bluuebunny/crossref_metadata_2025 huggingface dataset:
Decontamination Issues and Perceived Reliability of the Laryngoscope—A Clinician's Perspective
Authors: Yee K. F.
Published: January 2019

The laryngoscope is identified as a potential vector for cross-infection. Case reports are presented, as are reports of bacterial and occult blood contamination of laryngoscope blades and handles. Infection control policies covering laryngoscope blade and handle processing are outlined relative to procedures of a teaching hospital department. Repeated decontamination of laryngoscope blades has resulted in a perceived decrease in reliability. This is reflected in a departmental survey where 86% of respondents consider the standard laryngoscope is only intermittently reliable and that there is room for improvement.
Prolonged Intubation: An Alternative to Tracheosto my in Infants
Authors: Brandstater B.
Published: January 2019

In 12 patients, ranging in age from newborn to 4 years, endotracheal intubation has been used as a substitute for tracheostomy. Using plastic tubes it was possible to maintain a good airway for periods of up to 7 weeks. Painstaking care was necessary to prevent the tubes becoming blocked or malpositioned. The tubes were tolerated well. Good laryngeal function has been regained by all 9 survivors. If permanent laryngeal changes have occurred, they show no signs of being severe.

It is concluded that many cases customarily managed with tracheostomy can be equally well managed with intubation. Intubation may prove to be the preferred management in some cases of laryngeal oedema.
ARDS with Severe Hypoxia—Aeromedical Transportation during Prone Ventilation
Authors: Flabouris A. , Schoettker P. , Garner A.
Published: January 2019

Severe hypoxia, despite maximal conventional respiratory support, is one of the few remaining limitations to aeromedical transportation. A case of a 35-year-old female, who was referred 36 hours following major trauma for transfer by air to a tertiary center, is presented. At the time of referral the P a O 2/ FiO 2 ratio was 48. Usual manoeuvres to improve oxygenation had only minimal impact. The patient was turned and subsequently transported prone with resultant improvement in P a O 2/ FiO 2 ratio to 260. There were no patient- or transport-related adverse events. The implication of prone positioning during aeromedical transportation is discussed.
An Assessment of Small Simulators Used to Teach Basic Airway Management
Authors: Rosenthal E. , Owen H.
Published: January 2019

This study assessed small simulators sold for teaching basic airway management. The assessment used criteria based on guidelines produced by the Australian Resuscitation Council and our experience teaching health professional trainees. Criteria included how well the simulators demonstrated manoeuvres to open the airway, mouth-to-mouth and mask-to-mouth expired air resuscitation and artificial ventilation using a bag and mask. Simulators with permanently open airways (as is the case with some intubation manikins) were not tested. Each simulator was also assessed for realism in relation to look and feel, hygiene and sturdiness of construction.

Clinical staff and medical students who teach basic airway management undertook a standardized assessment of nine simulators. There were significant differences between simulators that could impact on learning. Generally, models with hard surfaces tended to be less realistic in both look and feel compared to those with flexible “skin”. Realism of lung inflation and its relationship to airway opening manoeuvres varied greatly between simulators.

The Little Anne small simulator functioned most realistically in our tests.
Pleural Puncture: An Unusual Complication of a Thoracic Epidural
Authors: Grieve P. P. , Whitta R. K. S.
Published: January 2019

Thoracic epidural analgesia is a common method of pain relief for major thoracic and abdominal surgery. Numerous complications may occur, including temporary or permanent neurological injury1. A rare and potentially life-threatening complication of thoracic epidural analgesia is pleural puncture by the needle or the catheter. Such a case is presented and pleural puncture in association with attempted thoracic epidural catheter placement is discussed.
Post Partum Pneumomediastinum
Authors: Duffy B. L.
Published: January 2019

A 19-year-old primigravida had a normal vaginal delivery after a 90-minute second stage of labour. Within two hours she complained of dyspnoea and was noticed to have unusual swelling of the face and neck. The diagnosis of subcutaneous emphysema was confirmed by chest X-ray and pneumomediastinum was also detected. Uneventful recovery over four days followed conservative management, administration of oxygen and use of simple analgesics.
The Costs of Caring for Patients in a Tertiary Referral Australian Intensive Care Unit
Authors: Rechner I. J. , Lipman J.
Published: January 2019

We determined the direct cost of an Intensive Care Unit (ICU) bed in a tertiary referral Australian ICU and the cost drivers thereof, by retrospectively analysing a number of prospectively designed Hospital- and Unit-specific electronic databases. The study period was a financial year, from 1 July 2002 to 30 June 2003. There were 1615 patients occupying 5692 fractional occupied bed days at a total cost of A$15,915,964, with an average length of stay of 3.69 days (range 0.5–77, median 1.06, interquartile range 2.33). The main cost driver not incorporated into this analysis was blood products (paid for centrally). The average costs of an ICU day and total stay per patient were A$2670 and A$9852 respectively. Staff-related charges were 68.76%, with consumables related expenditure making up 19.65%, clinical support services 9.55% and capital equipment 2.04%. Overtime charges and nursing agency staff were 19.4% of staff-related charges (2.9% for agency staff), 3.9% lower than expenditure associated with full-time employment charges, such as pension and leave. The emergency nature of ICU means it is difficult to accurately set a nursing establishment to cater for all admissions and therefore it is hard to decide what is an acceptable percentage difference between agency/overtime costs compared with the costs associated with full-time staff appointments. Consumable expenditure is likely to increase the most with new innovation and therapies. Using protocol driven practices may tighten and control costs incurred in ICU.
Changing Patterns in the Acute Pain Service: Epidural versus Patient-controlled Analgesia
Authors: Power G. E. , Warden B. , Cooke K.
Published: January 2019

