bluuebunny/crossref_metadata_2025 huggingface dataset:
Dynamic Airflow Limitation after Topical Anaesthesia of the Upper Airway
Authors: Ho A. M.-H. , Chung D. C. , Karmakar M. K. , Gomersall C. D. , Peng Z. , Tay B. A.
Published: January 2019

This prospective before-and-after observational study investigated the effect of upper airway anaesthesia on dynamic airflow. Six consenting ASA 1 adults, all authors of this study, underwent a series of Spirometric measurements before and after topical anaesthesia of the upper airway using lignocaine. Peak inspiratory flow rate, forced inspiratory flow between 25% and 75% of the maximum inhaled volume, forced expiratory volume at 1 second, and forced vital capacity in the supine and sitting positions were measured. The measured inspiratory parameters were significantly reduced after lignocaine topical anaesthesia of the upper airway. Expiratory flow parameters were not affected. We conclude that topical anaesthesia of the upper airway leads to dynamic inspiratory airflow limitation.
Anaesthesia Medical Workforce in New Zealand
Authors: King S. Y.
Published: January 2019

This survey was conducted in all 28 New Zealand District Health Boards with a response rate of 100%. The Clinical Directors of Departments of Anaesthesia were asked to quantify their current anaesthesia service delivery and to assess their workforce level. Over half of the District Health Boards reported understaffing, fifty percent occurring in hospitals of provincial cities or towns with an inability to attract specialist anaesthesia staff. Financial constraint was the other main reason for understaffing.

With the information from the survey, an attempt was made to predict future New Zealand anaesthesia workforce requirements. A model for Australasia established by Baker in 1997 was used. In comparing this survey to previous studies, there is evidence that the nature and expectations of the anaesthesia workforce are changing as well as the work environment. Currently, there is no indication that anaesthesia specialist training numbers should be reduced. Close, ongoing monitoring and planning are essential to ensure future demands for anaesthesia services can be met.
A Comparison of the Oropharyngeal Leak Pressure between the Reusable Classic™ Laryngeal Mask Airway and the Single-use Soft Seal™ Laryngeal Mask Airway
Authors: Hanning S. J. , Mcculloch T. J. , Orr B. , Anderson S. P.
Published: January 2019

We tested the oropharyngeal leak pressure with the reusable laryngeal mask airway and the single-use Soft Seal™ laryngeal mask airway. These two types of laryngeal mask airway (LMA) have a similar design but the reusable LMA cuff is made from silicone whereas the Soft Seal LMA cuff is Polyvinylchloride. Thirty-five healthy subjects were anaesthetized and paralyzed and the two types of Soft Seal LMA were compared in a blinded randomized cross-over trial. The oropharyngeal leak pressure was significantly higher with the Soft Seal than the reuable (21±7.6 and 16±6.7 cm H2O respectively, P=0.002). However, in four subjects the oropharyngeal leak pressure was higher with the reusable by >4 cm H2O. We concluded that the reusable LMA may provide a better seal in some individuals but that, on average, the Soft Seal provides a higher oropharyngeal leak pressure than the reusable LMA.
Subdural Spinal Haematoma after Epidural Anaesthesia in a Patient with Spinal Canal Stenosis
Authors: Chan M. Y. L. , Lindsay D. A.
Published: January 2019

A 60-year-old male with a past history of T12 fracture had epidural analgesia for a radical prostatectomy. It was unknown prior to epidural insertion that the patient had a canal stenosis at T12 from the previous injury. The patient developed severe bilateral buttock pain after epidural catheter removal. Magnetic resonance imaging demonstrated a spinal subdural haematoma from T10 to L2 with mild cord compression. The patient made a successful recovery with conservative management. Neuraxial blockade should be approached with caution in patients with previous back injury, and only after a thorough assessment has been obtained to exclude spinal canal stenosis.
An Introductory Guide to Survey Research in Anaesthesia
Authors: Jones D. , Story D. , Clavisi O. , Jones R. , Peyton P.
Published: January 2019

Surveys allow convenient and inexpensive research. Surveys include mail-out questionnaires, email questionnaires, telephone interviews, and personal interviews. Despite a widespread perception that surveys are easy to conduct, good surveys need rigorous design, implementation and analysis. This requires substantial planning, time and effort. The most important step in designing a survey is to clearly define the question (s) the survey aims to answer. The target population, measured variables and types of associations being investigated should be specific and unambiguous. Investigators should concentrate on what they ‘need to know’ rather than what would be ‘nice to know’. During development surveys should be piloted to identify problems. The main goal when implementing a survey is to maximize the response rate to avoid misleading results. Evidence-based strategies, including brief personalized surveys with stamped return envelopes, can be used to maximize the response rate. A poorly conducted survey can lead to misleading or invalid conclusions and may undermine participation in subsequent surveys by the target population.
The use of Ketamine as Rescue Analgesia in the Recovery Room following Morphine Administration—A Double-Blind Randomised Controlled Trial in Postoperative Patients
Authors: Gillies A. , Lindholm D. , Angliss M. , Orr A.
Published: January 2019

