bluuebunny/crossref_metadata_2025 huggingface dataset:
Continuous Venovenous Haemodiafiltration for Metformin-induced Lactic Acidosis
Authors: Pan L. T. T. , Maclaren G.
Published: January 2019

A 74-year-old man with cardiac failure and renal impairment was admitted to the cardiothoracic intensive care unit with metformin-induced lactic acidosis and shock. He was successfully treated with high-dose (80 ml/kg/hour) continuous venovenous haemodiafiltration. Lactic acidosis is a known complication of metformin and is associated with a high mortality. The use of high-dose continuous venovenous haemodiafiltration for this condition has not previously been reported.
An Audit of Potentially Recyclable Waste from Anaesthetic Practice
Authors: McGain F. , Hendel S. A. , Story D. A.
Published: January 2019

Little is known about the amount of anaesthesia waste that is recyclable. We tested the hypotheses: 1) that anaesthetists produce a small proportion (<10%) of total operating suite waste, 2) that much of this waste (>30%) is recyclable and 3) that there is little (<10%) cross-contamination of infectious and non-infectious waste. For five weekdays in a metropolitan hospital with six operating theatres, we weighed waste and determined the proportion of anaesthesia waste that was recyclable. Waste was routinely divided into general and infectious streams. For safety reasons the infectious waste was considered unavailable for recycling, leaving the general waste as potentially recyclable. Anaesthesia waste (90 kg) was 25% (95% confidence interval: 22 to 29%) of the total 357 kg of operating suite waste. Of 66 kg of general anaesthesia waste, 38 kg was recyclable (58%; 95% confidence interval: 47 to 67%). Most cardboard waste, however, was included in the operating suite waste; therefore we under-estimated the total amount of recyclable anaesthesia waste. Of 24 kg of anaesthesia infectious waste, 2 kg (8%) was recyclable. The general waste contained 4 kg (7%; 95% confidence interval: 3 to 13%) of infectious items. No sharps were found. Anaesthesia waste was a quarter of total operating suite waste. Almost 60% of anaesthesia general waste could be recycled. Failure to eliminate infectious waste from general waste could be a barrier to recycling.
The New College of Intensive Care Medicine – Update
Authors: van Heerden P. V.
Published: January 2019

Following a lengthy period of development of the training program in intensive care medicine in Australia and New Zealand and the strong support of the Fellowship, the time is right to establish a fully independent College of Intensive Care Medicine. This body will take over the functions of the current Joint Faculty of Intensive Care Medicine from 1 January 2010. Progress reports and news from the College will be posted on the College website: www.cicm.org.au
Cricothyroidotomy: Comparison of three Different Techniques on a Porcine Airway
Authors: Mariappa V. , Stachowski E. , Balik M. , Clark P. , Nayyar V.
Published: January 2019

We compared three different cricothyroidotomy techniques on a cadaveric porcine airway model to determine the most rapid, successful and safe method in emergency situations. In this observational comparative bench-test, surgical or scalpel cricothyroidotomy (ST), Cook Melker Cricothyrotomy Kit (CM) and Portex Cricothyroidotomy Kit (PCK) were evaluated. After a familiarisation program, four operators performed five procedures using each of the techniques. A dissected pig airway was housed in an airway training manikin. Time to successful completion of the procedure, complications and anatomical variations in the pig larynx were recorded.

A patent airway was established in 20 of 20 (100%) attempts with CM technique, 11 of 20 (55%) with ST and six of 20 (30%) with PCK technique. The CM technique was associated with a higher success rate (P <0.001). There was no significant difference (P=0.4) in the median time (interquartile range) taken to achieve a patent airway; CM 50 seconds (40 to 57), ST 47 seconds (41 to 55) and PCK 63 seconds (41 to 150). There was a higher rate of posterior tracheal wall injury with the PCK technique (n=11) and ST technique (n=5). No complications were observed with CM technique. There were no significant anatomical variations in the pig larynxes.

We conclude that the CM technique is safe, rapid and has a significantly higher success rate in achieving an artificial airway in this airway model. Overall, all the participants in our study preferred to use this kit in an emergency situation.
Aminoglycoside Clearance is a Good Estimate of Creatinine Clearance in Intensive Care Unit Patients
Authors: Jones T. E. , Peter J. V. , Field J.
Published: January 2019

The aim of this study was to determine whether creatinine clearance can be estimated as well by clearance of gentamicin/tobramycin as by routine, non-invasive estimates in the intensive care unit.

The volume of distribution and clearance values for gentamicin I tobramycin were obtained using first order kinetics and an estimate of creatinine clearance derived. Seven estimates of renal function (Cockroft-Gault, MDRD4 and MDRD6 equations, two- and 24-hour urine estimates, two equations utilising Cystatin C concentrations) were compared to the gentamicin/tobramycin clearance estimate in 100 intensive care unit patients.

The gentamicin clearance estimate was at least as reliable as other estimates. The two-hour was less reliable than the 24-hour urine estimate. The Cockroft-Gault appeared to out-perform the MDRD equation estimates. The MDRD4 was not as reliable as the MDRD6 estimate. Cystatin C estimates appeared not as reliable as the gentamicin estimate of renal function.