This study involved an audit and a survey of the Acute Pain Service at Princess Alexandra Hospital. It was found in the audit that the relative choice of epidural analgesia had declined by 50% over the five-year time period of 1998–2003. The survey of consultants showed that 82% of them had changed their practice and that they were performing fewer epidural anaesthetics. Two of the most common reasons given for this change in practice related to fear of litigation (34%) and lack of evidence (21%). These results show that within this department approaches to postoperative pain control had changed and that this appears to have resulted from factors such as the medicolegal environment and the possible influence of evidence based medicine.
Retrosternal Block Use in the Treatment for Dyspnoea
Authors: Barak M. , Isserles S. , Katz Y.
Published: January 2019

We present a technique of retrosternal block for symptomatic treatment for dyspnoea of various aetiologies. In our experience with 20 patients, a retrosternal block using lignocaine improved symptoms within minutes. The block was easy to perform and was helpful when the patients’ symptoms were not relieved by conventional therapy. Prospective controlled studies are needed to further assess this simple and promising treatment.
Impact of Operator Expertise on Collection of the APACHE II Score and on the Derived Risk of Death and Standardized Mortality Ratio
Authors: Ledoux D. , Finfer S. , Mckinley S.
Published: January 2019

We assessed the impact of operator expertise on collection of the APACHE II score, the derived risk of death and standardized mortality ratio in 465 consecutive patients admitted to a multi-disciplinary tertiary hospital ICU. Research coordinators and junior clinical staff independently collected the APACHE II variables; experts (senior clinical staff) rescored 20 % of the records. Agreement was moderate between junior clinical staff and research coordinators or senior clinical staff for most variables of the acute physiology score (weighted κ<0.6); agreement between research coordinators and senior clinical staff data collectors was good (weighted κ >0.75). The APACHE II score and its derived risk of death (ROD) were significantly lower using the junior clinical staff dataset compared to research coordinators and senior clinical staff (APACHE II score: 13.4±9.2 vs 16.8±8.5 vs 17.1±7.7, P<0.001; ROD: 14.7%±22.4% vs 21.6%±22.6% vs 20.8%±22.4%, P<0.01 respectively). The discriminative capacity was not altered by the lack of agreement (area under Receiver Operator Characteristic curve >0.8) but calibration of ROD from the junior clinical staff dataset was poor (Goodness-of-fit: P=0.001). The standardized mortality ratio (SMR) was higher with the junior clinical staff dataset (SMR: 1.22, 95% CI: 0.96-1.52 vs 0.87, 95% CI: 0.70-1.06 vs 0.76, 95% CI: 0.40-1.3 calculated from junior clinical staff, research coordinators and senior clinical staff data-sets respectively). We conclude that the expertise of data collectors significantly influences the APACHE II score, the derived risk of death and the standardized mortality ratio. Given the importance of such scores, ICUs should be provided with sufficient resources to train and employ dedicated data collectors.
Sub-Tenon's Block in Cataract Surgery—A Comparison of 1% Ropivacaine and a Mixture of 2% Lignocaine and 0.5% Bupivacaine
Authors: Koh J. W. M. , Cammack R.
Published: January 2019

Sub-Tenon's block for cataract surgery is an increasingly common technique. While this technique has been successfully applied, the optimal local anaesthetic solution is not known. This study was performed to assess any differences in anaesthesia and oculomotor block between 1% ropivacaine and a 2% lignocaine with 0.5% bupivacaine mixture. The results indicate that there was no difference noted in the clinical effect between the solutions.

“Who are you going to believe, me or your own eyes?”

—Groucho Marx (1890–1977)
Cost-effectiveness of Basal Flow Sevoflurane Anaesthesia Using the Komesaroff Vaporizer inside the Circle System
Authors: Nandalan S. P. , Eltringham R. J. , Fan Q. W.
Published: January 2019

After ethics committee approval, 51 consenting ASA physical status 1 or 2 adult patients were given basal flow sevoflurane anaesthesia using fresh gas flows of 150 to 300 ml.min-1 oxygen. A Komesaroff vaporizer was placed on the inspiratory limb of the circle system. Basal flows were introduced immediately following intravenous induction of anaesthesia. The vaporizer was set to deliver the maximum concentration until the inspired sevoflurane concentration (FSI) reached 3%. The dial was then adjusted to maintain the FSI at 3%. After every 60 minutes, the circuit was washed out with 100% oxygen at a flow rate of 10 l.min-1 for one minute.

