bluuebunny/crossref_metadata_2025 huggingface dataset:
Elective Awake Intubation in a Patient with Massive Multinodular Goitre Presenting for Radioiodine Treatment
Authors: Chakera A. , Van Heerden P. V. , Van Der Schaaf A.
Published: January 2019

We present the management of the potential airway complications in a case of massive multinodular goitre treated with radioactive iodine. The patient's trachea was prophylactically intubated, using a fibreoptic technique, to prevent further airway compromise due to thyroid oedema following radioactive iodine treatment. He remained awake and intubated for five days and was extubated when there was no clinical evidence of thyroid oedema as a consequence of his treatment. This approach avoided the considerable risk of thyroidectomy in a morbidly obese patient with airway obstruction. To the authors’ knowledge this approach has not been previously described.
Another Knotted Epidural Catheter
Authors: Macfarlane J. , Paech M. J.
Published: January 2019

A lumbar epidural catheter inserted in a 24-year-old woman for labour analgesia, and subsequently used for postcaesarean epidural analgesia, proved difficult to remove. After multiple attempts, the entrapped catheter was dislodged intact, revealing a knot near its distal tip. Knotting of an epidural catheter leading to entrapment is a rare complication of epidural catheterization.
Procalcitonin and Proinflammatory Cytokine Clearance during Continuous Venovenous Haemofiltration in Septic Patients
Authors: Dahaba A. A. , Elawady G. A. , Rehak P. H. , List W. F.
Published: January 2019

Procalcitonin (PCT), interleukin-6 (IL-6), tumour necrosis factor α (TNFα), and interleukin-1β (IL-1β) are important clinical prognostic markers in ICU septic patients. The goal of the study was to determine whether continuous venovenous haemofiltration (CVVH), using an AN69 haemofilter, leads to elimination of PCT, TNFα, IL-6 and IL-1βin 13 septic patients with multi-organ failure.

At the start of haemofiltration (0), 6 and 12 hours the mean afferent plasma concentration ±SD of PCT (10.1±9.1, 7±6, 5.9±5.7 ng/ml), IL-6 (804.6±847.6, 611.7±528.4, 575.2±539.2 pg/ml), and that of TNFα (4.5±2.6, 4±3.1, 3.8±2.9 pg/ml) significantly declined during CVVH. The efferent plasma concentrations were significantly lower than the corresponding afferent concentrations. PCT, IL-6 and TNFαwere detectable in the ultra-filtrate of all patients. IL-1βwas only detectable in the plasma of eight patients and the ultrafiltrate of five patients.

The plasma clearance of PCT, IL-6 and TNFαsignificantly decreased after 12 hours as a result of a decline in the adsorptive elimination of the mediators due to progressive membrane saturation.

We demonstrated that if PCT, IL-6 and TNFα are used as clinical prognostic markers in septic patients who are treated with CVVH using an AN69 membrane, one should be aware that their plasma level could be modified by the therapy. In addition CVVH could represent an appropriate tool to remove a broad spectrum of proinflammatory mediators, if such removal is required in septic patients.
Implementation and Evaluation of Guidelines for Preoperative Testing in a Tertiary Hospital
Authors: Greer A. E. , Irwin M. G.
Published: January 2019

The aim of this study was to determine the extent of unnecessary investigation performed as part of the preoperative preparation of elective surgical patients in a teaching hospital and to audit the effect of guidelines and education designed to reduce unnecessary investigation. Guidelines were developed for preoperative anaesthetic investigation for elective surgical procedures in patients over one year of age according to internationally accepted criteria, with some adjustment for local differences in patient morbidity. Forms outlining these criteria were placed in all operating theatres and anaesthetists were asked to determine whether tests performed were indicated or not, according to these criteria, over a two-week period, in each patient undergoing elective surgery. Tests indicated for surgical reasons were excluded. These same guidelines were then issued to all surgical departments along with explanatory lectures. The audit was repeated six months later and results compared. The incidence of over-investigation decreased from 13.8% to 11.6% (P=0.03) without a significant increase in under-investigation (0.7 v 1.0%; P=0.2). This study highlights the incidence of unwarranted screening tests in patients presenting for elective surgery and the role of protocols and ongoing education in reducing this incidence.
Prolonged Paralysis following Mivacurium Administration
Authors: Chung D. Y. , Hardman J.
Published: January 2019

Mivacurium is a benzylisoquinolone, choline-like, non-depolarizing muscle relaxant. Its onset of action is similar to that of atracurium but its duration of action is shorter (approximately 10–15 minutes). Mivacurium is metabolized by plasma cholinesterases at approximately 70% of the rate of metabolism of suxamethonium1. Deficiency or abnormality of plasma cholinesterase may cause the duration of action of both suxamethonium2,3 and mivacurium2,4,5,6 to be greatly prolonged. We describe a case of prolonged mivacurium paralysis after day surgery. Laboratory investigations showed a genetic tendency toward abnormal cholinesterase levels, but markedly depressed cholinesterase activity was suggestive of additional acquired causes. This patient had a history of liver disease, malnutrition and anticholinesterase use, which we believe were the most significant factors involved.
Intra-arterial Injection of Metoclopramide, Midazolam, Propofol and Pethidine
Authors: Murphy E. J.
Published: January 2019

