bluuebunny/crossref_metadata_2025 huggingface dataset:
Continuous Interscalene Analgesia for Rotator Cuff Repair: A Retrospective Comparison of Effectiveness and Cost in 205 Patients from a Multi-Provider Private Practice Setting
Authors: Fredrickson M. J. , Stewart A. W.
Published: January 2019

Several barriers exist to the routine use of continuous interscalene block (CISB) for postoperative analgesia following rotator cuff repair. There is a perception that the technique is feasible only for single operators exposed to a high volume case load. The aim of this retrospective review was to compare the three commonly employed analgesic techniques following rotator cuff repair in a multi-provider setting. The techniques studied were CISB, combined single injection interscalene block with postoperative intermittent intra-articular local anaesthetic infiltration (SSISB/IA) and intermittent intra-articular only local anaesthetic infiltration (IA). The clinical records of 205 consecutive patients having open rotator cuff repair over an 18-month period in two private care facilities were reviewed. The primary outcome endpoint was total opioid/tramadol consumption during the period of an overnight hospital stay. The median total opioid and tramadol consumption (in intravenous mg equivalents of morphine) from admission to the post anaesthesia care unit until discharge from hospital was 5 mg in the CISB group and 10 mg for the SSISB/IA and IA groups (P <0.0001). The proportion of subjects requiring more than one antiemetic for the same period was 1.9% in the CISB group, 16.4% for the SSISB/IA group and 36.1% for the IA group (P <0.0001). Costs related to the analgesic technique were similar in each group. CISB following rotator cuff repair in a multi-provider setting was associated with reduced total opioid/tramadol and antiemetic consumption, and occurred without a significant increase in the monetary cost.
Acid-Base Effects of a Bicarbonate-Balanced Priming Fluid during Cardiopulmonary Bypass: Comparison with Plasma-Lyte 148. A Randomised Single-Blinded Study
Authors: Morgan T. J. , Power G , Venkatesh B. , Jones M. A.
Published: January 2019

Fluid-induced metabolic acidosis can be harmful and can complicate cardiopulmonary bypass. In an attempt to prevent this disturbance, we designed a bicarbonate-based crystalloid circuit prime balanced on physico-chemical principles with a strong ion difference of 24 mEq/l and compared its acid-base effects with those of Plasma-Lyte 148, a multiple electrolyte replacement solution containing acetate plus gluconate totalling 50 mEq/l.

Twenty patients with normal acid-base status undergoing elective cardiac surgery were randomised 1:1 to a 2 litre prime of either bicarbonate-balanced fluid or Plasma-Lyte 148.

With the trial fluid, metabolic acid-base status was normal following bypass initiation (standard base excess 0.1 (1.3) mEq/l, mean, SD), whereas Plasma-Lyte 148 produced a slight metabolic acidosis (standard base excess -2.2 (2.1) mEq/l). Estimated group difference after baseline adjustment was 3.6 mEq/l (95% confidence interval 2.1 to 5.1 mEq/l, P=0.0001). By late bypass, mean standard base excess in both groups was normal (0.8 (2.2) mEq/l vs. -0.8 (1.3) mEq/l, P=0.5). Strong ion gap values were unaltered with the trial fluid, but with Plasma-Lyte 148 increased significantly on bypass initiation (15.2 (2.5) mEq/l vs. 2.5 (1.5) mEq/l, P <0.0001), remaining elevated in late bypass (8.4 (3.4) mEq/l vs. 5.8 (2.4) mEq/l, P <0.05).

We conclude that a bicarbonate-based crystalloid with a strong ion difference of 24 mEq/l is balanced for cardiopulmonary bypass in patients with normal acid-base status, whereas Plasma-Lyte 148 triggers a surge of unmeasured anions, persisting throughout bypass. These are likely to be gluconate and/or acetate. Whether surges of exogenous anions during bypass can be harmful requires further study.
Comparison of the Pentax Airway Scope® and McGrath® Videolaryngoscope with the Macintosh Laryngoscope in Tracheal Intubation by Anaesthetists Unfamiliar with Videolaryngoscopes: A Manikin Study
Authors: Sharma D.-J. , Weightman W. M. , Travis A.
Published: January 2019

Videolaryngoscopes are becoming widely available and have been suggested as a replacement for the Macintosh in cases of cervical instability or even for use in the first instance. There is limited existing data on the use of videoscopes by experienced anaesthetists who are inexperienced in the use of videoscopes. We used a manikin model to compare time to intubation between the Macintosh blade, Pentax Airway Scope® and the McGrath® videolaiyngoscope in a simulated urgent intubation by 23 experienced anaesthetists with no prior experience in the use of these videoscopes. We also measured the number of attempts and success of intubation within three minutes. Ease of device use and laiyngoscopic view obtained were also recorded. We found that all participants could intubate the manikin within three minutes, with a median of one attempt using the Pentax Airway Scope® 48% of participants (n = 11) could intubate within three minutes using the McGrath® videolaiyngoscope and required a median of three attempts. This difference occurred despite the majority of anaesthetists obtaining a Grade 1 Cormack and Lehane view with both videoscopes. We demonstrated that anaesthetists who were naive to these videoscopes can successfully intubate the trachea using the Pentax Airway Scope® but not the McGrath® videolaryngoscope.
Decreased Cytosolic Glucocorticoid Receptor Levels in Critically Ill Patients
Authors: Siebig S. , Meinel A. , Rogler G. , Klebl F. , Wrede C. E. , Gelbmann C. , Froh S. , Rockmann F. , Bruennler T. , Schoelmerich J. , Langgartner J.
Published: January 2019

The immune system and the hypothalamic-pituitary-adrenal axis are linked by several mechanisms. Intracellular glucocorticoid receptors represent one important connection. The aim of this study was to examine the coherence between the number of glucocorticoid receptors, activation of the hypothalamic-pituitary-adrenal axis, inflammatory cytokine levels and the severity of illness in critically ill patients.