The FSI reached 3% after an average of 8.5 (3.8) [mean (SD)] minutes. The trends in FSI and the expired sevoflurane concentrations were significantly different (P<0.05) between the mechanically ventilated patients (n=21) and the spontaneously ventilating patients (n=30) and demonstrated a more gradual build-up in the former group. The consumption of sevoflurane was found to be 9.2 (2.8) ml.h-1. This represented a 52.5% cost saving over the clinical application of the Mapleson's ideal fresh gas flow sequence for low-flow anaesthesia.
The Frequency of and Indications for General Anaesthesia in Children in Western Australia 2002–2003
Authors: Sims C. , Stanley B. , Milne E.
Published: January 2019

We conducted a retrospective database search of the Hospital Morbidity Data System at the Health Department of Western Australia to determine the number of anaesthetics given to children aged 16 years or less in Western Australia over a twelve-month period. Information was also collected to assess the types of surgery for which anaesthesia was being provided, and the categories of hospital in which children were being anaesthetized. We found that 28,522 anaesthetics were given to 24,981 children, and 2,462 (9.9%) children had more than one anaesthetic. Five and a half percent of the children in Western Australia had an anaesthetic during the twelve months studied. The most common types of surgery were ear nose and throat (28% of anaesthetics), general (21%), dental/oral procedures (17%) and orthopaedic (15%). There was a bimodal distribution in the incidence of anaesthesia versus age, with peaks at 4 years and at 16 years. The most common category of hospital that children were anaesthetized in was private metropolitan (40%) followed by tertiary (38%), rural (14%) and public metropolitan (8%). One thousand, seven hundred and seven children aged less than one year were given an anaesthetic. These anaesthetics were most frequently given to children in tertiary hospitals (62%) followed by private metropolitan (30%), public metropolitan (6%) and rural hospitals (2%).
Perioperative Beta-blockade: Guidelines and Practice in New Zealand
Authors: Weller J. , Karim Z.
Published: January 2019

The aim of our study was to describe the knowledge and practice of New Zealand anaesthetists in relation to perioperative beta-adrenergic blockade, and to define barriers to implementation of perioperative beta-blockade in surgical patients at risk of myocardial ischaemia.

A survey was sent to 400 New Zealand specialist anaesthetists. Information was sought on their knowledge and current practice relating to perioperative beta-blockade, and the barriers encountered to implementing therapy.

The response rate was 59%. Perioperative beta-blockade was seen as beneficial in at risk patients by 95% of responding anaesthetists, but practice varied widely. Only 45% of anaesthetists always or usually commenced a beta blocker perioperatively, a department protocol was available to only 20%, and understanding of indications and contraindications to beta-blockade varied. There were logistical difficulties when initiating and monitoring perioperative beta-blocker regimens, and where treatment required multidisciplinary commitment. The lack of clarity of the guidelines was also a barrier to more widespread use. Difficulties were encountered relating general guidelines to individual patients, when co-morbidities, concurrent treatment and the influence of regional or general anaesthesia may influence the risk/benefit ratio.

This study has identified variations in practice and reasons why New Zealand anaesthetists use of perioperative beta-blockers is at odds with published guidelines. Deficiencies in the guidelines are part of the problem. However, even with consensus on guidelines, effective multidisciplinary strategies will be required to optimize treatment of patients at risk of perioperative cardiac events.
Acute Respiratory Failure Due to Hypokalaemic Muscular Paralysis from Renal Tubular Acidosis
Authors: Gombar S. , Mathew P. J. , Gombar K. K. , D'Cruz S. , Goyal G.
Published: January 2019

We report a case of hypokalaemic quadriplegia with acute respiratory failure and life-threatening cardiac arrhythmias in a 26-year-old woman who was diagnosed to have distal renal tubular acidosis. She had persistent metabolic acidosis with severe hypokalaemia and required mechanical ventilation and potassium replacement. The anaesthetic implications of renal tubular acidosis are also discussed.
Severe Hypothermia: Challenging Normal Physiology
Authors: Brieva J. , Mcfadyen B. , Rowley M.
Published: January 2019

Accidental hypothermia is not a frequent cause of death in Australia. Moreover it is rare to have an admission to hospital with a core temperature below 32°C. Among the cases described in the literature, it is clear that temperature and prognosis are related. Our patient presented with severe accidental hypothermia and even though the admission core temperature was below 26 degrees she was successfully discharged from hospital after active re-warming with three different devices. She had laboratory and ECG findings associated with severe hypothermia.
Issues of Consent for Regional Analgesia in Labour: A Survey of Obstetric Anaesthetists
Authors: Black J. D. B. , Cyna A. M.
Published: January 2019

