterile gloves (85.7%), used antiseptic skin preparation (100%) and draped the site (57.1%). When performing caudal blocks, 43.1% used unstyletted needles, 27.2% used styletted spinal needles and 29.6% used intravenous cannulas. However, 11.9% did not wash hands, 10.7% did not wear gloves and 42.9% did not drape the site. Three respondents reported neither handwashing, wearing gloves or draping, instead only using an alcohol swab for skin preparation. The majority of respondents in our region appear to use some level of aseptic precautions, albeit to a variable degree. Published recommendations may either be perceived as overly cautious or as ambiguous in that they do not specify caudal practice as distinct from other epidural blocks. There is a need for clearer professional guidance to support a minimum level of aseptic precaution for single-shot caudal epidural blocks.
Early Tracheal Stenosis Causing Extubation Failure and Prolonged Ventilator Dependency
Authors: Dalar L. , Schuurmans M. M. , Eryuksei E. , Karasulu A. L. , Kosar A. F. , Altin S.
Published: January 2019

Postintubation stenosis is the most frequent cause of benign tracheal stenosis and may cause reintubation and delay in weaning of intensive care unit patients. This case study describes typical patients with tracheal stenosis and the management of these patients. Five patients requiring reintubation and mechanical ventilation due to early intubation-related stenosis are discussed. Stridor developed in three cases after extubation. In these cases, bronchoscopy revealed tracheal stenosis. Dilatation and silicone stent placement were performed using rigid bronchoscopy. The other two patients were on ventilators when they were admitted to the intensive care unit and their stenoses were also treated by rigid bronchoscopy. Hypercapnia and hypoxia resolved after intervention in three cases. Of the remaining two patients, one had the tracheostomy closed and in the other patient ventilation was stopped but the tracheostomy was maintained. Tracheal stenosis developing in the subglottic region after extubation, especially after exposure to cuff pressure, may lead to reintubation. A tracheostomy may hinder the diagnosis of progressive stenosis and may lead to unnecessary maintenance of ventilator treatment. Early intubation-related tracheal stenosis should therefore be considered in cases of weaning or extubation failure and prompt appropriate investigation and treatment.
Carbon Dioxide Clearance in Critical Care
Authors: Tiruvoipati R. , Botha J. A. , Pilcher D. , Bailey M.
Published: January 2019

Lung protective ventilation limiting tidal volumes and airway pressures were proven to reduce mortality in patients with acute severe respiratory failure. Hypercapnia and hypercapnic acidosis is often noted with lung protective ventilation. While the protective effects of lung protective ventilation are well recognised, the role of hypercapnia and hypercapnic acidosis remains debatable. Some clinicians argue that hypercapnia and hypercapnic acidosis protect the lungs and may be associated with improved outcomes. To the contrary, some clinicians do not tolerate hypercapnic acidosis and use various techniques including extracorporeal carbon dioxide elimination to treat hypercapnia and acidosis. This review aims at defining the effects of hypercapnia and hypercapnic acidosis with a focus on the pros and cons of clearing carbon dioxide and the modalities that may enhance carbon dioxide clearance.
Primary Anaesthetic Deaths in Western Australia from 1985–2008: Causation and Preventability
Authors: Gibbs N. M. , Rodoreda P.
Published: January 2019

This paper reports on the causes and preventability of primary anaesthetic deaths in Western Australia between 1985 and 2008. In Western Australia, it is a legal requirement to report all deaths that occur within 48 hours of an anaesthetic and later deaths if an anaesthetic complication is implicated. A committee assesses whether an anaesthetic factor caused the death (a primary anaesthetic death) or contributed to the death (an anaesthesia-related death). Of the 2361 deaths reported to the Committee over the 24-year period, 102 were considered anaesthesia-related and of these, 53 were considered a primary anaesthetic death. There were six main causes of primary anaesthetic death: failure to oxygenate; aspiration of gastric contents; adverse drug reaction; dose-related drug effect leading to an adverse cardiovascular event; intravascular injection of local anaesthetic; and injury related to an anaesthetic procedure or invasive monitoring. The most common cause was a dose-related drug effect leading to an adverse cardiovascular event. The medical condition of the patient was considered a significant contributing factor in 69% of the deaths and 72% were considered preventable. In the second 12-year period, there were fewer deaths overall (15 vs 38), proportionately fewer deaths related to failure to oxygenate (one vs six) and proportionately more deaths related to aspiration of gastric contents (four vs two). However, the percentage of deaths considered preventable was similar. These findings can be used to advise patients on anaesthetic risks, to educate anaesthetists about preventable deaths and to encourage the development of even safer anaesthetic drugs and techniques.
The Prevalence of Anaemia, Hypochromia and Microcytosis in Preoperative Cardiac Surgical Patients
Authors: David O. , Sinha R. , Robinson K. , Cardone D.
Published: January 2019