In a prospective study, blood was collected from 20 healthy members of the hospital staff (control group) and 50 ventilated patients (sample group) within the first 24 hours after intubation and within three days of extubation. 5H-dexamethasone-binding assay was used to assess cytoplasmatic free glucocorticoid receptors levels. ACTH, cortisol, IL-6 and TNFα. levels were measured by ELISA.

In the sample group, specific binding of 5H-dexamethasone was significantly decreased compared to the control group. Glucocorticoid receptor levels tended to be lower in more severely ill patients. Plasma cortisol and ACTH levels were significantly different from the control group after extubation but not at intubation.

Severe illness is associated with rapid down-regulation of 5H-dexamethasone binding. This decrease occurs before elevation of plasma cortisol. Therefore, down-regulation of cortisol binding may be directly associated with the stress response and not due to feedback regulation following increase in plasma cortisol levels.
A Randomised Comparison of Parecoxib Versus Placebo for Pain Management following Minor Day Stay Gynaecological Surgery
Authors: Luscombe K. S. , McDonnell N. J. , Muchatuta N. A. , Paech M. J. , Nathan E. A.
Published: January 2019

At therapeutic concentrations, parecoxib selectively inhibits the cyclo-oxygenase-2 enzyme. We investigated the impact of a single preoperative dose of parecoxib on pain relief following minor gynaecological surgery.

Ninety women undergoing uterine dilatation and curettage, with or without hysteroscopy, were randomised to receive either 40 mg of parecoxib intravenously or a saline placebo prior to induction of standardised general anaesthesia. Exclusion criteria included a preoperative history of renal dysfunction or hypertension and the pre-operative use of anti-inflammatory or opioid medication. The primary endpoint was the pain score during recovery.

There was no difference in global pain scores or area under the curve for pain scores in the recovery area. Pain scores with coughing one hour after surgery were low in both groups but significantly lower after parecoxib (median 2 [interquartile range 0 to 4] parecoxib group vs 2 [interquartile range 0 to 6] placebo group, P=0.037). The 24 hour Quality of Recovery score did not differ significantly between groups but the parecoxib group was less likely to experience headache at 24 hours postoperatively (12 vs 38%, P=0.007) and reported complete satisfaction more frequently (78 vs 57%, P=0.042).

The preoperative administration of parecoxib was associated with a significant but small decrease in dynamic pain scores one hour postoperatively. Women who received preoperative parecoxib had a lower incidence of postoperative headache and higher satisfaction.
The Effect of Remifentanil on the Incidence of Agitation on Emergence from Sevoflurane Anaesthesia in Children Undergoing Adenotonsillectomy
Authors: Dong Y. X. , Meng L. X. , Wang Y. , Zhang J. J. , Zhao G. Y. , Ma C. H.
Published: January 2019

The aim of the present study was to assess the effect of remifentanil on the incidence of emergence agitation in preschool-aged children undergoing adenotonsillectomy with sevoflurane anaesthesia. Sixty children, aged three to seven years, American Society of Anesthesiologists physical status I or II, were randomised into either group S (sevoflurane alone, n=30) or group R (sevoflurane plus remifentanil, n=30). Anaesthesia was induced with an intravenous bolus injection of fentanyl 3 μg/kg and propofol 2.5 mg/kg. Endotracheal intubation was facilitated by vecuronium 0.1 mg/kg. All patients were ventilated with 50% nitrous oxide and 1.5 to 2.5% sevoflurane in oxygen. End-tidal CO2 was maintained at 35∓4 mmHg. Group S received no other medication while group R received remifentanil 1 μg/kg/minute intraoperatively. Mean blood pressure, heart rate, pulse oximetry, eye-opening time and extubation time were recorded in the operating room. In recovery, emergence agitation was assessed using the Pediatric Anesthesia Emergence Delirium scale with a score ≥10 taken as indicating agitation. Emergence agitation occurred in 20 of the 30 patients in group S and seven of the 30 patients in group R (P <0.01). In preschool-aged children undergoing adenotonsillectomy with sevoflurane general anaesthesia, after propofol and fentanyl induction, intraoperative remifentanil decreased the incidence of emergence agitation.
Remifentail Infusion for Paediatric Bronchoscopic Foreign Body Removal: Comparison of Sevoflurane with Propofol for Anaesthesia Supplementation for Bronchoscope Insertion
Authors: Zhang J. , Wang Y. , Li B. , Zhang W.
Published: January 2019

The study compared sevoflurane or propofol as anaesthesia supplements to remifentanil infusion and topical local anaesthesia for insertion of a rigid bronchoscope for bronchial foreign body removal in children aged one to three years.

Seventy children were randomly allocated to two groups to receive remifentanil infusion at 0.2 μg.kg-1.min-1 with either sevoflurane or propofol supplements for insertion of the rigid bronchoscope. Heart rate and systolic blood pressure before anaesthesia, prior to and on insertion of the bronchoscope and one, three, five, seven and ten minutes after insertion were measured. Incidence of cough and apnoea were recorded.