In some patients, control of postoperative pain can be difficult with morphine alone. This double-blind randomised controlled trial was designed to evaluate whether a small bolus dose of ketamine could improve pain scores in those patients who had inadequate relief of their postoperative pain after two standard doses of morphine. Forty-one patients with uncontrolled postoperative pain were randomly assigned to receive either morphine (M) alone, or morphine plus 0.25 mg/kg ketamine (K) in the recovery room. No other analgesics were to be given. The study had adequate power to detect a 25% difference in pain scores. There was no statistically significant difference in verbal rating scale pain scores between the two groups either in the recovery room (K=5.16, M=6.28, P=0.065), or at a later time on the ward. There was no apparent difference between groups in sedation, morphine consumption, postoperative nausea and vomiting, quality of recovery or need for rescue analgesia. We could not demonstrate an effective role for ketamine in the management of problematic postoperative pain at the dose studied.
Radiation Exposure during Anaesthetic Practice
Authors: Durack D. P. , Gardner A. I. , Trang A.
Published: January 2019

With anaesthesia being administered more often outside of theatre in areas such as radiology suites, the occupational risk to anaesthetists from ionizing radiation may have increased. To determine radiation exposure from X-ray sources during normal anaesthetic practice, passive personal radiation monitoring devices were used to record the occupational exposure to radiation of 29 anaesthetists over a one calendar month period.

Occupational whole body effective dose was calculated and extrapolated to give an estimated annual radiation exposure. Seven of the 29 anaesthetists recorded a dose that was higher than the minimum detectable limit. Extrapolating to estimate yearly doses, no anaesthetist would have approached the annual occupational dose limits for ionizing radiation. The maximum extrapolated annual whole body effective dose was 2.14 mSv, the Australian Recommendation and National Standard for occupational exposure being less than 20 mSv per year.

The anaesthetist with the highest exposure would have exceeded the yearly recommended exposure limit for pregnant women (1 mSv). Even if they had worked all sessions in a radiation exposed environment, this person would not have exceeded the yearly annual occupational dose limits for ionizing radiation for non-pregnant staff, provided they had worn a standard protective lead gown. The collar dose for this person was 7.08 mSv which may represent a significant risk to the thyroid if a protective lead collar was not worn.

Although anaesthetists’ radiation exposure is within acceptable limits, caution should be taken in rostering pregnant staff to anaesthetize where radiation exposure occurs, and all anaesthetists should routinely wear thyroid collars in such areas.
Recovery after Prolonged Anaesthesia for Acoustic Neuroma Surgery: Desflurane versus Isoflurane
Authors: Boisson-Bertrand D. , Laxenaire M. C. , Mertes P. M.
Published: January 2019

In this study, 33 patients were randomly assigned to receive desflurane (D) or isoflurane (I) for acoustic neuroma surgery. The time from end of the procedure to spontaneous breathing, extubation, eye-opening, hand-squeezing to command, and ability to state name, birthdate and phone number were recorded. The Steward recovery score was also recorded every five minutes during the first 20 minutes postoperatively and then every 10 to 15 minutes.

Groups were similar regarding patient characteristics, depth of anaesthesia, sufentanil total dose, anaesthesia duration (D: 349.1 ±19.1 min; I: 349.2±22.9 min), haemodynamic/respiratory parameters, and surgical conditions (assessed by a bleeding score). The emergence time in the D group was significantly faster than the I group (D: 14.9±2.4 min vs I: 29.2±2.4 min for eye-opening). Full recovery also occurred earlier in the D group (D: 22.1±3.1 min vs I: 37.6±4.0 min, P<0.005 for stating name). Steward recovery scores were also better during the first postoperative hour in the D group (D: 40 min vs I: 90 min, P<0.005 for 100% of patients with Steward score of 6).

The results indicate that desflurane is associated with similar operating conditions and faster postoperative recovery following acoustic neuroma surgery. The faster recovery following desflurane may be desirable after long surgical procedures, enabling the patient's full cooperation and facilitating early diagnosis of any potential neurological deficit.
Propofol EDTA and Reduced Incidence of Infection
Authors: Jansson J-R. , Fukada T. , Ozaki M. , Kimura S.
Published: January 2019

Propofol formulated in a lipid vehicle supports the growth of microorganisms. There have been worldwide reports of extrinsic microbial contamination of propofol leading to outbreaks of serious postoperative nosocomial infections. Therefore it is essential that medical professionals follow strict aseptic precautions when handling propofol, as recommended by manufacturers of propofol and the Centers for Disease Control and Prevention. Non-adherence to these recommendations increases the risk of nosocomial postoperative infections, which impose a heavy burden of morbidity and mortality and have serious economic consequences.

It has also been recommended that the use of EDTA-containing formulations of propofol be considered. In vitro studies have confirmed that EDTA added to propofol retards microbial growth. Data on the incidence of nosocomial infections before and after the introduction of propofol with EDTA indicates that there have been no further cluster outbreaks and individual nosocomial infections appear to have been reduced. The addition of EDTA is an additional safety precaution to good aseptic practice.
Positive End-expiratory Pressure Ventilation Increases Extravascular Lung Water Due to a Decrease in Lung Lymph Flow
Authors: Maybauer D. M. , Talke P. O. , Westphal M. , Maybauer M. O. , Traber L. D. , Enkhbaatar P. , Morita N. , Traber D. L.
Published: January 2019

Positive end-expiratory pressure (PEEP) is used to improve gas exchange, increase functional residual capacity, recruit air spaces, and decrease pulmonary shunt in patients suffering from respiratory failure. The effect of PEEP on extravascular lung water (EVLW), however, is still not fully understood. This study was designed as a prospective laboratory experiment to evaluate the effects of PEEP on EVLW and pulmonary lymph flow (QL) under physiologic conditions.