The gentamicin/tobramycin estimate is at least as good as other estimates and it is available sooner than most others. It should be used in all patients who are prescribed gentamicin. The two-hour urine and MDRD4 estimates should not be used in the intensive care unit.
Incidence of Contrast-induced Nephropathy in Intensive Care Patients Undergoing Computerised Tomography and Prevalence of Risk Factors
Authors: Rashid A. H. , Brieva J. L. , Stokes B.
Published: January 2019

Computerised tomography (CT) with contrast is frequently used in intensive care. Contrast-induced nephropathy (CIN) is an important complication largely studied in stable cardiology patients and can lead to acute renal failure. The aim of this study was to determine the incidence of CIN in an intensive care unit (ICU) setting and describe the prevalence of associated risk factors. We performed a retrospective analysis by review of electronic laboratory database and manual chart review of all patients in two tertiary intensive care units in Newcastle, New South Wales who underwent CT with intravenous contrast during their ICU stay in 2006. CIN was defined as an absolute increment in serum creatinine of 44.2 μmol/l or a relative increment of 25% from baseline at 48 to 72 hours following intravenous contrast. Patients’ demographic, biochemical and contrast media data, physiological parameters, fluid and drug administrations and previously described as well as ICU specific risk factors were analysed. We compared CIN positive and CIN negative patients to identify risk factors associated with CIN. In total, 2043 patients were admitted to ICU during 2006 and 509 CT studies were performed. One hundred and forty-one of these included administration of intravenous contrast and 139 charts were reviewed. Sixteen out of 139 patients developed CIN (11.5%). More than 70% of patients had two or more risk factors. Age was the only risk factor found to be significantly associated with the development of CIN in a multivariate analysis (P value 0.04, OR 1.041, 95% confidence interval 1.002 to 1.081). Mortality was higher in CIN positive patients (31 vs 13%, P value 0.068). ICU and hospital length of stay was not significantly different in CIN positive and negative patients and persisting renal impairment was not found in CIN positive survivors. Based on this study, we cannot predict who will develop CIN in ICU using the described risk factors. Further prospective studies are needed to evaluate the incidence and outcomes of CIN in an ICU setting.
Regional Anaesthesia and Analgesia on the Front Line
Authors: Scott D. M.
Published: January 2019

Deployment to a combat zone with the military poses many challenges to the anaesthetist. One of these challenges is the safe, rapid and comfortable initial wound management and repatriation of wounded combat soldiers to their home country or tertiary treatment facility for definitive care and rehabilitation. The current conflict in Afghanistan is associated with injury patterns that differ from wars such as Vietnam or Korea. This report describes the experience of an Australian military anaesthetist and the value of regional anaesthesia and analgesia for the care of the wounded combat soldier.
Entrapment of the Introducing Sheath of a Pulmonary Artery Catheter
Authors: Ramaswamykanive H. , Bihari D. J.
Published: January 2019

We report an unusual complication of pulmonary artery catheterisation related to the removal of the pulmonary artery catheter introducing sheath. The sheath had been accidentally tethered to the suture line of the superior vena cava following cardiopulmonary bypass surgery. Physicians and nurses should abandon attempts to remove the pulmonary artery catheter or the introducing sheath after cardiac surgery if any resistance is noted. Minimal force might result in serious morbidity or death.
Cataract Surgery without Anaesthesia: Two Descriptions by Arthur Jacob
Authors: Haridas R. P.
Published: January 2019

Dr Arthur Jacob (1790-1874), of Dublin, Ireland, was one of the leading ophthalmologists of his time. He was the first to describe the membrane that contains the rods and cones in the eye (membrana Jacobi) and basal cell carcinoma (Jacob's ulcer). He made a curved needle for cataract surgery from a sewing needle (Jacob's needle). Two descriptions of cataract surgery without anaesthesia are presented.
Some prehistory of New Zealand intensive care medicine
Authors: Trubuhovich R. V.
Published: January 2019

In taking 1960 as the foundation year for the practice of intensive care medicine in New Zealand, this paper briefly looks into the previous two centuries for some interventions in life-threatening conditions. With the help of descriptions in early 19th century journals and books by perceptive observers, the author focuses on some beliefs and practices of the Maori people during pre-European and later times, as well as aspects of medical treatment in New Zealand for early settlers and their descendants. Dr Laurie Gluckman's book Tangiwai has proved a valuable resource for New Zealand's medical history prior to 1860, while the recent publication of his findings from the examination of coroners’ records for Auckland, 1841 to 1864, has been helpful. Drowning is highlighted as a common cause of accidental death, and consideration is given to alcohol as a factor. Following the 1893 foundation of the New Zealand Medical Journal, a limited number of its papers which are historically relevant to today's intensive care are explored: topics include tetanus, laryngeal diphtheria, direct cardiac massage, traumatic shock, thiopentone management for fitting and the ventilatory failure due to poliomyelitis.
Relative Adrenal Insufficiency in the Intensive Care Population; Background and Critical Appraisal of the Evidence
Authors: Cohen J. , Venkatesh B.
Published: January 2019

Dysfunction of the hypothalamo-pituitary adrenal axis has become a central feature in descriptions of the pathophysiology of sepsis. However, despite hundreds of published articles including literature reviews and consensus statements, controversy still exists regarding the fundamental nature of the disorder and its relevance to clinical management. Often referred to as ‘relative adrenal insufficiency’, a recent consensus conference has proposed the alternate term ‘critical illness related corticosteroid insufficiency’ and suggested diagnostic criteria of a delta serum cortisol of less than 9 μg/l after adrenocorticotrophic hormone administration or a random total cortisol of under 10 μg/l.