This retrospective study aimed to determine the prevalence of preoperative anaemia, hypochromia and microcytosis in cardiac surgery patients. Data was analysed for 943 patients (over a two-year period) undergoing coronary artery bypass graft, valve or combined coronary artery bypass graft and valve surgery at a tertiary hospital in South Australia. Overall prevalence of preoperative anaemia was 25.2%, greater in males than females (27.6 vs 19.9%, P <0.01). Of patients with preoperative anaemia, 19.3% had reduced red cell indices (mean corpuscular haemoglobin and/or mean corpuscular volume) compared to 4% of patients without anaemia. The proportion of anaemic patients with low red cell indices was significantly higher in women <50 years and 50–65 years, compared to those >65 years of age (P=0.003). Anaemic patients with low red cell indices had lower preoperative haemoglobin than anaemic patients without low red cell indices (median haemoglobin 112 vs 120 g/1, P=0.008). Compared to non-anaemic patients, anaemic patients had higher transfusion rates (79.8 vs 46.4%, P <0.0001), which were greater in those with reduced red cell indices compared to those with normal red cell indices (93.5 vs 76.6%, P=0.01). This study demonstrated a high prevalence of preoperative anaemia, microcytosis and hypochromia in cardiac surgical patients.
A Survey of the Management of Neuromuscular Blockade Monitoring in Australia and New Zealand
Authors: Phillips S. , Slewarl P. A. , Bilgin A. B.
Published: January 2019

This survey of anaesthetists in Australia and New Zealand aimed to investigate their attitudes and practice relating to the management of neuromuscular blockade monitoring. All medical practitioner members (3188) of the Australian and New Zealand Societies of Anaesthetists were invited to complete an anonymous survey, which was available online for two months. A total of 678 survey questionnaires were completed (response rate 21%). Most respondents (71.4%) underestimated the incidence of residual neuromuscular blockade and 63.2% believed this to be a significant clinical problem. Objective monitoring of neuromuscular function was used routinely only by 17% of respondents, although 70% believed routine monitoring would reduce the incidence of residual neuromuscular blockade. Only 25% of respondents correctly indicated that quantitative train-of-four counts of greater than 90% were the accepted criteria for safe extubation, with 52% using clinical judgement only. Only 29% of respondents believed neuromuscular function monitors should be part of minimum monitoring standards; quantitative neuromuscular function monitors were not available in 42% of the hospitals in which the respondents practiced. Despite the low response rate, the large sample size and heterogeneity of respondents make the findings of this survey concerning. There is a need for more education, availability of appropriate monitoring equipment and evidence-based guidelines for management of neuromuscular blockade in Australia and New Zealand.
Donation after Cardiac Death in Non-Survivable Burns
Authors: Widdicombe N. J. , Van Der Poll A. , Gould A. , Isbel N.
Published: January 2019

Major burns have previously been considered a contraindication to solid organ donation. We present two cases of successful organ donation and transplantation, after Maastricht category III cardiac death in adult patients with non-survivable burns injury. The implications of the outcome of these cases are that major burns should not be considered a contraindication to organ donation, and that cardiac death provides opportunity for patients with non-survivable burns to contribute to the pool of potential organ donors.
Spontaneous Intracranial Hypotension and Epidural Blood Patch: A Report Involving Seven Cases
Authors: Ferraro F. , Marano E. , Petruzzi J. , Tedeschi E. , Santulli L. , Elefante A.
Published: January 2019

Spontaneous intracranial hypotension is a rare condition caused by spontaneous cerebrospinal fluid leak. It is characterised by orthostatic headache, diffuse pachymeningeal enhancement on brain imaging and low cerebrospinal fluid pressure.