A case is reported in which metoclopramide, midazolam, propofol, and pethidine were injected arterially during the course of anaesthesia, resulting in oedema and discolouration of the hand initially, but no long-term sequelae. An AVI 470 pump (3M Corporation) was used to control the infusion, and prevented backflow through a cannula which was unintentionally sited in an artery rather than a vein. Few anaesthetic drugs have their effects well documented when given arterially, and in particular, there were no previous reported cases involving metoclopramide in this context. The pharmacology of metoclopramide is discussed with reference to the drug's known effects on vascular beds and platelet function.
Total Intravenous Anaesthesia for Tracheobronchial Stenting in Children
Authors: Choudhury M. , Saxena N.
Published: January 2019

Stenosis and malacia of the tracheobronchial tree, most often secondary to prolonged intubation, tracheostomy or following correction of a congenital cardiac lesion, present a significant therapeutic problem, especially when the lesions are extensive. The utilization of self-expanding tracheobronchial stents is a useful addition to the medical armamentarium for maintenance of airways in these patients with major airway stenosis and collapse. The majority of previous reported cases of tracheobronchial stenting have been performed under general anaesthesia with the help of rigid bronchoscopy under direct vision. We conducted two cases of tracheobronchial stenting in postoperative cardiosurgical babies under continuous propofol infusion taking advantage of cardiovascular stability during continuous infusion and rapid emergence after its discontinuation.
Ventricular Tachycardia in Congenital Adrenal Hyperplasia
Authors: Virdi V. S. , Bharti B. , Poddar B. , Basu S. , Parmar V. R.
Published: January 2019

Severe hyperkalaemia in patients with congenital adrenal hyperplasia in association with aggravating factors such as acidosis and hypocalcaemia can cause life-threatening ventricular arrhythmias. Treatment of the underlying cause may be the only modality required in such cases. We report a 20-day-old male presenting with ventricular tachycardia due to electrolyte abnormalities in salt-losing congenital adrenal hyperplasia. Sudden cardiac deaths reported earlier in such cases thus gain credence.
Remifentanil and Propofol Sedation for Retrobulbar Nerve Block
Authors: Rewari V. , Madan R. , Kaul H. L. , Kumar L.
Published: January 2019

We studied remifentanil and propofol for analgesia and sedation during the placement of an ophthalmic block. Eighty ASA I or II patients undergoing elective cataract surgery under a retrobulbar block in a rural camp setting were included in the study. Patients were randomly divided into four groups and received different drug combinations as follows: Group I—remifentanil 1 μg/kg, Group II—remifentanil 0.5 μg/kg and propofol 0.5 mg/kg, Group III— remifentanil 1 μg/kg with propofol 0.5 mg/kg and Group IV—saline 0.1 ml/kg. Patients were observed for degree of movement, sedation, pain, recall and respiratory depression.

No patient in the study groups reported pain or displayed movement whereas most of the patients in the control group had significant pain during the placement of the block. Also, seven (35%) patients in the control group showed significant movement which may have led to failure of block in two patients and retrobulbar haemorrhage in one patient. Incidence of significant respiratory depression was maximum in Group III patients (60%), followed by Group I (20%) and least in Group II (5%). All patients in the study groups remained cooperative and obeyed commands except four patients in group III (OAA/S-4). Postoperatively, other than the control group, recall was maximum in Group I (55%) and least in Group II (5%).

Hence, a combination of remifentanil 0.5 μg/kg with propofol 0.5 mg/kg as a bolus was considered to provide excellent relief of pain and anxiety with least adverse effects for the placement of ophthalmic blocks.
Anaphylaxis to Haemaccel® and Cross Reactivity to Gelofusin®
Authors: Russell W. J. , Fenwick D. G.
Published: January 2019

A recent change from Haemaccel® to Gelofusin® as the preferred colloid for resuscitation in our region caused us to review patients who were known to be allergic to Haemaccel. As Gelofusin and Haemaccel are both modified gelatine, it seemed likely that cross reactivity could occur. Two patients who had been diagnosed previously as having had anaphylactic reactions to Haemaccel were tested intradermally with dilutions of 1/100 of Haemaccel and Gelofusin. Both patients showed similar positive reactions to each agent. It appears that patients who are known to be allergic to Haemaccel are probably allergic also to Gelofusin.

Both patients have been given new Medic Alert bracelets stating “Allergic to Haemaccel and Gelofusin”.
A New Model for the Oxyhaemoglobin Dissociation Curve
Authors: Anstey C.
Published: January 2019

This paper describes a new model for the oxygen-haemoglobin dissociation curve in humans.

The model is based on the known structural alterations that occur in the quaternary haemoglobin molecule during oxygenation and deoxygenation. The two alternative structures, tense and relaxed, are described using hyperbolic tangent curves and linked with a probability function to obtain the completed mathematical description of the oxygen-haemoglobin dissociation curve. Model accuracy is assessed by a bias/precision analysis of calculated logit (S) and P50 against gold standard data. A mechanism for the transition between the two structures involving the chloride ion as a major allosteric effector is proposed.

Results were analysed against the Siggaard-Andersen model for bias, precision and calculated P50 in four saturation ranges—0.00<SO 2< 1.00, 0.20<SO 2< 0.80, 0.90<SO 2< 1.00 and 0.97<SO 2< 1.00. In each range except for 0.20<SO 2 <0.80, bias, precision and calculated P50 for the new model are significantly better (P<0.05). Analysis of calculated P50 across the entire saturation range revealed significant drift out of the acceptable range in the Siggaard-Andersen model for SO 2 >0.92. The new model remained within tolerance across the saturation range 0.00<SO 2 <1.00.