The haemodynamic changes during bronchoscopy were moderate and did not differ between groups. The sevoflurane group had a lower incidence of cough than the propofol group. No significant difference was detected in the incidence of apnoea between groups. It can be concluded that remifentanil infusion with modest use of general anaesthetic agents facilitates rigid bronchoscopy successfully in children.
Audit of Initial use of the Ultrasound-Guided Transversus Abdominis Plane Block in Children
Authors: Palmer G. M. , Luk V. H. Y. , Smith K. R. , Prentice E. K.
Published: January 2019

The extent of dermatomal block post transversus abdominis plane block is described in adults as T7-L1; other authors argue extent above T10 is infrequent (supra-iliac 20 ml injection). A paediatric guideline recommends this block for upper and lower abdominal surgery using 0.2 ml/kg. We aimed (through prospective audit) to document the multi-level block achieved with ultrasound-guided transversus abdominis plane block in children having abdominal surgery, during a departmental training period. Data included patient, anaesthetic and surgical details, transversus abdominis plane block characteristics (anterior supra-iliac injections) and dermatomal blockade to ice.

Twenty-seven children received 38 blocks performed by 58% consultant and 42% trainee operators (90% novices): 16 unilateral/11 bilateral for umbilical (1), inguinal (13), laparoscopic (8) and laparotomy (5) surgery. Dermatomal assessment for 35 blocks (mean local anaesthetic volume 0.4 ml/kg [SD 0.2]) revealed the median blockade achieved was 3 dermatomes (interquartile range 3 to 4) involving T10 to L1 in 75% of patients. Eight blocks (six patients) also involved T8 and T9, following 0.31 to 0.81 ml/kg. One patient (3% of assessed blocks) had no block to ice at 60 minutes, but required no postoperative analgesia.

Ultrasound-guided transversus abdominis plane blocks performed by supra-iliac approach and novice operators produced lower abdominal sensory blockade in children of usually 3 to 4 dermatomes, and should be offered for lower abdominal surgery only, as only 25% had upper abdominal block extension. The optimal local anaesthetic dose/volume, duration of effect and utility for these blocks in relation to peripheral and neuraxial blockade needs clarification.
Removal of an Impacted Distal Airway Foreign Body using a Guidewire and a Balloon Angioplasty Catheter
Authors: McAfee S. J. , Vashisht R.
Published: January 2019

Airway aspiration of foreign bodies is relatively common in young children. Visible objects are commonly removed under direct vision using grabbing forceps inserted through a rigid bronchoscope. We describe a case of aspiration of the hollow tip of a plastic pen which lodged distally in the right main bronchus of an older child. This object was located so distally that it could only be visualised using flexible fibreoptic bronchoscopy. A novel method was required for successful retrieval, which involved the passage of a guidewire through the centre of the foreign body. A balloon angioplasty catheter was then railroaded over the guidewire through the foreign body and the balloon inflated with saline. This allowed the foreign body to be pulled proximally out of the airway.
Optimum Bolus Dose of Propofol for Tracheal Intubation during Sevoflurane Induction without Neuromuscular Blockade in Children
Authors: Kim S.-H. , Hong J.-Y. , Suk E. H. , Jeong S. M. , Park P. H.
Published: January 2019

The purpose of this study was to determine the optimum bolus dose of propofol required to provide excellent conditions for tracheal intubation following inhalational induction of anaesthesia using 5% sevoflurane without neuromuscular blockade. Twenty-eight children, aged three to seven years, requiring anaesthesia for short duration surgery were recruited. Two minutes after beginning the inhalational induction with 5% sevoflurane and 60% nitrous oxide, a predetermined dose of propofol was injected over 10 seconds. Propofol dose was determined using the Dixon's up-and-down method, starting from 3 mg/kg (0.5 mg/kg as a step size). Laryngoscopy was performed 50 seconds after propofol injection. The optimum dose of propofol required for excellent intubating conditions was 1.39±0.37 mg/kg in 50% of children during inhalation induction using 5% sevoflurane and 60% nitrous oxide in the absence of neuromuscular blocking agents. From probit analysis, the 95% effective dose of propofol was 2.33 mg/kg (95% confidence interval 1.78 to 6.21 mg/kg).
Myocardial Injury in Remifentanil-Based Anaesthesia for off-Pump Coronary Artery Bypass Surgery: An Equipotent Dose of Sevoflurane versus Propofol
Authors: Kim T.-Y. , Kim D.-K. , Yoon T.-G. , Lim J.-A. , Woo N.-S. , Chee H.-K. , Shin J.-K. , Song M.-G. , Kim S.-H.
Published: January 2019

This randomised controlled trial compared the effect of equipotent anaesthetic doses of sevoflurane (S group) versus propofol (P group), during remifentanil-based anaesthesia for off-pump coronary artery bypass surgery, on myocardial injury. Either sevoflurane or propofol was titrated to maintain bispectral index values between 40 and 50. In both groups, a targeted concentration of remifentanil 20 ng.ml-1 was maintained during anaesthesia. The concentrations of creatine kinase MB and troponin I were measured before the start of surgery, on admission to the intensive care unit, and at 12 and 24 hours after intensive care unit admission. The postoperative values of creatine kinase MB (S group: 15.08±18.97, 20.78±20.92, 12.76±12.82 vs 2.09±1.54 ng.ml-1; P group: 10.99±13.15, 27.16±56.55, 11.88±18.80 vs 1.84±1.67 ng.ml-1) and troponin I (S group: 3.56±5.19, 5.66±7.89, 3.35±4.55 vs 0.52±1.90 ng.ml-1; P group: 2.42±3.33, 4.11±6.01, 3.04±5.31 vs 0.43±1.28 ng.ml-1) were significantly higher than preoperative values in both groups but there were no significant differences between the two groups. There were no significant differences in time to extubation (S group, 476±284 minutes; P group, 450±268 minutes) and intensive care unit length of stay (S group, 2775±1449 minutes; P group, 2797±1534 minutes) between the two groups. In conclusion, sevoflurane and propofol at equipotent doses guided by bispectral index with remifentanil 20 ng.ml-1 had similar creatine kinase MB and troponin I values.
The Effect of the Sitting Upright or ‘Beachchair’ Position on Cerebral Blood Flow during Anaesthesia for Shoulder Surgery
Authors: Soeding P. F. , Wang J. , Hoy G. , Jarman P. , Phillips H. , Marks P. , Royse C.
Published: January 2019