Seven patients with spontaneous intracranial hypotension were treated conservatively: of these, four responded to drug treatment and three underwent a lumbar autologous epidural blood patch (EBP). A complete response was obtained in two patients after a single EBP; one patient underwent a second EBP and then became asymptomatic. Clinical improvement coincided with a dramatic reduction of pachymeningeal enhancement. The aetiology and brain imaging findings, and the technique and effectiveness of EBP are discussed.
High Volume Local Infiltration Analgesia Compared to Peripheral Nerve Block for Hip and Knee Arthroplasty—What is the Evidence?
Authors: Fowler S. J. , Christelis N.
Published: January 2019

Since being reported in 2008, high volume local infiltration analgesia (HVLIA) has rapidly gained popularity for patients undergoing hip and knee replacement. We undertook this review to investigate whether there was evidence for equivalence of HVLIA compared to peripheral nerve block techniques with respect to early postoperative analgesia and functional recovery, or for other outcomes such as cost and process efficiency, persistent postsurgical pain and arthroplasty revision rate. We found that despite the popularity of HVLIA, supporting evidence for its use is currently limited. HVLIA certainly provides postoperative analgesia, but it is not clear whether it is equivalent to contemporary peripheral nerve block techniques in terms of either analgesia or early or later functional outcome in the context of a modern, comprehensive enhanced recovery program. Nor is it possible to state whether HVLIA provides benefits in terms of persistent postsurgical pain or cost and process efficiency. Well designed trials directly comparing peripheral nerve block with a standardised HVLIA technique are urgently required.
Feasibility of Anaesthetic Provision for Paediatric Patients Undergoing Off-Site Intraoperative MRI-Guided Neurosurgery: The Singapore Experience from 2009 to 2012
Authors: Lim E. , Rai E. , Seow W. T.
Published: January 2019

The benefits of using intraoperative magnetic resonance imaging (iMRI) for neurosurgery have been recognised. However, iMRI facilities are not available in all hospitals. For example, in Singapore iMRI is currently available only at the Singapore General Hospital, an adult hospital without facilities for intensive care management of patients less than 12 years of age. KK Women's and Children's Hospital is a dedicated children's hospital situated 6.3 km away from this facility. In order to obtain iMRI services for our paediatric patients, transport to Singapore General Hospital is required, with return to our hospital for postoperative management. Since July 2009 we have managed nine paediatric patients in this manner: three children with arteriovenous malformations and six children with brain tumours. There was no morbidity or mortality that could be attributed to the transport of patients either to or from Singapore General Hospital. Our experience suggests that with adequate planning and preparation, providing anaesthetic care and transporting children for off-site iMRI-guided neurosurgery is feasible and safe for selected children.
Duration of Cortisol Suppression following a Single Dose of Dexamethasone in Healthy Volunteers: A Randomised Double-Blind Placebo-Controlled Trial
Authors: Elston M. S. , Conaglen H. M. , Hughes C. , Tamatea J. A. U. , Meyer-Rochow G. Y. , Conaglen J. V.
Published: January 2019

The synthetic glucocorticoid dexamethasone is administered to many patients receiving a general anaesthetic to reduce the risk of postoperative nausea and vomiting. Dexamethasone is known to suppress the hypothalamic-pituitary-adrenal axis; however, the duration of this suppression following the standard anti-emetic intravenous dose of 4 to 8 mg used with anaesthesia is unknown.

A randomised controlled double-blind crossover trial assessing the effects of 8 mg intravenous dexamethasone versus saline control was performed in ten healthy male volunteers. The adrenal, thyroid and gonadal axes and glucose levels were assessed over a four-day period after dexamethasone administration.

All participants had normal baseline hypothalamic-pituitary-adrenal axis function. No difference in Cortisol levels was demonstrated at four or eight hours after dexamethasone administration compared with placebo. At 24 hours post dexamethasone, the Cortisol had dropped to less than 5% of baseline and returned to normal during the subsequent day. Increased plasma glucose levels were also observed in the dexamethasone group as compared with placebo.