The new model is significantly more accurate than the popular Siggaard-Andersen model, particularly in the range SO 2> 0.90.
Intubating Laryngeal Mask Airway
Authors: Caponas G.
Published: January 2019

The Intubating Laryngeal Mask Airway (ILMA) was introduced into clinical practice in 1997 following numerous clinical trials involving 1110 patients. The success rate of blind intubation via the device after two attempts is 88% in “routine” cases. Successful intubation in a variety of difficult airway scenarios, including awake intubation, has been described, with the overall success rate in the 377 patients reported being approximately 98%. The use of the ILMA by the novice operator has also been investigated with conflicting reports as to its suitability for emergency intubation in this setting.

Blind versus visualized intubation techniques have also been investigated. These techniques may provide some benefits in improved safety and success rates, although the evidence is not definitive. The use of a visualizing technique is recommended, especially whilst experience with intubation via the ILMA is being gained. The risk of oesophageal intubation is reported as 5% and one death has been described secondary to the complications of oesophageal perforation during blind intubation. Morbidity described with the use of the ILMA includes sore throat, hoarse voice and epiglottic oedema. Haemodynamic changes associated with intubation via the ILMA are of minimal clinical consequence.

The ILMA is a valuable adjunct to the airway management armamentarium, especially in cases of difficult airway management. Success with the device is more likely if the head of the patient is maintained in the neutral position, when the operator has practised at least 20 previous insertions and when the accompanying lubricated armoured tube is used.
Remifentanil Concentration during Target-controlled Infusion of Propofol
Authors: Crankshaw D. P. , Chan C. , Leslie K. , Bjorksten A. R.
Published: January 2019

After institutional approval and with written informed consent, eight surgical patients were infused intravenously with remifentanil at 250 ng.kg lean body mass (LBM) -1 .min -1 for 30 min. Cardiovascular and respiratory parameters were recorded and arterial blood samples were taken at regular intervals. In each patient, the same protocol was repeated 40 min later during propofol infused to a target concentration of 3.0 μg.ml -1. Blood concentrations of remifentanil and propofol were assayed using capillary gas chromatography and high performance liquid chromatography techniques respectively. The number of subjects enrolled was determined by testing the successive areas under the remifentanil time-concentration curve (AUC) for significant difference or non-difference using sequential analysis. The median measured propofol concentration was 3.5 (range: 2.6–4.5) μg.ml -1 which did not change significantly during the second remifentanil infusion. The median AUC during propofol infusion was greater than control in all subjects, although there was considerable variation of 94.4 (64.3–129.6) versus 64.6 (34.8–126.9) ng.ml -1 .min; P=0.008, n=8. After 30 min, there was no significant difference in remifentanil concentration during propofol infusion when compared with remifentanil alone of 4.6 (3.2–5.7) versus 3.8 (1.6–4.9) ng.ml -1; P=0.73, n=8. Co-administration of propofol and remifentanil may result in greater remifentanil concentrations than when remifentanil is infused alone.
Perioperative Plasma Concentrations of Atrial and Brain Natriuretic Peptides in Patients Undergoing Hip Arthroplasty
Authors: Terasako K.
Published: January 2019

Acute hypotension, transient hypoxaemia and elevation of pulmonary artery pressure are well known to occur during cemented arthroplasty. The aim of this prospective clinical study was to characterize the relationship between plasma concentrations of atrial and brain natriuretic peptides (ANP, BNP), and changes in blood pressure in patients undergoing hip arthroplasty. Elevated ANP and BNP levels may be markers of inadequate myocardial reserve. We measured plasma ANP and BNP levels before the operation and 20 minutes after the cementing in 18 patients (54–90 yr). We defined a hypotensive response after cementing as a decrease in systolic blood pressure of more than 15 mm Hg below the pre-cementing value. In the hypotensive group, preoperative values of ANP were 123±48.5 pg/ml and BNP, 138±71.7 pg/ml. These values are significantly greater than those in the normotensive group (ANP 35.9± 7.7, and BNP 17.2±3.2 pg/ml). High preoperative values of ANP and BNP are associated with more hypotension during cemented arthroplasty and could provide an indication of which patients are at risk of this complication.
The Effects of Sevoflurane on Isolated Gravid Human Myometrium
Authors: Turner R. J. , Lambros M. , Holmes C. , Katz S. G. , Downs C. S. , Collins D. W. , Gatt S. P.
Published: January 2019

The volatile anaesthetic agents are known to influence uterine muscle tone. All of the agents studied to date have been found to produce uterine relaxation. This property has been used to produce therapeutic uterine relaxation for difficult obstetric deliveries and the Ex Utero Intrapartum Treatment (EXIT) procedure. This study describes the effects of sevoflurane on isolated human myometrium at concentrations of 0.1, 0.25, 0.5, 0.75, 1.0, 1.5, 2.5 and 3.5 MAC. Sevoflurane produces dose-dependent depression of uterine muscle contractility with an ED 50 of 0.94 MAC. Frequency of contraction was increased at concentrations of 2.5 MAC and greater. At concentrations of 3.5 MAC and above, uterine activity was virtually abolished.
Genotoxicity of Waste Anaesthetic Gases
Authors: Bozkurt G. , Memis D. , Karabogaz G. , Pamukcu Z. , Ture M. , Karamanlioglu B. , Gunday I , Algunes C.
Published: January 2019

Background and aim: The possibility of a potential mutagenic or carcinogenic action of chronic exposure to low concentrations of inhalational anaesthetics has been previously studied, with conflicting results. The purpose of this study was to assess whether occupational exposure to waste anaesthetic gases increases genotoxic risk. We examined peripheral lymphocytes from anaesthetists for both sister chromatid exchange (SCE) and for cells with high-frequency SCEs (HFCs).