Twelve adult sheep were operatively prepared to measure haemodynamics of the systemic and pulmonary circulation, and to assess EVLW. In addition, the lung lymphatic duct was cannulated and a tracheostomy performed. The animals were then mechanically ventilated in the awake-state without end-expiratory pressure (PEEP 0). After a two-hour baseline period, PEEP was increased to 10 cmH2O for the duration of two hours, and then reduced back to 0 cmH2O. Cardiopulmonary variables, QL, and arterial blood gases were recorded intermittently; EVLW was determined two hours after each change in PEEP.

The increase in PEEP resulted in a decrease in QL (7±1 vs 5±1 ml/h) and an increase in EVLW (498±40 vs 630±58 ml; P<0.05 each) without affecting cardiac output. As PEEP was decreased back to baseline, QL increased significantly (5±1 vs 10±2 ml/h), whereas EVLW returned back to baseline.

This study suggests that institution of PEEP produces a reversible increase in EVLW that is linked to a decrease in QL.
Systemic Capillary Leak Syndrome Associated with Compartment Syndrome and Rhabdomyolysis
Authors: Sanghavi R. , Aneman A. , Parr M. , Dunlop L. , Champion D.
Published: January 2019

Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by recurrent spontaneous episodes of hypovolaemic shock due to marked plasma shifts from the intravascular to the extravascular space. This presents as the characteristic triad of hypotension, haemoconcentration and hypoalbuminemia often with an associated monoclonal gammopathy. We describe a patient with SCLS who required aggressive fluid resuscitation and emergency fasciotomies for compartment syndrome with rhabdomyolysis. At presentation the patient was considered to have severe erythrocytosis and was therefore initially referred to a haematologist, which appears to be a frequent sequence of presentation for patients with SCLS. This patient also highlights the importance of muscle compartment pressure monitoring during volume resuscitation in patients with SCLS.
Cricothyroidotomy: A Short-term Measure for Elective Ventilation in a Patient with Challenging Neck Anatomy
Authors: Paw H. G. W. , Sharma S.
Published: January 2019

Cricothyroidotomy is a well established technique of airway management in emergency situations where translaryngeal intubation cannot be achieved.

This case report describes a case where cricothyroidotomy was used for elective ventilation for short period of 48 hours in a patient who had a vocal cord palsy, supraglottic oedema and inflammation. Surgical tracheostomy was considered the preferred option, but this was deemed impossible due to the challenging neck anatomy in this case.
Protein Contamination of the Laryngeal Mask Airway and its Relationship to Re-use
Authors: Greenwood J. , Green N. , Power G.
Published: January 2019

The Laryngeal Mask Airway is a reusable device for maintaining the patency of a patient's airway during general anaesthesia. The device can be reused after it has been cleaned and sterilized. Protein contamination of medical instruments is a concern and has been found to occur despite standard sterilization techniques. The reason for the concern relates to the possibility of the transmission of prions and the risk of developing a neurodegenerative disorder such as Creutzveldt-Jacob disease. The purpose of this study was to quantify the amount of protein contamination that occurs, and to relate this to the number of times the Laryngeal Mask Airway has been used. Fifty previously used Classic Laryngeal Masks were collected after routine sterilization and packaging. The devices were immersed in protein detecting stain and then visual inspection performed to assess the degree and distribution of the staining. The researcher was blinded to the number of times the Laryngeal Mask Airway had been used. Linear regression analysis of the degrees of staining of the airway revealed that protein contamination occurs after the first use of the device and this increases with each subsequent use. This finding highlights the concern that the currently used cleaning and sterilization methods do not prevent the accumulation of proteinaceous material on Laryngeal Mask Airways. Consideration should be given to the search for more efficient cleaning and sterilization techniques or the use of disposable devices.
Intravenous Fluid to Prevent Hypotension in Patients Undergoing Elective Colonoscopy
Authors: Leslie K. , Tay T. , Neo E.
Published: January 2019

Colonoscopy may be associated with hypotension during sedation leading to postoperative morbidity. However, no treatment is proven to ameliorate intraoperative hypotension for this procedure. We therefore conducted a randomized trial to determine the effect of intravenous fluid infusion on the incidence of hypotension during sedation for colonoscopy. With institutional approval, 160 patients presenting for elective colonoscopy were randomized to 1.5 ml/kg or 15 ml/kg Hartmann's solution before colonoscopy. All observers were blind to group allocation. The incidence of hypotension during sedation (29% vs 25%; P=0.59) and postoperative morbidity (nausea, vomiting, headache, drowsiness and dizziness) (41% vs 39%; P=0.75) did not differ between the two groups. Hypotensive patients were older, had a higher baseline systolic blood pressure, and were thirstier after fluid infusion than normotensive patients. This study does not support the use of 15 ml/kg Hartmann's solution to reduce the incidence of hypotension or postoperative morbidity in patients undergoing elective colonoscopy.
10,000 Reasons to Step Out—Exercise Patterns and Pedometer Evaluation of Consultant Anaesthetists
Authors: Soh M. , Deam R. K. , Kluger R.
Published: January 2019