This review attempts to establish a critical reappraisal of the evidence for the existence of relative adrenal insufficiency/critical illness related corticosteroid insufficiency in patients with sepsis and examines the background, controversies and possibilities for future research into the condition.
A Comparison of Parametric and Non-Parametric Approaches to Target-Controlled Infusion of Propofol
Authors: Crankshaw D. P. , Brown M. J. , Bjorksten A. R.
Published: January 2019

Nineteen adult patients of either gender received intravenous infusions of propofol, scaled to estimated lean body mass (LBM), for 150 minutes as part of a balanced anaesthetic. Arterial blood was assayed for whole blood propofol. The first subject received propofol at a fixed rate of 0.058 mg.min-1.kgLBM-1. Subsequent groups received variable rate infusions based on the ratio of the infusion rate to the propofol concentration at each sampling point in the previous group, multiplied by the target concentration. After groups of one, two, five and 11 subjects, the median weighted residual was 0.040 and median absolute weighted residual was 0.153. Population pharmacokinetic analysis of the final group of six females and five males, aged 29 to 70 years and of 16.5 to 44.2% body fat, resulted in a two compartment pharmacokinetic model with coefficients and standard errors of V1=0.102 (0.0155) l/kgLBM, V2=0.257 (0.079) l/kgLBM, k10=0.423 (0.069) /min, k12=0.222 (0.051) /min, k21=0.084 (0.02) /min and clearance=0.0418 (0.0023) l.min-1.kgLBM-1. The only significant covariate was LBM. Within infusion data improved prediction when compared with data derived in previous studies from random observations.
Effect of Gabapentin on Pain after Cardiac Surgery: A Randomised, Double-Blind, Placebo-Controlled Trial
Authors: Rapchuk I. L. , O'Connell L. , Liessmann C. D. , Cornelissen H. R. , Fraser J. F.
Published: January 2019

This study evaluated whether perioperative administration of gabapentin in cardiac surgery patients could reduce postoperative opioid consumption, postoperative sleep or perceived quality of recovery. This randomised controlled trial assigned 60 patients undergoing cardiac surgery to receive 1200 mg of gabapentin or placebo two hours preoperatively, and then 600 mg of gabapentin or placebo twice a day for the next two postoperative days. Postoperative opioid use was measured by the amount of fentanyl used in the first 48 hours postoperatively. Pain at rest and with movement at 12, 24, 48 and 72 hours after surgery, sleep scores on postoperative days two and three and patient-perceived quality of recovery were also assessed. Fentanyl use, visual analog pain scores, sleep scores, adjunctive pain medication use and number of anti-emetics given were not significantly different between the gabapentin and placebo groups. The incidence of side-effects was similar between the gabapentin and placebo groups, and no difference was found between groups in relation to quality of recovery. These findings indicate that preoperative use of gabapentin followed by postoperative dosing for two days did not significantly affect the postoperative pain, sleep, opioid consumption or patient-perceived quality of recovery for patients undergoing cardiac surgery.
Anti-Emetic Effect of Midazolam Added to Morphine Patient-Controlled Analgesia After Total Abdominal Hysterectomy
Authors: Huh B. K. , Jung S. , White W. , Jeon Y.
Published: January 2019

Nausea and vomiting are frequent adverse effects of patient-controlled analgesia with opioids. This study was designed to compare the effect of midazolam to that of ondansetron for prevention of nausea and vomiting during morphine patient-controlled analgesia. In a randomised, double-blind, prospective trial, 90 patients were allocated to one of three groups of 30 each, to receive one of three patient-controlled analgesia regimens to manage postoperative pain: a combination of midazolam and morphine (group M), a mixture of ondansetron and morphine (group O) or morphine alone (group C). Patients were assessed for the incidence of nausea and vomiting, the degree of sedation (awake, mild, moderate, deep) and other side-effects during the first 24 hours after the operation. The frequency of nausea and vomiting was significantly lower in groups M (27%) and O (37%) compared with group C (70%) (P <0.05). The incidence of mild sedation in group M was significantly higher than that in groups O or C (P <0.05). We conclude that midazolam is as effective as ondansetron in preventing opioid-induced nausea and vomiting following total abdominal hysterectomy and has acceptable side-effects.
Relative Hypotension in the Beach-Chair Position: Effects on Middle Cerebral Artery Blood Velocity
Authors: McCulloch T. J. , Liyanagama K. , Petchell J.
Published: January 2019

When anaesthetising patients for arthroscopic shoulder surgery, it is common practice to sit the patient in the beach-chair position and to optimise arthroscopy by allowing relative hypotension. There is little published information regarding the cerebral haemodynamic effects of hypotension in the sitting position during general anaesthesia.

In this study, 19 patients scheduled for shoulder surgery were anaesthetised with desflurane. Phenylephrine and/or remifentanil were used to control blood pressure. Cerebral haemodynamics were assessed by monitoring middle cerebral artery blood velocity with transcranial Doppler, and by invasive arterial pressure monitoring with the transducer kept level with the external auditory meatus. Pressure and velocity waveforms were analysed to calculate apparent zero flow pressure and resistance area product. Cerebral haemodynamics in patients anaesthetised supine at the pre-induction blood pressure were compared with haemodynamics while seated at 45 degrees with hypotension. According to our routine practice, blood pressure management was guided by non-invasive measurement of systolic pressure using an arm cuff.