The sitting upright or ‘beachchair’ position is commonly used for shoulder arthroscopic surgery. There is a theoretical concern that anaesthetised patients placed in this posture are at risk of reduced cerebral blood flow (CBF), especially if there is associated hypotension. This study investigated the effect of anaesthetic-induced hypotension on estimated cerebral blood flow in patients placed in the beachchair position for shoulder surgery.

Forty patients were randomised to either sedation (propofol infusion 10 to 20 mg.hour-1, n=20) or general anaesthesia using sub minimum alveolar concentration of sevoflurane (n=20). All patients received an interscalene brachial plexus regional block. Internal carotid artery blood flow was measured using the time averaged velocity of the spectral Doppler waveform, and was then used as an estimate of global CBF. Following a pre-anaesthesia study, measurement of internal carotid artery blood flow was made before and after beachchair positioning, and at five-minute intervals during surgery.

Beachchair positioning during general anaesthesia significantly decreased the mean arterial pressure (34±10 mmHg) compared to sedation (4±2 mmHg, P <0.01), and vasopressor therapy was required more often. However, CBF remained constant in both anaesthetised (P=0.83) and sedated patients (P=0.68) despite beachchair positioning, and the fall in mean arterial pressure in the anaesthetised patients. There was no significant difference in CBF between groups (P=0.91). These findings indicate that in patients in the beachchair position receiving sevoflurane anaesthesia, CBF is maintained when mean arterial pressure is above 70 mmHg, consistent with intact autoregulation.
The Relationship between Blood Lactate and Survival following the Use of Adrenaline in the Treatment of Septic Shock
Authors: Omar S. , Burchard A. T. , Lundgren A. C. , Mathivha L. R. , Dulhunty J. M.
Published: January 2019

This prospective observational study evaluates the relationship between adrenaline, lactate and intensive care unit survival in septic shock. Forty patients requiring adrenaline therapy for a first episode of septic shock acquired >24 hours after admission to the intensive care unit had blood lactate levels measured two-hourly over a 24-hour period. Adrenaline therapy was escalated until target mean arterial pressure was reached. The lactate index was calculated as the ratio of maximum lactate increase to the adrenaline increase. Lactate increased from 2.3 to 2.9 mmol.l-1 (P=0.024) and the mean adrenaline increase was 0.14 μg.kg-1.minute-1. Peak lactate correlated with peak adrenaline (rho=0.34, P=0.032). Lactate index was the only independent predictor of survival after controlling for age and Acute Physiological and Chronic Health Evaluation II score (odds ratio 1.14, 95% confidence interval 1.03 to 1.26, P=0.009). A high lactate following adrenaline administration may be a beneficial and appropriate response.
Variability in Adequacy of Ventilation during Transport of Cardiac Surgery Patients: A Cohort Study
Authors: Rajasekaram R. , Reade M. C. , Shortal B. , Hart G. K. , Shaw M. , Bellomo R.
Published: January 2019

Inadequate ventilation of intubated patients during transport from the operating theatre to the intensive care unit with attendant hypercarbia may adversely affect haemodynamics. In a retrospective observational study, we assessed the incidence of inadequate ventilation during transport from the operating theatre to the intensive care unit in 99 consecutive cardiac surgery patients admitted to our university tertiary hospital.

Demographic, clinical, arterial blood gas and haemodynamic measurements were made on arrival in the intensive care unit after cardiac surgery. The relationships between arterial carbon dioxide tension (PaCO2), mean pulmonary artery pressure (MPAP) and other relevant haemodynamic variables were explored. Overall, hypocarbia (PaCO2<35 mmHg) occurred in 18.2% of patients, while 28.3% of patients had hypercarbia (PaCO2 >45 mmHg). Pulmonary hypertension was common, with nearly half of the cohort having MPAP ≥25 mmHg and 17.2% ≥30 mmHg. However, there was no association between PaCO2 and MPAP (R2=0.0076, P=0.39). Contrary to expectation, neither hypercarbia nor high MPAP were associated with measured adverse outcomes, although this may have been because we studied an insufficient number of patients with extreme values. Associations of higher MPAP, which would be expected to compromise cardiovascular status, included acidaemia, hypoxia and the requirement for noradrenaline. These factors define a group of high-risk patients who should receive particular attention and who should be the focus of future studies.
Quantification of Volume Loss and Haemodynamic Changes of Gelofusine®-induced Anaphylaxis during Cardiopulmonary Bypass
Authors: Clarke R. , Sadleir P. , Van Niekerk A. W. , Platt P.
Published: January 2019