Method: A group of 16 non-smoking anaesthetists with occupational exposure to anaesthetic gases and a sex- and age-matched group matched 16 non-smoking matched physicians without occupational exposure to anaesthetic gases were studied. The participants were also selected on the basis of similar responses to a questionnaire assessing risk of genotoxicity relating to other aspects of life.

Result: SCEs, and HFC percentages obtained from the exposed anaesthetists (6.6±2.4 and 12.2±15.9) were greater but not statistically significantly so than in the reference group (5.2±1.6 and 5.9±10.0).

Conclusion: This study does not support the existence of an association between occupational exposure to waste anaesthetic gases and an increase in SCEs in lymphocytes. The nature of our anaesthesia practice suggests exposure was likely to be low. It should be noted that some anaesthetic gases produce lesions that can be efficiently repaired in mitogen-stimulated lymphocytes in vitro but not in circulating lymphocytes.
Correct Positioning of the Venous Port-A-Cath Catheter: Comparison of Intravascular Electrocardiography Signal from Guidewire and Sodium Bicarbonate Flushed Catheter
Authors: Cheng K. I. , Chu K. S. , Chen L. T. , Tang C. S.
Published: January 2019

A prospective study comparing the efficacy of wire-conducted intravascular ECG (IVECG) signal and signal from the port with a sodium bicarbonate (NaHCO 3 ) flushed catheter to correctly place a catheter tip was carried out in 100 patients. The correct position of the catheter tip was confirmed as follows: with technique G, the IVECG signal was conducted from a guide wire to identify the tip position. With technique P, the IVECG signal was conducted from the port with a NaHCO 3 (0.8 mmol/ml) flushed catheter to ascertain the tip position. Each patient received both technique G and technique P in a randomized sequence. The quality of IV-ECG signals, which included baseline drift, P wave pattern and QRS wave pattern, were assessed for ten seconds. Satisfactory quality of these IVECG signals was observed in all of the patients with technique P and 90 of the 100 patients with technique G, and this difference was significant (P=0.001). There was no obvious difference between the techniques in catheter tip placement time or the measured optimal catheter length. The incidence of atrial premature contractions was higher with technique G than with technique P (13% vs 2%; P=0.003). Therefore, technique P is a practical alternative for correctly placing the catheter tip of a Port-A-Cath.
Effect of Age on Haemodynamic Response to Tracheal Intubation. A Comparison of Young, Middle-aged and Elderly Patients
Authors: Ismail S. , Azam S. I. , Khan F. A.
Published: January 2019

The effect of age on the haemodynamic response to tracheal intubation was studied. Ninety ASA 1 or 2 patients were divided into three groups of 30 each based on age; i.e., young (18–25 years), middle-aged (40–50 years) and elderly (65–80 years). The haemodynamic response after tracheal intubation was observed as percentage change in heart rate and blood pressure compared to the baseline. Inter-group comparison was also done at different time points. The greatest percentage change in the systolic arterial pressure after tracheal tube insertion was seen in the elderly group (15%). The increase in systolic arterial pressure was significantly less in the young group compared with the two older groups at one, two, three and four minutes post-intubation. The greatest percentage increase in the diastolic blood pressure compared to the baseline was seen in the middle aged group (24%). The elderly and young patients showed a significant difference in the diastolic blood pressure response only at one minute post-intubation. The heart rate response was greatest in the middle-aged patients (40%) and least in the elderly (16%). These differences may have clinical significance and should be considered in assessing and performing research into the haemodynamic response to intubation.
Acute Tracheal Trauma in Sheep Caused by Percutaneous Tracheostomy
Authors: Nickells J. S. , Dahlstrom J. E. , Bidstrup H. , Dobbinson T. L.
Published: January 2019

The aim of our study was to compare dilation forceps tracheostomy and sequential dilator tracheostomy in anaesthetized live adult sheep with respect to the characteristics of the stoma formed and the associated injury. We performed percutaneous tracheostomy on adult sheep randomly allocated to receive either dilation forceps or sequential dilators. Sheep were sacrificed immediately after insertion of the percutaneous tracheostomy and the tracheas dissected. Specimens were examined for site, shape and size of stoma, mucosal lacerations, and posterior wall trauma. Ten sheep had dilation forceps tracheostomy and ten had sequential dilator tracheostomy. All of the specimens were found to have cephalo-caudal mucosal tears, usually crossing tracheal rings. The dilation forceps technique was found to have a larger stoma (28.8 mm vs 24.0 mm, P=0.023). The incidence of posterior needle trauma and mucosal lacerations were common (35% and 50% respectively), but they were not statistically different between the two groups. The role of the mucosal tears in the development of tracheal stenosis is reviewed in the discussion.
Outcome of Stroke Patients Admitted to Intensive Care: Experience from an Australian Teaching Hospital
Authors: Fanshawe M. , Venkatesh B. , Boots R. J.
Published: January 2019

The objective of this study was to determine the mortality rate and the functional outcomes of stroke patients admitted to the intensive care unit (ICU) and to identify predictors of poor outcome in this population.