Changing from supine/normotensive to sitting/hypotensive caused mean arterial pressure at the auditory meatus to decrease 47±7% and middle cerebral artery blood velocity to decrease 22±7%. In the beach-chair position, systolic pressure was 96±10 mmHg in the arm and 76±10 mmHg at the auditory meatus (P <0.0001). Both resistance area product and apparent zero flow pressure decreased, suggesting decreases in cerebrovascular resistance and critical closing pressure.

Although there was some evidence of an autoregulatory response, middle cerebral artery blood velocity decreased when relative hypotension was induced in patients anaesthetised with desflurane in the beach-chair position.
Definition, Risk Factors and Outcome of Prolonged Surgical Intensive Care Unit Stay
Authors: Huang Y. C. , Huang S. J. , Tsauo J. Y. , Ko W. J.
Published: January 2019

There is no generally accepted definition for a “prolonged surgical intensive care unit (SICU) stay”. The aims of the current study were to: 1) define prolonged SICU stay; 2) identify risk factors of prolonged SICU stay; and 3) identify risk factors of hospital mortality in patients with a prolonged SICU stay. All SICU patients aged >16 years and with an intensive care unit (ICU) stay longer than three days without ICU readmission between 1 January 2004 and 30 November 2006 at the National Taiwan University Hospital were recruited to the study. A total of 2598 patients were recruited. ICU stay >16 days was defined as a prolonged SICU stay since rates of ICU mortality, hospital mortality and mortality one year after ICU discharge remained stationary after ICU stay was >16 days. A multivariate logistic regression model identified factors associated with a prolonged SICU stay, including age more than 70 years old, (odds ratio 1.587, 95% confidence interval 1.246 to 2.022), increasing pre-ICU hospital days (odds ratio 1.009, 95% confidence interval 1.003 to 1.015), admission from emergency (odds ratio 1.925, 95% confidence interval 1.455 to 2.548), use of mechanical circulation support (odds ratio 2.314, 95% confidence interval 1.458 to 3.674) and renal replacement therapy (odds ratio 5.140, 95% confidence interval 3.781 to 6.987). A multivariate logistic regression model identified factors associated with ICU mortality in patients with ICU stay >16 days, including renal replacement therapy (odds ratio 4.780, 95% confidence interval 2.687 to 8.504). An ICU stay >16 days could be used to define prolonged SICU stay when hospital and one-year mortality rates are considered. Prevention of organ failure requiring renal replacement therapy might prove a useful goal to avoid prolonged ICU stay and even hospital mortality.
Clinical Characteristics and Outcomes of Patients with Obstructive Sleep Apnoea Requiring Intensive Care
Authors: Hang L. W. , Chen W. , Liang S. J. , Lin Y. C. , Tu C. Y. , Chen H. J. , Chiu K. L.
Published: January 2019

We reviewed the clinical characteristics, required intervention and short- and long-term outcomes in obstructive sleep apnoea (OSA) patients requiring intensive care. A retrospective, single-centre, observational cohort study was undertaken in a multidisciplinary teaching medical and surgical intensive care unit. Adult patients with OSA (apnoea-hypopnoea index of 5 or higher) requiring intensive care from January 2000 to January 2005 were included. Thirty-seven OSA patients (age: 58±14 years, male:female 27:10) were admitted due to respiratory (n=12, 32%), cerebrovascular (n=8, 22%), cardiovascular (n=16, 43%) and infectious events (n=1, 2.7%). Comparing the clinical features, polysomnographic data and outcome among these groups, we found that OSA patients admitted due to respiratory events had significantly higher Acute Physiology and Chronic Health Evaluation II scores, lower arterial blood gas pH, higher PaCO2, a higher incidence of respiratory failure (92%) and required non-invasive ventilation after extubation (73%), and higher intensive care unit readmission rates than patients admitted due to cerebrovascular events and cardiovascular events (P <0.05). No difference was found in the in-hospital and long-term mortality rate.

The most common reason for intensive care unit admission in critically ill OSA patients was a cardiovascular event, followed by respiratory and cerebrovascular events. The baseline polysomnographic data of the OSA patients were not correlated with their clinical features and outcomes in the intensive care unit. A more complicated clinical course and higher intensive care unit readmission rate were encountered in OSA patients admitted due to respiratory events. Further studies would be required to evaluate the efficacy of non-invasive ventilation for facilitation of extubation in OSA patients presenting with hypercapnic respiratory failure.
Maximum Non-Reactive Concentration of Midazolam and Ketamine for Skin Testing Study in Non-Allergic Healthy Volunteers
Authors: Hagau N. , Bologa R. O. , Indrei C. L. , Longrois D. , Dirzu D. S. , Gherman-Ionica N.
Published: January 2019