A patient undergoing anaesthesia for coronary artery bypass surgery developed what was subsequently confirmed to be an anaphylactic reaction to succinylated gelatin (Gelofusine®). By virtue of being on cardiopulmonary bypass, rapid detection, quantification and treatment of volume loss (by vasodilatation and extravasation) was possible. The patient required 51 ml/kg of resuscitative fluids in the 15 minutes after onset of anaphylaxis, or 73% of her calculated preoperative blood volume. Alpha-adrenoceptor agonists and vasopressin were required to manage ongoing vasoplegia. This case emphasises the importance of volume resuscitation and vasopressors in the treatment of anaphylaxis.
A Rare Case of Antepartum Posterior Reversible Encephalopathy Syndrome
Authors: Hegde H. V. , Patil P. B. , Rameshkumar R. , Sunita T. H. , Bhat M. T. , Desai R. M. , Rao P. R.
Published: January 2019

Pre-eclampsia and eclampsia are well-known causative factors of posterior reversible encephalopathy syndrome (PRES). There are only a few reported cases of antepartum PRES. We report a 25-year-old primigravid woman who presented with eight months of amenorrhoea and an abrupt onset of eclampsia associated with a history of a fall. A computed tomography scan ruled out intracranial haemorrhage and PRES was diagnosed. She responded well to supportive care, labour was induced and maternal and neonatal outcomes were good. Antepartum PRES poses different challenges to those of PRES in non-obstetric or postpartum patients, because of the additional management aspects required to ensure foetal wellbeing. We were posed with a difficult decision about the disadvantages of caesarean section versus those of vaginal delivery in our patient.
Changing Patterns in Endotracheal Intubation for Anaesthesia Trainees: A Retrospective Analysis of 80,000 Cases over 10 Years
Authors: Smith N. A. , Tandel A. , Morris R. W.
Published: January 2019

Several overseas studies have suggested that opportunities for anaesthesia trainees to learn and practise endotracheal intubation have decreased over time. We analysed the operating theatre data collection system at a large Australian metropolitan teaching hospital from 1998 to 2008 to determine if numbers for trainees’ caseloads in general, and endotracheal intubation in particular, had changed. The total caseload per trainee of approximately 800 cases per year was stable throughout the study period. The number of gastrointestinal endoscopies per trainee increased significantly with a corresponding decrease in the number of other cases. The mean number of endotracheal intubations per trainee per year fell by 10% and of supraglottic devices by 16%, neither of which was statistically significant. Endotracheal intubation for caesarean sections did however fall significantly from an average of nine to an average of six cases per trainee per year. Our findings contrast with other reports of much larger decreases in the number of endotracheal intubations performed by trainees over the last decade, but suggest that our local practice is similar to the international experience of decreasing opportunities for endotracheal intubation in obstetric anaesthesia.
Initial Lactate Level and Mortality in Septic Shock Patients with Hepatic Dysfunction
Authors: Kang Y. R. , Um S.-W. , Koh W.-J. , Suh G. Y. , Chung M. P. , Kim H. , Kwon O. J. , Jeon K.
Published: January 2019

An elevated serum lactate level is associated with morbidity and mortality in patients with severe sepsis and septic shock. In patients with hepatic dysfunction, however, an elevated serum lactate level may be due to either impaired lactate clearance or excessive production. Thus, we evaluated whether the initial serum lactate level was also associated with mortality in septic shock patients with hepatic dysfunction. A retrospective observational study enrolled 307 patients with septic shock admitted to the intensive care unit (ICU) between May 2007 and July 2009. Hepatic dysfunction was defined as a serum total bilirubin >34.2 μmol/l (2 mg/dl). Selected patients were divided into high (>4 mmol/l) and low (<4 mmol/l) lactate groups, according to the initial serum lactate level. Of 307 patients with septic shock, 118 (38%) patients with hepatic dysfunction were eligible for this study. The median lactate levels were 5.9 (interquartile range 4.7 to 9.0) and 2.6 (interquartile range 1.7 to 3.2) mmol/l for the high and low lactate groups respectively (P <0.001). The initial serum lactate level was strongly associated with in hospital mortality in a univariate analysis (P <0.001). After adjusting for potential confounding factors, the initial serum lactate level remained significantly associated with in-hospital mortality (odds ratio 1.281, 95% confidence interval 1.097 to 1.496, P=0.002). In conclusion, the serum lactate level could be useful in predicting the outcome of patients with septic shock regardless of hepatic dysfunction.
Adverse Events in the Removal of Naltrexone Implants
Authors: Sadleir P. H. M. , Gardner A. I. , Hennessy B.
Published: January 2019

Naltrexone implants are used as an abstinence therapy for patients with opioid, amphetamine and alcohol abuse. This study was designed to assess the implications of this therapy in patients presenting for anaesthesia for removal of these implants. We conducted a retrospective case-note review of 37 patients undergoing removal of naltrexone implants in the period 2001 to 2008 at Sir Charles Gairdner Hospital. Indications for removal included infection at the insertion site, naltrexone intolerance or the requirement for effective opioid analgesia. Thirty-two patients had surgery under general anaesthesia, four under local anaesthesia and one under spinal anaesthesia. The perioperative opioid requirement varied from 0 to 100 mg of intravenous morphine equivalents (median 11.7 mg, mean 20.7 mg). The only factor that was associated with a higher perioperative opioid requirement was whether the implant was infected or not. Forty-four percent of patients having a general anaesthetic complained of moderate to severe pain postoperatively, and 64% of these patients had a prolonged stay in the post-anaesthesia care unit. We did not observe any instances of postoperative complications due to increased opioid sensitivity after removal of naltrexone implants. The majority of patients were discharged home by the first postoperative day. Anaesthesia for the removal of naltrexone implants was associated with a wide range of opioid analgesia requirements and a high incidence of pain postoperatively. Concern regarding increasing opioid sensitivity after removal of implants does not seem to preclude use of generous opioid analgesia in this group of patients.
Aminotransferase Levels in Relation to Short-Term use of Acetaminophen Four Grams Daily in Postoperative Cardiothoracic Patients in the Intensive Care Unit
Authors: Ahlers S. J. G. M. , van Gulik L. , van Dongen E. P. A. , Bruins P. , Tibboel D. , Knibbe C. A. J.
Published: January 2019