Anaesthetists are legally obliged to obtain consent and inform patients of material risks prior to administering regional analgesia in labour. We surveyed consultant members of the Australian and New Zealand College of Anaesthetists with a special interest in obstetric anaesthesia, in order to identify and compare which risks of regional analgesia they report discussing with women prior to and during labour. We also asked about obstetric anaesthetists’ beliefs about informed consent, the type of consent obtained and its documentation. Of 542 questionnaires distributed, 291 responses (54%) were suitable for analysis. The five most commonly discussed risks were post dural puncture headache, block failure, permanent neurological injury, temporary leg weakness and hypotension. Obstetric anaesthetists reported discussing a mean of 8.0 (SD 3.8) and 10 (SD 3.8) risks in the labour and antenatal settings respectively. Nearly 20% of respondents did not rank post dural puncture headache among their top five most important risks for discussion. Seventy percent of respondents indicated that they believe active labour inhibits a woman's ability to give ‘fully informed consent’. Over 80% of respondents obtain verbal consent and 57 (20%) have no record of the consent or its discussion. Obstetric anaesthetists reported making a considerable effort to inform patients of risks prior to the provision of regional analgesia in labour. Verbal consent may be appropriate for labouring women, using standardized forms that serve as a reminder of the risks, and a record of the discussion. Consensus is required as to what are the levels of risk from regional analgesia in labour.
Incidents during Out-of-Hospital Patient Transportation
Authors: Flabouris A. , Runciman W. B. , Levings B.
Published: January 2019

Out-of-hospital patient transportation (retrieval) of critically ill patients occurs within highly complex environments. Adverse events are not uncommon. Incident monitoring provides a means to better understand such events.

The aim of this study was to characterize incidents occurring during retrieval to provide a basis for developing corrective strategies.

Four organizations contributed 125 reports, documenting 272 incidents; 91% of forms documented incidents as preventable. Incidents related to equipment (37%), patient care (26%), transport operations (11%), interpersonal communication (9%), planning or preparation (9%), retrieval staff (7%) and tasking (2%). Incidents occurred during patient transport to the receiving facility (26%), at patient origin (26%), during patient loading (20%), at the retrieval service base (18%) and receiving facility (9%). Contributing factors were system-based for 54% and human-based for 42%. Haste (7.5%), equipment malfunctioning (7.2%) or missing (5.5%), failure to check (5.8%) and pressure to proceed (5.2%) were the most frequent contributing factors. Harm was documented in 59% of incidents with one death. Minimizing factors were good crew skills/teamwork (42%), checking equipment (17%) and patient (8%), patient monitors (15%), good luck (14%) and good interpersonal communication (4%).

Incident monitoring provides sufficient insight into retrieval incidents to be a useful quality improvement tool for retrieval services. Information gathered suggested improvements in retrieval equipment design and use of alternative power sources, the use of pro formae for equipment checking, patient assessment, preparation for transportation and information transfer. Lessons from incidents in other areas applicable to retrieval should be linked for analysis with retrieval incidents.
B-Type Natriuretic Peptide Concentrations and Myocardial Dysfunction in Critical Illness
Authors: Sturgess D. J. , Marwick T. H. , Joyce C. J. , Venkatesh B.
Published: January 2019

B-type natriuretic peptide (BNP) is the first biomarker of proven value in screening for left ventricular dysfunction. The availability of point-of-care testing has escalated clinical interest and the resultant research is defining a role for BNP in the investigation and treatment of critically ill patients.

This review was undertaken with the aim of collecting and assimilating current evidence regarding the use of BNP assay in the evaluation of myocardial dysfunction in critically ill humans. The information is presented in a format based upon organ system and disease category.

BNP assay has been studied in a spectrum of clinical conditions ranging from acute dyspnoea to subarachnoid haemorrhage. Its role in diagnosis, assessment of disease severity, risk stratification and prognostic evaluation of cardiac dysfunction appears promising, but requires further elaboration. The heterogeneity of the critically ill population appears to warrant a range of cut-off values. Research addressing progressive changes in BNP concentration is hindered by infrequent assay and appears unlikely to reflect the critically inpatient's rapidly changing haemodynamics. Multi-marker strategies may prove valuable in prognostication and evaluation of therapy in a greater variety of illnesses. Scant data exist regarding the use of BNP assay to alter therapy or outcome.

It appears that BNP assay offers complementary information to conventional approaches for the evaluation of cardiac dysfunction. Continued research should augment the validity of BNP assay in the evaluation of myocardial function in patients with life-threatening illness.
Use of Recombinant Activated Factor VII after Axillofemoral Bypass Grafting
Authors: Cheng C. A. Y. , M-H. Ho A.
Published: January 2019

Recombinant activated factor VII (rFVIIa) is a powerful prohaemostatic agent that theoretically predisposes to thrombosis after peripheral vascular surgery. We report the use of rFVIIa to reduce bleeding in a patient after axillofemoral bypass grafting for ruptured aorto-iliac pseudoaneurysm. Despite the increased risk of thrombosis, the patient made an uneventful recovery with preserved graft patency. The favourable result suggests that rFVIIa should be considered even in vascular surgical patients, if the risks of continued bleeding outweigh those of thrombosis. Better risk estimation is only possible if reports of rFVIIa use in vascular patients continue to appear and through controlled trials.
Comparison of Remifentanil and Fentanyl in Anaesthesia for Elective Cardioversion
Authors: Maltepe F. , Kocaayan E. , Ugurlu B. S. , Akdeniz B. , Guneri S.
Published: January 2019