The records of all patients admitted to the ICU with the diagnosis of stroke between January 1994 and December 1999 were reviewed. Patients with subarachnoid haemorrhage were excluded. Data were collected on clinical and biological variables, risk factors for stroke and the presence of comorbidities. Mortality (ICU, in-hospital and three-month) and functional outcome were used as end-points.

In the six-year-period, 61 patients were admitted to the ICU with either haemorrhagic or ischaemic stroke. Medical records were available for only 58 patients. There were 23 ischaemic and 35 haemorrhagic strokes. The ICU, in-hospital and three-month mortality rates were 36%, 47% and 52% respectively. There were no significant differences in the prevalence of premorbid risk factors between survivors and non-survivors. The mean Barthel score was significantly different between the independent and dependent survivors (94±6 vs 45±26, P<0.001). A substantial number of patients with good functional outcomes had lower Rankin scores (92% vs 11%, P<0.001). Only 46% of those who were alive at three months were functionally independent.

Intensive care admission was associated with a high mortality rate and a high likelihood of dependent lifestyle after hospital discharge. Haemorrhagic stroke, fixed dilated pupil(s) and GCS <10 during assessment were associated with increased mortality and poor functional outcome.
Paediatric Day Stay Tonsillectomy Service: Development and Audit
Authors: Stewart P. C. H. , Baines D. B. , Dalton C.
Published: January 2019

Day stay paediatric tonsillectomy is well established in many parts of the world but not in Australia. This audit presents the protocol and results of the first one hundred and twenty-five patients managed this way at our hospital. Patients assessed as being at low risk of postoperative complications were offered the procedure as a day patient. All patients had a standardized relaxant anaesthetic technique with an intraoperative opioid and antiemetics. The patients were observed for six hours postoperatively in the Day Stay Unit and contacted the day following surgery to assess any problems. The overall incidence of postoperative vomiting was 15.6%. Two patients required overnight admission. One child was re-admitted on day four for delayed postoperative haemorrhage. Forty-four of the first forty-nine patients’ parents were contacted four to six weeks later to assess their experiences of the process. Although approximately three-quarters of the parents rated their child's pain as moderate or severe at some stage, all but one felt the analgesic regimen was good or adequate. Eighty per cent were satisfied with having the surgery as a day stay procedure.
Airway Management on Placental Support (AMPS)—The Anaesthetic Perspective
Authors: Collins D. W. , Downs C. S. , Katz S. G. , Gatt S. P. , Marsland C. , Abrahams N. , Turner R. J.
Published: January 2019

Neonatal airway obstruction has been reported to have a high mortality. Antenatal diagnosis of this condition is now possible. Anaesthetic and surgical techniques have been developed that allow neonatal airway obstruction to be managed at delivery, while the fetus remains oxygenated via the placental circulation. Three case studies are presented, and the anaesthetic issues for mother and fetus/neonate are discussed with reference to previously published cases of airway management on placental support. In particular, techniques for uterine relaxation and maintenance of placental circulation are explored. The history of these procedures and issues of planning and logistics are also discussed.
Systemic Air Embolism after Intercostal Chest Drain Insertion and Positive Pressure Ventilation in Chest Trauma
Authors: Brownlow H. A. , Edibam C.
Published: January 2019

Systemic air embolism is a potentially lethal often unrecognised complication of severe chest trauma. We present a case of delayed diagnosis of cerebral air embolism in a patient with severe thoracic trauma. The initiation of positive pressure ventilation, systemic hypotension, intraparenchymal chest drains and aerial transfer to an intensive care unit were all factors contributing to the development of systemic air embolism. The common clinical features, diagnostic tests and management of systemic air emboli are discussed.
Retroperitoneal Haematoma Associated with Low Molecular Weight Heparin
Authors: Power G. E. , Rogers P.
Published: January 2019

Enoxaparin (a low molecular weight heparin) has been used extensively for its antithrombotic properties. Complications of its haemorrhagic side-effects have previously been described. We report two cases of extensive retroperitoneal haematoma requiring blood transfusion and inotropic support. One patient developed acute renal failure and did not respond to intensive resuscitative efforts.
An Undiagnosed Phaeochromocytoma of the Urinary Bladder
Authors: Tan S. M. , Chan S. T.
Published: January 2019

Phaeochromocytoma of the urinary bladder is rare. We report a case of a patient with undiagnosed bladder phaeochromocytoma who developed haemodynamic disturbances during routine diagnostic cystoscopy. The diagnosis was only confirmed postoperatively.
The ProSeal Laryngeal Mask in Myasthenia Gravis
Authors: Gardner S. V. , Evans N. R.
Published: January 2019

This case describes the anaesthesia management of a patient with myasthenia gravis who required mastectomy with axillary lymph node clearance. After withholding medical therapy for the myasthenia preoperatively on the day of surgery, anaesthesia was maintained with halothane, nitrous oxide and a remifentanil infusion. Muscle relaxants were avoided, facilitated by the use of a ProSeal (Intravent, Orthofix, Maidenhead, United Kingdom) laryngeal mask airway for positive pressure ventilation. The ProSeal laryngeal mask airway is a new laryngeal mask device with a modified cuff and a drainage tube which has been shown to have advantages over older designs for use during positive pressure ventilation. The rationale for the management of this patient with myasthenia is discussed.
The Cerebrovascular Effects of Adrenaline, Noradrenaline and Dopamine Infusions under Propofol and Isoflurane Anaesthesia in Sheep
Authors: Myburgh J. A. , Upton R. N. , Grant C. , Martinez A.
Published: January 2019

Infusions of catecholamines are frequently administered to patients receiving propofol or isoflurane anaesthesia.