Major international bodies recommend that adults should accumulate at least 30 minutes of moderate intensity physical activity every day. Ten thousand steps a day has been found to approximate 30 minutes of exercise. A questionnaire regarding exercise patterns was sent to all (584) Victorian consultant anaesthetists, and 30 consultants wore a pedometer for one week, during working hours only. The questionnaire response rate was 59.4% (347). Of these respondents, 58% indicated that they had a formal exercise program. There were no significant differences between people with a set exercise program and those without, with respect to age, gender, working hours or smoking. Those with a set exercise program exercised a median of four times per week and the commonest exercise listed was gymnasium attendance (40%). The main reasons cited for having a regular exercise program were maintenance of physical health (77%), mental health (71%) and weight control (35%). The main reasons for not having an exercise program were fatigue (40%), too busy (70%), family commitments (67%) or just not interested (18%). The overall median steps per day for the pedometer group was 4770 with a range of 1667 to 9630, fitting into the classification of ‘sedentary’. In summary this study has shown that a significant number of anaesthetists do not achieve adequate physical activity in or out of working hours and has identified some reasons for this behaviour. This will hopefully provide motivation and information for the implementation of useful strategies to increase the level of physical activity performed by anaesthetists.
Data Linkage Enables Evaluation of Long-Term Survival after Intensive Care
Authors: Williams T. A. , Dobb G. J. , Finn J. C. , Knuiman M. , Lee K. Y. , Geelhoed E. , Webb S. A. R.
Published: January 2019

Outcomes of intensive care are important to the patient and for assessment of benefit. Short-term outcomes after critical illness are well described, but less is known about long-term outcomes. This study describes the use of data linkage, combining intensive care unit (ICU) clinical data with administrative morbidity and mortality data, to assess long-term outcomes after treatment in ICU.

The hospital-based cohort study was conducted in a 22-bed general ICU in a metropolitan teaching hospital. All patient admissions admitted to ICU from 1 January 1987 to 31 December 2002 were included.

The prospective ICU clinical database with patient demographics, ICU diagnoses, severity of illness, daily assessment of organ failures and common daily treatments used was linked using probabilistic methods to the state-wide hospital morbidity and mortality databases to describe long-term survival.

There were 26,019 ICU admissions (22,980 patients) with 25,972 records (99.8%) linked to a hospitalization event that included the index ICU admission. Unadjusted survival was 84.7% at 1 year decreasing progressively to 50.7% at 15 years. Age, type of admission, severity of illness (measured by Acute Physiologic and Chronic Health Evaluation (APACHE) II and the presence of organ failure), ICU length of stay, comorbidity (Chronic Health Evaluation and Charlson comorbidity index) and ICU admission diagnosis, were all associated with survival at 1, 3, 5, 10, and 15 year follow-up (P<0.001 at all time points).

Linkage of clinical and administrative data provides a feasible method for ascertaining long-term survival after critical illness. Age, admission severity of illness, diagnosis and comorbidity influenced long-term unadjusted survival.
Recombinant Human Erythropoietin in Severe Anaemia: Issues of Dosing and Duration
Authors: Charles A. , Purtill M. , Napolitano L. M.
Published: January 2019

The majority of Jehovah's Witnesses refuse blood product transfusion, even when it can be lifesaving. Treatment with recombinant human erythropoietin (RHuEPO) is a valuable adjunct in Jehovah's Witness patients undergoing surgery. A number of additional strategies, including acute normovolaemic haemodilution, intra-operative blood salvage and reinfusion, iron and folate supplementation are also utilized to avoid blood transfusion. Critically ill patients have blunted erythropoietin production and decreased endogenous iron availability. This case report reviews the treatment of anaemia in critically ill Jehovah's Witness patients after surgery and discusses the potential need for higher RHuEPO dosing strategies and longer duration of therapy.
Short-Term Low-Dose Propofol Anaesthesia Associated with Severe Metabolic Acidosis
Authors: Chukwuemeka A. , Ko R. , Ralph-Edwards A.
Published: January 2019

Propofol-induced metabolic acidosis is well recognised in the paediatric literature, but the existence of such a syndrome in adults remains contentious. In most reported cases, metabolic acidosis complicated prolonged administration of propofol in critically ill patients. We present a case of severe non-fatal reversible metabolic acidosis, without ventilatory depression or hypoxia, related to short-term propofol infusion in an adult during and after coronary artery bypass grafting. We suggest that lactic acidosis occurred in a genetically susceptible patient with an abnormality of mitochondrial function. This report discusses an unusual adverse effect of propofol anaesthesia and sedation and highlights the need for further investigation to define propofol toxicity.
A Comparison of Patient Self-administered and Investigator-administered Measurement of Quality of Recovery Using the QoR-40
Authors: Gower S. T. , Quigg C. A. , Hunt J. O. , Wallace S. K. , Myles P. S.
Published: January 2019