This prospective, randomized, double-blind study was designed to compare the recovery characteristics of remifentanil and fentanyl in combination with propofol for direct current cardioversion. Patients undergoing elective cardioversion received either intravenous fentanyl 1 μg/kg (n=33) or remifentanil 0.25 μg/kg (n=30) and propofol was titrated to a Ramsay sedation score of 5 by slow intravenous injection. Heart rate, systolic, diastolic and mean blood pressures decreased significantly following sedation in both groups but did not show a significant difference between the groups. Time to answer a question (306±83 vs 383±131s, mean±SD, P=0.014) and time to sit up (412±90 vs 511±126s, P=0.002) were significantly shorter in the remifentanil group compared to the fentanyl group. Side-effects and patient discomfort were similar for both groups. Remifentanil can be used as a suitable supplement to propofol for direct current cardioversion and may provide a faster recovery profile than fentanyl.
Severe Dehydration and Acute Renal Failure Associated with External Ventricular Drainage of Cerebrospinal Fluid in Children
Authors: Simpson S. , Yung M. , Slater A.
Published: January 2019

We report three paediatric cases of severe dehydration and hyponatraemia with circulatory compromise associated with the use of external ventricular drainage of cerebrospinal fluid. Two of the children had cardiac arrests. All were successfully resuscitated. While there were additional factors that contributed to other fluid losses, and fluid balance data are incomplete, these cases highlight a need for increased vigilance when managing children with external ventricular drains.
Salmon Calcitonin in the Treatment of Post Herpetic Neuralgia
Authors: Visser E. J. , Kwei P. L.
Published: January 2019

A 78-year-old man with severe chronic obstructive pulmonary disease presented to our pain medicine clinic for treatment of post herpetic neuralgia. Pharmacotherapy with tricyclic antidepressants, anticonvulsants, tramadol and traditional analgesics had failed, primarily due to adverse drug effects, particularly sedation, dizziness and nausea. Consequently, intravenous salmon calcitonin was administered, based on evidence of efficacy in the treatment of other neuropathic pain syndromes and its relatively benign side-effects profile. The patient reported immediate and sustained improvement in his post herpetic neuralgia for over two months, without adverse effects from the calcitonin therapy.
Incidence of Infections in Patients with Status Epilepticus Requiring Intensive Care and Effect on Resource Utilization
Authors: Ala-Kokko T. I. , Säynäjäkangas P. , Laurila P. , Ohtonen P. , Laurila J. J. , Syrjälä H.
Published: January 2019

Data from a six-year period were retrospectively retrieved from medical records and an intensive care unit data management system to study the impact of infections on patients with status epilepticus. Out of 161 admitted patients, 33 had a community-acquired infection and 35 acquired an infection during their hospital stay, 10 while in a ward before admission to the intensive care unit and 25 while in an intensive care unit, giving an infection rate of 42% of all admissions (68 patients). The patients with intensive care unit-acquired infection had three times longer stays in the intensive care unit than those without any infection (P<0.001), and they utilized almost four times more nursing resources than those without infections (P<0.001). Furthermore, they were more often sedated with thiopentone infusion, either alone or in combination with other drugs, than the non-infectious patients (80% vs 20%, P<0.001). Both community- and hospital-acquired infections were related to longer intensive care unit stays (P<0.001). The hospital stay of patients with hospital-acquired infection was threefold compared to that of patients without infection (P<0.001), and these patients utilized almost three times more nursing resources than those without any infection (P<0.001). Patients with infections consumed 65.5% of the intensive care unit nursing resources of status epilepticus patients.

In conclusion, the infection rate of status epilepticus patients was high and nosocomial infections were associated with more severe illness, treatment escalation, prolonged hospital stay and enhanced resource utilization.
Assessing the Accuracy of Self-Reported Height and Weight in an Elective Surgical Population in a Melbourne Metropolitan Hospital
Authors: Bowden C. , Loughnan T.
Published: January 2019

A Health Questionnaire serves as a screening form as part of our Hospital Preadmission process and is completed by all patients scheduled for elective surgery. We reviewed the completed Health Questionaires of 444 patients. Completion of the Health Questionnaire requires patients to record their height and weight. At the time of admission their actual height and weight was measured and recorded by nursing staff as part of the preoperative assessment. We compared their estimated body mass index (BMI) from self-reported height and weight, with their actual BMI calculated from height and weight measured upon admission. The measured BMI accorded well with that calculated from reported values and showed no systematic over- or under-reporting. Of 70 patients with a BMI greater than 35, only ten estimated their BMI less than 35 and only five of these had more than a two unit difference. Perioperative patients appear to be more accurate at providing height and weight than previously analysed non-patient groups. However there is not complete accuracy and some patients still provide unreliable information. Whether or not individual practitioners utilize BMI from self-reported height and weight will depend on the accuracy that they require for their purposes. Of note there was greater accuracy in prediction of height and weight than in the derived variable of BMI due to the calculations required.
Acid-Base and Bio-Energetics during Balanced versus Unbalanced Normovolaemic Haemodilution
Authors: Morgan T. J. , Venkatesh B. , Beindorf A. , Andrew I. , Hall J.
Published: January 2019

Fluids balanced to avoid acid-base disturbances may be preferable to saline, which causes metabolic acidosis in high volume. We evaluated acid-base and bio-energetic effects of haemodilution with a crystalloid balanced on physical chemical principles, versus crystalloids causing metabolic acidosis or metabolic alkalosis.