A volunteer study suggested that taking paracetamol 4 g daily could result in elevated alanine aminotransferase plasma levels in a substantial proportion of healthy volunteers. The safety of this dose of paracetamol for acute postoperative pain remains controversial. This study aimed to examine the incidence of alanine aminotransferase elevations after short-term use of paracetamol 4 g daily, as part of the standard pain management protocol, for 93 consecutive patients after cardiothoracic surgery. Alanine aminotransferase levels and other liver function tests were measured preoperatively as baseline and once daily after surgery during the intensive care unit stay. Preoperative alanine aminotransferase levels of more than one time the upper limit of normal (ULN, >40 U/l) was observed in 11% (n=10) of the patients but none of these baseline alanine aminotransferase levels exceeded three times the ULN (>3×ULN). The average daily dose of paracetamol administered was 50 mg/kg (SD=16) after surgery. Postoperative alanine aminotransferase levels of >1×ULN was observed in 17% (n=16), and 4% (n=4) exceeded >3×ULN. The other liver function tests of the latter four patients, including aspartate aminotransferase (range 173 to 5590 U/l), γ-glutamyltransferase (range 56 to 103 U/l), lactate dehydrogenase (range 376 to 3518 U/l) and the International Normalised Ratio (range 2.0 to 6.6), were all abnormal. These four patients all had right ventricular failure or cardiogenic shock during the postoperative period which could explain the significant rises in alanine aminotransferase after surgery. In conclusion, the incidence of significant alanine aminotransferase elevations after using daily paracetamol as an analgesic agent for cardiac surgery, at a dose of 4 g per day, was low and mostly due to complications after surgery. Our results, albeit still very limited, provided some reassurance about the safety of paracetamol 4 g daily, as a supplementary analgesic agent for adult patients undergoing cardiac surgery.
Evaluation of a Humidified Nasal High-Flow Oxygen System, Using Oxygraphy, Capnography and Measurement of Upper Airway Pressures
Authors: Ritchie J. E. , Williams A. B. , Gerard C. , Hockey H.
Published: January 2019

In this study, we evaluated the performance of a humidified nasal high-flow system (Optiflow™, Fisher and Paykel Healthcare) by measuring delivered FiO2 and airway pressures. Oxygraphy, capnography and measurement of airway pressures were performed through a hypopharyngeal catheter in healthy volunteers receiving Optiflow™ humidified nasal high flow therapy at rest and with exercise. The study was conducted in a non-clinical experimental setting. Ten healthy volunteers completed the study after giving informed written consent. Participants received a delivered oxygen fraction of 0.60 with gas flow rates of 10, 20, 30, 40 and 50 l/minute in random order. FiO2, FEO2, FECO2 and airway pressures were measured. Calculation of FiO2 from FEO2 and FECO2 was later performed. Calculated FiO2 approached 0.60 as gas flow rates increased above 30 l/minute during nose breathing at rest. High peak inspiratory flow rates with exercise were associated with increased air entrainment. Hypopharyngeal pressure increased with increasing delivered gas flow rate. At 50 l/minute the system delivered a mean airway pressure of up to 7.1 cmH2O. We believe that the high gas flow rates delivered by this system enable an accurate inspired oxygen fraction to be delivered. The positive mean airway pressure created by the high flow increases the efficacy of this system and may serve as a bridge to formal positive pressure systems.
Nasogastric Medication for Perioperative Parkinson's Rigidity during Anaesthesia Emergence
Authors: Stagg P. , Grice T.
Published: January 2019

We present a case of severe rigidity during emergence from general anaesthesia in a 64-year-old man who had suffered from Parkinson's disease for nine years. Controversy still exists over how to optimally manage these patients perioperatively. We successfully managed his Parkinsonism with administration of crushed Sinemet® and amantadine via a nasogastric tube. This case report serves as a reminder of the importance that patients receive their anti-Parkinsonian medications perioperatively, and highlights the potential benefits of inserting a gastric tube to continue anti-Parkinson's medication dosing during prolonged surgery.
Hypnosis for Cataract Surgery in an American Society of Anesthesiologists Physical Status IV Patient
Authors: Kiss G. , Butler J.
Published: January 2019

A 73-year-old morbidly obese female patient (weight 125 kg, height 156 cm) was scheduled for cataract surgery of her right eye. Due to a number of severe co-morbidities general anaesthesia was contraindicated. However, the patient was very anxious and requested sedation if the procedure was to be undertaken under local anaesthesia. She responded very positively to the proposal of utilising perioperative hypnosis. Hypnotic induction was achieved with the heavy eyelid technique, putting the patient into trance within 30 seconds. Continuous relaxing suggestions as described by the patient herself the day before surgery were used to maintain the trance state. She later reported that she was not aware of being in the operating room, but experienced profound relaxation during the procedure. Perioperative hypnosis proved to be a satisfactory option for sedation in this high-risk patient and should be actively considered for similar, easily suggestible patients who are undergoing minor surgery.
Unrestricted Access to Sugammadex: Impact on Neuromuscular Blocking Agent Choice, Reversal Practice and Associated Healthcare Costs
Authors: Ledowski T. , Hillyard S. , Kozman A. , Johnston F. , Gillies E. , Greenaway M. , Kyle B. C.
Published: January 2019