A dose of 8 mg of dexamethasone results in significant suppression of the hypothalamic-pituitary-adrenal axis and elevated plasma glucose levels. The Cortisol suppression is maximal at approximately 24 hours post dose.
Phenytoin Loading Doses in Adult Critical Care Patients: Does Current Practice Achieve Adequate Drug Levels?
Authors: Putt M. T. , Udy A. A. , Jarrett P. , Martin J. , Hennig S. , Salmon N. , Lipman J. , Roberts J. A.
Published: January 2019

Phenytoin is regularly employed in the critically ill for prophylaxis against or treatment of seizure disorders. No prior studies have examined current dosing practices in an Australasian intensive care unit (ICU) setting. The aims of this study were to: a) describe the adequacy of contemporary dosing in respect to free and total serum phenytoin concentrations; b) identify factors associated with therapeutic drug concentrations; and c) examine the accuracy of predictive equations that estimate free concentrations in this setting. All patients receiving a loading dose of phenytoin in a tertiary-level ICU were eligible for enrolment; 53 patients were enrolled in the study. Serum samples to determine free and total phenytoin concentrations (measured by high performance liquid chromatography) were then drawn prior to the following dose. Free concentrations below the recommended target (<1 mg/1) were considered as suboptimal. The most common indication for phenytoin loading was traumatic brain injury (49%) and the mean administered dose was 14.5 (3.66) mg/kg. Twenty-six patients (49%) had suboptimal trough free concentrations, although this subgroup was significantly heavier and therefore received a lower per kilogram dose (12.8 [3.1] vs 16.3 [3.4] mg/kg, P=0.001). In multivariate analysis, larger weight adjusted doses ( P=0.018), higher albumin concentration ( P=0.034) and receiving phenytoin for an indication other than seizure ( P=0.035), were associated with a greater likelihood of adequate concentrations. In conclusion, phenytoin dosing remains complex in critically ill patients, although lower per kilogram loading doses are strongly associated with free concentrations below the desired target.
Diagnostic Potential of Open Lung Biopsy in Mechanically Ventilated Patients with Diffuse Pulmonary Infiltrates of Unclear Aetiology
Authors: Depuydt O. E. , Daeze C. , Benoit D. , Praet M. , Vermassen E. , Decruyenaere M.
Published: January 2019

Acute respiratory failure with bilateral pulmonary infiltrates is a clinical problem with a wide differential diagnosis. We evaluated whether open lung biopsy offered a diagnosis and therapeutic guidance in cases of unclear diagnosis after non-invasive tests. For this purpose, we reviewed 60 cases of open lung biopsy performed between 2002 and 2009 in patients with acute respiratory failure and bilateral infiltrates at the intensive care unit of Ghent University Hospital. Pathological diagnosis was classified as specific or non-specific and its contribution to therapy and decision-making was evaluated by a panel of three intensive care unit physicians. We found that a specific pathological diagnosis was present in 39 open lung biopsy patients (65%; 95% confidence interval 52 to 76%): idiopathic interstitial pneumonia in 24 patients, malignancy in four patients, pulmonary infectious disease in nine patients, and a combination of specific diagnoses in two patients. Open lung biopsy contributed to patient management in 53 cases (88%) as it led to the initiation, modification or discontinuation of therapeutic drugs in 36, and contributed to the decision to continue or withdraw ventilator support in 17. Complications of open lung biopsy were noted in 14 patients (23%). We conclude that open lung biopsy was a useful diagnostic intervention in of a selected group of patients with acute respiratory failure and bilateral infiltrates of unclear clinical diagnosis, as it offered a specific diagnosis in 65%.
Mental Health and Welfare in Australian Anaesthetists
Authors: Mcdonnell N. J. , Kaye R. M. , Hood S. , Shrivaslava P. , Khursandi D. C. S.
Published: January 2019

This survey was designed to evaluate the factors affecting mental health and welfare in Australian anaesthetists and to investigate current sources of support.

An electronic survey was sent to 500 randomly selected Fellows and trainees of the Australian and New Zealand College of Anaesthetists. Questions were related to: anxiety, stress, depression, substance misuse, self-medication, suicide, reporting illness, and help-seeking. Current psychological wellbeing was assessed using the Kessler Psychological Distress Scale (K10).

A total of 191 completed surveys were received (a response rate of 38%): 26% had attended their general practitioner for mental health issues, of whom half had been diagnosed with a mental illness; 7% of all respondents were currently prescribed medication for this; 25% had previously self-prescribed psychoactive medication; 17% admitted to using alcohol to deal with stress, anxiety or depression; and 8% responded that mental illness had at some point impaired clinical care. Sixteen percent of all respondents reported previous suicidal ideation.