Anaesthetised, mechanically ventilated Sprague-Dawley rats (n=32, allocated to four groups) underwent six exchanges of 9 ml crystalloid for 3 ml blood. Exchange was with one of three crystalloids with strong ion difference (SID) values of 0, 24 (balanced) and 40 mEq/l. Controls did not undergo haemodilution.

Mean haemoglobin concentration fell to approximately 50 g/l after haemodilution. With SID 24 mEq/l fluid, metabolic acid-base remained unchanged. Dilution with SID 0 mEq/l and 40 mEq/l fluids caused a progressive metabolic acidosis and alkalosis respectively. Standard base excess (SBE) and haemoglobin concentration were directly correlated in the SID 0 mEq/l group (R2=0.61), indirectly correlated in the SBE 40 mEq/l group (R2=0.48) and showed no correlation in the SID 24 mEq/l group (R2=0.003). There were no significant differences between final ileal values of CO2 gap, nucleotides concentration, energy charge, or luminal lactate concentration. SID 40 mEq/l crystalloid dilution caused a significant rise in subcutaneous lactate. In this group mean kidney A TP concentration was significantly less than controls and renal energy charge significantly lower than SID 0 mEq/l and control groups.

We conclude that a crystalloid SID of 24 mEq/l provides balanced haemodilution. Bio-energetic perturbations with higher SID haemodilution may be more severe and need further investigation.
Update in Computer-Driven Weaning from Mechanical Ventilation
Authors: Rose L. , Presneill J. J. , Cade J. F.
Published: January 2019

Weaning from mechanical ventilation is a complex process requiring assessment and interpretation of both objective and subjective clinical parameters. For many years, automated computerised systems for various medical processes, including respiratory management, have been proposed to optimise decision-making and reduce variation amongst clinicians. SmartCare™/PS, available since 2003 as a software application for the EvitaXL ventilator (Drager Medical AG & Co. KG, Lübeck, Germany), is one of the first such ventilator systems to be made commercially available. SmartCare/PS can be described as a knowledge-based weaning system, which adjusts pressure support based on measurement of the patient's respiratory status, specifically the spontaneous respiratory rate, tidal volume and end-tidal carbon dioxide with the aim of optimising the weaning process. The primary proposed advantage of this system is an ability to provide management of ventilatory weaning through continuous physiological monitoring and real-time interventions. The relatively small number of available clinical studies indicate the system is able to deliver appropriate ventilation during pressure support weaning from both short-term and prolonged ventilation. Of potential clinical note, a recent study suggested that use of SmartCare/PS might be associated with useful reductions in the duration of weaning compared to existing clinical practice using weaning protocols. One recently published randomised trial supports this conclusion. However, given the known large variation in international critical care ventilatory practices further randomised trials are desirable.
Treatment of Multilevel Degenerative Disc Disease with Intradiscal Electrothermal Therapy
Authors: Malik K.
Published: January 2019

Intradiscal electrothermal therapy is a frequently performed procedure for the pain of internal disc disruption. It is typically performed on one to two discs; the discal treatment is followed by a long period of rest and rehabilitation. In patients with multilevel disc disease, intradiscal electrothermal therapy is either not contemplated or only one to two discs are treated at a time. This approach therefore either denies these patients the potential benefits of intradiscal electrothermal therapy or significantly prolongs the period of pain and disability.

A 25-year-old female patient presented with internal disc disruption at four lumbar disc levels, diagnosed by provocative discography and post discography CT scan. All these discs were treated simultaneously by intradiscal electrothermal therapy. The patient tolerated the procedure well and responded favourably with significant and prolonged decrease in her symptoms. She reported sustained reduction in her pain and showed no clinical evidence of early neurological or infectious complications during 18 months of follow-up.

This report indicates that intradiscal electrothermal therapy can be performed at multiple levels at a single sitting, compared to intradiscal electrothermal therapy performed at one to two discs at a time, this approach may obviate the need for surgery and may reduce the duration of pain and disability incurred. However, the influence of multilevel intradiscal electrothermal therapy on long-term complications or outcome is not known.
Transtracheal Jet Ventilation in Management of the Difficult Airway
Authors: Mchugh R. , Kumar M. , Sprung J. , Bourke D.
Published: January 2019

We present the use of transtracheal jet ventilation in two uncooperative patients with a difficult airway. Although transtracheal jet ventilation is considered as a last resort option in the difficult airway algorithm, its use can be a valuable tool in selected difficult airway situations. Transtracheal jet ventilation can effectively maintain arterial oxygenation and provide extra time for attempts to intubate the trachea, either directly or fibreoptically.
Phaeochromocytoma Causing Acute Pulmonary Oedema during Emergency Caesarean Section
Authors: Golshevsky J. R. , Karel K. , Teale G.
Published: January 2019