Sugammadex is known to rapidly and completely reverse the effects of amino-steroidal neuromuscular blocking agents. However, the high costs of sugammadex have so far prevented its introduction as the standard reversal agent in most healthcare systems. At the Royal Perth Hospital, sugammadex was recently introduced as an unrestricted alternative to neostigmine for the reversal of amino-steroidal neuromuscular blocking agents. The aim of this retrospective observational audit was to investigate the impact of this change on clinical practice and associated healthcare costs.

Data from all patients intubated during a one-month period in April to May 2010 and for a similar period in 2011 were retrospectively collected and the use of neuromuscular blocking agents and reversal agents were identified and the associated costs were calculated. More steroidal neuromuscular blocking agents and sugammadex (+743%), but less glycopyrrolate and neostigmine (-48%) were used in 2011. Using the manufacturer's list price, muscle relaxation and reversal costs increased from about A$42 per case to about A$127 per case. Between the investigated time periods no differences were found for anaesthesia time, operating time or time spent in the post anaesthesia care unit. However, there was a statistically significant decrease in the time between surgery and discharge (median 2.0 vs 2.2 days). While the design of the audit was such that no inferences can be made about the cause of this change, this is an interesting observation worthy of further investigation.
Gastric Rupture following Nasopharyngeal Catheter Oxygen Delivery—A Report of Two Cases
Authors: Yao H. H. I. , Tuck M. V. , Mcnally C. , Smith M. , Usatoff V.
Published: January 2019

Iatrogenic gastric distension and subsequent rupture following nasal or nasopharyngeal catheter oxygen delivery is a rare but life-threatening condition that requires urgent laparotomy. We report two cases recently encountered at our institution. Both patients exhibited symptoms of abdominal pain and distension following oxygen delivery involving a nasopharyngeal catheter during procedural sedation. Oxygen flow rates were 4 l/minute in both cases. The diagnosis was made by urgent imaging. Both patients survived following laparotomy and repair of gastric rupture. Seventeen cases have been reported previously in the literature. We recommend avoidance of nasal or nasopharyngeal catheters and the use of alternative oxygen delivery methods such as nasal prongs and face masks.
Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) Protocol in Critically Ill Surgical Patients: A Multicentre Prospective Evaluation
Authors: Declercq B. , Deane A. M. , Wang M. , Chapman M. J. , Heyland D. K.
Published: January 2019

Suboptimal levels of feeding in critically ill patients are associated with poor clinical outcomes. The Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol was developed to improve nutritional delivery in the critically ill and has been studied in several hospitals. However, the experience with this protocol in surgical patients is limited to date. The objective of this analysis was to describe the experience with this protocol in surgical patients. We analysed observational patient data obtained from the 2013 International Nutrition Survey. We compared nutritional practices and outcomes of patients admitted for surgical and medical reasons to ICUs in sites that implemented the PEPuP protocol. We used surgical ICU patients in non-PEPuP sites as a concurrent control group. In sites that implemented the PEPuP protocol, surgical patients received a smaller proportion of prescribed calories (43% versus 61%, P=0.004) and protein (38% versus 57%, P=0.002) compared to medical patients. When compared to the cohort of surgical patients from control sites, the surgical patients from PEPuP sites received similar amounts of calories and protein. Although surgical PEPuP patients were more likely to receive trophic and volume-based feeds compared to surgical patients in control sites, other aspects of the PEPuP protocol were not adequately implemented. We conclude that nutritional delivery to surgical patients remains inadequate and the PEPuP protocol seems ineffective in improving nutritional intake in this population. Further research to determine methods of optimising PEPuP protocol implementation and adherence in surgery patients is needed.
Automated External Defibrillator Use for In-Hospital Emergency Management
Authors: Huschak G. , Dünnebier A. , Kaisers U. X. , Bercker S.
Published: January 2019

The in-hospital spread of automated external defibrillators (AEDs) is aimed to allow for a shock-delivery within three minutes. However, it has to be questioned if the implementation of AED alone really contributes to a ‘heart-safe hospital’. We performed a cohort study of 1008 in-hospital emergency calls in a university tertiary care hospital, analysing cardiopulmonary resuscitation (CPR) cases with and without AED use. In total, 484 patients (48%) had cardiac arrest and received CPR. Response time of the emergency team was 4.3 ± 4.0 minutes. Only 8% percent of the CPR cases had a shockable rhythm. In three of 43 placements a shock was delivered by the AED. There were no differences in survival between patients with CPR only and CPR with AED use. Our data do not support the use of an AED for in-hospital CPR if a professional response team is rapidly available.
A Feasibility Study of Functional Status and Follow-Up Clinic Preferences of Patients at High Risk of Post Intensive Care Syndrome
Authors: Farley K. J. , Eastwood G. M. , Bellomo R.
Published: January 2019