Interactions between these drugs may affect regional circulations, such as the brain.

The aim of this animal (sheep) study was to determine the effects of ramped infusions of adrenaline, noradrenaline (10, 20, 40 μg/min) and dopamine (10, 20, 40 μg/kg/min) on cerebral blood flow (CBF), intracranial pressure (ICP), cerebrovascular resistance (CVR) and cerebral metabolic rate for oxygen (CMRO 2 ). These measurements were made under awake physiological conditions, and during continuous propofol (15 mg/min) or 2% isoflurane anaesthesia. All three catecholamines significantly and equivalently increased mean arterial pressure from baseline in a dose-dependent manner in the three cohorts (P<0.001). In the awake cohort (n=8), dopamine (P<0.01) significantly increased CBF from baseline whilst adrenaline and noradrenaline did not (P> 0.05). Under propofol (n=6) and isoflurane (n=6), all three catecholamines significantly increased CBF (P<0.001). Dopamine caused the greatest increase in CBF, and was associated with significant increases in ICP (awake: P<0.001; propofol P<0.05; isoflurane P<0.001) and CVR (isoflurane P<0.05). No significant changes in CMRO 2 were demonstrated.

Under propofol and isoflurane anaesthesia, the cerebrovascular effects of catecholamines were significantly different from the awake, physiological state, with dopamine demonstrating the most pronounced effects, particularly under propofol. Dopamine-induced hyperaemia was associated with other cerebrovascular changes. In the presence of an equivalent effect on mean arterial pressure, the exaggerated cerebrovascular effects under anaesthesia appear to be centrally mediated, possibly induced by propofol- or isoflurane-dependent changes in blood-brain barrier permeability, thereby causing a direct influence on the cerebral vasculature.
The Effects of Intravenous Lignocaine on Haemodynamics and Seizure Duration during Electroconvulsive Therapy
Authors: Wajima Z. , Yoshikawa T. , Ogura A. , Shiga T. , Inoue T. , Ogawa R.
Published: January 2019

Electroconvulsive therapy (ECT) is commonly associated with acute hyperdynamic cardiovascular responses, and we hypothesize that intravenous lignocaine can blunt this response. We have measured the effect of lignocaine 1.5 mg/kg IV on heart rate and mean arterial pressure during electroconvulsive therapy. Furthermore, we also assessed seizure duration using both the cuff method and two-lead electroencephalography.

We studied 25 patients using a randomized, double-blind, placebo-controlled crossover study design. Patients in the control group were given intravenous saline 0.075 ml/kg, and those in the lignocaine group were given intravenous lignocaine 2% 1.5 mg/kg, and this treatment was conducted one minute before intravenous propofol 1.5 mg/kg to induce unconsciousness. Succinylcholine 1.5 mg/kg was then administered intravenously and electrical stimulation was administered after fasciculation. Measurements were taken at the baseline, prior to succinycholine, prior to electroconvulsive therapy and at the peak response after electroconvulsive therapy.

Intravenous lignocaine significantly reduced the increases in heart rate after electroconvulsive therapy, as compared with the placebo. The use of intravenous lignocaine was, however, associated with a remarkably shortened seizure duration.

Due to the reduction in seizure duration, routine administration of intravenous lignocaine may not be advisable since it may interfere with the psychotherapeutic efficacy of electroconvulsive therapy. However, intravenous lignocaine medication for electroconvulsive therapy is potentially useful for reducing tachycardia in high-risk patients and reducing the severity of propofol injection pain in comparison with a placebo.
Reliability of Procalcitonin as a Severity Marker in Critically Ill Patients with Inflammatory Response
Authors: Tugrul S. , Esen F. , Celebi S. , Ozcan P. E. , Akinci O. , Cakar N. , Telci L.
Published: January 2019

Procalcitonin (PCT) is increasingly recognised as an important diagnostic parameter in clinical evaluation of the critically ill. This prospective study was designed to investigate PCT as a diagnostic marker of infection in critically ill patients with sepsis.

Eighty-five adult ICU patients were studied. Four groups were defined on the basis of clinical, laboratory and bacteriologic findings as systemic inflammatory response syndrome (SIRS) (n=10), sepsis (n=16), severe sepsis (n=18) and septic shock (n=41). Data were collected including C-reactive protein (CRP), PCT levels and Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II scores on each ICU day.

PCT levels were significantly higher in patients with severe sepsis and septic shock (19.25±43.08 and 37.15± 61.39 ng/ml) than patients with SIRS (0.73±1.37 ng/ml) (P<0.05 for each comparison). As compared with SIRS patients, plasma PCT levels were significantly higher in infected patients (21.9±47.8 ng/ml), regardless of the degree of sepsis (P<0.001). PCT showed a higher sensitivity (73% versus 35%) and specificity (83% versus 42%) compared to CRP in identifying infection as a cause of the inflammatory response. Best cut-off levels were 1.31 ng/ml for PCT and 13.9 mg/dl for CRP.