We report a case of severe acute pulmonary oedema following induction of general anaesthesia for emergency caesarean section. After several hours of aggressive resuscitation, both mother and child had a favourable outcome. Postoperative investigation of acute renal failure demonstrated a supra-adrenal mass. Further investigation confirmed bilateral phaeochromocytoma as the cause of her condition. A literature review confirmed this to be a rare but important clinical entity, owing to its high mortality. Antenatal diagnosis greatly improves survival. Magnesium sulphate appears to be a useful and safe agent to employ in cases of undiagnosed hypertensive obstetric emergencies.
The Use of Activated Protein C in Severe Plasmodium Falciparum Malaria
Authors: Rankin L. G. , Austin D. L. H.
Published: January 2019

A 56-year-old man presented to a peripheral hospital in New Zealand with severe Plasmodium falciparum malaria with cerebral involvement and subsequently developed multi-system organ failure. Activated protein C was used in an attempt to stop the cascade of events into multiorgan failure.

Severe infection with P. falciparum is life-threatening and appears to activate a hypercoagulable state similar to that of severe sepsis. Activated protein C is currently used in the treatment of severe sepsis and may provide a new adjuvant therapy for severe P. falciparum malaria.
Unsuspected Colchicine Overdose in a Female Patient Presenting as an Acute Abdomen
Authors: Blackham R. E. , Little M. , Baker S. , Augustson B. M. , Macquillan G. C.
Published: January 2019

We report a case of multi-system organ failure as a result of unsuspected colchicine overdose in a patient with known gout and bulimia nervosa. The patient had initially presented with mild gastrointestinal symptoms with rapid progression to fulminant hepatic failure and multiple organ dysfunction before the causative agent was identified. The patient survived with aggressive intensive care support and ongoing medical treatment. Physicians should be aware of the risk assessment based on the ingested dose, that the clinical presentation of colchicine in toxic doses may be nonspecific with high potential for severe morbidity or death and that survival may occur despite multiple organ failure requiring aggressive support.
Examining the Occurrence of Adverse Events within 72 hours of Discharge from the Intensive Care Unit
Authors: Mclaughlin N. , Lesliet G. D. , Williams T. A. , Dobb G. J.
Published: January 2019

Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for readmission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a ‘do-not-resuscitate’ order. Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.
Systemic Anticoagulant Effect of Low-Dose Subcutaneous Unfractionated Heparin as Determined Using Thrombelastography
Authors: Matzelle S. J. , Gibbs N. M. , Weightman W. , Sheminant M. , Rowe R. , Baker S.
Published: January 2019

In an observational study using heparinase-modified thrombelastography, we investigated the percentage of elective cardiothoracic surgical patients receiving low-dose unfractionated heparin (5000 IU 12 hourly subcutaneously) who had a demonstrable systemic heparin effect.

Blood samples were obtained at induction from 40 adult elective cardiothoracic surgical patients who had received 5000 IU unfractionated heparin subcutaneously within six hours. Simultaneous kaolin and heparinase-modified thrombelastographies were run on all samples. Fourteen patients (35%; 95% CI: 20 to 50%) had a demonstrable heparin effect(defined as a kaolin thrombelastography R time >25% longer than the heparinase-modified control). Their mean±SD kaolin thrombelastography R time was 13.6±5.9 minutes (normal range 4 to 8 minutes) vs. 7.1±2.0 minutes for the heparinase-modified controls. In 10 patients the thrombelastography R times were >50% longer and in four patients >100% longer, than their respective heparinase-modified controls. In a post hoc analysis, there was little correlation between the extent of the prolongation and patient age (r=0.02), weight (r=-0.31), preoperative creatinine (r=-0.17), or time since administration of heparin (r=0.14).

These results indicate that about one third of patients who have received low-dose unfractionated heparin subcutaneously within six hours have a demonstrable heparin effect. The potential for this effect should be considered if central neural blockade is planned.
Nitric Oxide Production is More Prominent in off-Pump than in On-Pump Coronary Artery Bypass Surgery
Authors: Mitaka C. , Yokoyama K. , Imai T.
Published: January 2019

The aim of our study was to elucidate the extent to which cardiopulmonary bypass contributes to endogenous nitric oxide (NO) production in patients undergoing coronary artery bypass grafts (CABG). One-hundred-and-sixteen patients undergoing elective CABG with (on-pump, n=66) and without cardiopulmonary bypass (off-pump, n=50) were included. Urinary nitrite/nitrate (NOx) excretion was measured as an index of endogenous NO production during the first two postoperative days. Haemodynamic profiles, serum CK-MB and C-reactive protein (CRP) concentrations were measured after the operation. There was no significant difference in urinary NOx/creatinine (Cr) excretion on day one post CABG. The mean urinary NOx/Cr excretion ratio significantly (P <0.01) decreased from days one to two in the on-pump group, but not in the off-pump group. The mean urinary NOx/Cr excretion ratio was significantly (P<0.01) higher in the off-pump group (0.51± 0.26 μmol/mg) than in the on-pump group (0.38± 0.20 μmol/mg) on day two. The mean serum CRP concentration was also significantly (P <0.01) higher in the off-pump group than in the on-pump group on day two. There was no significant difference in the mean cardiac index or the mean systemic vascular resistance index between the two groups after surgery. The mean serum CK-MB concentration was significantly (P<0.05) lower in the off-pump group than in the on-pump group on days one and two. These findings suggest that endogenous NO production is stimulated by a surgical inflammatory response and that the cardiopulmonary bypass procedure per se is not the inciting stimulus for NO production in patients undergoing CABG.
Airway Management Equipment in a Metropolitan Region: An Audit
Authors: Baker P. A. , Hounsell G. L. , Futter M. E. , Anderson B. J.
Published: January 2019