After prolonged mechanical ventilation patients may experience the ‘post intensive care syndrome’ (PICS) and may be candidates for post-discharge follow-up clinics. We aimed to ascertain the incidence and severity of PICS symptoms in patients surviving prolonged mechanical ventilation and to describe their views regarding follow-up clinics. In a teaching hospital, we conducted a cohort study of all adult patients discharged alive after ventilation in ICU for ≥7 days during 2013. We administered the EuroQol-5D (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) via telephone interview and asked patients their views about the possible utility of a follow-up clinic. We studied 48 patients. At follow-up (average 19.5 months), seven (15%) patients had died and 14 (29%) did not participate (eight declined; two were non–English speakers; four were non-contactable). Among the 27 responders, 16 (59%) reported at least moderate problems in ≥1 EQ-5D dimension; 10 (37%) in ≥2 dimensions, and 8 (30%) in ≥3 dimensions. Moreover, 10 (37%) patients reported marked psychological symptoms; six (22%) scored borderline or abnormal on the HADS for both anxiety and depression; and four (15%) scored borderline or abnormal for one component. Finally, 21/26 (81%) patients stated that an ICU follow-up clinic would have been beneficial. At long–term follow-up, the majority of survivors of prolonged mechanical ventilation reported impaired quality of life and significant psychological symptoms. Most believed that a follow-up clinic would have been beneficial.
Global Safe Anaesthesia and Surgery Initiatives: Implications for Anaesthesia in the Pacific Region
Authors: Cooper M. G. , Wake P. B. , Morriss W. W. , Cargill P. D. , McDougall R. J.
Published: January 2019

In 2015 three major events occurred for global anaesthesia and surgery. In January, the World Bank published Disease Control Priorities 3rd edition (DCP 3rd edition). This volume, Essential Surgery, highlighted the cost effective role of anaesthesia and surgery in global health. In April, the Lancet Commission on Global Surgery released its report “ Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development”. The report focuses on five key areas to promote change including: access to timely surgery, surgical workforce and procedural capability, surgical volume, data collection such as perioperative mortality rate, and financial protection. In May, the 68th World Health Assembly (WHA) voted in favour of Resolution A68/31: Strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage. The resolution was passed unanimously and it is the first time that surgery and anaesthesia have received such prominence at WHA level. These three events all have profound implications for the provision and access of safe anaesthesia and surgery in the Pacific region in the next 15 years. This article considers some of the regional factors that affect these five key areas, especially with regard to anaesthetic specialist workforce density in different parts of the region. There are many challenges to improve anaesthesia access, safety, and workforce density in the Pacific region. Future efforts, initiatives and support will help address these problems.
Care-related Pain in Critically Ill Mechanically Ventilated Patients
Authors: Ayasrah S.
Published: January 2019

Despite advances in pain management, critically ill patients continue to have unacceptably high rates of uncontrolled pain. Using the Behavioural Pain Scale and physiological indicators of pain, this study examines pain levels in mechanically ventilated patients prior to and during routine nursing procedures. A prospective descriptive design was used to assess and describe care-related pain associated with nociceptive procedures (repositioning, endotracheal suctioning, and vascular punctures) and non-nociceptive procedures (mouth care, eye care and dressing change). A sample of 247 mechanically ventilated Jordanian patients was recruited from intensive care units in a military hospital. The overall mean procedural pain score of 6.34 (standard deviation [SD] 2.36) was significantly higher than the mean preprocedural pain score of 3.43 (SD 0.67, t[246] = 20.82, P <0.001). The highest mean procedural pain scores were observed during repositioning (9.25, SD 1.29). Few patients received analgesics and/or sedatives in the hour prior to the procedures. The mean Ramsay Scale score was 2.49 (SD 0.95), indicating that patients were either anxious or responsive to command only. The mean physiological indicators of pain increased during repositioning and endotracheal suctioning and decreased during the rest of the procedures. Mechanically ventilated patients experience pain prior to and during routine nursing procedures. Harmless and comfort procedures are actually painful. When caring for nonverbal critically ill patients, clinicians need to consider care-related pain associated with their interventions. Relying on changes in vital signs as a primary indicator of pain can be misleading.
Safety of Nicotine Replacement Therapy in Critically Ill Smokers: A Retrospective Cohort Study
Authors: Kerr A. , McVey J. T. , Wood A. M. , Van Haren F. M. P.
Published: January 2019

Nicotine replacement therapy (NRT) is a common first-line treatment to prevent nicotine withdrawal in smokers. However, available literature reports conflicting results regarding its efficacy and safety in critically ill patients. The objective of this study was to evaluate the relationship between NRT in smokers in the intensive care unit (ICU) and outcomes. This case-control study was conducted in a university-affiliated tertiary hospital ICU. Over a period of five years, 126 active smokers who received transdermal NRT were matched to 126 active smokers who did not receive NRT. The groups were case-matched for sex, age and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The primary outcome was administration of antipsychotic medication. Secondary outcomes included use of physical restraints, 30-day mortality, and ventilation requirements. Antipsychotic medication was prescribed in 43 (34.1%) patients who received NRT compared to 14 (11.1%) in controls ( P <0.01). Physical restraints were used in 37 (29.4%) patients who received NRT, compared to 12 (9.5%) of controls ( P <0.01). The 30-day mortality and number of patients intubated was not statistically different between groups. Average length of intubation time was greater in the NRT group (2.56 days; standard deviation 4.16) compared to the control group (1.44 days; standard deviation 2.68) ( P=0.012). The use of NRT to prevent nicotine withdrawal in ICU patients is associated with increased use of antipsychotic medication and physical restraint, and with prolonged mechanical ventilation.