A 40-item questionnaire (the QoR-40) had been previously developed to measure five dimensions of quality of recovery after anaesthesia and surgery. Each of the 40 items is rated on a scale of 1 to 5, with a maximum score of 200. In this study we compared patient self-administered with investigator-administered QoR-40. We studied 62 postoperative patients within 48 hours of their surgery. Agreement between the two methods was analysed using the intraclass correlation coefficient, bias and limits of agreement. There was strong correlation between the investigator-administered and patient self-administered QoR-40 scores, intraclass correlation coefficient 0.86 (95% CI: 0.77 to 0.92), P<0.001. The bias and limits of agreement were 3.1 and -22 to 28, respectively. There were 10 (16%) patient self-administered questionnaires that were not completed at first attempt. The time to complete the questionnaire when investigator-administered was 253 (16) s [mean,(SD)], and on first attempt for patients was 362 (19) s, P<0.001. The QoR-40 is as valid measure of postoperative recovery when administered with the assistance of an investigator as compared with the patient self-administered version. Investigator-administered measurement of the QoR-40 is a more efficient use of resources, as complete and more timely data are collected.
A Comparison of the Degree of Residual Mitral Regurgitation by Intraoperative Transoesophageal and Follow-up Transthoracic Echocardiography following Mitral Valvuloplasty
Authors: Gillham M. , Diprose P. , Ambler J.
Published: January 2019

Patients who undergo mitral valve repair for mitral regurgitation and have mild residual mitral regurgitation may have an increased risk of re-operation in future years. Intraoperative transoesophageal echocardiography has now become a standard of practice for mitral valve repair surgery. We identified 106 patients who underwent attempted mitral valve repair over a three-year period in our institution. We retrospectively reviewed the grade of residual mitral regurgitation assigned following successful mitral valve repair (‘mild’ or less residual regurgitation) by intraoperative transoesophageal echocardiography and compared it to the observed grade of mitral regurgitation seen at follow-up transthoracic echocardiography. No patient had unexpected moderate or severe mitral regurgitation postoperatively, suggesting that intraoperative transoesophageal echocardiography performed in a medium-sized department is a sensitive tool for the early detection of failed mitral repair. Mild residual mitral regurgitation on intraoperative transoesophageal echocardiography was not reliably associated with mild mitral regurgitation on follow-up transthoracic echocardiography. In fact, 61% of patients with mild mitral regurgitation identified by intraoperative transoesophageal echocardiography had reduced mitral regurgitation at follow-up transthoracic echocardiography (to nil/trace residual mitral regurgitation). This observation, in conjunction with the limitations of the data supporting the goal of ‘echo perfect’ repair, suggests that a second attempt at repair should not be made based on the intraoperative transoesophageal echocardiography finding of mild residual mitral regurgitation alone.
The Cardiovascular Effects of Adrenaline, Dobutamine and Milrinone in Rabbits Using Pressure-Volume Loops and Guinea Pig Isolated Atrial Tissue
Authors: Royse C. F. , Royse A. G. , Rohrlacf R. , Wright C. E. , Angus J. A.
Published: January 2019

This study evaluated the effects of milrinone, adrenaline and dobutamine with pressure-volume loops and isolated atrial tissue.

Agonist dose-response curves to incremental drug infusions were acquired in 11 anesthetised rabbits using pressure-volume loops and preload recruitable stroke work indicated contractility. Agonist concentration-response curves were completed in eight guinea pig isolated atria, for effects on atrial rate and force.

Adrenaline and dobutamine increased contractility (P=0.006 and 0.044), whereas milrinone did not (P=0.895). Only adrenaline increased myocardial stiffness (P<0.001). Milrinone decreased vascular resistance (P<0.001) and elicited the greatest fall in mean arterial pressure (P<0.001) and increased ejection fraction (P<0.001). Adrenaline decreased heart rate (P<0.001), whereas dobutamine and milrinone increased it (P=0.006 and 0.011). Milrinone increased the force of left atrial contraction, but its inotropic effect was weak and significantly less than with dobutamine and adrenaline (P <0.001).

Adrenaline acted as an inoconstrictor, dobutamine an inodilator and milrinone predominantly a vasodilator.
Variations in Cerebral Haemodynamics during Irrigation Phase in Neuroendoscopic Procedures
Authors: Prabhakar H. , Rath G. P. , Bithal P. K. , Suri A. , Dash H.H.
Published: January 2019

Not many centres measure intracranial pressure during an endoscopic procedure. However, if the irrigation fluid during endoscopy is not simultaneously drained, then some rise in intracranial pressure can be anticipated. This study was carried out to measure and monitor changes in intracranial pressure during the irrigation phase in a neuroendoscopic procedure using a Codman catheter placed in the parenchyma. Intracranial pressure was monitored in 13 patients undergoing surgical neuroendoscopic procedures under a standardised anaesthetic technique. Heart rate, mean arterial pressure, intracranial pressure and cerebral perfusion pressure were recorded at baseline and during the irrigation phase of the procedure. The heart rate during irrigation was comparable to baseline values, but the mean arterial pressure at the time of irrigation increased an average of 7 mmHg (P =0.02). At the same time there was an average 34 mmHg increase in intracranial pressure (P <0.001), producing an average 26 mmHg decrease in the cerebral perfusion pressure (P <0.001) during irrigation. There was an average of four episodes of raised intracranial pressure (> 25 mmHg) during the irrigation phase per patient. We suggest that the intracranial pressure be routinely monitored during neuroendoscopic procedures. Only then can the potential adverse effect of irrigation on intracranial pressure and cerebral perfusion pressure be assessed.
Right Upper Lobe Collapse Secondary to an Anomalous Bronchus after Endotracheal Intubation for Routine Surgery
Authors: Critchley L. A. H. , Ho A. M. -H. , Lee S. Y.
Published: January 2019