Difficult airway equipment containers are commonly found in operating rooms, but the availability of airway equipment beyond that environment is unknown. Using the Difficult Airway Society (U.K.) and American Society of Anesthesiologists’ guidelines, we conducted an inspection audit of airway equipment at all anaesthetic sites in our region. Staff knowledge about the equipment was assessed and feedback was provided to each site.

Eighteen of the 42 sites had an airway container. Equipment for an unexpected difficult intubation, according to the guidelines, was deficient at all sites. Equipment to detect oesophageal intubation was inadequate. Locations remote from the operating suite lacked emergency invasive airway equipment and were, on average, a 4.3 minute walk from the nearest appropriate equipment. Two clinics had no emergency invasive airway equipment. Half of the airway containers with check lists had items missing. One third of the items with an expiry date were expired. Quality control and implementation of airway guidelines could rectify these deficiencies. Anaesthesia organisations should be encouraged to publish detailed equipment guidelines.
Milrinone Does Not Improve Free Flap Survival in Microvascular Surgery
Authors: Jones S. J. , Scott D. A. , Watson R. , Morrison W. A.
Published: January 2019

Free flap microvascular surgery involves the transfer of a mobilised tissue flap with complete vascular reanastomosis at the new site. Ischaemia frequently threatens flap survival and may require a return to the operating theatre for anastomotic revision. Arterial spasm and hypoperfusion are recognised as factors in flap ischaemia. Phosphodiesterase inhibitors such as milrinone may improve flap blood flow and possibly flap survival by arterial dilation and increasing cardiac output. To investigate the role of milrinone in this type of surgery, a double-blinded randomised controlled trial was conducted with 88 patients receiving either a milrinone bolus and infusion throughout surgery or placebo (normal saline). We found that milrinone did not improve graft survival, return to theatre rate, or surgically graded arterial spasm, but did require more vasopressor support. We conclude that intraoperative milrinone did not improve flap outcomes in microvascular surgery.
Comparison of Airway Management during Anaesthesia Using the Laryngeal Mask Airway CTrach™ and Glidescope™
Authors: Ng S. Y. , Ithnin F. , Llm Y.
Published: January 2019

The design of the Laryngeal Mask Airway CTrach™ combines the fibreoptic viewing capability of the Glidescope™ and the ability for ventilation of the Fastrach™. We conducted a prospective randomised trial comparing the intubation characteristics of the CTrach™ and Glidescope™ to investigate the difference in clinical performance for airway management during anaesthesia. One-hundred-and-six patients with normal airways were recruited and randomly assigned to the CTrach™ or Glidescope™ group. A standardised anaesthesia and airway management protocol was used. The time to intubation was significantly shorter for the Glidescope™ compared to the CTrach™ (43±22 vs. 73±36 s, P <0.001). The success rates of intubation within first and three attempts were significantly higher for Glidescope™. There was no apparent difference in complications of device insertion. Our results suggest that during elective management of normal airways, the time to intubation with the Glidescope™ is significantly shorter than the CTrach™. Further studies are required to compare these devices in patients with difficult airways.
Difficult Decisions in the Intensive Care Unit: An Illustrative Case
Authors: Freshwater-Turner D. A. , Boots R. J. , Bowman R. N. , Healy H. G. , Klestov A. C.
Published: January 2019

Difficult clinical decision-making is a common experience in intensive care units. There is often considerable pressure on time and decisions may have to be made in a stressful environment. Patients in the intensive care unit not infrequently present with extreme or rare manifestations of a disease process. Clinical evidence to guide management of such patients may be incomplete, non-existent, or its relevance to the problem at hand may be questionable. In this context, formal decision-making analytical tools are often impractical.

Unconscious cognitive biases have been shown to play an important role in medical decision-making, particularly in these settings. While mostly these contribute to doctors making appropriate and timely decisions, occasionally they lead to errors. Despite 30 years of research into models of clinical reasoning, most doctors are unaware of how biases affect their thinking and are unfamiliar with techniques of detecting and neutralising bias in clinical practice.

We present the case of a patient with Wegener's granulomatosis, which highlights many of the difficulties outlined above. We review the clinical evidence for our decisions at each stage and explain the rationale for our choices, highlighting the many situations for which high quality evidence was lacking. Examples of cognitive bias are identified and techniques of metacognition (thinking about thinking) that can be useful in limiting the effects of bias on complex decision-making are reviewed. The intensivist's evaluation of management alternatives has an important role in steering medical management towards optimal patient outcomes.