We suggest that PCT is a more reliable marker than CRP in defining infection as a cause of systemic inflammatory response.
Ratio of Patient's Height to Thyromental Distance Improves Prediction of Difficult Laryngoscopy
Authors: Schmitt H. J. , Kirmse M. , Radespiel-Troger M.
Published: January 2019

Several tests have been proposed to predict difficult laryngoscopy or intubation. The thyromental distance (TMD) is often used for these purposes but this measurement, used alone, is unreliable. This study tested the hypothesis that the ratio of the patient's height to TMD (ratio of height to TMD=RHTMD) would improve the accuracy of predicting difficult laryngoscopy compared with TMD alone. Two hundred and seventy patients were evaluated preoperatively using the TMD and RHTMD. The two tests were compared analyzing the area under the receiver operating characteristic curves (AUC). Difficult laryngoscopy occurred in 16 patients (5.9%). The AUC of RHTMD was significantly greater (P<0.007) when compared to TMD, indicating a more accurate prediction by the RHTMD. A ratio of 25 for the RHTMD was found to be the optimal cut-off value to predict difficult laryngoscopy. When the sensitivity of both tests was 0.81, the RHTMD had a significantly greater specificity (0.91) than the TMD (0.73). Based on our results, we recommend that the RHTMD should be used instead of the TMD.
Reflex Responses to Insertion of the Intubating Laryngeal Mask Airway, Intubation and Removal of the ILMA
Authors: Shimoda O. , Yoshitake A. , Abe E. , Koga T.
Published: January 2019

We studied 21 patients (ASA 1 or 2) to investigate the skin vasomotor reflex (SVmR) and haemodynamic responses to insertion of an intubating laryngeal mask airway (ILMA), tracheal intubation using the ILMA and removal of the ILMA. Anaesthesia was induced with fentanyl, midazolam, vecuronium and nitrous oxide. A size 4 ILMA was inserted using the standard technique, and a silicone reinforced tracheal tube (7.5 mm, ID) was passed through it. After confirming successful intubation, the ILMA was removed using the stabilizing rod. The three procedures were performed at approximately one-minute intervals. Insertion of the ILMA, intubation and removal of the ILMA all significantly reduced the skin blood flow on the ring finger in all patients. The mean amplitudes of the SVmR were 0.46 (SD 0.29), 0.54 (0.32) and 0.68 (0.21) respectively. The magnitude of the SVmR and the haemodynamic changes induced by removal of the ILMA were significantly larger than those accompanying the other two procedures. Use of the ILMA for intubation and removal of the ILMA produces three stimuli and the removal of the ILMA produces the greatest response.
Factors Affecting Performance of Air Tonometry Using the TONOCAP®
Authors: Dullenkopf A. , Cornelius A. , Gerber A. C. , Weiss M.
Published: January 2019

Saline tonometry has been replaced by automated air tonometry (TONOCAP ® ). As with saline tonometry there are some pitfalls to consider. We investigated the influence of different filling handicaps to the tonometry catheter sampling balloon on measurement of regional PCO 2 (PrCO 2 ). In an in vitro set-up, PrCO 2 was measured using the TONOCAP ® at intervals of 10 minutes from a 8F tonometry catheter sampling balloon placed in a container with constant PCO 2 (PcCO 2 ). Catheter alarms displayed by the TONOCAP® device were noted. The following experiments were performed: A) control measurement without modifications; B) adding deadspace of 7 ml into the sampling line; C) placing the sampling balloon in a 3 ml syringe; D) cross-clamping of the sampling balloon. Each experiment was performed four times using two catheters on two TONOCAP ® devices. Differences between PcCO 2 and PrCO 2 were calculated as Pc-rCO 2. Results are presented as mean±SD and were compared using ANOVA with Scheffe's correction. Pc-rCO 2 in the control set-up (A) amounted to 0.16±0.22%. Increasing catheter deadspace (B) resulted in a higher Pc-rCO 2 of 3.2±0.57% (P<0.0001). Restriction of balloon expansion (C) caused an Pc-rCO 2 gap of 1.17±0.36% (P<0.0001). With filling restriction (D) the Pc-rCO 2 gap increased to 3.87±0.29% (P<0.0001). The catheter alarms provided were not able to indicate all catheter problems and initial alarms disappeared although the problems continued. We conclude that impaired catheter deadspace to balloon volume relation can negatively influence accuracy of PrCO 2 measurement by the TONOCAP ®.
The ULCO Anaesthetic Suitcase
Authors: Perndt H. K. S.
Published: January 2019

This paper describes the ULCO Portable Field Anaesthesia Machine, also known as the ULCO Anaesthetic Suitcase. The ULCO Anaesthetic Suitcase is a portable and versatile anaesthetic machine. It consists of flowmeters, back bar with two Penlon Oxford Miniature Vaporizers (OMV 50) and a common gas outlet mounted in the lid of a sturdy aluminium suitcase. A choice of drawover circuit, circle absorber system or a MultiCircuit System valve allows either drawover, circle or Mapleson A or D continuous flow (plenum) anaesthesia to be given in virtually any situation, oxygen supply permitting.
An Evaluation of the Flexiguide Introducer with the Flexible Laryngeal Mask Airway
Authors: Cook T. M. , Ford P. , Craft T. M. , McCormick B. , Ryder S-A.
Published: January 2019

Insertion of the flexible Laryngeal Mask Airway has been achieved by a variety of techniques.