Despite a low response rate, and the possibility of responder bias, the mental health of Australian anaesthetists would appear to be subject to common and persistent risk factors, many of which are well described in previous studies. We identify general practitioners as particularly valuable in targeting initiatives for improvements in mental health and welfare. The significant prevalence of suicidal ideation and reluctance to approach senior colleagues with concerns about mental health or welfare issues are specific causes for concern and suggest that further investigation, education and a potential review of support networks is required.
Type 2 Diabetes Mellitus, Independent of Insulin Use, is Associated with an Increased Risk of Cardiac Complications after Vascular Surgery
Authors: Barker E. J. , Valentijn T. M. , Van De Luijtgaarden K. M. , Hoeks S. E. , Voute M. T. , Goncalves F. B. , Verhagen H. J. , Stolker R. J.
Published: January 2019

Previous reports on the prognostic value of diabetes mellitus for cardiac complications after vascular surgery show divergent results, especially in regards to the role of type 2 diabetes as a cardiac risk factor, which remains unclear. The aim of this study was to assess the impact of type 2 diabetes on 30-day cardiac complications after vascular surgery.

Patients undergoing elective vascular surgery between 2002 and 2011 were included in this retrospective cohort study. Previous diagnosis of type 1 and 2 diabetes and use of oral glucose-lowering medications and insulin were recorded. Patients with type 1 diabetes were excluded from the analysis. The main outcome parameter was cardiac complications, a composite of cardiovascular death, non-fatal myocardial infarction, congestive heart failure, severe arrhythmia and asymptomatic troponin release within 30 days of surgery. In multivariate analysis, corrections were made for comorbidities, demographics, medication use and surgical risk.

Of 1462 patients, 329 (22.5%) patients had type 2 diabetes. Cardiac complications occurred in 155 (13.7%) patients without diabetes and in 68 (20.7%) with type 2 diabetes. In multivariate analysis, type 2 diabetes was associated with a significantly increased risk of 30-day cardiac complications (odds ratio 1.80; 95% confidence interval 1.25 to 2.60). Results were similar for type 2 diabetes patients managed with (odds ratio 1.84; 95% confidence interval 1.01 to 3.37) and without (odds ratio 1.79; 95% confidence interval 1.19 to 2.70) insulin.

Type 2 diabetes is an independent risk factor for cardiac complications after vascular surgery and should be treated as such in preoperative cardiac risk stratification.
On the Origin of the First Australian Medical Journal
Authors: Bailey R. J.
Published: January 2019

The Australian Medical Journal is important to Australian anaesthesia in that, as well as associated editorials, it recorded the first use of ether for surgical operations. Though it survived from 1 August 1846 until 1 October 1847, its first issue was surrounded with mystery, referring to an earlier publication. Proof of this earlier issue of April 1846 has been discovered though no copy remains extant.
Central venous Oxygen Saturation during High-Risk General Surgical Procedures—Relationship to Complications and Clinical Outcomes
Authors: Boyle M. S. , Bennett M. , Keogh G. W. , O'Brien M. , Flynn G. , Collins D. W. , Biharih D.
Published: January 2019

Major non-cardiac surgery is associated with postoperative morbidity, and perioperative central venous oxygen saturation (ScvO2 may be a predictor of morbidity. This pilot study aimed to define intraoperative ScvO2 and to identify factors associated with postoperative complications. ScvO2 (reflection spectrophotometry) was recorded continuously in a convenience sample of adults undergoing high-risk general surgery. Demographics, intraoperative management, surgery duration, postoperative complications and deaths within 28 days were recorded. Data from 51 patients were analysed. Two (4%) died and 24 (47%) had at least one complication (range 1 to 5). The hospital length-of-stay and duration of surgery were longer in those with complications (22.1±6.1 versus 9.6±3.6 days, P <0.0001, and 328±162 minutes versus 241±94 minutes, P=0.02, respectively). Overall, the ScvO2 was 82±8% and ranged from 40% to 97% with 17 (33%) patients having at least one episode of ScvO2 <70%. Hospital length-of-stay ( P <0.0001), time ScvO2 <90% ( P=0.003), surgery duration ( P=0.005) and blood loss ( P=0.02) were correlated with the number of complications. Using multivariate analysis, surgery duration (odds ratio 1.008 [95% confidence interval 1.002 to 1.013]; P=0.006) and change in oxygen extraction ratio (O2ER) at the end of surgery compared to the beginning (odds ratio 1.13 [95% confidence interval 1.001 to 1.28]; P=0.04) were independently associated with complications. The surgery duration and an increased O2ER are factors related to the development of postoperative complications.
Randomised Comparison of an End-Hole, Triple-Hole and Novel Six-Hole Catheter for Continuous Interscalene Analgesia
Authors: Fredrickson M. J.
Published: January 2019