Perioperative hypoxaemia is a common but serious problem with well recognised causes. However, an anomalous bronchus causing lobar collapse as a cause is seldom mentioned. A healthy young male patient was anaesthetised for a knee operation. He required reintubation immediately postoperatively for hypoxia. He was found to have right upper lobe collapse. Fibreoptic examination of the trachea demonstrated an anomalous bronchus as the cause. Intra-operatively, the endotracheal tube had been inserted too deeply and the bronchial orifice had been obstructed by the tip. It took several hours for the lung to re-expand. Greater awareness of this potential complication is needed.
Anaesthesia for Robotic-Assisted Radical Prostatectomy: Considerations for Laparoscopy in the Trendelenburg Position
Authors: Phong S. V. N. , Koh L. K. D.
Published: January 2019

Two cases of anaesthetic complications after robotic-assisted laparoscopic radical prostatectomy using the da Vinci Remote-Controlled Surgical System are presented. Case 1 describes a patient with post-extubation respiratory distress requiring reintubation and subsequent ventilation in an intensive care unit. This was attributed to laryngeal oedema, which was most likely due to the reduction in venous outflow from the head caused by the pneumoperitoneum and prolonged, extreme Trendelenburg position. Case 2 describes a patient with mild brachial plexus neurapraxia, which was most likely due to compression by shoulder braces (to prevent cephalad sliding) during the exaggerated head-down tilt. For this procedure, the authors recommend limiting the duration and extent of head-down tilt as much as possible, avoiding excessive intravenous fluids and careful positioning of the patient with avoidance of shoulder braces whenever possible.
Aniline-Induced Methaemoglobinaemia in a Glucose-6-Phosphate Dehydrogenase Enzyme Deficient Patient
Authors: Mullick P. , Kumar A. , Dayal M. , Babbar S. , Kumar A.
Published: January 2019

A case of methaemoglobinaemia following ingestion of an aniline-containing material is described. The detrimental effect of methylene blue, the classical antidote of methaemoglobinaemia, in a patient with glucose-6-phosphate dehydrogenase deficiency is highlighted.
NT-Pro BNP Secretion and Clinical Endpoints in Cardiac Surgery Intensive Care Patients
Authors: Jogia P. M. , Kalkoff M. , Sleigh J. W. , Bertinelli A. , La Pine M. , Richards A. M. , Devlin G.
Published: January 2019

The primary objective of this study was to determine the pattern of N-Terminal pro brain natriuretic peptide (NT-pro BNP) secretion pre and post cardiac surgery and then to investigate the correlation between levels of serum NT-pro BNP and postoperative clinical and biochemical endpoints. This was a prospective observational study performed at a tertiary centre in New Zealand, examining 118 adult patients undergoing cardiac surgery. Interventions included blood samples for NT-Pro BNP and troponin-T taken 48 hours prior to operation and 12, 36 and 72 hours postoperatively. The plasma NT-pro BNP levels increased fourfold postoperatively, to plateau at 36 to 72 hours. Preoperative NT-pro BNP levels correlated with ventilation time (r=0.46), length of stay in intensive care unit (r=0.59), total perioperative noradrenaline dose (r=0.55), but not with postoperative atrial fibrillation or mortality. Using multivariate analysis, serum NT-pro BNP levels at 36 hours were associated with increased noradrenaline dose (P=0.001), decreased preoperative ejection fraction (EF) Group (P=0.013) and elevated preoperative NT-pro BNP (P <0.001). Factors not associated with NT-pro BNP levels at 36 hours include the operation type, bypass and cross-clamp times, use of milrinone and troponin-T. We conclude that NT-pro BNP levels increased markedly after cardiac surgery and that high preoperative NT-pro BNP levels are associated with a slow postoperative recovery, but do not predict the occurrence of postoperative atrial fibrillation or mortality. Myocardial ischaemia is an unlikely cause of the NT-pro BNP elevation, because no correlation existed between troponin-T and NT-pro BNP levels.
High Thoracic Epidural Analgesia for Cardiac Surgery: An Audit of 874 Cases
Authors: Royse C. F. , Soeding P. F. , Royse A. G.
Published: January 2019

Despite clinical use for over 10 years, high thoracic epidural analgesia for cardiac surgery remains controversial, due to a perceived increased risk of epidural haematoma resulting from anticoagulation for cardiac pulmonary bypass. There are no sufficiently large randomised studies to address this question and few large case series reported. For this reason, we conducted an audit of neurological complications related to high thoracic epidural analgesia during cardiac surgery in our institution between 1998 and end 2005. During this period 874 patients received epidural analgesia. There were no neurological complications attributable to epidural use. Our findings suggest that major neurological complications related to high thoracic epidural use during cardiac surgery are rare.
Accuracy of Dilution of Morphine for Intrathecal Use
Authors: Baker A. R. , Rutherford D. M. , Myles P. S.
Published: January 2019