The objective of our study was to determine the maximal non-reactive concentrations for midazolam and ketamine in healthy volunteers using both prick and intradermal skin tests. Twenty-one healthy Caucasian volunteers were tested for midazolam and ketamine using more clustered concentrations (identical for both prick and intradermal tests) than those resulting from decimal dilutions. The criteria for positivity were based on dilutions of drugs that cause wheal and flare reactions in subjects without history of allergy. For the prick method, the concentrations that did not produce wheal and flare were 1 mg/ml for midazolam and 10 mg/ml for ketamine. For intradermal tests, using serial dilutions, we found that the highest concentration for which the subjects did not pass the positivity criteria was 0.25 mg/ml for both drugs.
An Evaluation of the Laryngeal Mask Airway Supreme™ in 100 Patients
Authors: Tan B. H. , Chen F. G. , Liu E. H. C.
Published: January 2019

The Laryngeal Mask Airway (LMA) Supreme™ is a new supraglottic airway incorporating features of the LMA Proseal™, LMA Fastrach™ and LMA Unique™. We evaluated the LMA Supreme in 100 patients with normal airways having elective surgery. Our success rates of insertion and ventilation were 96% at the first attempt and 100% after two attempts. The median time to successful placement was 15 seconds (interquartile range 12 to 18 seconds). Forty-five patients breathed spontaneously and 55 patients had controlled ventilation. The incidence of blood staining on removal was 7% and 7% of patients had mild sore throat one hour postoperatively. One patient who had been placed in the left lateral position during surgery had left lingual nerve palsy postoperatively, which recovered completely after one month. Our findings suggest that in patients with normal airways, the LMA Supreme is easy to insert and provides a satisfactory airway with adequate seal pressures for ventilation.
Continuous Tunnelled Femoral Nerve Block for Palliative Care of a Patient with Metastatic Osteosarcoma
Authors: Pacenta H. L. , Kaddoum R. N. , Pereiras L. A. , Chidiac E. J. , Burgoyne L. L.
Published: January 2019

An 18-year-old man with metastatic femoral osteosarcoma had inadequate pain control with gabapentin, naproxen and intravenous fentanyl. A tunnelled femoral nerve catheter was used to administer a continuous infusion of 0.2% ropivacaine and 4 μg/ml clonidine (10 ml/hour) until his death 88 days later. During discharge from hospital, catheter disconnection resulted in severe pain and readmission. Tunnelling, aseptic insertion technique, antibiotics and sterile infusate prepared by the pharmacy may have reduced the chance of infection. We propose that this is a suitable and effective technique in the long-term management of patients with terminal cancer and should be considered on a case-by-case basis.
Impact of Assessments on Learning and Quality of Life during Anaesthesia Training in Australia and New Zealand
Authors: Weller J. M. , Henning M.
Published: January 2019

Assessments are a major factor in the life of anaesthesia trainees, and the impact of assessments on learning is widely acknowledged. Assessment format can have a significant impact on how trainees learn and the extent to which they reach the goals of the curriculum. The assessment format can affect approaches to learning, encouraging surface, deep or strategic learning. The assessment system will not only influence what is learnt, but how well it is learnt. Well-constructed assessments can support and promote learning as trainees progress through the training program. Specialist examinations are stressful and examination preparation has a major impact on lifestyle, stress and burnout, which have been identified as major concerns in doctors. The additional burden of assessments may contribute. A better understanding of the impact of assessments on both learning and quality of life is required to better inform decisions on future directions in anaesthesia training in Australia and New Zealand.
The Second-Generation Air-Q® Intubating Laryngeal Mask for Airway Maintenance during Anaesthesia in Adults: A Report of the First 70 Uses
Authors: Joffe A. M. , Liew E. C. , Galgon R. E. , Viernes D. , Treggiari M. M.
Published: January 2019

The second-generation air-Q® intubating laryngeal airway is a newer commercially available supraglottic airway device. In this retrospective review, we describe our initial clinical experience of 70 insertions. The ease and number of insertion attempts, airway leak pressure, device positioning, duration of use, success of fibreoptic-aided intubation and oropharyngeal morbidity were recorded.

The intubating laryngeal airway was successfully inserted in all 70 patients and functioned adequately as a primary airway in all 57 patients in which it was used. The median airway leak pressure was 25 and 30 cmH2O for the single-use and reusable devices (P=0.001), respectively. Fibreoptic-aided intubation using the intubating laryngeal airway as a conduit was successful in 12/13 (92%) cases. One in four (26%) patients complained of mild sore throat postoperatively before discharge.

In our series, the intubating laryngeal airway performed adequately as a primary airway during anaesthesia with respect to ease of insertion, adequacy of airway maintenance, and as a conduit for intubation in both anticipated and unanticipated difficult airways. Further investigation is warranted regarding the role of the intubating laryngeal airway as a conduit for both blind and fibreoptic-aided intubation. In addition, the incidence of postoperative throat complaints deserves further scrutiny.
Concentration-Dependent Effect of Hypocalcaemia on Mortality of Patients with Critical Bleeding Requiring Massive Transfusion: A Cohort Study
Authors: Ho K. M. , Leonard A. D.
Published: January 2019