Epidural analgesia studies and a recent continuous peripheral nerve block study suggest multi-hole perineural catheters perform better than end-hole catheters. Confounding catheter positioning issues limit interpretation of the latter study. One hundred and fifty-six patients receiving an anterolateral interscalene catheter for elective shoulder surgery were randomised to three groups: following out-of-plane ultrasound confirmation of the needle tip immediately lateral to the C5/6 roots, an end-hole (n=52), triple-hole (n=53) or six-hole (n=51) non-stimulating catheter was positioned 3 cm beyond the needle tip. Ropivacaine 0.375% 15 ml was administered preoperatively via the catheter before surgery under general anaesthesia. A ropivacaine 0.2% 2 ml/hour infusion with mandatory six-hourly, and on-demand hourly, 5 ml boluses was continued for >48 hours with tramadol available as rescue. Patients were questioned in the recovery room and at 24 hours for numerical rating pain score (0 to 10), ropivacaine bolus and tramadol consumption. The frequency of recovery room pain was similar between groups ( P=0.75) and demonstrated strong evidence for equivalence at the 5% significance level. Neither time to first pain, “average” or “worst” pain during the first 24 hours, ropivacaine bolus or tramadol consumption significantly differed between groups. Catheter threading difficulty was more common for the square-tipped end-hole catheters (end-hole=19% versus triple-hole=6%, six-hole = 0%, P <0.001). This study found no evidence to support catheter orifice configuration significantly affecting the quality of continuous peripheral nerve blockade. These findings are in contrast to epidural catheter studies, and suggest that anatomical factors have a significant bearing on whether multi-orifice catheters confer advantage over the single-orifice design.
Preventing Cerebral Oedema in Acute Liver Failure: The Case for Quadruple-H Therapy
Authors: Warrillow S. J. , Bellomo R.
Published: January 2019

Severe cerebral oedema is a life-threatening complication of acute liver failure. Hyperammonaemia and cerebral hyperaemia are major contributing factors. A multimodal approach, which incorporates hyperventilation, haemodiafiltration, hypernatraemia and hypothermia (quadruple-H therapy), may prevent or attenuate severe cerebral oedema. This approach is readily administered by critical care clinicians and is likely to be more effective than the use of single therapies. Targeting of PaCO2 in the mild hyperventilation range, as seen in acute liver failure patients before intubation, aims to minimise hyperaemic cerebral oedema. Haemodiafiltration aims to achieve the rapid control of elevated blood ammonia concentrations by its removal and to reduce production via the lowering of core temperature. The administration of concentrated saline increases serum tonicity and further reduces cerebral swelling. In addition, the pathologically increased cerebral blood-flow is further attenuated by therapeutic hypothermia. The combination of all four treatments in a multimodal approach may be a safe and effective means of attenuating or treating the cerebral oedema of acute liver failure and preventing death from neurological complications.
Sugammadex Hypersensitivity—A Case of Anaphylaxis
Authors: Jeyadoss J. , Kuruppu P. , Nanjappa N. , Van Wijk R. M.
Published: January 2019

We describe a case of a patient undergoing open abdominal aneurysm surgery who developed a severe, life-threatening allergic reaction immediately after administration of sugammadex. The manifestation was purely a cardiovascular collapse. The mainstay of treatment was administration of high-dose adrenaline and fluid resuscitation. The diagnosis of anaphylaxis was supported by a positive serum mast cell tryptase (93 μg/1) at one hour post-event. Sugammadex was confirmed as the cause of the anaphylaxis by a positive intradermal allergy test (25 mm diameter response to 1:100 dilution), with a normal saline control and a negative response to the other drugs used during the event. This case report is a reminder that the use of sugammadex is associated with rare but serious risks.
Pituitary Apoplexy with Reversible Cerebral Vasoconstrictive Syndrome after Spinal Anaesthesia for Emergency Caesarean Section: An Uncommon Cause for Postpartum Headache
Authors: Mathur D. , Lim L. F. M. , Mathur M. , Sng B. L.
Published: January 2019

Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.
A Technique of Placing Cuffed Endotracheal Tubes through in Situ Paediatric Laryngeal Mask Airways
Authors: Ho A. M. H.
Published: January 2019