Morphine is administered intrathecally alone or in combination with other drugs to provide spinal analgesia. Dose-finding studies have recommended 100 μg be used intrathecally to optimise analgesia and minimise side-effects for caesarean section and hip replacement surgery. Dilute solutions of morphine are generally not available, mandating preparation from a 10 mg/ml ampoule. We postulated that diluting morphine would be inaccurate and imprecise, contributing to the variability in patient response often reported. Twenty consultant and trainee anaesthetists were recruited and asked to prepare 100 μg of morphine from 10 mg/ml vials and from a hypothetical prediluted 500 μg/ml solution. The resultant samples were analysed using liquid chromatography. Prepared morphine doses ranged from 25 μg to 289 μg. Dilution of morphine was less accurate (P=0.001) and more imprecise (P=0.001) compared with using a prediluted solution. A single-step dilution technique using 0.1 ml of a solution diluted to 1.0 mg/ml was more accurate than when a double-dilution technique was used (P=0.047). Given that dose-finding studies suggest that analgesia and side-effects vary at the dose range found in this study, we advocate the use of prediluted solutions. If dilution is to be performed a single-step dilution technique should be used.
Outcome of Patients who Have Therapy Withheld or Withdrawn in ICU
Authors: Lewis J. P. , Ho K. M. , Webb S. A. R.
Published: January 2019

Many deaths among patients treated in intensive care units (ICUs) occur following the withdrawal or withholding of life support. Following limitation of life support, most of these patients die in the ICU or ward after the decision to limit life support is made, although some may survive to hospital discharge. This study described the characteristics of patients who had life support limitations in ICU and their subsequent in-hospital and out-of-hospital survival using linked data from the state's death registry. Among 26,019 ICU admissions between 1987 and 2002 there were 396 patients (1.5%) who had life support limitations. The hospital mortality of the patients who had life support limitations was 97.7% and this accounted for 16.2% of the hospital mortality of all ICU admissions. Of the 396 patients who had life support limitations, 315 patients (79.5%) died in the ICU, 72 patients (18.2%) died in the wards and nine patients (2.3%) were discharged from hospital. Of these nine patients who survived to hospital discharge, four died within 10 days of hospital discharge and a further two died within six months. There were two patients, both with significant neurological disabilities at hospital discharge, who survived for longer than three years after hospital discharge. Long-term survival in critically ill patients who had life support limitations was very rare in this ICU.
The Effects of Acidosis and Hypothermia on Blood Transfusion Requirements following Factor VII Administration
Authors: Hall K. , Forrest P. , Sawyer C.
Published: January 2019

While there is laboratory evidence that the activity of recombinant activated factor VII (rFVIIa) is reduced by the presence of acidosis and hypothermia, there is limited clinical data to support this observation. Recombinant FVIIa may be used as rescue therapy in surgical patients who have bleeding that is refractory to conventional therapy. However, these patients are also frequently acidotic and hypothermic at the time the drug is administered. In this retrospective study, the records of 38 adult surgical patients who received rFVIIa intraoperatively or within six hours postoperatively were reviewed. The requirements for red cell transfusion in the two hours following the administration of rFVIIa and the need for repeated doses of rFVIIa were recorded. The relationship between red cell transfusion and pH and temperature of the patient at the time of rFVIIa administration was assessed by multiple regression analysis.

The major finding was an inverse relationship between the degree of acidosis at the time of rFVIIa administration and the requirement for either subsequent blood transfusion or repeat dosing of rFVIIa (P=0.003 and P <0.001 respectively). For patients with apH <7.2 vs. pH >7.2, the odds ratio for receiving two or more packs of red blood cells within two hours of rFVIIa administration was 15:1. This effect was not observed for hypothermia.

The implication of this study is that rFVIIa may be less effective when administered to severely acidotic patients. Further studies are required to examine whether this is related to the acidosis directly, or is secondary to other intraoperative variables affecting acidosis. The clinical utility of rFVIIa in acidotic patients also requires further investigation.
Perioperative Epidural Anaesthesia and Analgesia—An Appraisal of Its Role
Authors: Davies M.J.
Published: January 2019

Perioperative epidural anaesthesia and analgesia (PEA) has become controversial because of its doubtful effect on patient outcome and its serious complications. These scientific considerations have been affected by the changing medicolegal climate in Australia and has led to a reappraisal of this technique in our practice of anaesthesia. Many anaesthetists are now uncertain about indications, consent requirements, optimal management and the prevention and early detection of complications of PEA. The aim of this paper is to present a personal perspective of the place and use of PEA in current anaesthetic practise. The primary indication for PEA should be pain relief for open abdominal or thoracic surgery because there is level 1 evidence that it provides better analgesia than parenteral opioids. There is reasonable evidence that outcome is improved but the studies are conflicting. Coagulation status needs to be assessed carefully before the insertion and removal of epidural catheters. Consent issues are difficult in practice, both from the timing and the content of the information. The decrease in the use of PEA may paradoxically result in more complications as loss of expertise becomes an issue. PEA is labour intensive and therefore needs the support of an Acute Pain Service in order to use this technique safely and recognise problems early. Permanent neurological complications are the most feared complication of this technique but early recognition of these problems can improve outcome. These complications need to be balanced against the potentially serious hypoxaemia associated with parenteral opioids used for postoperative pain relief.
Levosimendan in Acute Pulmonary Embolism
Authors: Powell B. P. , Simes D.
Published: January 2019