Mortality of patients with critical bleeding requiring massive transfusion is high. Although hypothermia, acidosis and coagulopathy have been well described as important determinants of mortality in patients with critical bleeding requiring massive transfusion, the risk factors and outcome associated with hypocalcaemia in these patients remain uncertain. This cohort study assessed the relationship between the lowest ionised calcium concentration during the 24-hour period of critical bleeding and the hospital mortality of 352 consecutive patients, while adjusting for diagnosis, acidosis, coagulation results, transfusion requirements and use of recombinant factor VIIa. Hypocalcaemia was common (mean concentrations 0.77 mmol/l, SD 0.19) and had a linear, concentration-dependent relationship with mortality (odds ratio [OR] 1.25 per 0.1 mmol/l decrement, 95% confidence interval [CI]: 1.04 to 1.52; P=0.02). Hypocalcaemia accounted for 12.5% of the variability and was more important than the lowest fibrinogen concentrations (10.8%), acidosis (7.9%) and lowest platelet counts (7.7%) in predicting hospital mortality. The amount of fresh frozen plasma transfused (OR 1.09 per unit, 95% CI: 1.02 to 1.17; P=0.02) and acidosis (OR 1.45 per 0.1 decrement, 95% CI: 1.19 to 1.72; P=0.01) were associated with the occurrence of severe hypocalcaemia (<0.8 mmol/l). In conclusion, ionised calcium concentrations had an inverse concentration-dependent relationship with mortality of patients with critical bleeding requiring massive transfusion. Both acidosis and the amount of fresh frozen plasma transfused were the main risk factors for severe hypocalcaemia. Further research is needed to determine whether preventing ionised hypocalcaemia can reduce mortality of patients with critical bleeding requiring massive transfusion.
Performance of Sequential Organ Failure Assessment, Logistic Organ Dysfunction and Multiple Organ Dysfunction score in severe sepsis within Chinese intensive care units
Authors: Wang H. , Ye L. , Yu L. , Xie G. , Cheng B. , Liu X. , Jin Y. , Wu S. , Zhu T. , Chen Q. , Fang X.
Published: January 2019

This study assessed the performance of Sequential Organ Failure Assessment, Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score in outcome prediction in severe sepsis. A total of 528 consecutive patients with a diagnosis of severe sepsis were enrolled from two surgical intensive care units of university hospitals in China. Clinical and laboratory data of patients were collected and admission and maximum values of each scoring system were calculated. Areas under the receiver operating characteristic curve, which were used to assess discrimination, were 0.80, 0.83 and 0.74 for admission Sequential Organ Failure Assessment, Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score respectively, and 0.91, 0.93 and 0.86 for corresponding maximum values respectively. Calibration assessed by the Hosmer-Lemeshow statistic was better with admission (χ2=18.2) and maximum Logistic Organ Dysfunction Score (χ2=19.6) than with admission (χ2=98.1) and maximum Multiple Organ Dysfunction Score (χ2=30.9). Brier Scores, indicating the overall performance of the scores, were 0.18, 0.17 and 0.22 for admission Sequential Organ Failure Assessment, Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score respectively, and 0.12, 0.10 and 0.15 for their maximum counterparts respectively. This study found good performance of both admission Sequential Organ Failure Assessment and Logistic Organ Dysfunction Score in severe sepsis, and a slightly weaker performance of admission Multiple Organ Dysfunction Score. Since poor calibration was observed in Logistic Organ Dysfunction Score and Multiple Organ Dysfunction Score, we suggest further study of customisation of these scores in critical illness with severe sepsis.
Ultrasound-Guided Lateral Femoral Cutaneous Nerve Block: Comparison of Two Techniques
Authors: Hara K. , Sakura S. , Shido A.
Published: January 2019

To aim of this study was to compare the feasibility and efficacy between two techniques of ultrasound-guided lateral femoral cutaneous nerve with or without locating the nerve. The study enrolled 106 patients undergoing knee surgery who received 5 ml of 1% mepivacaine immediately under the inguinal ligament 1 to 2 cm medial to the anterior superior iliac spine (subinguinal technique) or around the lateral femoral cutaneous nerve located (nervetargeting technique). The time required to perform the block and the onset time of the block were similar for both techniques. However, a significantly higher percentage of patients obtained loss of pinprick sensation on the lateral thigh within 10 minutes with the subinguinal technique than with the nerve-targeting technique. The findings suggest that ultrasound-guided lateral femoral cutaneous nerve blocks can be easily performed and that injecting local anaesthetic immediately under the inguinal ligament rather than around the nerve itself blocks the nerve more reliably.
Long-Term Follow-up of Patients with Post-Traumatic Refractory High Intracranial Pressure Treated with Lumbar Drainage
Authors: Llompart-Pou J. A. , Abadal J. M. , Pérez-bárcena J. , Molina M. , Brell M. , IbáÑEz J. , Raurich J.-M. , IbáÑEz J. , Homar J.
Published: January 2019

Drainage of cerebrospinal fluid by means of external lumbar drainage (ELD) is controversial in the adult population with traumatic brain injury. We report our experience with ELD in the treatment of post-traumatic high intracranial pressure (ICP) and the results of the long-term follow-up in these patients.

We undertook clinical evaluation of 30 patients with traumatic brain injury and high ICP treated with second-tier measures or with first-tier measures if second-tier measures were contraindicated. The study involved a retrospective review of collected data. Outcome at intensive care unit discharge and three to five years after injury were evaluated with the Glasgow Outcome Scale.