If tracheal intubation is not possible using direct laryngoscopy, one option is to use a laryngeal mask airway (LMA) through which an endotracheal tube (ETT) can be passed. In children, however, the size of an uncuffed ETT that can pass through the lumen of an LMA is sometimes too small for the trachea, resulting in gas leakage around the ETT. Using a cuffed ETT may reduce the gas leak but withdrawal of the LMA is then prevented by the pilot balloon. In this study, the largest sizes of cuffed and uncuffed Mallinckrodt™ ETTs that could pass with ease through various sizes of paediatric Classic™ and ProSeal™ LMAs were documented. For cuffed ETTs, withdrawal of the LMA was made possible by simply cutting off the pilot balloon. The ETT cuff-inflating mechanism was then repaired by passing a 20 or 22 gauge cannula into the cut end of the inflating tubing. The proximal end of the cannula was then connected to a one-way valve or a three-way stopcock. This technique of cutting off the pilot balloon of the cuffed ETT made it possible to use paediatric cuffed ETTs in exchange for the LMAs tested. The task was easy to perform. Subsequent repair of the cuff-inflation tubing was effective and could withstand high pressures. These findings indicate that it is possible to pass cuffed ETTs through paediatric LMA lumens, which can provide ventilation without gas leaks, unlike uncuffed ETTs.
Effect of Magnetic Resonance Imaging on Core Body Temperature in Anaesthetised Children
Authors: Lo C. , Ormond G. , Mcdougall R. , Sheppard S. J. , Davidson A. J.
Published: January 2019

Children undergoing magnetic resonance imaging (MRI) often require general anaesthesia (GA). Children under GA are at risk of decreases in body temperature. This risk may be greater during MRI due to MRI scanners requiring cool ambient temperatures. Conversely, radiofrequency radiation emitted by MRI scanners is absorbed by the patient as heat energy, creating a risk of an increase in body temperature. The aim of this study was to determine the proportion of anaesthetised children undergoing an MRI scan who develop hyperthermia or hypothermia, and the risk factors associated with temperature changes in these children. Pre-scan and post-scan tympanic temperatures were obtained from 193 children (aged three months to six years) undergoing an MRI procedure under GA. No active warming or cooling devices were used during the MRI scans. The median duration for anaesthesia was 42 minutes (35 to 57 minutes). Fifty-two percent of children were hypothermic after their scan, while no subjects were hyperthermic after their scan. The mean (± standard deviation) pre-scan temperature was 36.2°C±0.5°C, and the mean (± standard deviation) post-scan temperature was 35.9°C±0.6°C (an overall mean temperature decrease of 0.28°C was observed [95% confidence interval, −0.36°C to −0.19°C], P <0.001). In conclusion, core body temperature was found to decrease slightly during an MRI scan under GA. These results suggest that more focus is needed regarding the cooling effects of GA agents during MRI, as opposed to the heating effects of the MRI scanner.
Long-Term Outcomes of Minor Troponin Elevations in the Intensive Care Unit
Authors: Velasquez A. , Ghassemi M. , Szolovits P. , Park S. , Osorio J. , Dejam A. , Celi L.
Published: January 2019

The aim of our study is to determine the short-term and long-term outcomes of intensive care unit (ICU) patients with minor troponin elevations. The retrospective study compared ICU patients with peak troponin elevation less than 0.1 ng/ml to those with only negative tests during their hospital stay. Data were gathered from ICUs at Beth Israel Deaconess Medical Center between 2001 and 2008. A total of 4224 patients (2547 controls and 1677 positives) were analysed. The primary outcome was mortality at one year. Secondary outcomes were 30-day mortality and hospital and ICU lengths of stay. After adjusting for age, sex, Simplified Acute Physiology Score, Sequential Organ Failure Assessment and combined Elixhauser score, we found that minor troponin elevations (peak troponin elevation between 0.01 and 0.09 ng/ml) were associated with a higher one-year mortality (Hazard Ratio 1.22, P <0.001 for binary troponin presence; Hazard Ratio 1.03, P <0.001 for each 0.01 ng/ml troponin increment). This relationship held for the subgroup of seven-day post-discharge survivors (Hazard Ratio 1.26, P <0.001). Minor elevations of troponin also significantly increased the net reclassification index over traditional risk markers for mortality prediction (net reclassification score 0.12, P <0.001). Minor troponin elevation was also associated with 30-day mortality (odds ratio 1.33, P=0.003). Importantly, troponin testing did not increase the adjusted mortality odds ( P=0.9). Minor elevations in troponin substantially increase one-year, all-cause mortality in a stepwise fashion; it was also independently associated with 30-day mortality. We propose that minor elevations in troponin should not be regarded as clinically unimportant, but rather be included as a prognostic element if measured. We recommend prospective ICU studies to assess prognostic value of routine troponin determination.
Low-Cost High-Fidelity Anaesthetic Simulation
Authors: Hartwell D. A. , Grayling M. , Kennedy R. R.
Published: January 2019