Levosimendan has been used successfully in the treatment of ischaemic cardiac failure and myocardial stunning. There is growing evidence from both human and animal experiments that levosimendan has particularly favourable effects on the right ventricle. We describe a case of life-threatening pulmonary embolus supported by the use of levosimendan.
Preoperative Hypnotherapy in the Management of a Child with Anticipatory Nausea and Vomiting
Authors: Mackenzie A. , Frawley G. P.
Published: January 2019

A six-year-old boy with oesophageal strictures secondary to neonatal repair of oesophageal atresia and requiring six to eight weekly oesophageal dilatations by bouginage developed anticipatory nausea and vomiting. This was effectively managed by a course of preoperative hypnotherapy over four sessions. Resolution of anticipatory nausea and vomiting occurred along with cessation of postoperative nausea and vomiting. This case supports early intervention with preoperative hypnotherapy in children with anticipatory nausea and vomiting that has not responded to other measures.
Recurrence of Focal Seizure Activity in an Infant during Induction of Anaesthesia with Sevoflurane
Authors: Rewari V. , Sethi D.
Published: January 2019

A three-month-old male infant, previously diagnosed with seizures with a focal origin induced by hypocalcaemia secondary to hypoparathyroidism, presented for right cataract surgery. The hypocalcaemia and seizure activity had resolved with medical therapy, with normal calcium levels and no seizures for a month. Anaesthesia with halothane and isoflurane for left cataract surgery two days previously had been uneventful. During induction of anaesthesia with sevoflurane for the right cataract surgery, the patient had a focal seizure similar to those previously occurring when the patient was hypocalcaemic. The patient had normal calcium levels at the time of surgery. It appears likely that sevoflurane had triggered seizure activity in the apparently controlled focus. The potential for sevoflurane to induce epileptogenic activity in patients with reduced seizure threshold is discussed.
The Incidence and Risk of Central Venous Catheter Malpositioning: A Prospective Cohort Study in 1619 Patients
Authors: Pikwer A. , Bååth L. , Davidson B. , Perstoft I. , Åkeson J.
Published: January 2019

Central venous catheters are used in various hospital wards. An anterior-posterior chest X-ray is usually obtained soon after cannulation to assess the location of the catheter tip. This prospective clinical study was designed to determine the radiographic catheter tip position after central venous cannulation by various routes, to identify clinical problems possibly associated with the use of malpositioned catheters and to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition. A total 1619 central venous cannulations were recorded during a three-year period with respect to patient data, information about the cannulation procedures, the radiographic catheter positions and complications during clinical use. The total incidence of radiographic catheter tip malposition, defined as extrathoracic or ventricular positioning, was 3.3% (confidence interval 2.5 to 4.3%). Cannulation by the right subclavian vein was associated with the highest risk of malposition, 9.1%, compared with 1.4% by the right internal jugular vein. Six of the 53 malpositioned catheters were removed or adjusted. No case of malposition was associated with vascular perforation, local venous thrombosis or cerebral symptoms. We conclude that the radiographic incidence of central venous catheter malpositioning is low and that clinical use of malpositioned catheters is associated with few complications. However, determination of the catheter position by chest X-ray should be considered when mechanical complications cannot be excluded, aspiration of venous blood is not possible, or the catheter is intended for central venous pressure monitoring, high flow use or infusion of local irritant drugs.
The Influence of Passive Leg Elevation on the Cross-Sectional Area of the Internal Jugular Vein and the Subclavian Vein in Awake Adults
Authors: Kim J.-T. , Kim H.-S. , Lim Y.-J. , Bahk J.-H. , Lee K.-H. , Kim C.-S. , Kim S.-D. , Jeon Y.
Published: January 2019

The aim of this study was to evaluate the influence of passive leg elevation and Trendelenburg position on the cross-sectional area (CSA) of the internal jugular (IJ) and subclavian veins (SCV). Ultrasound imaging was used for the following measurements of both the IJV and SCV: baseline in the supine position (control); Trendelenburg position 15°; reverse Trendelenburg position 15° and passive leg elevation 50°. Twenty healthy male volunteers were studied. Mean CSA of the IJV was 1.12±0.57 cm2 in control, 1.66±0.67 cm2 in the Trendelenburg position (P <0.0001 vs. control), 0.38±0.23 cm2 in the reverse Trendelenburg position (P <0.0001 vs. control), and 1.40±0.64 cm2 during passive leg elevation (P <0.0001 vs. control). Mean CSA of the SCV was 0.92±0.23 cm2 in control, 0.98±0.17 cm2 in the Trendelenburg position, 0.86±0.21 cm2 in the reverse Trendelenburg position and 0.93±0.18 cm2 during passive leg elevation. The results indicate that passive leg elevation increases the CSA of the IJV but has little effect on the SCV. The CSA of the IJV appears to be influenced more by gravitational factors than the SCV.