The mean age of patients was 34.9±12.5 years and 25 (83%) were male. The median (interquartile range) Glasgow Coma score was 8 (7 to 10). ICP before and one hour after ELD placement was 33.7±9.0 and 12.5±4.8 mmHg respectively, a decrease in 21.2±8.3 mmHg (P <0.0001). ELD was placed after a mean of 8.6±3.9 days. Cerebrospinal fluid drainage was maintained for a mean of 6.6±3.5 days. Four patients (13%) required ELD replacement and one patient developed a cerebrospinal fluid infection (3%). No pupillary changes were noted within 48 hours of ELD placement. Long-term outcome was favourable (good recovery or moderate disability) in 62% of the patients studied.

The use of ELD resulted in a marked decrease in ICP. These patients presented a good outcome in 62% of the cases in the long-term evaluation. Few complications related with ELD use were noted.
Post-Craniotomy Pain in a Paediatric Population
Authors: Teo J. H. , Palmer G. M. , Davidson A. J.
Published: January 2019

There is little information about analgesia use or pain experienced in children after neurosurgery. The aims of this study were to assess the degree of pain experienced by children after neurosurgery and the analgesic regimens used, and to identify factors associated with significant pain.

Data for 52 children who underwent craniotomy were collected contemporaneously over 72 hours. Data included demographics, intraoperative surgical and anaesthetic details, postoperative medications and postoperative pain scores as routinely collected by nursing staff. Pain was also assessed by an independent observer (auditor) using an age and developmentally appropriate tool, on a scale from zero to 10.

For most of the time the children had little or no pain. Over the 72 hours the median pain score recorded by nursing staff was 0.7 and by the auditor was 1.3. However, in spite of the low median scores, 42% of children had at least one episode of a pain score ≥3.

Postoperatively, 71% of children received parenteral morphine, 92% of children received paracetamol, 35% oxycodone, 19% oral codeine, 4% tramadol and 2% ibuprofen. Using multivariate regression, duration of procedure was the only factor associated with parenteral morphine use for >24 hours, and older age was the only factor associated with having an episode of pain scoring >3. No episodes of significant respiratory depression were noted.

At our institution, children receive multimodal analgesia after neurosurgery, commonly parenteral morphine, and this is usually associated with low pain scores.
Can Accurate Ultrasonographic Measurement of the Optic Nerve Sheath Diameter (a Non-Invasive Measure of Intracranial Pressure) be Taught to Novice Operators in a Single Training Session?
Authors: Potgieter D. W. , Kippin A. , Ngu F. , McKean C.
Published: January 2019

Novices can be quickly and easily taught to ultrasonographically measure optic nerve sheath diameter as a non-invasive surrogate for intracranial pressure. One intensive care unit senior medical officer, one junior intensive care unit registrar, one junior neurosurgery trainee and two registered nurses, all ultrasound novices, were given a four-hour workshop on how to measure the optic nerve sheath diameter with ultrasound. One week later they had the accuracy of their technique assessed by recording their measurements for both eyes of 12 healthy volunteers. Each eye was measured three times and the average and ‘best’ measurements were determined. The median, 5th and 95th centiles and standard deviation for intra-observer variation were calculated. Median, 5th and 95th centiles for inter-observer variation were obtained by comparing each of the novice operator's measurements with those of an experienced sonographer. Median intra-observer difference was ≤0.27 mm, standard deviation ≤0.46 mm and 95th centiles ≤1.19 mm for the five novice operators. Comparing the average of three measurements for each eye, median inter-observer difference for all operators was ≤0.42 mm and 95th centile values ≤1.15 mm. Using the single ‘best’ measurement for each eye, median inter-observer difference was ≤0.3 mm and 95th centiles ≤1.43 mm. Ultrasonographic optic nerve sheath diameter measurement can be taught to novice operators in a four-hour workshop with variation comparable to published results collated from ‘experts’.
The Effects of Positive or Negative Words when Assessing Postoperative Pain
Authors: Chooi C. S. L. , Nerlekar R. , Raju A. , Cyna A. M.
Published: January 2019

Negative or harsh words such as ‘pain’ and ‘sting’ used to describe sensations prior to potentially painful procedures have been shown to increase pain. We aimed to determine whether the reporting of pain and its severity is affected by the way it is assessed during anaesthesia follow-up after caesarean section. Following caesarean section, 232 women were randomised prior to post-anaesthesia review. Group N participants were asked questions containing the negative word ‘pain’, “Do you have any pain?” and then asked to rate it on a 0 to 10 point Verbal Numerical Rating Scale. Group P participants were asked questions using more positive words, “How are you feeling?” and “Are you comfortable?”. Data are presented as median, interquartile range. In Group N, 63 participants (54.3%) reported pain compared with only 28 participants (24.1%) in Group P (P <0.001). There were no significant differences between groups for Verbal Numerical Rating Scale at rest: Group N 2 (0 to 3) vs Group P 1 (0 to 4); P=0.97, or Verbal Numerical Rating Scale with movement, Group N 5 (3 to 6) vs Group P 5 (3 to 6.3); P=0.90. The assessment of pain after caesarean section, using more positive words, decreases its incidence but does not affect its severity when measured by pain scores. Words that focus the patient on pain during its assessment may lead some to interpret sensations as pain which they might not do otherwise. These findings may have important implications when assessing and researching postoperative pain.
Intensivists’ Opinion and Self-Reported Practice of Oxygen Therapy
Authors: Eastwood G. M. , Reade M. C. , Peck L. , Jones D. , Bellomo R.
Published: January 2019