We have evaluated the Flexiguide™ for aiding introduction of a flexible Laryngeal Mask Airway in 100 anaesthetised patients. We were successful in establishing a clear airway on the first attempt on 84 (84%) occasions and within two attempts in 97 (97%). The positioning of the laryngeal mask airway was assessed by five measures and was optimally placed in 85% of cases and good in 96%. A clear airway was achieved in 92% of cases. Insertion of the flexible Laryngeal Mask Airway with the Flexiguide was easy in 82 (82%) and slightly difficult in 15 (15%) of cases. Removal of the Flexiguide from the device was easy in 95 (95%) of cases. Airway manoeuvres were used to assist airway placement in 55% of cases with jaw thrust being most common. Minor complications occurred in three (3%) patients: two coughed and one experienced minor tissue trauma during mask insertion. There were no complications associated with use of the Flexiguide during the procedure or after anaesthesia.

The Flexiguide is a useful tool to assist insertion of the flexible Laryngeal Mask Airway and is associated with few complications.
Use of Oral and Implantable Naltrexone in the Management of the Opioid-Impaired Physician
Authors: Hulse G. K. , O'Neil G. , Hatton M. , Paech M. J.
Published: January 2019

Doctors are at an increased risk for prescription drug use, particularly opioids and benzodiazpines. This use can interfere with work function and has major potential negative implications for patient safety. Oral naltrexone, an opioid antagonist, has been used as part of a management strategy for opioid-dependent physicians. While some patients stabilize on oral naltrexone, others relapse to opioid use. An alternative method of naltrexone maintenance involves the injection or surgical insertion of a sustained release preparation of naltrexone. This approach dramatically improves compliance, removing the onus from the previously opioid impaired physician to use daily oral naltrexone.

This article describes the cases of four opioid-impaired doctors who received naltrexone (either oral or implant) as part of their management. The authors conclude that monitoring daily oral naltrexone use and detecting early opioid relapse is difficult, placing both the opioid impaired physician and their patients at risk. In contrast, by using implantable naltrexone, compliance is assured and opioid abstinence can virtually be guaranteed for five months. It is argued that naltrexone implants offer a level of protection not achieved with any previous treatment. It is recommended that management should involve early and close collaboration between the treating doctor and the Medical Board, with initial treatment, ongoing monitoring and follow-up being a Medical Board requirement for registration.
Heart and Brain: A Case of Focal Myocytolysis in Severe Pneumococcal Meningoencephalitis with Review of the Contemporary Literature
Authors: Brander L. , Weinberger D. , Henzen C.
Published: January 2019

We report electrocardiographic changes mimicking myocardial ischaemia in a 73-year-old man with fatal pneumococcal meningoencephalitis, present the autopsy-confirmed histological picture of extensive focal myocytolysis (contraction band necrosis) without myocardial infarction or myocarditis, and review the contemporary literature.

Potentially reversible, probably non-ischaemic myocardial dysfunction may occur in association with acute noncardiac illnesses, such as brain injuries. Biochemical and morphological abnormalities in acutely failing hearts from head-injured organ donors point to specific pathophysiological mechanisms, which are different from heart failure from other causes. Sepsis-related factors may add to the myocardial dysfunction in patients with brain injury from meningoencephalitis.
Pseudo-renal Failure following the Delayed Diagnosis of Bladder Perforation after Diagnostic Laparoscopy
Authors: Kruger P. S. , Whiteside R. S.
Published: January 2019

We present a case of bladder injury as a complication of gynaecological laparoscopic surgery. A young female presented with peritonitis, an acute systemic inflammatory response and biochemical features of acute renal failure secondary to urinary peritonitis. Laparotomy with drainage of urine from the peritoneal cavity and repair of the bladder perforation resulted in rapid resolution of the biochemical abnormalities.
The Effect of Infusions of Adrenaline, Noradrenaline and Dopamine on Cerebral Autoregulation under Isoflurane Anaesthesia in an Ovine Model
Authors: Myburgh J. A. , Upton R. N. , Grant C. , Martinez A.
Published: January 2019

The effects of infusions of adrenaline, noradrenaline and dopamine on cerebral autoregulation under steady-state isoflurane anaesthesia were compared with the awake state.

Six studies each were conducted in two cohorts of adult ewes: awake sheep and those anaesthetized with 2% isoflurane anaesthesia. In random order, each animal received ramped infusions of adrenaline, noradrenaline (0-40 μg/min) and dopamine (0-40 μg/kg/min).

Cerebral blood flow was measured continuously from changes in Doppler velocities in the sagittal sinus. Autoregulation was determined by linear regression analysis between cerebral blood flow and mean arterial pressure.

Isoflurane did not significantly alter cerebral blood flow relative to pre-anaesthesia values (P>0.05). All three catecholamines significantly and equivalently increased MAP from baseline in a dose dependent manner in both the awake and isoflurane cohorts. Although adrenaline significantly increased cerebral blood flow from baseline in the awake cohort (P< 0.01), none of the catecholamines significantly increased cerebral blood flow during isoflurane anaesthesia. No significant differences were demonstrated between the slopes and intercepts of regression lines for adrenaline, noradrenaline and dopamine within either cohort (ANCOVA). Inter-cohort comparisons between the two autoregulation curves demonstrated no significant difference between the slopes of the autoregulation curves for the awake (pooled slope=0.39) and isoflurane cohorts (pooled slope=0.28) (P>0.05).

Over a specific dose range, systemic hypertension induced by adrenaline, noradrenaline and dopamine did not significantly increase cerebral blood flow under 2% isoflurane anaesthesia. The concomitant administration of isoflurane and the catecholamines was not associated with altered autoregulatory function compared to the awake state.