Simulation has been advocated as a useful training tool, and specific manikin simulators have been developed for use in this role. Debriefing and repetition have been identified as key to achieving educational goals and, while the technical features of manikin simulators can influence simulation outcomes, their cost and infrastructure requirements reduce their suitability for smaller healthcare facilities. We describe a local solution using biomedical calibration machines and modified basic manikins already available in our institution to form a high-fidelity anaesthetic simulator at minimal cost. This was effective in running high-fidelity, team-based in situ simulations and ‘can't intubate, can't oxygenate’ assessments for anaesthetic trainees. Though equipment in other centres may differ both in availability or suitability for simulation, the option we describe or similar may offer a low-cost solution for peripheral centres to run limited high-fidelity scenarios on a regular basis.
Comparison of Electromyography and Kinemyography during Recovery from Non-Depolarising Neuromuscular Blockade
Authors: Stewart P. A. , Freelander N. , Liang S. , Heller G. , Phillips S.
Published: January 2019

In this study, two commercially available quantitative neuromuscular function monitoring techniques, electromyography (EMG) and kinemyography (KMG), were compared with respect to repeatability and accuracy during late recovery from neuromuscular blockade. Train-of-four (TOF) ratios were recorded in 30 patients using KMG and EMG at the adductor pollicis muscle. Measurements were taken on the same hand using the Datex-Ohmeda NeuroMuscular Transmission monitor (GE Healthcare, Helsinki, Finland). Instrumental precision was evaluated using the coefficient of repeatability, while accuracy was assessed using the bias and limits of agreement. The coefficients of repeatability were similar for both techniques (0.035 for KMG and 0.043 for EMG), indicating a similar level of precision. KMG overestimated the TOF ratios measured with EMG with a bias of 0.11 (95% limits of agreement: −0.13 to 0.35). At a TOF ratio of 0.90 the bias was 0.08 (95% limits of agreement: −0.08 to 0.25). This means that at a TOF ratio of 0.90 measured with KMG will be approximately equivalent to a TOF ratio of 0.80 measured with EMG at the adductor pollicis muscle, but it may indeed be as low as 0.65 or as high as 1.00. Therefore, TOF ratios measured by KMG and EMG cannot be used interchangeably.
Standardised Training Program in Spinal Ultrasound for Epidural Insertion: Protocol-Driven versus Non—Protocol Driven Teaching Approach
Authors: Terblanche N. C. S. , Arzola C. , Wills K. E. , Lawson R. , Blackford D. , Balki M.
Published: January 2019

Spinal ultrasonography provides guidance for epidural insertion in obstetric patients. The primary objective of the study was to develop a training program in spinal ultrasound for anaesthetists and to determine its effect on the skill acquisition of anaesthetists with no prior spinal ultrasound experience. Eighteen anaesthetists underwent two structured workshops (one week apart), each followed by a practice session and videorecorded assessments. Participants were randomised to a protocol-driven or non–protocol driven spinal ultrasound teaching program. Two experts rated each individual's performance using a global rating scale (GRS), checklist and image quality scale. The primary outcome was the mean difference in GRS score between the two workshops, analysed using linear mixed models. Intraclass correlation coefficients were calculated to assess agreement between assessors’ ratings. A total of 108 ultrasound scans were performed on five pregnant volunteers during the assessment periods. After adjusting for confounders, GRS scores increased on all three rating scales at the second workshop, this increase being 6.01 points (95% confidence interval 4.56 to 7.46, P <0.001) from a mean score of 28.4 (95% confidence interval 24.8 to 32.0). There was no significant difference in the scores between the two teaching groups (difference in GRS scores=1.36 points, 95% confidence interval −0.77 to 3.50, P=0.211). Intraclass correlation coefficients showed substantial assessor agreement for all three assessment methods (range 0.59 to 0.89). The results demonstrate that programmed spinal ultrasound training sessions involving practice with guidance and feedback from an expert, whether protocol-based or non–protocol based, lead to improved performance.