Intensivists frequently prescribe oxygen therapy for critically ill patients, however little is known about how intensivists manage oxygen therapy, or what factors influence their decisions. We surveyed intensivists listed on the Australian and New Zealand Intensive Care Society Clinical Trials Group database to investigate how intensivists report their approach to the monitoring, prescription and management of risks associated with oxygen therapy. The response rate was 60.4% (99/164 intensivists). Overall 81 (83.5%) respondents practised in metropolitan units and 50 (50.5%) had ≥14 years of intensive care unit specialty practice. All respondents reported using pulse oximetry and >93% reported having access to a blood gas machine within their intensive care unit. Sixty-one percent of respondents (60/98) reported assessing other indices of tissue oxygenation (pH, lactate, MvO2). Twelve respondents (12.8%) believed that oxygen toxicity was a greater threat to lung injury than barotrauma when commencing mechanical ventilation. A significantly (P=0.016) greater proportion of regional (5/16) than metropolitan (7/70) respondents were concerned that a high FiO2 is a greater threat to the lungs than barotrauma. For a ventilated acute respiratory distress syndrome patient, 36.8% (36/98 respondents) would not allow an SaO2 of >85% for ≤15 minutes, and 27.6% (27/96 respondents) would not allow an SaO2 >90% for >24 hours. Respondents with ≤14 years of specialty practice were more likely to specify the oxygen delivery device to be used (P=0.014). Recognising the factors that currently influence oxygen administration decisions is a necessary prelude to the potential conduct of interventional studies, as well as for the development of better guidance for oxygen therapy in critical care.
An Itinerant Mesmerist
Authors: Todd E. M.
Published: January 2019

Mesmerism had its roots in late 18th century France, but it was not until the 1830s in Britain that it was systematically applied to the problem of pain. The application of mesmerism in the clinical setting was extremely contentious and it was with some relief that doctors turned to the far more consistent results of chemical anaesthesia. However, though mesmerism were superseded by chemical anaesthetic agents in many areas of application, mesmerism continued to have a life during the second half of the 19th century. In the 1850s, the decade following the introduction of ether and chloroform, Dr John Elliotson established the London Mesmeric Infirmary, in which he used mesmerism both therapeutically and for pain relief, and established a training programme for apprentice mesmerists. In the mid-1890s on the other side of the globe, Mr Newham Waterworth travelled from Tasmania up the east coast of Australia, performing public demonstrations of mesmerism for pain relief during dental extractions. The first of these took place in Hobart in 1890, more than 40 years after many in Britain had declared mesmerism dead. The extractions were performed by respected dentists and, according to witnesses, Waterworth's mesmerism produced the same effects of insensibility to pain as ether and chloroform. With an examination of the continued application of mesmerism after the advent of chemical anaesthesia, this paper will focus on the work of Newham Waterworth in the 1890s and speculate as to why mesmerism might have resurfaced to some appeal in the Australian colonies in this period.
Horner's Syndrome in Patients Admitted to the Paediatric Intensive Care Unit: Epidemiology, Diagnosis and Clinical Practice
Authors: Lazar I. , Cavari Y. , Rosenberg E. , Knyazer B.
Published: January 2019

Horner's syndrome appears when the three-neuron sympathetic pathway is interrupted anywhere from the posterior-lateral nuclei of the hypothalamus through the spinal cord to the eye. In children, Horner's syndrome can be either congenital or acquired, but overall it is a rare finding. There are several causes of Horner's syndrome, some of iatrogenic. Although uncommon in the paediatric population, prompt recognition of the syndrome and immediate treatment may prevent permanent damage to the neuronal pathway. Awareness of the risk of developing iatrogenic Horner's syndrome and early detection of signs are recommended to minimise future disability.
Comparison of Physiological Responses to Spontaneous Breathing Trials with a T-Tube and Low-Level Pressure Support
Authors: Ruan S. Y. , Wu H. D. , Kuo Y. W. , Kuo P. H. , Huang C. T.
Published: January 2019

Previous studies have shown that spontaneous breathing trials (SBT) with a T-tube or low-level pressure support are comparable. However, low-level pressure support may overestimate the ability of a patient to sustain spontaneous breathing, resulting in premature extubation. Understanding factors contributing to different responses by patients to the two SBT methods aids in clarifying the limitation of using low-level pressure support for SBT. We performed a prospective observational study in 80 consecutive adult patients with mechanical ventilation to identify the factors contributing to different responses of a patient to the two SBT methods. The 80 patients underwent both a T-tube trial and pressure support ventilation of 6 cmH2O (PS-6) on the day of extubation. Stratified analysis was used to evaluate the effects of age, respiratory compliance and resistance, PaO2/FiO2 ratio and underlying disease on post-SBT responses. Comparing the responses to a T-tube trial and PS-6, the patients with old age, poor pulmonary compliance (≤40 ml/cmH2O) and chronic obstructive pulmonary disease had a higher heart rate (difference [95% CI]: 4 [0,8], 5 [2,9], 5 [0,10] beats/minute, respectively) and systolic blood pressure (10 [4,16], 11 [5,16], 7 [0,13] mmHg, respectively) after the T-tube trial. In conclusion, this research shows that old age and impaired respiratory mechanics contribute to different responses to spontaneous breathing trials with a T-tube and low-level pressure support. Further studies are needed to compare the effectiveness of the two SBT methods in predicting successful extubation in such patient groups.